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8 Dental Tribune Middle East & Africa Edition | July - August 2013MEDIA CME Centre for Advanced Professional Practices (CAPP) is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. CAPP designates this activity for 2 continuing education credits. Air Polishing mCME articles in Dental Tribune have been approved by HAAD as having educational content for CME credit hours. This article has been approved for 2 CME credit hours. Other research has shown that air- powder polishing can render ce- mentum surfaces more uniformly smooth, compared with traditional polishing or the use of curets.5 The air-powder polisher can remove subgingival bacteria through the Ven- turi effect. This occurs when the air/ water/powder spray is directed at a 90-degree angle to the interproximal spaces so that a vacuum is created that extracts tissue fluids, including subgingival bacteria from the subgin- gival space. The air-powder polisher has been used for debridement of Class V abraded areas before place- ment of glass ionomer cements. When compared with cleaning the area with a rubber-cup polisher, the air-powder polished tooth had less microleakage around the enamel- cement interface. Similar results were noted when using the air-powder pol- isher before sealant application. It was reported to be superior to rubber- cup polishing in preparing enamel for etching and sealants. Deeper resin penetration into enamel and increased sealant bond strength was also reported in comparison with traditional polishing with pumice and water. In addition, clinicians pre- fer using the air-powder polisher on orthodontic patients, and research has shown that it does not affect the bracket adhesive system. Types of powder The most common type of abrasive particle used with the air-powder pol- isher is sodium bicarbonate, which is treated to be free-flowing with cal- cium phosphate and silica. Sodium bicarbonate is a food grade material, and each particle is approximately 74 mcm in size. The Mohs’ scale hard- ness number for sodium bicarbonate is 2.5. In comparison, Pumice has a Mohs’ hardness number of 6. Sodium bicarbonate is safe for use on enamel, amalgam, gold, porcelain, implants (titanium) and orthodontic materials. However, its use should be avoided on all types of composites, glass ionomers and luting agents (ce- ments).13 When used on implants, air polishing with sodium bicarbo- nate, should not be directed subgin- givally, thus it is the method of choice for decontamination of implants. A sodium-free powder for air-pow- der polishing is available (Fig. 2) (Jet Fresh from DENTSPLY Professional, York, Pa.). Developed for patients who are sodium intolerant, this pow- der is made of aluminum trihydrox- ide, which has a Mohs’ hardness number of 2.5 to 3.5 and a particle range in mesh size from 80 mcm to 325 mcm. Aluminum trihydroxide powder is safe for enamel; however, it is too abrasive for use on other tooth struc- tures, and its use should be avoided on all dental materials. While using aluminum trihydroxide does not cause surface disruption to porcelain, its use can remove the luting agent, causing a compromise in the margin integrity that can quickly lead to de- cay.4 Patient assessment Because of the various indications and contraindications associated with use of the air-powder polisher, patient assessment and treatment planning are critical prior to use. The patient assessment process should include a thorough health history evaluation to identify and possibly rule out pa- tients who have hypertension and/or are on a physician-directed, sodium- restricted diet. However, the amount of sodium bicarbonate ingested dur- ing air polishing is not sufficient to cause alkalosis or an increase in blood pressure or sodium levels in the blood. Other patients who are contraindicat- ed include those who have end-stage renal disease, are immunocompro- mised, have a communicable infec- tion or have Addison’s or Cushing’s disease. In addition, patients with respiratory problems, such as chronic obstructive pulmonary disease or any condition that interferes with breath- ing or swallowing, should be treated with an alternative approach. Such patients could be compromised by the aerosols created by airpowder polish- ing, and they are also vulnerable to the development of pneumonia.4 Contraindications for using the air- powder polisher also include patients taking potassium, anti-diuretics or steroid therapy — all of which can disrupt the acid/base balance. Con- traindications for use of the air-pow- der polisher also extend to the hard and soft tissues; therefore, the dental history assessment is paramount. Hard tissue that presents with any composite resins, sealants or glass ionomers should be avoided because of susceptibility of those materials to surface roughness or pitting. Porcelain margins and margins of all restorations can be altered by ex- tensive exposure of the airpowder polisher, and this can lead to loss of marginal integrity, surface rough- ness, staining and pitting.1 Exposed cementum or dentin, because they are not as mineralized as enamel, are more susceptible to abrasion. In addi- tion, patients who present with active periodontal conditions with soft and spongy tissue are contraindicated because the air-powder polisher can cause air embolism or small blood clots. Lastly, pediatric patients with deciduous teeth or newly erupted permanent teeth are contraindicated. Patient preparation It is with utmost importance that be- fore using the air-powder polisher, clinicians must prepare themselves and their patients. Patient prepara- tion would include a thorough ex- planation of the procedure, review of medical history and taking of blood pressure. The clinician should place a disposable or plastic drape over the patient’s clothing, provide the patient with safety glasses and confirm re- moval of contact lenses. The clinician should make sure the patient is in a more upright position. A non-petro- leum lubricant should be applied to the patient’s lips to protect them from the abrasive spray, which can dry the lips. Research has confirmed that when the clinician performs air-powder polishing, aerosols of microorgan- isms can contaminate surfaces several feet from the operative site. Instruct- ing the patient to use an antimicrobial preprocedural rinse, such as 0.12 per- cent chlorhexidine, can reduce risk of bacterial contamination from these aerosols. Air-powder polishing unit and opera- tor preparation The clinician should be properly pro- tected when performing air-powder polishing. Standard precautions in- clude wearing fluid-resistant protec- tive apparel, using a face shield or protective safety glasses with side shield and wearing gloves and a well-fitting mask with high filtration capabilities. In addition, because of the risk of contamination from the aerosols, the use of a high-speed evacuation system is recommended. Clinicians should always follow the manufacturer’s user directions that are specific to the air-polishing unit being used. Unit preparation includes obtaining all necessary equipment, such as the air-powder polishing unit and abra- sive powder, according to patient se- lection. The unit and handpiece nozzle is pre- pared according to manufacturer’s directions, and the powder compart- ment is filled with the appropriate abrasive recommended for the ma- chine being used (Fig. 3). The unit should be turned on for at least 15 seconds to eliminate residual powder or moisture in the lines. Also, water lines need to be flushed before use, according to the recommendations of the Centers for Disease Control and Prevention. When the unit’s hamber is being filled with abrasive powder, the unit must be turned off. It needs to be filled with powder to the top of the center tube. The clinician can place a finger over the tube in the middle of the chamber to prevent powder from blocking the air line. Next, the clinician needs to use the control on top of the powder chamber cap to adjust the powder flow accord- ing to the patient’s needs. For treating patients with heavy stains, it is recom- mended that the control knob should be turned to “H” for heavy powder flow, which is approximately the 12 o’clock position. For patients with light staining, the control knob will be set to “L” for reduced powder flow, which is approximately the 6 o’clock position (Fig. 4). An aerosol-reduction device that connects to the saliva-ejector or high- speed-evacuation system used with the air-polisher handpiece has been shown to be effective in controlling and reducing airpowder aerosols, thus decreasing the potential for dis- ease transmission. The aerosol-reduc- tion device reduces or eliminates the visible aerosols normally produced during air-powder polishing. Addi- tionally, the aerosol-reduction device (Fig. 5) eliminates the need for exact angulations with cup/nozzle, use of gauze, hand cupping and patient po- sitioning. Another advantage to the aerosol-re- duction device is that it minimizes the possibility of tooth abrasion because the cup is placed on the tooth — as in traditional polishing techniques. When using the aerosol-reduction device, the clinician must follow the manufacturer’s instructions for as- sembling and disassembling. The aer- osol-reduction device contains two By Salim Rayman, RDH, MPA, and Elvir Dincer, DDS ________________________ T he concept of air polishing is based on a technology developed by Dr. Robert Black in 1945. Black in- vented a device called the Air Dent, which used compressed air, water and a highly abrasive powder to eliminate pain from cavity preparation, making anesthesia unnecessary. While the Air Dent presented many problems, the technology represented the first step in air-polishing devices. Air polishing was first marketed in 1976, and from that time forward it became widely available. Air-powder polishing is accomplished by the pro- pulsion of abrasive particles through a mixture of compressed air and wa- ter through a handpiece nozzle. The handpiece nozzle through which the slurry is propelled is activated with a foot control. The air pressure produced, measured in pounds per square inch (psi), depends on the type of air-powder polisher being used. Air-powder polishers are manufac- tured as separate handpiece units that attach directly to the air/water con- nector on the dental unit as a separate device or in combination with an ul- trasonic scaler. Indications for use Coronal polishing is a cosmetic pro- cedure designed to remove extrinsic stains from the enamel surfaces of the teeth. This can be accomplished by abrasion and erosion of the extrinsic stain. The most common technique for stain removal is rubber cup pol- ishing. This technique uses an abra- sive polishing agent and a slowly re- volving polishing cup to abrade stain from the tooth surface. Air-powder polishing is accomplished by erosion of extrinsic stains by suspended abra- sive particles within a moving fluid. Kinetic energy propels the air-pow- der polishing slurry particles against the tooth surface, thus removing stain (Figs. 1a, b). The air-powder polisher is shown to be efficient, safe and effective in re- moving extrinsic stain and plaque bi- ofilm from tooth surfaces. It is equally effective in decreasing root surface roughness after instrumentation. It is also reported to remove plaque biofilm and staining as effectively as a rubber cup and does so in less time.2 Patients often exhibit extensive stain- ing on root surfaces, specifically on areas of recession and at the cemen- toenamel junction. Removing these stains with a curet has been shown to reduce root structure. However, when stain removal is for esthetic reasons, the air-powder polisher is preferable to the curet. The air-powder polisher removes less root structure than the curet in simulated three-month re- calls for three years. The stain was also removed more than three times faster with the air-powder polisher.5 Using the air-powder polisher also creates less discomfort for patients who have dentinal hypersensitivity because the sodium bicarbonate par- ticles embed in the dentinal tubules, lessening dentinal hypersensitivity discomfort almost immediately. In vitro, research has shown that there is little or no disruption of enamel, ce- mentum and dentin surfaces withair- powder polishing. Fig. 1a,b Removal of extrinsic stains. (Photo/Provided by Yosi Behroozan, DDS, DENTSPLY Professional) Fig. 2 Jet Fresh prophy powder. (Photos/Provided DENTSPLY Professional unless otherwise noted) Fig. 3 Fill the powder chamber with an abrasive recommended by the manufacturer. Fig. 4 Powder control knob.