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Dental Tribune Middle East & Africa Edition | 5/2016 hygiene tribune 2 Subgingival air polishing: A new method By Dr Franck Simon and Dr Jérôme Liberman,France Teaching our patients correct oral hygiene techniques is an obvious and essential part of our treatment of periodontal disease. Controlling the bacteria is essential and the aim of the etiological treatment phase of periodontitis is to remove all the elements that contribute to main- taining or developing inflammation. These include iatrogenic blockages, traumaticocclusion,calculusandsu- pra-andsubgingivalbiofilm. Increasingly less aggressive instru- mentation has been developed to remove biofilm from the root sur- face. Root planning that causes ir- reversable removal of cementum has evolved toward a concept of de- contamination of the root and the periodontal pocket. Manual curettes can be substituted by ultrasonic mi- cro-inserts. More recently, the new supra- and especially subgingival air polishing techniques, with inno- vative powders, appear to offer new prospectsin periodontaltreatment. Non-abrasivepowder The same applies for implant main- tenance. Peri-implant cleaning is very difficult to achieve. Indeed, it is difficult to find effective bio- film removal instrumentation that doesn’t cause deterioration of the implant surface. Ultrasonics as well as conventional mechanical instru- mentation has been shown to dam- age titanium (Kawashima, 2007).1 Plastic curettes are not very effective in biofilm removal and are difficult to use in proximal areas (Schmage, 2012).2 Air polishing seems to be the most suitable technique, provided that a non-abrasive powder is used for the implant surface. However, onlylimitedclinicalsuccesshasbeen achieved with early generations of air polishing devices due to limited accesstothesubgingivalarea. The “Air-Flow” (EMS) method now allows the spraying of a glycine- based powder (Air-Flow Perio) of fine grain size (25 μm) or a new extra fine powder, “Air-Flow Plus” (14 μm), containing erythritol and 0.3% chlo- rhexidine subgingivally. The latter powderisparticularlyinterestingbe- cause it offers superior effectiveness in the elimination of bacterial bio- film compared to powders of larger grainsizes(Dragoetal.,2014).3 The very small particle size has the advantage of striking the tooth sur- face (dentine or cementum) as well as the implant surface with minimal impact per particle. The effective- ness against biofilm is due to the large number of sprayed particles as well as the combined action of the erythritolandthechlorhexidine. Recently, a Japanese study has shown that this polyol inhibits bio- film formation, notably with an ac- tion on Porphyromonas gingivalis. This gives the powder, if retained, a possible effect on the treated peri- odontal pockets and a preventive action against periodontal disease (Hashinoetal.,2013).4 This powder can be used supra- gin- givallyorsubgingivallythankstothe handpiece (“Perio-Flow”) combined with the disposable tips. These pro- vide delivery of powder to the bot- tom of the periodontal pockets with a duration of action of only five sec- ondspersite(Figure1). CaseNo1 A 25-year-old patient presented with generalised aggressive periodontitis; (Figures 2a-c). Periodontal treatment was performed with ultrasonic de- bridement and povidone-iodine ir- rigation. Air polishing using powder containingglycinewasperformedin eachsession(Figure2d-f). Throughout the orthodontic phase, the patient undergoes maintenance cleaningswithsupra-gingivalairpol- ishing and subgingival treatment of themostsensitivesites(Figures2g-j). Periodontal treatment is performed with ultrasonic debridement and povidone-iodineirrigation. CaseNo2 A 50-year-old patient was referred for periodontal assessment. Bacte- rial plaque was found in the area of the crown and interdentally. Clinical examination revealed periodontal pockets of 6-8mm in the cuspid ar- eas and in the palatine area from the incisor-canine block to the maxilla. It also revealed a purulent exudate in the vestibule of 12 and 22 (Figures 3a-c). There was a II.1 class on the oc- clusal plane with retro palate bite. In accordancewithparafunction,atypi- cal swallowing was found. Swallow- ing re-education sessions were con- ductedbyaspeechtherapist. After initial periodontal preparation, three non-surgical cleaning sessions wereconductedinthemaxillaunder LA. The removal of hard subgingival deposits was carried out with ultra- sonic micro-inserts and povidone- iodine irrigation. Following this, air polishing via the use of a glycerine- based powder (“Air-Flow Plus”) was carried out supra-gingivally. All pockets deeper than 4mm were treated with the handpiece (“Perio- Flow”)andspecifictips. At four months, a decrease in pocket depth of 3-4mm and an absence of bleeding on probing was found. A maintenance phase was established with supra- and subgingival air pol- ishingeveryfourmonths.Morethan a year after initial treatment, the sit- uationisstable(Figure3dto3f). CaseNo3 Apatientpresentedwithaperiodon- talabscessinthe36-37sectorinApril 2013(Figures4a-b).Fromtheocclusal perspective,animportantclassIIwas found with only posterior contacts. Evidence of bruxism was also dis- covered and associated with atypical swallowing. Initial therapy involved the construction of a nocturnal splint as well as occlusal equilibra- The latest supra- and especially subgingival air polishing techniques, with innovative powders offer new prospects in periodontal treatment and implant maintenance Figure 1. Disposable tip (“Perio-Flow”) with three horizontal outlet openings for the air-powder mixture and a vertical outlet openingforwater. Figure 3c. Initial long cone results showing the presence of subgingival tartar and a sig- nificant osseousalveolysis. Figure 3f. Long cone x-ray results at + one year. Figure4a-b.Retroalveolarx-raysattheini- tialconsultation.Notetheadvancedbone lossdistal to47andat thelevelof36. Figure 4e-f. Situation one year after the start of periodontal and occlusal therapy. The very good response of bone lesions initially observed in 47 and 36 can be observed. Figure 4c-d. X-rays in January 2014, six months after periodontal cleaning and night mouthguard. Figure 3d-e. Absence of gingival inflam- mation and reduction of periodontal pocket one year after periodontal treat- ment. Figure 2a. 8 mm pockets on 12 and 22 with a mobility of 2 + on 12 were found at theinitialconsult in2011. Figure2b.Initialx-ray. Figure 2h. X-ray of 12 during the ODF treatment. Figure 2i. Periodontal maintenance with supra-gingival air polishing. The hand- piece is oriented with an angle of 30° to 60° at a distance of 4 mm (according to the recommendations of the EMS). Note the very fine particles of the “Plus” pow- der. Figure 2j. The remaining deep pockets (larger than 4 mm) are treated by spray- ing powder (“Plus”) and tips (“Perio- Flow”). Figure 3a-b. Initial situation: Purulent dis- charge in the vestibule of 12 and 22 and significant perio pockets in the palatine areas. Figure 2c. Periodontal abscess with puru- lent exudateon43. Figure 2d-f. One year after the start of the initial periodontal therapy, the disease hasbeenbroughtundercontrol.Atempo- raryrestraintwasputinplacetosecure12 to 13. Orthodontic treatment could then beginundergoodconditions. tionconductedatthesametime.Fol- lowing this, the patient underwent two sessions of periodontal debride- ment including the use of ultrasonic scalersandsubgingivalair-polishing (Figures4c-f). CaseNo4 Thepatientpresentedwithachronic ÿPage 4 Figure 2g. Absence of inflammation in 12 during theODF treatment.