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»Inside This Issue2 Perio Reports6 Profile in Oral Health: How Subgingival Air Polishing will

Turn Dental Hygiene Upside Down

Polishingby Trisha E. O’Hehir, RDH, MSHygienetown Editorial Director

The subgingival root surfaces feel smooth to theexplorer and the patient appears to be doing well withoral hygiene, yet there is bleeding upon probing. Why?There’s buzz about the immune response explainingthis bleeding. The immune response explains the sec-ond stage of this disease. The first is infection triggeredby toxic waste products from subgingival bacterialbiofilm. Endotoxins and antigens pass through analtered junctional epithelium, triggering the body’simmune system. It is this bacterial infection that trig-gers the second step – the immune response. For theimmune system, the first line of defense is white bloodcells. The body sends polymorphonuclear neutrophils(PMNs) to the area to phagocytize the intruding bacte-ria. Mast cells around the blood vessels in the connec-tive tissue release histamines causing vasodilation andslowing of the blood flow so that PMNs can exit theblood vessels by squeezing between the endothelialcells. The PMNs are on a mission to attack the bacte-ria in the sulcus and to reach the sulcus they must travelthrough healthy connective tissue and epithelium. ThePMNs release cytokines that act as chemical machetesto chop through and destroy healthy cells. At last thePMNs reach the sulcus, which takes them outside thebody where they no longer function. Their traverse anddestruction of healthy tissue didn’t eliminate bacteria inthe sulcus. With a constant influx of endotoxins andantigens, the body’s immune system continues sendingPMNs to the area causing significant connective tissue,bone and epithelial damage.

The key is removal of subgingival bacterial biofilm.Hand instruments, power scaler and rubber cup polish-ing are used but these approaches need to touch eacharea of bacterial biofilm to remove it. Glycine, a new airpolishing powder that is safe for subgingival use justmight turn dental hygiene treatment upside down,resulting in faster and better removal of subgingivalbacterial biofilm. n

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hygienetownperio reports

Following periodontal therapy, subgingival microflorareturns within days, necessitating periodontal supportivetherapy (PST) visits every few months to maintain peri-odontal tissue health. Mechanical disruption of the subgin-gival microflora has long been accomplished with handinstruments. Scraping of the root surfaces removes cemen-tum, creating irreversible hard tissue damage and in somecases, recession.

Air polishing traditionally uses a sodium bicarbonatepowder that effectively removes plaque and stains fromtooth surfaces, but damages gingival tissues when directedsubgingivally. To solve this problem, a glycine power wasrecently introduced that does not cause tissue trauma whendirected subgingivally. To enhance subgingival cleaning,EMS designed a tip to direct the glycine powder subgingi-

vally with lower jet spray flow and lower pressure than isused supragingivally.

Researchers at the University of Geneva in Switzerlandcompared air polishing with glycine powder using the newsubgingival tip to hand instrumentation in 50 periodontalmaintenance patients. These subjects all had at least tworesidual pockets measuring 5mm or more in two separatequadrants. Sites for each patient were randomly assigned totest and control treatments. This seven-day study measuredsubgingival microflora and bleeding upon probing.

Air polishing time averaged 30 seconds per site comparedto curette use averaging 1.4 minutes per site. Bleeding uponprobing was reduced for both groups, with greater reductionin the control group. No differences were observed for sub-gingival microflora between test and control groups. No tis-

sue trauma was noted with air polishing.Patients preferred air polishing over curettes.

Clinical Implications: The new subgingi-val air polishing tip provides an alterna-tive to hand instruments for SPT. n

Moëne, R., Décaillet, F., Andersen, E., Mombelli, A.: Subgingival Plaque

Removal Using a New Air-Polishing Device. J Perio 81: 79-88, 2010.

Air Polishing to Replace Subgingival Instrumentation

Air polishing in the past used a bicarbonate of soda pow-der that was effective for plaque and stain removal, but dam-aging for the tissues. Today, glycine powder is available for airpolishing that can be used with a new tip to polish subgingi-vally, reaching into both shallow and deep pockets.

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

Subjects were all found positive for intra-oral levels of P.gingivalis and T. forsythia. Probing depths ranged from 4mm

to 9mm. Patients were instructed to rinse twice daily with0.12 chlorhexidine mouthrinse for two weeks followingtreatment. Microbial and clinical indices were repeated at day10 and day 90.

At each time point, the patients receiving the subgingivalGPAP had lower total viable bacterial counts in the moder-ate to deep pockets compared to those receiving instrumen-tation with curettes and rubber cup polishing. Patients foundboth treatment approaches comfortable. Air polishing withglycine powder in subgingival pockets is more effective thanusing curettes to shift the oral flora from one conducive toinfection to one more conducive to periodontal health.

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

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

Perio Reports Vol. 26, No. 1Perio Reports provides easy-to-read research summaries on topics of specificinterest to clinicians. Perio Reports research summaries will be included in eachissue to keep you on the cutting edge of dental hygiene science.

New Tip for Air Polishing Reaches Subgingivally

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Air Polishing Treats Peri-implantitis

Peri-implant mucositis is inflammation limited tothe mucosa, while peri-implantitis is characterized bychanges in bone levels plus bleeding. The three pri-mary risk factors for peri-implantitis are poor oralhygiene, smoking and a history of periodontal disease.

Non-surgical treatment of peri-implant mucositis,including mechanical instrumentation, ultrasonics,and delivery of chemicals, is usually successful inreversing the infection. Not so in cases of peri-

implantitis which has unpredictableoutcomes limited to six-12 months.

The use of air polishing has notbeen an option with the traditionalsodium bicarbonate powder because itdamages implant surfaces. With theintroduction of amino acid glycinepowder, air polishing can now be usedon implants.

Researchers at Heinrich HeineUniversity in Düsselfdorf, Germany,

compared air polishing using glycine powder and thenew subgingival Perio-Flow tip from EMS to the useof carbon curettes and subgingival delivery ofchlorhexidine.

One month prior to baseline, the 30 patients withearly to moderate peri-implantitis received a prophy-laxis and oral hygiene instructions. This protocol wasrepeated at baseline and every two weeks for threemonths and then monthly for the next three months.

Both treatments resulted in reduced probingdepths of half a millimeter. Bleeding was reducedmore in the air polishing group, from 95 percent to50 percent compared a reduction from 95 percent to84 percent in the curette and chlorhexidine group.

Clinical Implications: Air polishing with glycinepowder using the new subgingival tip providesanother option for treating peri-implantitis. n

Sahm, N., Becker, J., Santel, T., Schwarz, F.: Non-Surgical Treatment of Perio-Implantitis

Using an Air-Abrasive Device or Mechanical Debridement and Local Application of

Chlorhexidine: A Prospective, Randomized, Controlled Clinical Study. J Clin Perio 38: 872-

878, 2011.

Subgingival Use of Glycine Powder Safe for Tissue

Glycine particles are about four times smaller thansodium bicarbonate particles and because of this and theparticle shape, they are less abrasive to the tissue. Air polish-ing has been limited to supragingival surfaces, due to the tis-sue damage caused by the sodiumbicarbonate particles. Glycine par-ticles allow air-polishing to com-fortably reach subgingival surfaces.

Researchers at WestfalianWilhelm University in Münster,Germany, compared air-polishingwith sodium bicarbonate; air pol-ishing with glycine powder; instru-mentation with a Gracey 7/8; anda control group receiving no treat-ment. Treatments were performed on facial and lingual sur-faces of a designated quadrant (one treatment per tooth),followed by a biopsy along the gingival margin on the dayof treatment and another biopsy from another site 14 dayslater, all part of scheduled surgeries. Aluminum foil wasused to isolate teeth during treatment.

Microscopic examination of the tissue specimensrevealed no alterations to the gingival sulcular tissue for con-trols or Clinpro treated sites. Sites treated with sodiumbicarbonate and the curette did show signs of change. Scoresfrom 1-4, least to most damage, were 1 for both control andClinpro treated sites, 3 for sodium bicarbonate treated sitesand 4 for curette treated sites.

Clinical Implications: Air-polishing with Clinproglycine powder results in less tissue alteration than handinstruments or sodium bicarbonate air-polishing pow-der. Air polishing with Clinpro glycine powder is now achoice for subgingival biofilm removal without causingtissue damage. n

Petersilka, G., Faggion, C., Stratmann, U., Gerss, J., Ehmke, B., Haeberlein, I., Flemmig, T.: Effect of

Glycine Powder Air-Polishing on the Gingiva. J Clin Perio 35: 324-332, 2008.

continued on page 4




Peri-implantitis is difficult to treat. Fortunately,the success rate of implant placement is around 95percent. As more and more implants are placed, the

incidence of peri-implantitis mightincrease, posing major treatmentchallenges. Implant surfaces andthreads pose significant challengesto mechanical disruption to bacte-rial biofilm. In a recent consensusreport, it was concluded that tradi-tional non-surgical therapy forperi-implantitis was not effective.Slightly better results are possiblewith the Er:YAG laser.

Researchers at Kristianstad University inKristianstad, Sweden, compared the new EMSglycine air polishing powder with the EMS new dis-posable subgingival tip to the KaVo Laser 3 Perio laserfor treating peri-implantitis with 21 subjects in eachgroup over six months.

All test subjects received a Philips SonicareFlexCare power toothbrush, detailed oral hygieneinstructions and new brush heads every three months.

Both groups showed significant healing with 25percent of subjects in the laser group with averageprobing depth reductions of 1mm and 38 percent ofthose in the air polishing group showing a 1mm aver-age probing depth reduction. Laser treatment resultedin improved health at 44 percent of implant sites andair polishing at 47 percent of sites.

Although both the laser and the air polishing didhelp some sites with severe peri-implantitis, neithertherapy provided predictable treatment for severeperi-implantitis.

Air Polishing and Laser Both Effective for Treating Peri-implantitis

Subgingival Debridement Effective with Air Polisher

Periodontal therapy patients are seen frequently for sup-portive periodontal maintenance visits to control subgingivalmicroflora. This is usually done with curettes or powerscalers. A new subgingival approach uses glycine powder inan air polisher.

Researchers at the University of Gothenburg, Sweden,compared subgingival air polishing with glycine powder toultrasonic scaling. Perio maintenance patients with twoprobing sites measuring 5-8mm in different quadrants wereincluded in this two-month study. The control group wastreated subgingivally with the EMS Piezon Master piezoelec-tric scaler set at 75 percent power with water coolant. Thetest group was treated with a new subgingival tip on theEMS Air-Flow air polisher with glycine powder.

Subgingival bacterial samples were collected before treat-ment, right after treatment, two days later and at 14 days.

Clinical indices were taken before treatment, 14 days and at60 days. A total of 20 patients were treated with air polish-ing at a test site in one quadrant and ultrasonic scaling at asecond site in another quadrant.

Both treatments resulted in significant reductions in sub-gingival bacteria immediately after treatment and two dayslater. By day 14, both groups returned to baseline levels ofsubgingival bacteria.

Clinical reductions in probing depths and bleedingscores were significant for both the treatment and controlsites. Patients were also asked to rate comfort with each pro-cedure. Air polishing was found more comfortable thanultrasonic scaling.

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

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

Clinical Implications: For severe peri-implantitisboth air polishing with glycine power using thedisposable subgingival plastic tip and laser treat-ment using an Er:YAG might improve somelesions, but not with any degree of predictability. n

Renvert, S., Lindahl, C., Jansaker, A., Persson, G.: Treatment of Perio-Implantitis Using an

Er:YAG Laser or an Air-Abrasive Device: A Randomized Clinical Trial. J Clin Perio 38: 65-

73, 2011.

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hygienetownprofile in oral health

How SubgingivalAir Polishing Will

Turn

Air polishing was first introduced to the North Americandental profession in the 1970s as an effective means of quicklyand easily removing extrinsic stains and soft debris from toothsurfaces. Despite scientific evidence showing it to be an effectiveand efficient means of plaque and stain removal, being at leastthree times faster than rubber cup polishing,it hasn’t been widely accepted. This is likelydue to the fact that dental hygiene programsdon’t routinely incorporate air polishing intothe curriculum, preferring instead to focuson rubber cup polishing. Opposition oftenpoints to the mess of aerosolized sodiumbicarbonate coating everything in the opera-tory, people included.

Air polishing research has taken an inter-esting turn, focusing more recently on sub-gingival biofilm removal to control disease,rather than stain removal for aesthetic rea-sons. To do this, a new powder was neededthat was significantly less abrasive thansodium bicarbonate yet effective for biofilm removal. Glycinepowder is 80 percent less abrasive, safe on oral tissues and rootsurfaces, effective for biofilm removal, and comfortable for thepatient. One of the leaders in this research endeavor is Dr.Thomas Flemmig, currently a professor at the University ofWashington in Seattle. His work focuses on the subgingivaleffects of glycine air polishing as well as the economic and clin-ical practice implications. I recently had the pleasure of speakingwith Dr. Flemmig on this subject.

What peaked your interest in air polishing?Flemmig: Several years ago I read a research abstract about

how air polishing with sodium bicarbonate reduced subgingivalbiofilms in periodontal pockets. At the time, conventional wis-dom suggested that sodium bicarbonate was so abrasive that it

caused root surface abrasion and trauma-tized gingival tissues. What we needed was apowder that was less abrasive than sodiumbicarbonate and less harmful to the tissue yetstill removed biofilm. With that as our goal,we looked into other powders, testing manytypes and finding glycine powder to be 80percent less abrasive than sodium bicarbon-ate and safe for the gingival tissues. Wetested the glycine powder in an air polishingunit with a standard, supragingival nozzleand found it effectively removed both supraand subgingival biofilm and was safe on rootsurfaces. With a standard air polishing noz-zle the powder opened the sulcus to allow

the glycine powder to access the subgingival area to remove sub-gingival biofilm (Fig. 1).

How did you test the glycine powder clinically?Flemmig: In a series of clinical trials, we compared hand

instrumentation for subgingival biofilm removal and air polish-ing with glycine powder. In the first two clinical trials we founda significantly greater reduction in viable counts of subgingivalbacteria following glycine air polishing with a standard nozzle

UP

side DOWN

An interview with Dr. Thomas Flemmig, professor in the Department of Periodontics at the University of Washington. by Trisha E. O’Hehir, RDH, MS

Dent

al H

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Fig. 1

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continued on page 8

compared to hand instrumentation. No adverse effects wereexperienced by the patients; in fact, the patients preferred the airpolishing to hand instrumentation. They found it to be moregentle and comfortable.

How much time was spent air polishing each tooth?Flemmig: Without any previous studies to guide the time

factor, we limited the time to five seconds per surface, whichequates to approximately nine minutes for a full dentition.Recent data in our laboratory using a biofilm model indicatedthat the time may be cut in half, but that still needs to be con-firmed in a clinical trial.

Many hygienists today use an ultrasonic powerscaler to deplaque sugbingival areas. How does thiscompare to air polishing?

Flemmig: Air polishing is more effectiveas the spray reaches much further than thelocalized effect of an ultrasonic scaler. To effec-tively remove subgingival biofilm, the ultra-sonic tip must be moved in an overlappingfashion to touch the entire surface while theair polisher spray easily reaches a broader area.

What about reaching into a deep peri-odontal pocket rather than a healthysulcus?

Flemmig: With a standard nozzle, air pol-ishing with glycine powder has been shown tobe significantly more efficacious in removingsubgingival biofilm. EMS developed a subgingival nozzle toreach deeper sites. The subgingival nozzle will reach pocketdepths up to 9mm (Fig. 2). In studies comparing the subgingi-val nozzle to hand instruments, air polishing is consistentlymore effective for biofilm removal.

How do you see air polishing with glycine powderbeing used clinically today?

Flemmig: In a healthy mouth or one with mild gingivitiswith probing depths of 4mm, the standard nozzle with glycinepowder will be effective. In sites with deeper probing depths of5mm or more, the subgingival nozzle with glycine powder willbe the instrument of choice. Air polishing is done first to removebiofilm, the primary cause of both caries and periodontal dis-ease. When this is complete, calculus is easier to see and can beremoved with a power scaler or hand instruments.

Clinicians feel strongly that air polishing is too abra-sive and harmful to gingival tissues. Is the glycinepowder both effective and safe?

Flemmig: Yes, the glycine powder is effective for biofilmremoval and safe for gingival tissues and mucous membranes.

The low abrasive nature of glycine makes it safe for root surfacesand oral mucous membranes. Rather than the stinging feeling ofair polishing with sodium bicarbonate, air polishing withglycine powder feels as gentle as the water syringe spray on thetissues. In fact, in a recently published clinical trial we havedirected the air polishing toward all the mucous membrane tis-sues in the mouth with no damage or discomfort for patients.

Since much of the initial air polishing research tookplace in Europe and glycine powder is easily availablethere, has this approach been widely accepted?

Flemmig: Yes, reports suggest that supra- and subgingivalair polishing with glycine powder is widely accepted in Europe.

Do you anticipate North American hygienists willembrace this approach to treatmentas glycine powder becomes morewidely available here?

Flemmig: We are creatures of habit andthe longer we are in practice, the harder it is tochange. The idea of replacing hand instru-mentation and prophy cup polishing with afew minutes of air polishing with glycine pow-der feels to clinicians as though their patientcare is put into question. Change comesslowly when it turns a long-held approachupside down. Traditionally the approach todeplaquing subgingival areas has been toinsert instruments to the base of the pocketand move the biofilm in an apical to coronal

direction. With subgingival air polishing with glycine powder,the approach is coronal to apical.

Were you immediately convinced that air polishingeffectively removed subgingival biofilm?

Flemmig: I was skeptical at first, as I expect most clinicianswould be. After subgingival air polishing with glycine powder Iwent back and checked with the probe and curettes to see if infact it was effective. My colleagues did the same. We weren’tready to trust that this easier, faster approach was as good as ourold ways. When we were convinced it was effective and hadsound evidence from randomized controlled clinical trials, weembraced the change in patient care as it led to better treatmentin less time with more comfortable patients. It takes time toovercome skepticism of this new approach.

There is some worry that this technology will causeemphysema by forcing air and powder into the tis-sues. What are the statistics on this?

Flemmig: Based on the published cases with air emphysemafollowing glycine powder air polishing, the estimated incidenceof air emphysema is 1 in 666,666. That means that a hygienist

Fig. 2




would have to perform glycine powder air polishing on all of herpatients for 350 years to experience one emphysema case.Furthermore, all of the three reported emphysema cases follow-ing glycine powder air polishing resolved without treatment. Ithas not been a serious issue.

Is there still a use for sodium bicarbonate air polish-ing powder?

Flemmig: Yes, for supragingival areas with heavy stain,sodium bicarbonate powder, which is much more abrasive thanglycine powder, is the powder of choice. For deplaquing, glycineis the powder of choice because it is effective, safe and comfort-able for the patient.

I realize your research has been with glycine powderfor subgingival air polishing. Are there other powderson the market for subgingival deplaquing?

Flemmig: There are several otherpowders on the market for supragingivalair polishing: sodium bicarbonate, cal-cium carbonate, aluminum trihydrox-ide and calcium sodium phosphosilicate.When selecting an air polishing powderfor subgingival deplaquing, it must be safeon root surfaces and gingivae. Many ofthese other powders are safe on enamel,but too abrasive for root surfaces and gin-givae. Check abrasiveness before usingpowders other than glycine subgingivally.There are more than 30 publicationsdemonstrating that glycine powder is safe on a variety of restora-tive materials, orthodontic brackets and root surfaces, and isapproximately five times less abrasive than sodium bicarbonate.

Besides being safe on root surfaces, you showedthat glycine powder is safe on all the oral tissues.What prompted you to go beyond tooth surfaces forbiofilm removal?

Flemmig: The concept of full-mouth disinfection ledus to consider using the air polisher for all oral tissues:tongue, buccal mucosae and palate. Bacteria are not lim-ited to supra- and subgingival tooth surfaces. The oralcavity is a reservoir for recolonization. These tissues har-bor microflora contributing to new biofilm formation onthe teeth so it makes sense to include them in thedeplaquing approach and not limiting the air polishing tojust the teeth. Air polishing with glycine powder is fasterand much easier than profuse irrigation of the entiremouth and oral tissues with chlorhexidine. Our goal withthese studies was a Proof of Principle that a low abrasiveair polishing approach to full-mouth disinfection was asafe and effective option (Fig. 3). We were able to show ina clinical trial that in patients with periodontitis, full-

mouth glycine air polishing significantly reduced the oral loadof Porphyromonas gingivalis compared to conventional treatmentusing hand instruments. Our future research will be conductedincluding this approach.

How do you see subgingival air polishing with glycinepowder impacting dental hygiene care in the future?

Flemmig: This new technology will make work easier andfaster for the RDH. It will reduce the amount of time and effortneeded to effectively deplaque the mouth. Prophylaxes accountsfor approximately one quarter of the national expenditures fordental services. Here is an example of how adding this new tech-nology that takes less time will impact the business of dentalhygiene and the practice. For this I will use nationwide surveys bythe ADA to compare an average restorative dental practice withthree operatories and no hygienist to the same practice plus anadditional operatory for a dental hygienist seeing eight patients a

day or 1,900 prophylaxis or periodontalmaintenance visits per year. The take-home income of the dentist employing anRDH is 40 percent higher than the den-tist working alone. If the RDH nowincorporates subgingival air polishingwith glycine powder and saves 12 minutesper appointment, allowing him/her to see10 patients per day, the costs don’t go upbut the profit doubles, providing a finan-cial benefit to both the hygienist and thedentist. On the business side, this newapproach to patient care provides a bene-

fit for the patient of greater health and comfort, an easier appoint-ment for the hygienist and increased income for both the dentistand the hygienist. Embracing new technology provides benefitsfor all involved: the patient, the RDH and the dentist.

Thank you Dr. Flemmig for your focus on the future,your exciting research findings and your dedicationto improving patient oral health. n

To comment on this article, visit Dentaltown.com/magazine.aspx.

continued from page 7

Fig. 3

Author’s Bio

Dr. Thomas Flemmig is a Professor in the Department of Periodontics at theUniversity of Washington. He earned his dental degree at the University ofFreiburg in Germany and training in Oral Surgery at the University ofHamburg in Germany and in Periodontics at UCLA. His PhD is from theUniversity of Würzburg, and MBA and certificate in Health SectorManagement from Duke University. He also maintains a periodontal practicein Seattle, Washington. He has served on the editorial board of several sci-entific journals and published more than 150 scientific papers.


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