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Dental Tribune Middle East & Africa Edition | 6/2016 hygiene tribune D4 AirPolishingDevices: BasicPrinciples The basic concept for air polishing is nothing new. In fact, it was first introduced in the dental market in 1945 for cavity preparation using aluminum particles [2]. Modern air polishing devices use pressurized air and water to deliver a controlled streamofpowderinaslurrythrough a handpiece nozzle. There are usu- ally 2 concentric openings, with the air and powder through the inner oneandwaterthroughtheouterone [3] (Figure 2). This is directed towards the tooth surface to remove surface stains, dental plaque and other soft deposits. The ability of the combination of air, water and powder to remove substances on the treated surface is dependent on several factors and we can broadly classify them under hy- dropneumatic factors, abrasive me- dia related factors and user-related factors[4]. Hydropneumaticfactors: a)Amountofwater b)Airpressure Abrasivemediarelatedfactors: a)Emittedpowdermass b)Grainsize c)Grainshape d)Grainhardness User-relatedfactor a) Distance between nozzle and treated sur- face b)Angulationofnozzle c) Instrumentation time To explain briefly, for example, the higher the air pressure, the higher the efficacy for substance removal. Larger grain size, more angulated edges and higher mohs hardness value will result in higherabrasivity. The tables below (Ta- ble 1,2,3) illustrate the mohs hardness values of various materials used for polishing, and how they compare with the hardness of tooth structures as well asthecommonrestora- tive materials. Conven- tional material used as polishing agents like pumice, silicon car- bide, emery, zirconium silicate etc all have a higher mohs hardness value than tooth struc- tures and restorative materials. Prolonged usage can result in irre- versible and iatrogenic removal of enamel, dentin and cementum. In addition, restorative materials can be abrad- ed and roughened, and this can cause them to be more plaqueretentiveinthelongrun. Sodiumbicarbonatepowder(egEMS Classic Powder) has been used in the marketsincethe1980s.Itisnon-tox- ic and water soluble, although up to 0.8% of silicium oxide or tricalcium phosphateisusuallyincorporatedto enhance hydrophobicity, an impor- tant characteristic to sustain powder flow when mixed with water. It is commonly used for removal of su- pra-gingival stains and plaque from intact enamel surface because it is safe and efficient without causing clinically significant surface alterna- tions or substance loss [5]. In fact, it has been shown that air polishing using sodium bicarbonate takes only one third the time required for supra-gingival stains and plaque re- moval compared with hand instru- mentations or rubber cups with pol- ishing paste [6]. However, sodium bicarbonate powder should not be used for sub-gingival plaque remov- al. Experimental results have dem- onstrated substantial root substance loss when it is directed towards de- nuded root surface [7]. In addition, it has also been documented to cause severe epithelial erosion when it is directed towards the soft tissues [8]. Thus, usage of sodium bicarbonate for sub-gingival plaque removal shouldalwaysbeavoided. Glycine powder (eg EMS Perio Pow- der, 3M ESPE Clinpro Prophy Pow- der)cameintothemarketduringthe mid-2000s to address the clinical limitations of using sodium bicarbo- nate powder. It allows sub-gingival plaque removal while minimizing trauma to the root surface and soft tissues. Glycine is a non-essential amino acid and an important com- ponent of most polypeptides. It is also commonly used in the food in- dustryasaflavourenhancerbecause of its light sweet taste. The mean particle size of glycine powder used for air polishing is less than 45 µm, 4 times smaller than conventional sodium bicarbonate particles, which accounts for its lower abrasive na- ture. Erythritolpowder(EMSPlusPowder) was recently launched in 2013 to in- corporate the stain removing capa- bility of sodium bicarbonate powder together with the gentle characteris- tic of glycine powder on both hard and soft tissue. It is being promoted asthepowdertobeusedbothsupra- and sub-gingivally at the same time. Erythritol is a sugar substitute (poly- ol) that is commonly used as a food additive.Itiscurrentlytheairpolish- ing powder with the smallest mean particle size of 14 µm available in the market. Although the impact per particle is extremely low due to its smallsize,thehighpowderflowden- sity allows it to effectively remove moderate stains. Figure 3 illustrates the stain removal effect of erythritol powderonaquaileggsurface. Indications The indications for air polishing can besummarizedbelow: Primaryindications: a) Biofilm removal both supra-gin- givally (Sodium bicarbonate, glycine or erythritol powder) and sub-gingi- vally(Glycineorerythritolpowder) b) Stains removal especially at mis- aligned teeth and interproximal ar- eas c) Implant maintenance (to be cov- eredinthenextissue) Extendedfieldofapplication: a) Cleaning of tooth surface before bonding of orthodontic brackets as well as around orthodontic brackets duringreviewappointments b) Cleaning prior to bleaching treat- ment c) Cleaning prior to fissure sealant application d) Cleaning prior to placement of prosthesis eg inlays, onlays, crowns, acid-etchedbridge e) Cleaning prior to fluoride applica- tion Clinicalevidence andconsensus In the modern world of evidence- based dentistry, no product can stand the test of time if its perceived clinical efficacy, benefits and safety cannot be substantiated through research data. Numerous studies have been carried out over the years to demonstrate the use of air pol- ishing technology as a modern reli- able treatment modality for biofilm Figure4 Figure5 Figure3 removal and the results have been mostlypositive. In a clinical trial conducted on pa- tients undergoing supportive peri- odontaltherapy,usingasplit-mouth design, sites with residual probing depth of 5-8mm were randomly as- signed to either ultrasonic instru- mentation or sub-gingival biofilm removal using air polishing device with a special sub-gingival nozzle (Figure 4) and glycine powder [9]. Both treatments resulted in signifi- cant reductions in orange and red microorganism complexes as well as probing depth and bleeding on probing after 2 months, and there were no significant differences be- tween the 2 treatment modalities. Perceived treatment discomfort, however, was lower for air polishing thanultrasonicinstrumentation. In a recent in-vitro study involving theuseoferythritolpowder,4differ- ent treatment modalities were com- pared in terms of biofilm removal and reformation, surface alterations, tooth substance and attachment of periodontal ligament (PDL) fibro- blasts [10]. Using an experimental pocket model, hand curettes, ul- trasonic scaling, sub-gingival air polishing using erythritol powder with or without chlorhexidine were compared as shown in Figure 5. Re- sults from this experiment demon- strated highest bacterial reduction when treated with air polishing us- ing erythritol and chlorhexidine, highest tooth substance loss when treated with hand curettes, signifi- cant roughened surface when treat- ed with curette and ultrasonic and highest PDL fibroblast attachment when treated with ultrasonic and air polishingusingerythritol. Based on the results obtained from various studies, the following con- sensus was reached during the 7th Europeriocongress[11]: a) Air-polishing devices have been shown to be efficacious in removing supra- and sub-gingival biofilm and stain b) Indications for the use of air pol- ishing devices have been expanded from supra-gingival air polishing to sub-gingivalairpolishing c) The development of low-abrasive glycine-based powders and devices with sub-gingival nozzles provide better access to sub-gingival and in- terdentalareas d) Mineralised deposits (calculus) havetoberemovedbypower-driven orhandinstruments Conclusionsandfuture directions Based on current evidence, the use of air polishing device with the ap- propriate powder may have opened a whole new horizon in preventing dentistry. With a sound track record of clinical efficacy and comfort in biofilm removal for natural teeth, its indications have also been extended to preventive care in implant main- tenance and management of peri- implantitis. With heightened aware- Table3.Mohshardnessofvariouspolishingmaterials ness and proper training among the dental professionals and Oral Health Therapistsontheuseofairpolishing devices, better dental care, especially preventive measures can be provid- edforthepublicforyearstocome. References 1.Socransky SS, Haffajee AD. Dental biofilms:difficulttherapeutictargets Periodontol.2000;2008(28):12–55. 2. Black R. Technic for nonmechani- cal preparation of cavities and prophylaxis. J Am Dent Assoc 1945: 32:955-965. 3. Petersilka G J. Subgingival air-pol- ishing in the treatment of periodon- tal biofilm infections. Periodontol- ogy2000,Vol.55,2011,124–142 4. Horowitz I. Oberfla¨ chenbehan- dlung mittels Strahlmitteln. Essen: VulkanVerlag,1982. 5. Kontturi-Narhi V, Markkanen S, Markkanen H. Effects of airpolishing on dental plaque removal and hard tissues as evaluated by scanning electron microscopy. J Periodontol 1990:61:334–338. 6. Weaks LM, Lescher NB, Barnes CM, Holroyd SV. Clinical evaluation of the Prophy-Jet as an instrument for routine removal of tooth stain and plaque. J Periodontol 1984: 55:486– 488. 7. Horning GM, Cobb CM, Killoy WJ. Effect of an air-powder abrasive sys- tem on root surfaces in periodontal surgery.J Clin Periodontol 1987: 14: 213–220. 8. Kontturi-Narhi V, Markkanen S, Markkanen H. The gingival effects of dental airpolishing as evaluated by scanning electron microscopy. J Peri- odontol1989:60:19–22. 9. Wennström JL1, Dahlén G, Ram- berg P. Subgingival debridement of periodontal pockets by air polishing in comparison with ultrasonic in- strumentation during maintenance therapy. J Clin Periodontol. 2011 Sep;38(9):820-7 10. Hägi T, Klemensberger S, Bereiter R, Nietzsche S, Cosgarea R, Flury S, Lussi A, Sculean A, Eick S. A biofilm pocket model to evaluate differ- ent non-surgical periodontal treat- ment modalities in terms of biofilm removal and reformation, surface alterations and attachment of peri- odontal ligament fibroblasts. PLoS One.2015Jun29;10(6) 11. Sculean A, Bastendorf KD, Beck- er C, Bush B, Einwag J, Lanoway C, Platzer U, Schmage P, Schoeneich B, Walter C, Wennström JL, Flemmig TF. A paradigm shift in mechanical biofilm management? Subgingival air polishing: a new way to improve mechanical biofilm management in thedentalpractice.QuintessenceInt. 2013Jul;44(7):475-7 Dr.WongLiBeng,Consultant Periodon- tist,DirectorofPreventiveDentistry, Departement ofDentistry,JurongHealth Adjunct Lecturer,DiplomainDental Hygiene&Therapy. MDS(Periodontology)(Singapore),MRD RCS(Edinburgh),BDS(Singapore),FAMS (Periodontics). ◊PageD2 Table1.Mohshardnessofvariousdentalrestorativema- terials Table2.Mohshardnessofvarious toothstructures