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Subgingival air-polishing with erythritol during periodontal maintenance.Randomized clinical trial of twelve months

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Objectives To evaluate repeated subgingival air-polishing in residual pockets with a new erythritol powder containing 0.3% chlorhexidine.Material and methodsSingle-center, examiner masked, randomized clinical trial of 12 months with a two-arm, within-subject parallel design. 50 patients in periodontal maintenance were monitored in 3-month intervals. At months 0, 3, 6 and 9, all sites presenting with a probing depth (PD) >4 mm were subject to subgingival air-polishing (test side) or ultrasonic debridement (control side). The primary endpoint was presence/absence of PD >4 mm after 12 months.Results6918 sites were monitored at baseline, 457 of them had a PD>4 mm (range 5-9 mm). The number of pockets >4 mm per subject, PD and bleeding on probing were significantly lower at month 12. Differences between test and control were not significant. There was a significant difference in favor of air-polishing for the perception of pain/discomfort. Differences of frequencies at >1000 and >100′000 cells/ml of six microorganisms between baseline and month 12 were not significant. At month 12, test sites were less frequently positive for Aggregatibacter actinomycetemcomitans at >1000 cells/ml than controls, and counts never exceeded 100'000 cells/ml.Conclusions Repeated subgingival air-polishing reduced the number of pockets >4 mm similar to ultrasonic debridement. It was safe and induced less pain.This article is protected by copyright. All rights reserved.
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Subgingival air-polishing with
erythritol during periodontal
maintenance
Randomized clinical trial of twelve months
M
uller N, Mo
ene R, Cancela JA, Mombelli A. Subgingival air-polishing with
erythritol during periodontal maintenance. J Clin Periodontol 2014; doi: 10.1111/
jcpe.12289.
Abstract
Objectives: To evaluate repeated subgingival air-polishing in residual pockets
with a new erythritol powder containing 0.3% chlorhexidine.
Material and Methods: Single-centre, examiner masked, randomized clinical trial
of 12 months with a two-arm, within-subject parallel design. Fifty patients in
periodontal maintenance were monitored in 3-month intervals. At months 0, 3, 6
and 9, all sites presenting with a probing depth (PD) >4 mm were subject to sub-
gingival air-polishing (test side) or ultrasonic debridement (control side). The pri-
mary endpoint was presence/absence of PD >4 mm after 12 months.
Results: Totally 6918 sites were monitored at baseline, 457 of them had a
PD >4 mm (range 59 mm). The number of pockets >4 mm per subject, PD and
bleeding on probing were significantly lower at month 12. Differences between
test and control were not significant. There was a significant difference in favour
of air-polishing for the perception of pain/discomfort. Differences of frequencies
at >1000 and >100,000 cells/ml of six microorganisms between baseline and
month 12 were not significant. At month 12, test sites were less frequently posi-
tive for Aggregatibacter actinomycetemcomitans at >1000 cells/ml than controls,
and counts never exceeded 100,000 cells/ml.
Conclusions: Repeated subgingival air-polishing reduced the number of pockets
>4 mm similar to ultrasonic debridement. It was safe and induced less pain.
Nada M
uller, Rapha
el Mo
ene, Jos
eA.
Cancela and Andrea Mombelli
Division of Periodontology and Oral
Pathophysiology, School of Dental Medicine,
University of Geneva, Geneva, Switzerland
Key words: air-polishing; clinical trial;
maintenance; subgingival plaque removal
Accepted for publication 7 July 2014
Accumulation of bacterial deposits
on teeth is the primary cause of
periodontitis, and thorough removal
of such deposits has proven to be
efficient in the treatment of this dis-
ease. Deep lesions may, however,
not revert rapidly and fully to a sul-
cus with physiological probing depth
(PD) (Heitz-Mayfield et al. 2002,
van der Weijden & Timmerman
2002). As self-performed oral
hygiene procedures have a limited
capacity to remove newly formed
bacterial deposits from residual
pockets, regular debridement by pro-
fessional intervention is necessary to
prevent recurrence of disease. This
absorbs a considerable amount of
work time of qualified dental profes-
sionals, notably dental hygienists. As
an example, 704 residual pockets
with PD >4 mm were counted upon
completion of active periodontal
therapy in a cohort of 172 patients
on average 4.1 per patient (Matuli-
ene et al. 2008). A total of 959 pock-
ets, or 5.4 per patient, were present
at a re-evaluation after a mean of
11 years in supportive periodontal
therapy.
Conflict of interest and source of
funding statement
RM has been asked to lecture for the
sponsor. The authors report no other
conflicts of interest related to this
study.
This study was supported by a
research grant from EMS Electro
Medical System S.A., Nyon, Switzer-
land.
©2014 The Authors. Journal of Clinical Periodontology Published by John Wiley & Sons Ltd 1
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License,
which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and
no modifications or adaptations are made.
J Clin Periodontol 2014; doi: 10.1111/jcpe.12289
Traditionally, calcified and non-
calcified bacterial deposits (i.e. calcu-
lus and biofilm) are removed from
root surfaces by scraping with a steel
curette, or using a steel tip activated
by sonic or ultrasonic oscillation.
Repeated instrumentation of this
kind has unwanted effects that may
cumulate over time. They include
gingival recession and loss of tooth
substance. As subgingival bacterial
deposits may not mineralize between
two maintenance visits to form hard
and firmly attached calculus, meth-
ods less harmful than instrumenta-
tion with steel instruments may be
more appropriate in this situation.
Bacterial deposits can also be
removed by “air-polishing”, a tech-
nology to clean or polish a surface
with a jet of compressed air contain-
ing an abrasive powder (Petersilka
et al. 2003). Using a low abrasive
agent and a nozzle that can be intro-
duced into a periodontal pocket, it is
possible to remove subgingival bio-
film from root surfaces in residual
pockets. The safety, patient accep-
tance and short-term (7 days) micro-
biological effects of this method
were evaluated in 50 patients with
residual pockets >4 mm deep, by
testing a newly designed nozzle that
allowed the projection of the air-
powder jet onto the root surface,
and glycine powder with a grain size
of 20 lm as the agent (Mo
ene et al.
2010). The results indicated that this
procedure was safe, more acceptable
and more time efficient than SRP.
The clinical and microbiological
effects in the longer term remained
to be determined. A split-mouth
study of two months duration in 20
recall patients confirmed these
results, revealing no relevant differ-
ences in clinical or microbiological
outcomes between subgingival air-
polishing and ultrasonic debridement
(Wennstrom et al. 2011). A subse-
quent study (Flemmig et al. 2012)
examined the effects on bacterial
biofilm in moderate-to-deep peri-
odontal pockets over a period of
90 days and demonstrated beneficial
shifts in the composition of the sub-
gingival microbiota.
In the studies conducted thus far
the procedure was applied only once
and the benefit of the intervention
was only evaluated short term. As it
is customary in periodontal mainte-
nance to clean subgingival root
surfaces repeatedly, the objective of
the present study was to evaluate the
benefit of repeated subgingival clean-
ing with such an air-polishing device
in residual pockets >4 mm over a
period of 1 year.
Material and Methods
This was a single-centre, examiner
masked, randomized clinical trial of
12 months duration with a two-arm,
within-subject parallel design to
compare the long-term effects of
subgingival air-polishing (test group)
with ultrasonic instrumentation (con-
trol group). The Ethical Committee
of the University Hospitals of Gen-
eva approved the protocol. Research
was conducted according to the prin-
ciples outlined in the Declaration of
Helsinki on human medical experi-
mentation. All participants were
informed about the procedures and
signed a consent form in advance of
their inclusion in the study.
Subjects
Fifty systemically healthy patients
were recruited between September
2011 and November 2012 from
patients previously treated for peri-
odontal disease at the School of
Dental Medicine, University of Gen-
eva. The clinical procedures and
evaluations were carried out between
October 2011 and November 2013.
The participants were included
based on the following criteria: in
maintenance care at least 3 month
after completion of comprehensive
periodontal therapy, aged 18 or
over, and the presence of at least
one residual pocket with PD >4mm
on the right and the left side of the
dentition, absence of clinically
detectable subgingival calculus, in
the area between the distal aspect of
the first incisor and the mesial aspect
of the second molar. Exclusion crite-
ria included chronic bronchitis or
asthma and major systemic illnesses
(i.e. diabetes mellitus, cancer, HIV,
bone metabolic diseases or disorders
that compromise wound healing,
radiation or immunosuppressive
therapy), antibiotics, anti-inflamma-
tory drugs or other medication taken
within the previous 28 days that
may affect the outcome of the study,
confirmed or suspected intolerance
to the test products (erythritol or
chlorhexidine), and any physical lim-
itations or restrictions that might
preclude normal oral hygiene proce-
dures. The smoking history was
recorded, but smoking was not an
exclusion criterion. Dental profes-
sionals or dental students were not
allowed to participate.
Test products and randomization
Subgingival air-polishing was carried
out with erythritol powder (Air
Flow
â
Powder PLUS, mean grain
size of 14 lm, Fig. 1) containing
0.3% chlorhexidine, using the air-
polishing device of the Air-Flow
â
Master Piezon unit (all products
from EMS Electro Medical System
S.A., Nyon, Switzerland). A special
disposable nozzle made from ther-
moplastic elastomer was utilized
(Perio-Flow
â
Nozzle, EMS Electro
Medical System S.A., Nyon, Switzer-
land). The air-powder mixture exits
from this nozzle horizontally. The
pocket is irrigated concurrently with
water exiting from an outlet at the
tip of the nozzle (Mo
ene et al. 2010).
The test procedure consisted in
inserting the tip into the pocket
(Fig. 2) and activating the device for
5 s. The control treatment was sub-
gingival instrumentation with the
ultrasonic scaler (Piezon
â
LED, tip
PS, EMS Electro Medical System
S.A., Nyon, Switzerland) of the same
unit for approximately 20 s per site.
Treatments were carried out without
anaesthesia.
In each patient, one side of the
dentition was assigned to treatment
with the test and the other with the
control procedure. The sponsor allo-
cated the treatments and specified
the sequence of treatments, using a
computer-generated randomization
Fig. 1. Erythritol powder containing
0.3% chlorhexidine (Air Flow
â
Powder
PLUS).
©2014 The Authors. Journal of Clinical Periodontology Published by John Wiley & Sons Ltd
2M
uller et al.
list. At baseline, month 3, 6 and 9,
each site with PD >4 mm was trea-
ted.
Two clinicians performed all pro-
cedures involving a contact with the
participants. The examiner (RM)
enrolled the patients, recorded the
data and took microbiological sam-
ples. Treatment allocation was con-
cealed to the examiner. The operator
(NM) opened a sealed envelope with
the instructions for subgingival
debridement immediately before the
therapy was to be carried out. With
the exception of the periodontal
pocket chart, necessary to identify
the pockets >4 mm needing treat-
ment, she was unaware of previously
recorded data.
Clinical protocol
On the right and the left side of the
dentition, in the region between the
distal aspect of the first incisor and
the mesial aspect of the second
molar, the site with the deepest PD
on a vital tooth was designated as
the study site. Root hypersensitivity
was assessed and microbiological
samples were taken at these two sites
in each participant.
On six sites of all teeth, except
third molars, the following clinical
parameters were recorded: Plaque
Index (PlI; Silness & L
oe 1964), PD,
Bleeding upon Probing (BOP) and
Recession (REC; positive if gingival
margin located apical, negative if
located coronal to the cemento-
enamel junction).
Root hypersensitivity was evalu-
ated using a visual analogue scale
(VAS). A stream of air from the
three-way syringe was directed
towards the tooth surface close to
the gingival margin during 2 s.
Participants were asked to place a
mark on a horizontal line, 100 mm
long, labelled with “no pain” at one
end and with “worst pain” at the
other. Within minutes after the test
and control treatment the partici-
pants were asked to rate pain caused
by the respective intervention using
a similar VAS. The oral hard and
soft tissues, including the lips, ton-
gue, gingivae, sublingual area, inner
surfaces of the cheeks, mucobuccal
folds, hard and soft palate, pharynx
and the cervical area of all teeth
were examined using a structured
checklist. Assessments included col-
our, texture, soft tissue abrasion and
any irregularities or defects. All
adverse events reported by the sub-
ject, or observed by the examiner or
operator, were recorded and docu-
mented throughout the entire study.
In the enrolment visit the exam-
iner recorded the medical history,
obtained informed consent, and
selected the study teeth and the
study sites. Two days before the first
subgingival treatment (day 2) the
examiner collected a subgingival pla-
que sample in the two study sites
with one sterile paper point inserted
to the bottom of each pocket and
left in situ for 10 s. On the day of
subgingival treatment the operator
removed supragingival calculus, stain
and plaque with hand instruments in
the entire dentition and instructed
the subjects in proper oral hygiene
during 510 min (review of tooth
brushing and inter-dental cleaning).
Next, the randomization envelope
for the subject number was opened
to reveal the treatment assignment.
On the test side, all pockets >4mm
were treated with the air-polishing
device, on the control side with the
ultrasonic device. Upon completion
of either air-polishing or ultrasonic
debridement in the first half of the
dentition, the operator noted the
time elapsed from picking-up the air-
polishing or ultrasonic hand-piece to
putting it back onto the instrument
holder. The patient was asked to
rate the pain experienced on a VAS.
Any other comments were recorded.
Then the second half of the dentition
was treated with the other method.
Time and pain were recorded once
more.
The participants returned to the
clinic after 3, 6, 9 and 12 month. At
months 3, 6 and 12 the examiner
collected subgingival plaque samples
from the study sites. At all time
points he inspected the oral tissues,
assessed root hypersensitivity at the
study sites and recorded, PlI, PD,
BOP, REC at six sites of all teeth.
Then the operator took over, giving
instructions for improvement of oral
hygiene and removing supragingival
soft and hard deposits. All sites with
aPD>4 mm were treated subgingi-
vally, on the test side with air-polish-
ing and on the control side with the
ultrasonic device. Each time the
operator noted the time spent for
the subgingival debridement and
asked the patient to rate the pain.
At 12 month the participants were
only seen by the examiner who col-
lected the final subgingival plaque
samples and recorded the clinical
data.
Microbiological procedures
Genomic DNA was extracted using
the GenElute Bacterial Genomic
DNA Kit (Sigma-Aldrich Co., St.
Louis, MO, USA) in accordance
with the manufacturer’s instructions.
Quantitative real-time PCR was
performed to detect and quantify six
specific bacteria (Porphyromonas gin-
givalis,Aggregatibacter actinomyce-
temcomitans,Tannerella forsythia,
Treponema denticola,Prevotella
intermedia,Parvimonas micra) using
species-specific primers (Shelburne
et al. 2000, Kozarov et al. 2006).
SYBR Green (Life Technologies,
Carlsbad, CA, USA) was used as
nucleic acid stain. Real-time PCR
was carried out using an ABI Prism
â
7900HT Sequence detection system
(Applied Biosystems, Foster City,
CA, USA). Bacterial counts were
calculated by comparison with
homologous reference. The detection
limit was 1000 cells/ml.
Statistical analysis
Average scores were generated of the
test and control side of each patient,
at each examination, by summing the
scores and dividing by the number of
sites graded on that side. The primary
endpoint was presence or absence of
PD >4 after 12 months (persisting
pockets >4 mm are commonly per-
ceived as needing continuous subgin-
Fig. 2. Subgingival air-polishing in a resi-
dual pocket, using a special nozzle (test).
©2014 The Authors. Journal of Clinical Periodontology Published by John Wiley & Sons Ltd
Subgingival air-polishing 3
gival maintenance care in clinical
practice). Secondary clinical out-
comes included changes in PD,
BOP+, REC (clinical attachment level
CAL =PD +REC), presence or
absence of target microorganisms
above >1000 (detection threshold)
and >100,000 cells/ml before and
after 3, 6 and 12 months. The sample
size was chosen based on the clinical
considerations. After 12 months of
supportive periodontal care with
subgingival debridement mean PD
changes of 0.37 0.15 mm have
been reported (Heasman et al. 2002).
Assuming that the common standard
deviation of PD is 1 mm, a sample of
50 per group would provide 80%
power to detect a true difference of
0.4 mm between groups. The t-test
was used to determine differences
between test and control. Longitudi-
nal changes were analysed in all
patients completing the trial using the
Wilcoxon matched-pairs signed-ranks
test. Adverse events and observations
concerning oral hard and soft tissues
were summarized by treatment group
for all evaluable subjects. One statis-
tical program package (IBM SPSS
Statistics 22; IBM Corporation, Som-
ers, NY, USA) was used for all statis-
tical analyses. Adjusting for multiple
comparisons, pvalues <0.01 were
accepted for statistical significance.
Results
Fifty persons gave informed consent,
were enrolled in the study and
received treatment as allocated. The
mean age was 58.5 years. There were
21 (42%) males and 29 (58%)
females; 31 (62%) were non-smokers
and 19 (38%) were smokers. A total
of 49 subjects completed the study.
One participant was not willing to
continue participating at month 3
and withdrew. A total of 6918 sites
(six on a total of 1153 teeth) were
clinically monitored. A total of 457
(7%) sites had a PD >4 mm: 328
were 5 mm deep, 99 were 6 mm
deep, 24 were 7 mm deep and 3 were
9 mm deep. Table 1 displays the
baseline characteristics, given as
patient means per treatment proto-
col. The overall mean PD was
2.8 0.3 mm.
Table 2 shows the baseline char-
acteristics of the study sites one
site per participant on the test and
one on the control side. By definition,
all these 100 sites had a PD >4mm
and 53% of them were BOP+.
Except for PD of the study sites, the
clinical status of the two groups was
homogeneous and revealed no statis-
tically significant differences. The six
studied microorganisms showed no
significant difference with regard to
the frequency of detection at >1000
or >100,000 cells/ml between the two
groups.
All 457 sites with a PD >4mm
received subgingival cleaning: 229
sites were treated with air-polishing
and 228 sites with ultrasonic instru-
mentation. The perception of pain,
assessed on a VAS from 1 to
100 mm, was 20.4 21.7 mm for
the test and 48.6 29.2 mm for the
control treatment. The difference in
favour of air-polishing was statisti-
cally significant (p=0.004). The
most frequent comment made by the
subjects upon questioning after treat-
ment was that they felt a sensation
to cold during air-polishing. Five
participants commented that the
powder had a bad taste. When called
up to confirm the 3-month visit, one
person reported that he had experi-
enced malaise and fever during the
night after the first treatment that
disappeared by itself within a few
hours. The average time required by
the operator on the test side of the
dentition, from picking-up the hand-
piece from the instrument holder,
air-polishing all sites >4 mm, to
putting the hand-piece back, was
1.5 1.4 min per person. The
respective time on the control side
was, 1.7 1.5 min.
At month 3, periodontal probing
by the examiner revealed 428 sites
with a PD >4 mm. Two hundred
and thirty of them were treated with
air-polishing and 198 with ultrasonic
instrumentation. At month 6, the
examiner revealed 395 sites with a
PD >4 mm. Two hundred of them
were treated with air-polishing and
195 with ultrasonic instrumentation.
At month 9, the examiner revealed
363 sites with a PD >4 mm. A total
of 194 sites with a PD >4 mm were
treated with air-polishing and 169
with ultrasonic instrumentation.
Over the course of the year 284 sites
were subjected to air-polishing: 112
sites had received one, 73 sites had
Table 1. Clinical baseline characteristics of all 6918 monitored sites by treatment
Test side Control side pValue
nsites per patient 70.9 (11.7) 72.5 (11.2) n.s.
nsites with PD >4 mm 4.6 (5.6) 4.8 (5.2) n.s.
PlI, score 03 0.4 (0.2) 0.4 (0.2) n.s.
PD, mm 2.8 (0.3) 2.8 (0.3) n.s.
BOP+, % 22 (10) 21 (10) n.s.
REC, mm 0.9 (0.7) 0.9 (0.7) n.s.
Data are means (SD) per patient (n=50).
PlI, Plaque Index; PD, probing pocket depth; BOP+, bleeding on probing; REC, recession.
Table 2. Baseline characteristics of the study sites (in each participant the site with the
deepest PD on the test and control side, n=50 sites on each side)
Test site Control site pValue
PD, mm 5.2 (0.4) 5.4 (0.6) 0.003
BOP+, % 58 (50) 48 (50) n.s.
REC, mm 1.0 (0.9) 0.9 (1.0) n.s.
Root hypersensitivity, mm VAS 22.2 (27.4) 21.2 (21.2) n.s.
AA >1000; >100,000 7; 1 7; 0 n.s.; n.s.
BF >1000; >100,000 37; 20 39; 15 n.s.; n.s.
PG >1000; >100,000 37; 14 37; 12 n.s.; n.s.
TD >1000; >100,000 42; 22 42; 27 n.s.; n.s.
PI >1000; >100,000 20; 8 14; 6 n.s.; n.s.
PM >1000; >100,000 44; 19 49; 23 n.s.; n.s.
Clinical data are means (SD), microbiological data are numbers of sites positive with counts
>1000 and >100,000.
PD, probing pocket depth; BOP+, bleeding on probing; AA, Aggregatibacter actinomycetem-
comitans; BF, Tannerella forsythia; PG, Porphyromonas gingivalis; TD, Treponema denticola;
PI, Prevotella intermedia; PM, Parvimonas micra.
©2014 The Authors. Journal of Clinical Periodontology Published by John Wiley & Sons Ltd
4M
uller et al.
received two, 60 sites had received
three and 39 sites had received four
rounds of air-polishing. During the
same period, 290 sites were subjected
to ultrasonic instrumentation: 116
sites had received one, 69 sites had
received two, 50 sites had received
three and 55 sites had received four
rounds of ultrasonic instrumenta-
tion. Table 3 shows the status at
12 months of all 6750 sites that were
clinically monitored over 1 year as
means per patient. The total number
of pockets remaining with PD
>4 mm was 176 on the test sides and
164 on the control sides, correspond-
ing to 3.6 residual pockets with a
PD >4 mm per participant in the
area treated using air-polishing and
3.9 residual pockets with a PD
>4 mm in the area maintained using
ultrasonic instrumentation. The
majority of these residual pockets
were 5 mm deep. A total of 36 and
32 sites had a PD of 6 mm, respec-
tively, 5 and 2 sites had a PD of
7 mm, and none were deeper. Com-
pared to baseline the mean number
of pockets >4 mm per subject was
significantly lower with both proto-
cols (p<0.001); the difference
between groups was not significant
(primary outcome).
Table 4 shows the clinical and mi-
crobiologic status of 49 test and 49
control study sites after 12 months.
From baseline to month 12 there
were significant improvements of PD
and BOP+in the test sites (PD
p<0.001, BOP+p=0.007) and of
PD in the control sites (p<0.001).
The differences between test and con-
trol did not reach a level of statistical
significance.
The detection frequencies of the
studied microorganisms at >1000
and >100,000 cells/ml were not sig-
nificantly different before and after
12 months. However, at the final
examination the frequency of sites
with counts of A. actinomycetem-
comitans >1000 cells/ml was lower in
the test compared to the control
group, and no sample contained
>100,000 cells/ml, compared to two
in the control group.
Discussion
The aim of this study was to evalu-
ate the benefit of repeated subgingi-
val air-polishing in residual pockets
>4 mm over a period of 1 year. A
within-subject parallel design was
chosen. This method has repeatedly
been used in studies evaluating local
treatments (Wennstrom et al. 2011).
However, intra-individual compari-
sons have their limitations as local
therapy may have systemic effects
and hereby influence outcomes in
other sites in the same dentition
(Antczak-Bouckoms et al. 1990).
Even if the risk for crossover effects
appears minimal, as treatment was
provided to only a restricted number
of sites, the design of the study needs
to be considered in the interpretation
of the data. The primary endpoint,
i.e. the reduction of sites with PD
>4 mm, was achieved to a similar
degree by treatment according to
both protocols: On the test side the
average number of sites decreased
from 4.6 to 3.6 per person, and on
the control side from 4.8 to 3.9. To
achieve this goal, sites were retreated
variable numbers of times. Due to
the continued presence of PD>4 mm,
55 sites assigned to ultrasonic instru-
mentation were instrumented at all
four treatment visits, whereas only
39 sites received four rounds of air-
polishing. The sample size for the
study was chosen considering that
mean PD changes in the order of
0.4 mm may be expected in
12 months of supportive periodontal
care with subgingival debridement
(Heasman et al. 2002). Although this
is the largest trial on subgingival air-
polishing conducted so far, the size
of the sample may still be insufficient
to detect a difference in presence or
absence of PD >4 after 12 months.
However, the findings suggest that
repeated subgingival air-polishing in
residual pockets was beneficial since
the mean number of pockets >4mm
per subject was significantly reduced
after 12 months (p<0.001).
In comparing these results with
results from other trials it is impor-
tant to note that the treated sites
had previously been subject to com-
prehensive periodontal therapy and
subsequently may have been exposed
numerous times to mechanical
debridement in the context of peri-
odontal maintenance. Conceptually,
Table 3. Clinical characteristics at month 12 of 6750 monitored sites by treatment
Test side Control side pValue
nsites per patient 70.9 (11.8) 72.6 (11.3) n.s.
nsites with PD >4 3.6 (5.8) 3.9 (6.2) n.s.
PlI, score 03 0.3 (0.1) 0.3 (0.1) n.s.
PD, mm 2.8 (0.5) 2.7 (0.5) n.s.
BOP+, % 15 (6) 14 (6) n.s.
REC, mm 0.9 (0.7) 0.9 (0.7) n.s.
Data are means (SD) per patient (n=49).
PlI, Plaque Index; PD, probing pocket depth; BOP+, bleeding on probing; REC, recession.
Table 4. Status of the study sites at month 12 (in each participant the site with the deepest
PD on the test and control side, n=49 sites on each side)
Test site Control site pValue
PD, mm 4.5 (1.0) 4.4 (1.1) n.s.
BOP+, % 31 (47) 27 (45) n.s.
REC, mm 1.0 (1.0) 0.8 (1.1) n.s.
Root hypersensitivity, mm VAS 21.3 (23.0) 16.6 (17.8) n.s.
AA >1000; >100,000 3; 0 10; 2 0.035; n.s.
BF >1000; >100,000 35; 18 35; 19 n.s.; n.s.
PG >1000; >100,000 33; 9 34; 10 n.s.; n.s.
TD >1000; >100,000 36; 21 38; 17 n.s.; n.s.
PI >1000; >100,000 17; 4 11; 4 n.s.; n.s.
PM >1000; >100,000 41; 19 41; 16 n.s.; n.s.
Clinical data are means (SD), microbiological data are numbers of sites positive with counts
>1000 and >100,000.
PD, probing pocket depth; BOP+, bleeding on probing; AA, Aggregatibacter actinomycetem-
comitans; BF, Tannerella forsythia; PG, Porphyromonas gingivalis; TD, Treponema denticola;
PI, Prevotella intermedia; PM, Parvimonas micra.
©2014 The Authors. Journal of Clinical Periodontology Published by John Wiley & Sons Ltd
Subgingival air-polishing 5
it is more challenging to obtain a
further clinical improvement in such
residual lesions than in previously
untreated pockets. It is important to
understand moreover that in the
present study, according to common
practice in supportive periodontal
care, a decision to treat was made
for each individual site at each visit
(treatment according to the pre-
defined protocol if PD >4 mm).
Studies on the reproducibility of
probing have shown that a deviation
in PD of 1 mm must be expected
in about one-third of pockets that
are re-probed after 13 weeks (Isidor
et al. 1984, Mombelli et al. 1989).
This means that some sites with an
initial PD in the 45 mm range may
have been treated only in the second,
third or fourth visit. Lastly, one
should also consider that 19 subjects
(38%) in this trial were smokers.
Long-term observations show the
negative influence of tobacco smok-
ing on periodontal tissues (Berg-
strom et al. 2000, Bergstrom 2004).
The reduction of residual pockets,
from 4.6 to 3.6 per person in the
area treated using air-polishing,
compares favourably to the counts
of residual pockets in patients on
long-term maintenance after peri-
odontal therapy, for example from
4.1 at completion therapy to 5.4
after 11 years of supportive care
(Matuliene et al. 2008).
The evaluation of pain yielded an
average VAS score of 20.4 mm for
the test and 48.6 mm for the control
treatment, with a significantly better
outcome for air-polishing. For acute
pain, the minimal clinically signifi-
cant VAS change is 16 mm (Galla-
gher et al. 2002). We noted no
clinically visible changes of the hard
tissues and observed no signs of soft
tissue damage. This trial confirms
the findings of our previous study
testing the nozzle for subgingival air-
polishing for the first time in patients
(Mo
ene et al. 2010) and the follow-
ing trials on the same procedure
(Wennstrom et al. 2011, Flemmig
et al. 2012). Erythritol was, however,
used in the present study instead of
glycine powder. The new powder has
a finer grain size and may, therefore,
be even more tissue friendly. Erythri-
tol, a sugar alcohol (polyol), is a
non-toxic, chemically neutral and
water-soluble agent that is used as a
food additive (Munro et al. 1998).
The effects of air-polishing with ery-
thritol powder on dentine have been
compared to sodium bicarbonate
and glycine powder in vitro (Tocha
2013). Erythritol induced the lowest
volume loss and defect depth and
produced the smoothest surface. In a
two-species biofilm model erythritol
showed inhibitory effects on oral
streptococci and P. gingivalis (Hashi-
no et al. 2013). The effect of one
round of subgingival air-polishing
with erythritol powder on BOP+has
been evaluated in 91 residual pockets
in 40 patients (H
agi et al. 2013).
After 3 months, the bleeding ten-
dency was significantly lower, how-
ever, with no difference to the
control treatment (SRP). No adverse
events were recorded and the
patients tolerated the test better than
the control treatment.
Detection frequencies of the stud-
ied microorganisms at >1000 and
>100,000 cells/ml were not markedly
different at the beginning and at the
end of our study. It has been shown
in the past that bacterial biofilms
can grow back rapidly after subgin-
gival instrumentation (Sharawy et al.
1966) and that the composition of
the microbiota may reach pretreat-
ment levels within months (Haffajee
et al. 1997). The microbiological find-
ings of our study, derived from sam-
ples taken 3 months after previous
treatment, may essentially mirror re-
colonization. The lower frequency of
sites with counts of A. actinomycetem-
comitans >1000 cells/ml, and the
absence of sites with counts
>100,000 cells/ml in the test group
may warrant further attention in
future trials. Several studies have
shown that traditional mechanical
debridement alone seems to have a
limited effect especially on A. actino-
mycetemcomitans (Slots & Rosling
1983, Sato et al. 1993, Mombelli et al.
1994a,b). It is unclear to what extent
this potential advantage may be
attributed to the addition of 0.3%
chlorhexidine to the polishing powder.
The manufacturer actually adds
chlorhexidine for the purpose of con-
serving the powder, not with the inten-
tion to have a therapeutic effect.
Time efficiency, high patient accep-
tance and minimal tissue damage are
essential requirements for treatments
that are repeated many times in peri-
odontal maintenance care. An addi-
tional aspect, not evaluated here but
that would merit a comprehensive
comparative evaluation, is cost-effi-
ciency. Repeated subgingival cleaning
of residual pockets with a new air-pol-
ishing device over a period of
12 month was safe, induced less pain
and reduced the number of pockets
>4 mm. The findings regarding safety
are limited to clinical examination and
thus, to overt clinical adverse events.
Long-term effects of protocols for
periodontal maintenance should be
studied further with a focus on hard
tissue safety.
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Address:
Andrea Mombelli
Division of Periodontology and Oral
Pathophysiology
School of Dental Medicine
University of Geneva
Rue Barth
elemy-Menn 19
CH-1205 Geneva
Switzerland
E-mail: andrea.mombelli@unige.ch
Clinical Relevance
Scientific rationale for the study:As
subgingival bacterial deposits may
not mineralize between two
maintenance visits to form calcu-
lus, methods less aggressive than
debridement with steel instruments
may be more appropriate for resid-
ual pockets.
Principal findings: We compared
repeated subgingival air-polishing of
residual pockets using a new erythri-
tol powder containing 0.3% chlorh-
exidine to conventional ultrasonic
debridement. Subgingival air-polish-
ing of residual pockets was safe and
induced less pain than ultrasonic
instrumentation. Outcomes at
month 12 were not significantly dif-
ferent.
Practical implications: For mainte-
nance of residual pockets air-pol-
ishing is a valid alternative to
conventional debridement.
©2014 The Authors. Journal of Clinical Periodontology Published by John Wiley & Sons Ltd
Subgingival air-polishing 7
... Hägi et al. 2015 19 only reported intra-group results, with no inter-group comparison.Patient comfortEight studies reported patient comfort. Four used glycine 4,15,16,31 , three used erythritol5,18,28 and one used trehalose powder.8 Three compared air polishing devices with US scalers,8,16,28 three with hand instruments,15,18 and two with hand instruments combined with US scalers5,31 . ...
... Seven studies reported statistically significant differences between the groups, with air polishing group reporting higher patient comfort. However one study 31 reported no statistically significant differences between groups.Only three authors addressed professional time in their studies.4,18,28 Two of these studies used erythritol18,28 and one used glycine 4 powder. ...
... However one study 31 reported no statistically significant differences between groups.Only three authors addressed professional time in their studies.4,18,28 Two of these studies used erythritol18,28 and one used glycine 4 powder. Two compared air polishing devices with hand instruments 4,18 and one compared air polishing devices with US scalers.28 ...
Article
Objectives: The aim of this review was to compare air polishing devices with conventional periodontal therapy (hand instrumentation and/or ultrasonic debridement), in terms of their clinical, microbiological and patient related outcomes in patients undergoing periodontal maintenance therapy. Methods: An online database search was performed to identify randomized controlled trials (RCTs) published between January 1987 and March 2021. Selection, data extraction and assessment risk of individual bias were conducted by two independent reviewers. The PICO method was employed to formulate the question: "In patients undergoing periodontal maintenance therapy/supportive periodontal therapy, do air polishing systems result in better clinical, microbiological and patient related outcomes than ultrasonic instrumentation or hand instrumentation?". Primary outcomes were bleeding on probing (BoP), gingival index (GI) and/or bleeding index (BI). Secondary outcomes were probing depth (PD), clinical attachment level (CAL) plaque index (PI), microbiological counts and/or patient tolerance. The risk of bias was evaluated and the systematic review protocol was registered in PROSPERO. Results: The electronic search yielded 501 references of which 14 were included in this review. A meta-analysis was not performed due to great heterogeneity within the studies. Air polishing devices and conventional periodontal therapy presented identical results in the 14 studies analysed; however, air polishing devices presented better antimicrobial behaviour and better patient related outcomes. Conclusions: Both air polishing devices and conventional techniques demonstrated no difference in terms of clinical efficacy; however, air polishing devices seems to present improved antimicrobial results. In addition, they are also a safer, faster, and more comfortable option for the patients undergoing supportive periodontal therapy.
... It has been indicated that this combination had stronger antimicrobial and antibiofilm activity than glycine powder [26]. In another clinical study, this combination was similar to ultrasonic scaler for reducing the number of pockets > 4 mm and it has been found that it was safe and caused less pain [27]. ...
... In test group, first, periodontal pockets were treated with an air-polishing device (EMS Air-Flow® Handy Perio, Switzerland) (erythritol/chlorhexidine powder) with a subgingival nozzle for 5 s due to previous research [17,24,27,48] and also the manufacturer's instructions. The nozzle was placed into the periodontal pocket and erythritol/chlorhexidine powder was ejected to the root surface perpendicularly. ...
... It has a remarkable effect in removing subgingival plaque on root surfaces. Considerable antimicrobial effects on A. actinomycetemcomitans and P. gingivalis were reported for this powder [23,27]. This powder also has stronger antimicrobial and antibiofilm activity than glycine powder and inhibits recolonization effectively [25,26]. ...
Full-text available
Article
Objectives Evaluating the efficiency of combined air polishing and Nd:YAG laser application in addition to scaling and root planning (SRP) in treatment of periodontal pockets of stage III grade C periodontitis patients was the aim of this clinical trial. Materials and methods Twenty-four systemically healthy, stage III grade C periodontitis patients were recruited for this clinical trial. In this split-mouth study, the quadrants were randomly allocated to either SRP with combined air polishing (erythritol/chlorhexidine powder) and Nd:YAG laser (2 W, 200 mJ/pulse, 10 Hz) therapy (test group) or SRP alone (control group). A masked examiner recorded clinical parameters such as plaque index (PI), gingival index (GI), bleeding on probing (%) (BOP %), probing depth (PD), and clinical attachment level (CAL) on periodontal charts at baseline, 1 month and 3 months after treatment. Results The clinical parameters had significantly reduced 1 and 3 months after treatment compared to baseline for both study groups (p < 0.05). Considering PI, GI, and BOP (%) parameters, there were no significant differences between the study groups at any time points (p > 0.05). While PD and CAL reductions were similar in study groups for moderately deep pockets (5 to 6 mm) (p > 0.05), PD and CAL reductions were significantly greater in test group compared to control group for deep pockets (PD ≥ 7 mm) (p < 0.05). Conclusions The present clinical trial demonstrated that SRP with combined application of air polishing and Nd:YAG laser may be advantageous in sites where mechanical debridement alone cannot access, such as deep pockets in the short term. Long-term, well-designed future studies including clinical, biochemical, and microbiological analyses are needed to determine the effectiveness of this procedure. Clinical relevance SRP with combined application of air polishing and Nd:YAG laser provided more reductions in probing depth and clinical attachment level parameters in deep pockets compared to SRP alone.
... The commercially available erythritol powder has a mean particle size of 14 μm and can be used for supra and subgingival removal of biofilm and stains (Air-flow Plus, EMS, Electro Medical Systems, Nyon, Switzerland). Erythritol powder air-polishing (EPAP) as monotherapy has demonstrated comparable outcomes during supportive periodontal therapy to conventional power-driven and manual debridement (Hägi et al., 2013(Hägi et al., , 2015Müller et al., 2014). ...
... In addition to erythritol, glycine has also been shown to reduce the numbers of P. gingivalis and Aggregatibacter actinomycetemcomitans during supportive periodontal treatment (Flemmig et al., 2012;Müller et al., 2014). ...
... would be more suitable to describe the mode of action and will be used for the following discussion. Multiple studies have shown that air-flow debridement can be effective in supportive periodontal therapy (Müller et al., 2014;Sekino et al., 2020;Petersilka et al., 2021). ...
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Article
Aim: To assess the efficacy of the adjunct use of a subgingival erythritol powder air-polishing device (EPAP) in comparison to conventional subgingival instrumentation alone during initial non-surgical periodontal therapy. Materials and methods: Twenty-one patients with generalized Stages 2 and 3 grade B periodontitis were included in this single centre, single blinded, split-mouth, randomized clinical trial. Teeth on the control side were treated with conventional hand and ultrasonic instrumentation, while those on the contralateral test side was treated using EPAP as adjunct to conventional subgingival instrumentation with hand and ultrasonic instruments. Three months after initial instrumentation, persisting pockets of ≥4 mm were re-treated, in both control and test sides, again with the respective treatment approach-subgingival instrumentation alone on control, and subgingival instrumentation + EPAP on test side. Clinical parameters such as probing pocket depth (PPD), bleeding on probing, and relative attachment level were recorded at baseline and 3 and 6 months following the initial instrumentation. Subgingival plaque samples were collected at baseline, immediately post surgery, as well as at 1 week, 1 month, 3 months, and 6 months after initial instrumentation. Results: In the test group after 6 months, a significantly larger number of initially deep pockets (PPD ≥ 5.5 mm) were reduced to shallow (PPD ≤ 3.4 mm), and a larger attachment gain was observed. No statistically significant microbiological differences could be found between test and control group. Conclusions: The results of the present study indicate that the adjunct use of subgingival airflow therapy with EPAP during initial non-surgical periodontal therapy might be beneficial in initially deep pockets (PPD ≥ 5.5 mm).
... APDs has been said to be more comfortable than the conventional debridement modality [10]. The effectiveness of APDs versus conventional hand instruments and/or power-driven scalers, both on natural dentition or on dental implants has been studied widely [10][11][12][13][14][15][16][17][18][19][20][21]. ...
... The Revised Cochrane RoB-2 tool (Fig. 2) was selected to evaluate the risk of bias and to determine the internal validity of the selected studies. Studies by Hagi et al. [13] and Muller et al. [18] were considered to have some concerns of bias. While studies by Kargas et al. [14]; Kruse et al. [15]; Lupi et al. [17]; and Ziebolz et al. [21] were regarded as high risk of bias. ...
... PPD was evaluated in all SPT and implant maintenance studies. Generally, SPT studies reported statistically significant PPD reduction after repeated debridement with APDs after 6 months [13,15] or 12 months [18]. However, there was no statistically significant difference between test (APDs) and control (hand instruments and/ or power-driven instruments) groups except in one study that favoured the control treatment [14]. ...
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Background Supportive periodontal therapy (SPT) is the key for a stable periodontal health following active treatment. Likewise, implant maintenance is crucial following implant placement. This systematic review aimed to assess clinical outcomes, patients’ perception, and cost-effectiveness of repeated periodontal therapy with air polishing devices (APDs) in comparison with hand instruments and/or power-driven instruments (conventional interventions) in SPT and implant maintenance. Methods Electronic search for randomised controlled clinical trials with minimum 6 months follow-up for SPT and implant maintenance programme was conducted for data published from 01 January 2000 to 30 April 2020 using multiple databases and hand searching. Risk of bias was assessed using the Revised Cochrane Risk-of-Bias tool (RoB 2). Results A total of 823 articles were screened. 4 SPT and 2 implant maintenance studies were eligible for inclusion. For SPT, repeated APDs interventions revealed no statistically significant difference when compared to the conventional interventions (weighted mean difference [WMD] 0.11 mm, p = 0.08). Likewise, no statistical difference was noted in terms of percentage of bleeding on probing (BOP) and clinical attachment level (CAL) gain. APDs were associated with lower pain score (based on Visual Analogue Scale) and higher patient acceptance in SPT studies. For implant maintenance, APDs resulted in reduction in PPD and percentage of BOP. However, CAL gain was comparable between the two groups. In terms of patient reported outcomes, no implant maintenance studies recorded any forms of patient reported outcomes. In addition, no studies reported on economic evaluation of APDs in both SPT and implant maintenance. Conclusion Within the limitations of this systematic review and meta-analysis, repeated subgingival debridement using APDs in SPT resulted in similar clinical outcomes but better patients’ comfort when compared to the conventional interventions. For implant maintenance, there is limited evidence to show that repeated application of APDs leads to improved clinical outcomes when compared to conventional treatments.
... One of the main variables used to evaluate the severity and progress of Periodontitis; likewise, the clinical success of periodontal therapy is Bleeding on Probing (BoP), and another one is periodontal Pocket Depth (PD). In non-surgical treatment, the baseline of treatment is SRP (manual or mechanical, long enough to remove most of the biofilm-about 30sec per tooth surface is recommended), which can be supported with local or general antibiotics supplements or some the use of lasers [4,[9][10][11][12]16,[17][18][19][20][21]. Pockets 3-4mm deep can be easily treated with mechanotherapy and air-polishing; it is highly effective and safe [17], but periodontal pockets with a depth ≥5, 6mm are considered "critical" and present a risk factor for both the progression of periodontal disease, tooth loss and periimplantitis next to adjacent teeth [4,5,18]. ...
... In non-surgical treatment, the baseline of treatment is SRP (manual or mechanical, long enough to remove most of the biofilm-about 30sec per tooth surface is recommended), which can be supported with local or general antibiotics supplements or some the use of lasers [4,[9][10][11][12]16,[17][18][19][20][21]. Pockets 3-4mm deep can be easily treated with mechanotherapy and air-polishing; it is highly effective and safe [17], but periodontal pockets with a depth ≥5, 6mm are considered "critical" and present a risk factor for both the progression of periodontal disease, tooth loss and periimplantitis next to adjacent teeth [4,5,18]. These deep pockets are difficult to access for SRP in the form of curettes or mechanical units. ...
... Water-soluble powders based on glycine and erythritol have shown themselves well in treating periodontal diseases, and in maintenance therapy and hygiene procedures. (26)(27)(28) One of the most important properties of these powders is their unique abrasiveness, which allows them to effectively clean the tooth surface while causing minimal irritation to the adjacent gingiva without leading to significant loss of cementum and root dentin. This beneficial balance was achieved due to the special hardness of powder microparticles, which in the case of Air-Flow Plus and Air-Flow Perio ranges from 1.0 to 2.0 on the Mohs scale. ...
Article
The aim of this study was to determine the average amount of silicon ions on the surface of titanium implants after air abrasion with powders based on glycine and erythritol, and to measure the content of silicon ions in separated water-insoluble fractions of these powders. Methods and Results: The study investigated 2 air-abrasive powders, one based on glycine (Air-Flow Perio, EMS, Switzerland) and another on erythritol (Air-FlowPlus, EMS, Switzerland). These abrasives were tested for solubility in water and the content of Si+ in insoluble fractions of these powders. Also, the weight percent (wt %) of Si+ was measured on the surface of failed titanium implants after air abrasion with Air-Flow Perio (Group 1) and Air-FlowPlus (Group 2). Scanning electron microscopy and determining the elemental composition of obtained samples were carried out on an SEM-EVO MA 10 (Carl Zeiss) and energy dispersive X-ray spectrometer with EDS Aztec Energy Advanced X-Act (Oxford Instruments). It was found that air-abrasive mixtures based on glycine and erythritol are not completely soluble in water due to the presumed presence of silica in them. It was also found that air-abrasive cleaning of contaminated dental implants with an erythritol-based mixture contributed to a significant increase (P=0.000) in the Si+ content on their surfaces in comparison to implants treated with glycine-based powder.
... Introduction Dental prophylaxis and periodontal maintenance therapy have been proven important in achieving good oral health [1]. It is known that gingival inflammation is an outcome of an unsatisfactory supragingival plaque control [2]. ...
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The aim of this in-vitro study is to compare the prophylaxis powder Airflow ® Plus to a conventional prophylaxis paste with regards to surface abrasion and roughness on four different restorative materials. A total of 80 samples were fabricated, including 20 of each investigated material. Among those were a nanocomposite (Ceram X Spectra ™ ST, Dentsply), a glass ionomer cement (Ketac Fill ™ , 3M ™ ), a cast metal alloy (Bio Maingold SG ® , Heraeus Kulzer) and a ceramic (HeraCeram ® Saphir, Heraeus Kulzer). Of each material, all samples were equally divided into two groups. Samples in one group were treated with AirFlow ® Plus using the AirFlow ® Prophylaxis Master (EMS, Switzerland) (Group AF) and the ones in the other group with Prophy Paste (Cleanic ™ , Kerr, Austria) (Group CL) on a rubber cup. Applied force amounted to 1.5 N at 2000 rpm. Under controlled reproduceable conditions, a 10-year interval with 4 application per year, a total of 200 seconds, was simulated. Size of each sample amounted to 6 mm in diameter and 2 mm in height. Half side of each sample were treated. While comparing the treated and untreated area of each sample, surface abrasion and roughness were measured using an optical 3D system. Roughness was measured based on the arithmetic roughness average of the surface (Ra) and root mean square of the surface roughness (Rq). The statistical evaluation of the data was carried out using the non-parametric Mann-Whitney-U-test, Wilcoxon-test and the Kruskal-Wallis test for group comparisons. In conclusion, the use of the rubber cup with Prophy Paste caused a significantly higher abrasion on composite, ceramic and gold compared to the AirFlow ® Plus powder (p < 0.05). In group AF, the significant highest values for Ra were determined on GIC, followed by composite, gold and then ceramic in intragroup comparison. Ra on GIC was significantly higher in group AF (p < 0.05).
... For example, in APT, for the test group, Park et al. [11] used EPAP and SRP; Jentsch et al. [12] used subgingival instrumentation + subgingival EPAP; Mensi et al. [13] used ultrasonic instrumentation and supragingival and subgingival EPAP; and Stein et al. [14] used FMD and EPAP. In SPT, same differences were encountered: Hagi et al. [15] used EPAP, while Muller et al. [16] and Ulvik et al. [17] used subgingival EPAP. Therefore, utilizing different protocols the results represented a bias, and accurate statistical analysis could not be achieved. ...
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The purpose of the present systematic review was to analyze the effectiveness of erythritol-based air-polishing in non-surgical periodontal therapy. Materials and methods: The protocol details were registered in the PROSPERO database (CRD42021267261). This review was conducted under the PRISMA guidelines. The electronic search was performed in PubMed, Scopus, and Web of Science databases to find relevant clinical trials published until January 2022. The inclusion criteria consisted of human clinical trials which reported the use of nonsurgical periodontal treatment and erythritol air-polishing compared to non-surgical periodontal treatment alone in patients with good systemic health requiring treatment for periodontal disease. Results: 810 studies were imported into the Covidence Platform. Of these, seven clinical trials met the inclusion criteria. In active periodontal therapy, for PD (probing depth), CAL (clinical attachment level), and BOP (bleeding on probing), no statistical significance was achieved at 6 months follow-up. In supportive periodontal therapy for PD, CAL, and BOP, no statistical significance was achieved at 3 months follow-up. Conclusions: The findings suggest that erythritol air-polishing powder did not determine superior improvements of periodontal parameters compared to other non-surgical periodontal therapies. Future randomized clinical trials (RCTs) with calibrated protocols for diagnosis, therapeutic approaches, and longer follow-up are needed to draw a clear conclusion about the efficiency of erythritol air-polishing powder.
... This conventional type is highly abrasive and destructive, leaving damage and roughness on the surface of the restorations as well as on the enamel [6]. With the intention to eliminate the negative effects, glycine, calcium carbonate, reduced particle size sodium-bicarbonate, and erythrol-based prophylactic powders were introduced in the early 2000s [9,10]. During their use, the particles reach the tooth surface in a controlled radius accompanied by air and water. ...
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Air-abrasion is a popular prophylactic procedure to maintain oral hygiene. However, depending on the applied air-abrasive powder, it can damage the surface of the tooth and restorations, making it susceptible to plaque accumulation. The purpose of this study was to investigate the effect of 5s and 10s air-abrasion of calcium-carbonate on surface roughness (Ra) of enamel, nan-ofill and microhybrid resin-composites and the effect of post-polishing with two-step rubber- (RP) or one-step brush polisher (BP) to re-establish the surface smoothness. Surface topography was visualized by scanning-electron-microscopy. The quantitative measurement of the Ra was carried out with atomic-force-microscopy. Air-abrasion for 10s decreased the Ra of enamel as a result of abrasion of the natural surface texture. Post-polishing with RP after 10s air-abrasion did not change the Ra, BP however, increased Ra significantly by scratching the surface. Air-abrasion increased the Ra of resin-composites significantly irrespective of the application time. While RP provided a similarly smooth surface to the control in the case of microhybrid resin-composite, BP increased the Ra significantly. The Ra for the control group of the nanofill-resin-composite was initially high, which was further increased by air-abrasion. RP and BP re-established the initial Ra with deeper and shallower scratches after BP. Both material and treatment type showed a large effect on Ra. Keywords: air-abrasion, enamel, microhybrid, nanofill, polishing, resin-composite, surface roughness
Chapter
Periodontitis is a major public health problem, that can have local and systemic consequences ranging from tooth loss to the aggravation of other chronic diseases. The consequences of which have an impact on patient's overall general health and quality of life. Periodontal treatments include a large range of techniques and concepts from plaque control to periodontal debridement, surgery and regeneration. Regardless of the treatment proposed, it always begins with the same first essential simple step that is etiological therapy which includes oral hygiene management and the control of periodontal risk factors. The aim of this first step, presented in this chapter, consists mainly in reducing oral bacterial load and inflammation by the means of daily oral hygiene methods and sub-gingival biofilm disruption. Although understanding of the pathogenesis and molecular and cellular mechanisms involved in periodontitis has increased, treatment wise, non-surgical debridement remains the keystone of every periodontal treatment and supportive periodontal therapy. Once risk factors are monitored and plaque control mastered by the patient, root instrumentation can be performed with hand or power-driven instruments. However effective, sub-gingival biofilm disruption has some limits and can be improved with adjunctive therapies such as antiseptics, antibiotics, air polishing or other emerging devices and therapies. Unfortunately, the lack of clear clinical guidelines, concerning these adjunctive therapies, still remains, thus pointing out the necessity of more standardized clinical studies. Also, if some patients can return to a healthy periodontal state, most periodontal patients will remain at periodontal risk for life. Proper assessment of the patient's periodontal risk will help establish correct monitoring of patients successfully treated for their periodontal disease.
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Supragingivally applied glycine powder air polishing (SupraGPAP) has been shown to remove biofilms in shallow periodontal pockets. This study assesses efficacy and safety of subgingivally applied glycine powder air polishing (SubGPAP) in moderate-to-deep periodontal pockets. Patients with chronic periodontitis and intraoral Porphyromonas gingivalis (P. gingivalis) and Tannerella forsythia who completed initial therapy were randomly assigned to receive SubGPAP in periodontal pockets with probing depths of 4 to 9 mm, SupraGPAP in all other shallow periodontal sites, and at mucous membranes followed by removal of calculus using curets (full-mouth GPAP) or scaling and root planing followed by coronal polishing (SRP). Patients rinsed with 0.12% chlorhexidine gluconate after debridement, and twice daily, for 2 weeks. All 30 patients enrolled completed the baseline, day 10, and day 90 visits. SubGPAP resulted in significantly lower total viable bacterial counts in moderate-to-deep pockets when compared to SRP immediately after debridement and at day 10 (P <0.05). Total P. gingivalis counts in the oral cavity were significantly reduced after full-mouth GPAP compared to SRP at day 90 (P <0.05). Patients' comfort levels were high for both treatments. There were no adverse events related to full-mouth GPAP. The results indicate that SubGPAP is more efficacious in removing subgingival biofilm in moderate-to-deep periodontal pockets than SRP. Furthermore, full-mouth GPAP may result in a beneficial shift of the oral microbiota and appears to be well tolerated.
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Objectives: The aim of this prospective, randomized, controlled clinical study was to compare the clinical outcomes of the subgingival treatment with erythritol powder by means of an air-polishing (EPAP) device and of scaling and root planing (SRP) during supportive periodontal therapy (SPT). Method and materials: 40 patients enrolled in SPT were randomly assigned to two groups of equal size. Sites had to show signs of inflammation (bleeding on probing [BOP]-positive) and a probing pocket depth (PPD) of ≥ 4 mm, however, without presence of detectable subgingival calculus. During SPT, these sites were treated with EPAP or SRP, respectively. Full mouth and site-specific plaque indices, BOP, PPD, and clinical attachment level (CAL) were recorded at baseline (BL) and at 3 months, whereas the percentage of study sites positive for BOP (BOP+) was considered as primary outcome variable. Additionally, patient comfort using a visual analog scale (VAS) and the time needed to treat per site was evaluated. Results: At 3 months, mean BOP level measured 45.1% at test sites and 50.6% at control sites, respectively, without a statistically significant difference between the groups (P > .05). PPD and CAL slightly improved for both groups with comparable mean values at 3 months. Evaluation of patient tolerance showed statistically significantly better values among patients receiving the test treatment (mean VAS [0-10], 1.51) compared to SRP (mean VAS [0-10], 3.66; P = .0012). The treatment of test sites was set to 5 seconds per site. The treatment of control sites, on the other hand, lasted 85 seconds on average. Conclusion: The new erythritol powder applied with an air-polishing device can be considered a promising modality for repeated instrumentation of residual pockets during SPT. Clinical relevance: With regard to clinical outcomes during SPT, similar results can be expected irrespective of the two treatment approaches of hand instrumentation or subgingival application of erythritol powder with an air-polishing device in sites where only biofilm removal is required.
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The effects of sugar alcohols such as erythritol, xylitol, and sorbitol on periodontopathic biofilm are poorly understood, though they have often been reported to be non-cariogenic sweeteners. In the present study, we evaluated the efficacy of sugar alcohols for inhibiting periodontopathic biofilm formation using a heterotypic biofilm model composed of an oral inhabitant Streptococcus gordonii and a periodontal pathogen Porphyromonas gingivalis. Confocal microscopic observations showed that the most effective reagent to reduce P. gingivalis accumulation onto an S. gordonii substratum was erythritol, as compared with xylitol and sorbitol. In addition, erythritol moderately suppressed S. gordonii monotypic biofilm formation. To examine the inhibitory effects of erythritol, we analyzed the metabolomic profiles of erythritol-treated P. gingivalis and S. gordonii cells. Metabolome analyses using capillary electrophoresis time-of-flight mass spectrometry revealed that a number of nucleic intermediates and constituents of the extracellular matrix, such as nucleotide sugars, were decreased by erythritol in a dose-dependent manner. Next, comparative analyses of metabolites of erythritol- and sorbitol-treated cells were performed using both organisms to determine the erythritol-specific effects. In P. gingivalis, all detected dipeptides, including Glu-Glu, Ser-Glu, Tyr-Glu, Ala-Ala and Thr-Asp, were significantly decreased by erythritol, whereas they tended to be increased by sorbitol. Meanwhile, sorbitol promoted trehalose 6-phosphate accumulation in S. gordonii cells. These results suggest that erythritol has inhibitory effects on dual species biofilm development via several pathways, including suppression of growth resulting from DNA and RNA depletion, attenuated extracellular matrix production, and alterations of dipeptide acquisition and amino acid metabolism.
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Our objective was to compare three methods (enzyme-linked immunosorbent assay [ELISA], endpoint and quantitative polymerase chain reaction [E-PCR and Q-PCR]) for detection and quantitation of Bacteroides forsythus in 56 plaque samples from seven subjects with progressive periodontal disease. Samples collected in buffer were pelleted and resuspended in 500 μl of water. Fifty μl aliquots were removed for an ELISA performed on bacteria or plaque immobilized on 96-well plates and probed with B. forsythus specific antibody. An occurrence of 3.7±0.6·104 or more bacteria were detected by ELISA in pure culture; 26 of 54 plaque samples were positive, two samples could not be analyzed. Samples for PCR were autoclaved for 10 min prior to use. The detection level of E-PCR using primers specific for B. forsythus 16S rRNA was 200 cells and 42 out of 56 samples were positive based on ethidium bromide stained agarose gels. Q-PCR using the same primers combined with a nested fluorescent oligonucleotide probe detected 10±0.32 bacteria in pure culture; 43 of 56 plaque samples were positive. The ELISA and Q-PCR obtained identical results with 36 of the 54 samples assayed; there were one false positive and 17 false negative ELISA results using Q-PCR as standard. The positive proportions of plaque samples were almost the same for E-PCR and Q-PCR. We conclude that the PCR methods are more appropriate for a multicenter study because of greater sensitivity and convenience of sample transportation from clinics to a central laboratory.
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Abstract The aim of the present investigation was to analyse the effect of subgingival scaling and root planing in subjects who prior to treatment exercised meticulous supragingival plaque control. 300 subjects were examined at baseline and after 1 and 2 years without treatment. After the year 2 examination, 62 subjects were randomly selected for therapy. They were given detailed instruction in proper self-performed toothcleaning measures and were carefully monitored during the subsequent 2 years. Following the year-4 examination, 2 quadrants, 1 maxillary and 1 mandibular in each subject, were randomly selected for additional therapy. The teeth in the selected quadrants were exposed to subgingival scaling and root planing. The subgingival therapy was repeated until a site no longer bled on gentle probing. This basic therapy was completed within a 2-month period. All subjects were re-examined after another 12-month interval. The examinations at year 4 and 5 included assessment of plaque, gingivitis, probing pocket depth and analysis of samples obtained from the subgingival microbiota at 134 selected sites. The findings from the present study demonstrated: (i) that subgingival scaling and root planing were effective in eliminating subgingival plaque and gingivitis; (ii) that professional therapy resulted in a pronounced reduction of probing depth at sites which at year 4 had a probing depth >3 mm; (iii) that in non-scaled quadrants, the extension of self-performed plaque control resulted in a continued improvement of the periodontal conditions at sites which at year 4 were < 5 mm deep.
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Since recent studies have implicated Actinobacillus actinomycetemcomitans in the etiology of localized juvenile periodontitis, this investigation determined the effectiveness of subgingival debridement, topical Betadine Solution®, and systemic tetiacycline in suppressing subgingival A. actinomycetemcomitans and other microorganisms. A total of 20 deep periodontal pockets and 10 normal periodontal sites of 6 localized juvenile periodontitis patients was included in the study. Each patient was treated in 3 stages over a period of 22 weeks, and the result of treatment was monitored for an additional 38 weeks. The first stage of treatment included plaque control, as well as thorough scaling and root planing, composed of at least 6 h of debridement. No concomitant periodontal surgery was performed. In the second stage, Betadine saturated cotton gauze was inserted into the periodontal pockets for 10 min. Stage 3 involved systemic tetracycline therapy (1 g/day) for J4 days. The subgingival microflora was determined at frequent intervals by selective culturing of A. actinomycetemcomitans and Capnocytophaga and by direct microscopic examination. The clinical effect was assessed by measuring changes in probing periodontal attachment level, probing periodontal pocket depth, radiographic alveolar bone mass, and other relevant clinical parameters.
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The presence of paired or multiple organs (arches, quadrants, teeth) and the chronic nature of many dental diseases suggest the use of split-mouth (trials in which each subject receives ≥2 treatments, each to a separate section of the mouth) and cross-over research designs (trials in which each subject receives ≥ 2 treatments in sequence). While these designs offer potential savings in resources, their usefulness can be negated if several strict scientific and statistical assumptions are not met. The primary prerequisites for the use of split-mouth and crossover designs are that: (1) the disease to be investigated is relatively stable and uniformly distributed; (2) the effects of the treatments to be evaluated are short lived or reversible for cross-over studies, or are localized for split-mouth designs. Other important factors that influence the appropriate use of these designs include: the method of treatment sequencing and assignment, and the cross-over rules used; blinding of patient assignment, patients and observers; assessment of order effects including period, carry-over or spill-over effects; the choice of statistical analysis, the sample size utilized, and the special importance of patients lost to study or of faulty data points. The objective of this study was to review 3 journals for studies using split-mouth or cross-over designs to determine how the assumptions underlying these research designs are considered and applied in dental research. The majority of studies used adequate methods for treatment allocation and sequencing; however, many studies failed to take advantage of the research designs in the statistical analysis of data. In addition, very few studies considered the possibility of order effects or reduced bias through blinding procedures.
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Abstract Pocket depth, attachment level and bone level assessments were carried out using flexible splints to produce readily identifiable reference points and to standardize the probing spot and the direction of probe insertion. The pocket depth and attachment level measurements were carried out twice at intervals of 3 weeks, both before and 3 months after periodontal treatment. The level of alveolar bone was measured by transgingival probing (“sounding”) and again following elevation of a mucoperiosteal flap. The measurements were made with a periodontal probe to the nearest higher millimeter. Complete agreement was found between the first and second measurements of pocket depths and attachment level for approximately 60% of the examined surfaces, both before and after periodontal treatment. A deviation of 1 mm or less was found for approximately 95% of the surfaces, and the difference between the first and second measurement never exceeded 3 mm. When transgingival probing measurements were compared to the measurements of the periodontal bone level assessed after elevation of a mucoperiosteal flap, complete agreement was found for 60% of the surfaces, and a deviation of 1 mm or less was found for 90% of the surfaces. No discrepancy exceeding 3 mm was observed. The results of this study indicate that readily identifiable reference points can be produced by flexible splints in assessments of pocket depth, attachment level and bone level alterations in studies on the effect of periodontal treatment.
Article
The objective was to determine clinical and microbiological effects and perceived treatment discomfort of root debridement by subgingival air polishing compared with ultrasonic instrumentation during supportive periodontal therapy (SPT). The trial was conducted as a split-mouth designed study of 2-month duration including 20 recall patients previously treated for chronic periodontitis. Sites with probing pocket depth (PPD) of 5-8 mm and bleeding on probing (BoP+) in two quadrants were randomly assigned to subgingival debridement by (i) glycine powder/air polishing applied with a specially designed nozzle or (ii) ultrasonic instrumentation. Clinical variables were recorded at baseline, 14 and 60 days post-treatment. Primary clinical efficacy variable was PPD reduction. Microbiological analysis of subgingival samples was performed immediately before and after debridement, 2 and 14 days post-treatment. Both treatment procedures resulted in significant reductions of periodontitis-associated bacterial species immediately and 2 days after treatment, and in significant reduction in BoP, PPD and relative attachment level at 2 months. There were no statistically significant differences between the treatment procedures at any of the examinations intervals. Perceived treatment discomfort was lower for air polishing than ultrasonic debridement. This short-term study revealed no pertinent differences in clinical or microbiological outcomes between subgingival air polishing and ultrasonic debridement of moderate deep pockets in SPT patients.