1. health and fitness
2. disease

Air polishing 2015: Supra and Sub-Gingival biofilm removal
Diane M. Daubert, RDH, MS
April 10, 2015
Course Objectives
Objectives of maintenance therapy
Biofilm removal techniques
Historical air polishing review
Air polishing powders
Air polishing delivery devices
Subgingival air polishing techniques
Clinical outcomes
What is the Endpoint of Maintenance Treatment?
Calculus Removal?
Tangible method for assessment of skills
Easily becomes focus of instrumentation in education settings
No longer determined by attaining a smooth surface
Determined by biological response to therapy
What is the Endpoint of Treatment?
The Periodontal Balance
Plaque as a Biofilm
Biofilms have organized structure
In lower layers, microbes are bound together by polysaccharide matrix and organic, inorganic
materials
Nutrients come from surrounding media and fluid channels run through plaque mass
Specific Bacterial Behavior in Biofilm
Resistance to antibiotics is greatly increased in biofilm vs. planktonic bacteria
1000-1500 times more resistant than planktonic
Due to slower growth rate, variations in nutritional status, pH, prior exposure to antibiotic,
resistance to diffusion of antibiotic
Antimicrobial Resistance and Health Care-Associated Infections
What is antimicrobial resistance?
WHO, CDC and IDSA recognize antimicrobial resistance as among the greatest threats to human
health worldwide.
World Health Day 2011 was devoted to combating antimicrobial resistance.
Multiple-drug resistant organisms are increasingly encountered in hospital and community
health settings (Virginia Mason 2015)
One of the most significant factors is the indiscriminate and inappropriate use of antibiotics
Supra and Sub-gingival Biofilm Removal Techniques
Oral hygiene
Coronal polish
Hand instrumentation
Ultrasonic/sonic instrumentation
Antimicrobial rinses
Subgingival air polishing
Coronal Polishing
Evolving standards of care
Therapeutic or non-therapeutic?
Disadvantages:
Removes cementum
Can abrade esthetic restorations
Will not reach interproximal
Will not reach subgingival
Root Instrumentation. Power-driven versus manual scalers
Old standard: aggressive SRP needed to remove endotoxins from root surfaces
New: endotoxin is loosely adherent and powered instruments can accomplish removal without
excessive cementum removal
Microbial and clinical parameters are equal or better with powered instrumentation
Drisko, C. Dent Clin N Am. 1998. 42:229-44
Cavitron defect depth after 40 seconds of instrumentation
Flemmig et al. Working Parameters of a Magnetostrictive Ultrasonic Scaler Influencing Root
Substance Removal In Vitro. 1997
Air Polishing Historical Review
Alternative to conventional coronal polish in 1970s utilizing specially process sodium
bicarbonate powder with compressed air and water
Primary objective is to remove stain and biofilm while preserving tooth structures and
restorations
Mechanism of Action
Air polishing works through a combination of abrasive particles with water and compressed air
Rate of abrasion is determined by:
Speed
Air and water pressure
Quantity of abrasive
Size, shape and hardness of abrasive
Air polishing
Historically limited to supragingival surfaces for biofilm and stain removal
Better access around orthodontic appliances
Many devices commercially available to dental professionals
Historical technique for supra-gingival Air Polishing
Select powder and setting
Move tip at 2-4 mm from tooth surface
Angulation of tip is perpendicular to surface of the tooth
Never aim into sulcus (Dentsply website)
Sodium bicarbonate restrictions
Not for use on patients with sodium restricted diets
Not recommended for use with patients with respiratory diseases
Air Embolism
Sudden facial swelling resulting from dental procedure that forces air into subcutaneous tissue
Most common after surgical extraction of 3rd molars, rct, use of dental handpiece, air water
syringe
Rare occurrence with air polishing devices
Aquilana,P et al. EMA 2004. 16: 244-246
Treatment of Air Embolism
Cases vary from mild swelling that resolves after 2-3 days to more severe swelling
Moderate swelling – prophylactic antibiotics
Severe swelling and pain admit to hospital – airway or throat tightness
Surgical drainage may be required
Aquilana,P et al. EMA 2004. 16: 244-246
Air Polishing Devices
Many products available in US including Dentsply, Satelec, Kavo, Hu-Friedy/EMS
Specifications on clinical use are based on design of device and handpiece
Safety of device and warranties are based on approved use
Device Selection
What type of powder do you want to use?
Supra or Subgingival use?
Price-point
EMS Air-Flow Master®
Two separate handpieces for supragingival or subgingival use
Two separate powder chambers
Power and water control
Setting for Perio-flow versus Air-flow
EMS Handy 3®
Separate device for supragingival or subgingival tips
Wide powder selection available
Connects directly to high speed connection
Satelec Air n Go®
Interchangable tips for supra or subgingival use
Interchangable powder chambers
Cavitron® Jet Plus
Single device for ultrasonic instrumentation and air polishing
Manufacturer warranty is void with use of powders other than sodium bicarbonate and
aluminum trihydroxide
Not for subgingival use
Air Polishing Powders
Powder Selection
Powder selection for specific purpose
Stain removal
Subgingival biofilm removal
Supragingival biofilm removal
Enamel versus restorative materials
Air Polishing Powders
Many powders are commercially available
Sodium bicarbonate
Calcium sodium phosphosilicate
Calcium carbonate
Aluminium trioxide
Glycine
Erythritol*
Manufacturer Variablilty
No universal formula used by all manufacturers
Formulation including particle size can vary
Hardness values vary
Powder Considerations
Esthetic restorative materials
Traditional restorative materials
Implants
Enamel, Dentin and Cementum
Gingiva and periodontal tissues
Air Polishing Powder Summary
Pelka et al, Influence of air-polishing devices and abrasives on root dentin – An in vitro confocal laser
scanning microscope study. Quintessence Int, 2010
Sodium Bicarbonate
Traditional air polishing powder
Safe for use on enamel and on dental implants
Contraindicated on dentin, cementum, gold, esthetic restorations
Improved efficiency in plaque removal around orthodontic brackets versus rubber cup
Efficient stain removal
May be used prior to sealant placement for increase bond strength
Contraindications to Air Polishing with sodium bicarbonate powder
Patients with chronic bronchitis or asthma
Patients on a low salt diet
Patients with contact lens must remove prior to use
Patients with infectious disease
Calcium Carbonate
Highly abrasive on dentin and cementum
Recommended for supragingival stain removal
Aluminum Trihydroxide
Developed as an alternative for patients with heavy stain who cannot tolerate sodium
bicarbonate
for supragingival use
Should be avoided on composites, around margins of cemented restorations, and ol gold.
Can damage dentin, cementum restorative materials and implants
Calcium Sodium Phosphosilicate (Novamin)
Most abrasive of all air polishing powders tested
Evidence of blockage of dentinal tubules and sensitivity reduction with significant loss of dentin
structure
Glycine
Developed for subgingival removal of biofilm
Least abrasive powder in comparative testing (erythritol not tested)
Safe for use on all restorative materials, root surfaces and implants
Many clinical trials presenting data on safety, efficacy for subgingival use
Available from several manufacturers
Select 25µm glycine powder for subgingival use (AIR-FLOW® PERIO)
Select 50µm glycine powder for more stain with supragingival use (AIR-FLOW® SOFT)
Erythritol
Clinical trials show safety and efficacy for subgingival use
Better for supragingival stain removal
Currently available in Europe only but will be available . . .
Efficacy of supra-gingival air polishing delivery systems
If a powder is available that is safe to use on root surfaces, how effective will it be in subgivgival
biofilm removal?
Subgingival Glycine Powder Application
Standard tip aimed at 60° to long axis of tooth. Note deflection of tissue.
Tip is moved in circular motion 5 seconds per surface
Test sites of 3-5mm probing depth treated with glycine powder, curet or no treatment
Glycine powder was superior in reduction of bacteria
Less time required for gpap and no safety issues
Subgingival Device
Current devices were only effective to max of 4mm.
New device needed to reach deeper pockets
New device designed which could reach depth of pocket and deliver powder toward root
surface
Incidence of embolism with Subgingival Air Polishing
Small number of facial emphysemas have been attributed to subgingival air polishing
Incidence is estimated to be 1 in 666,666
HVAC
Standard of Care
Ergonomic considerations for working without an assistant: ERGO-VAC
Autoclavable
Hagar Worldwide : Multi-function as retractor and evacuation
Air Polishing for Implant Maintenance
Glycine, bicarbonate safe on titanium
Rubber cup polishing contraindicated on titanium
Peri-implantitis is caused by biofilm
Barnes, CM et al. Int J Oral and Maxillofacial Imiplants 1991; 6(4) 462-469
Bicarbonate powder safe to use on titanium implants
Clinical Endpoints
Periodontal health
Microbial
BOP
PDs
Patient comfort
Operator time
20 subjects with sites of 5-8 mm who are in SPT.
Test group received gpap with Perio-flow nozzle for 5 sec per site
Control group had ultrasonic instrumentation for 30 sec per site
Aim was to determine patient comfort, safety and microbial analysis
Results: Pt judged on vas that GPAP was more comfortable than control. Both tx and control
groups significantly reduced BOP and PD. No statistically significant difference in microbiological
variables in two groups at any of the exam dates
Results: GPAP had lower bacterial counts than control after debridement and at day 10. Pg counts
were significantly reduced in sub GPAP group compared to SRP at day 90.
Tx was safe and both groups had high comfort
Of note: GPAP can be safely used to reduce FM bacterial count on tongue, hard and soft palate and
buccal mucosa.
Final Notes
Air polishing does not removed calculus
Air polishing is not a substitute for hand or powered instrumentation for calculus removal
Subgingival air polishing is a addition to the armamentarium for efficient, patient friendly biofilm
removal