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Perio Reports

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Perio Reports  Vol. 26, No. 1
Perio Reports provides easy-to-read research summaries on topics of specific interest to clinicians. Perio Reports research summaries will be included in each issue to keep you on the cutting edge of dental hygiene science.
New Tip for Air Polishing Reaches Subgingivally

Following periodontal therapy, subgingival microflora returns within days, necessitating periodontal supportive therapy (PST) visits every few months to maintain periodontal tissue health. Mechanical disruption of the subgingival microflora has long been accomplished with hand instruments. Scraping of the root surfaces removes cementum, creating irreversible hard tissue damage and in some cases, recession.

Air polishing traditionally uses a sodium bicarbonate powder that effectively removes plaque and stains from tooth surfaces, but damages gingival tissues when directed subgingivally. To solve this problem, a glycine power was recently introduced that does not cause tissue trauma when directed subgingivally. To enhance subgingival cleaning, EMS designed a tip to direct the glycine powder subgingivally with lower jet spray flow and lower pressure than is used supragingivally.

Researchers at the University of Geneva in Switzerland compared air polishing with glycine powder using the new subgingival tip to hand instrumentation in 50 periodontal maintenance patients. These subjects all had at least two residual pockets measuring 5mm or more in two separate quadrants. Sites for each patient were randomly assigned to test and control treatments. This seven-day study measured subgingival microflora and bleeding upon probing.

Air polishing time averaged 30 seconds per site compared to curette use averaging 1.4 minutes per site. Bleeding upon probing was reduced for both groups, with greater reduction in the control group. No differences were observed for subgingival microflora between test and control groups. No tissue trauma was noted with air polishing. Patients preferred air polishing over curettes.

Clinical Implications: The new subgingival air polishing tip provides an alternative to hand instruments for SPT.

Moëne, R., Décaillet, F., Andersen, E., Mombelli, A.: Subgingival Plaque Removal Using a New Air-Polishing Device. J Perio 81: 79-88, 2010.

Air Polishing to Replace Subgingival Instrumentation

Air polishing in the past used a bicarbonate of soda powder that was effective for plaque and stain removal, but damaging for the tissues. Today, glycine powder is available for air polishing that can be used with a new tip to polish subgingivally, reaching into both shallow and deep pockets.

Researchers at the University of Washington in Seattle, Washington, compared full-mouth Glycine Powder Air Polishing (GPAP) to traditional scaling and root planing with curettes plus rubber cup polishing. All patients had undergone initial periodontal therapy prior to this study.

Subjects were all found positive for intra-oral levels of P. gingivalis and T. forsythia. Probing depths ranged from 4mm to 9mm. Patients were instructed to rinse twice daily with 0.12 chlorhexidine mouthrinse for two weeks following treatment. Microbial and clinical indices were repeated at day 10 and day 90.

At each time point, the patients receiving the subgingival GPAP had lower total viable bacterial counts in the moderate to deep pockets compared to those receiving instrumentation with curettes and rubber cup polishing. Patients found both treatment approaches comfortable. Air polishing with glycine powder in subgingival pockets is more effective than using curettes to shift the oral flora from one conducive to infection to one more conducive to periodontal health.

Clinical Implications: Despite our tradition of instrumenting all subgingival areas during a perio maintenance visit, these findings suggest that air polishing with glycine power in the subgingival areas just might be able to replace subgingival instrumentation with curettes.

Flemmig, T., Arushanov, D., Daubert, D., Rothen, M., Mueller, G., Leroux, B.: R andomized controlled trial assessing efficacy and safety of glycine powder air polishing in moderate-to-deep periodontal pockets. J Perio 83:(4)444-452, 2012.
Subgingival Use of Glycine Powder Safe for Tissue

Glycine particles are about four times smaller than sodium bicarbonate particles and because of this and the particle shape, they are less abrasive to the tissue. Air polishing has been limited to supragingival surfaces, due to the tissue damage caused by the sodium bicarbonate particles. Glycine particles allow air-polishing to comfortably reach subgingival surfaces.

Researchers at Westfalian Wilhelm University in Münster, Germany, compared air-polishing with sodium bicarbonate; air polishing with glycine powder; instrumentation with a Gracey 7/8; and a control group receiving no treatment. Treatments were performed on facial and lingual surfaces of a designated quadrant (one treatment per tooth), followed by a biopsy along the gingival margin on the day of treatment and another biopsy from another site 14 days later, all part of scheduled surgeries. Aluminum foil was used to isolate teeth during treatment.

Microscopic examination of the tissue specimens revealed no alterations to the gingival sulcular tissue for controls or Clinpro treated sites. Sites treated with sodium bicarbonate and the curette did show signs of change. Scores from 1-4, least to most damage, were 1 for both control and Clinpro treated sites, 3 for sodium bicarbonate treated sites and 4 for curette treated sites.

Clinical Implications: Air-polishing with Clinpro glycine powder results in less tissue alteration than hand instruments or sodium bicarbonate air-polishing powder. Air polishing with Clinpro glycine powder is now a choice for subgingival biofilm removal without causing tissue damage.

Petersilka, G., Faggion, C., Stratmann, U., Gerss, J., Ehmke, B., Haeberlein, I., Flemmig, T.: Effect of Glycine Powder Air-Polishing on the Gingiva. J Clin Perio 35: 324-332, 2008.

Air Polishing Treats Peri-implantitis

Peri-implant mucositis is inflammation limited to the mucosa, while peri-implantitis is characterized by changes in bone levels plus bleeding. The three primary risk factors for peri-implantitis are poor oral hygiene, smoking and a history of periodontal disease.

Non-surgical treatment of peri-implant mucositis, including mechanical instrumentation, ultrasonics, and delivery of chemicals, is usually successful in reversing the infection. Not so in cases of periimplantitis which has unpredictable outcomes limited to six-12 months.

The use of air polishing has not been an option with the traditional sodium bicarbonate powder because it damages implant surfaces. With the introduction of amino acid glycine powder, air polishing can now be used on implants.

Researchers at Heinrich Heine University in Düsselfdorf, Germany, compared air polishing using glycine powder and the new subgingival Perio-Flow tip from EMS to the use of carbon curettes and subgingival delivery of chlorhexidine.

One month prior to baseline, the 30 patients with early to moderate peri-implantitis received a prophylaxis and oral hygiene instructions. This protocol was repeated at baseline and every two weeks for three months and then monthly for the next three months.

Both treatments resulted in reduced probing depths of half a millimeter. Bleeding was reduced more in the air polishing group, from 95 percent to 50 percent compared a reduction from 95 percent to 84 percent in the curette and chlorhexidine group.

Clinical Implications: Air polishing with glycine powder using the new subgingival tip provides another option for treating peri-implantitis.

Sahm, N., Becker, J., Santel, T., Schwarz, F.: Non-Surgical Treatment of Perio-Implantitis Using an Air-Abrasive Device or Mechanical Debridement and Local Application of Chlorhexidine: A Prospective, Randomized, Controlled Clinical Study. J Clin Perio 38: 872- 878, 2011.

Air Polishing and Laser Both Effective for Treating Peri-implantitis

Peri-implantitis is difficult to treat. Fortunately, the success rate of implant placement is around 95 percent. As more and more implants are placed, the incidence of peri-implantitis might increase, posing major treatment challenges. Implant surfaces and threads pose significant challenges to mechanical disruption to bacterial biofilm. In a recent consensus report, it was concluded that traditional non-surgical therapy for peri-implantitis was not effective. Slightly better results are possible with the Er:YAG laser.

Researchers at Kristianstad University in Kristianstad, Sweden, compared the new EMS glycine air polishing powder with the EMS new disposable subgingival tip to the KaVo Laser 3 Perio laser for treating peri-implantitis with 21 subjects in each group over six months.

All test subjects received a Philips Sonicare FlexCare power toothbrush, detailed oral hygiene instructions and new brush heads every three months.

Both groups showed significant healing with 25 percent of subjects in the laser group with average probing depth reductions of 1mm and 38 percent of those in the air polishing group showing a 1mm average probing depth reduction. Laser treatment resulted in improved health at 44 percent of implant sites and air polishing at 47 percent of sites.

Although both the laser and the air polishing did help some sites with severe peri-implantitis, neither therapy provided predictable treatment for severe peri-implantitis.

Clinical Implications: For severe peri-implantitis both air polishing with glycine power using the disposable subgingival plastic tip and laser treatment using an Er:YAG might improve some lesions, but not with any degree of predictability.

Renvert, S., Lindahl, C., Jansaker, A., Persson, G.: Treatment of Perio-Implantitis Using an Er:YAG Laser or an Air-Abrasive Device: A Randomized Clinical Trial. J Clin Perio 38: 65- 73, 2011.

Subgingival Debridement Effective with Air Polisher

Periodontal therapy patients are seen frequently for supportive periodontal maintenance visits to control subgingival microflora. This is usually done with curettes or power scalers. A new subgingival approach uses glycine powder in an air polisher.

Researchers at the University of Gothenburg, Sweden, compared subgingival air polishing with glycine powder to ultrasonic scaling. Perio maintenance patients with two probing sites measuring 5-8mm in different quadrants were included in this two-month study. The control group was treated subgingivally with the EMS Piezon Master piezoelectric scaler set at 75 percent power with water coolant. The test group was treated with a new subgingival tip on the EMS Air-Flow air polisher with glycine powder.

Subgingival bacterial samples were collected before treatment, right after treatment, two days later and at 14 days. Clinical indices were taken before treatment, 14 days and at 60 days. A total of 20 patients were treated with air polishing at a test site in one quadrant and ultrasonic scaling at a second site in another quadrant.

Both treatments resulted in significant reductions in subgingival bacteria immediately after treatment and two days later. By day 14, both groups returned to baseline levels of subgingival bacteria.

Clinical reductions in probing depths and bleeding scores were significant for both the treatment and control sites. Patients were also asked to rate comfort with each procedure. Air polishing was found more comfortable than ultrasonic scaling.

Clinical Implications: Subgingival air polishing with this new tip and glycine power could replace ultrasonic instrumentation during periodontal maintenance visits.

Wennström, J., Dahlén, G., Ramberg, P.: Subgingival Debridement of Periodontal Pockets by Air Polishing in Comparison with Ultrasonic Instrumentation during Maintenance Therapy. J Perio 38: 820-827, 2011.
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