r air polishing: an update e v i

INTERNATIONAL JOURNAL OF MAXILLOFACIAL RESEARCH VOLUME 1 ISSUE 1 2015

22

Air Polishing: An Update

Mohan R1 , Chowdhary Z2 , Sharma V3 ,Rai R4

Time has seen the emergence of more efficient and effective devices like jet abrasives.

Oral health care professionals have a responsibility to patients to engage in life-long learning

in order to provide the most contemporary clinical care. This review of air polishing should

enable clinicians to make sound decisions regarding the most appropriate treatment for each

patient.

INTRODUCTION

The aim of periodontal therapy is

to achieve a tooth surface conducive to the

maintenance of a healthy dento-gingival

complex1, which requires the removal of

external deposits as well as the plaque

biofilm from the tooth surface to eliminate

bacteria and bacterial by-products from the

gingival area. [Kaldahl et al. 1996,

Westfelt 1996].2 There is a general

consensus that the smoother the tooth

surface is the better the clinical results will

be.3,4,5,6 A smooth tooth surface may be

advantageous near the gingival margin,

since this type of surface is less likely to

accumulate plaque than a rough surface,

and plaque removal is more effective with

a smooth rather than a rough surface1

which could be achieved by tooth

polishing.

Routine tooth polishing continues

to be an integral part of clinical practice, as

it assists in the removal of stains and

plaque biofilm.7 For over half a century,

the most common method of tooth

polishing is using rubber cup and pumice8,

which has been nowadays replaced by air

powder polishing devices.9

Air-polishing device [APD] was

introduced [in early 1980s] for clinical use,

aimed at rapidly and efficiently removing

stains and plaque from the supragingival

tooth surface with less fatigue and with the

advantage of reaching areas of difficult

accessibility [Willmann et al. 1980,

Atkinson et al. 1984,Berkstein et al. 1987,

Kozlovsky et al.1989].2 Botti et al

suggested the benefits of air polishing on

the overall health of the subgingival

R

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environment through its use in shallow

pockets for removal of plaque biofilm and

even reported that air polishing cleaned

pits and fissures of teeth better and was

easier to use than synthetic brushes.10

A variety of air polishing models

has been introduced to the market in the

last 10 years. In addition to the traditional

self–contained units, handpiece units now

afford clinicians with a convenient,

alternative delivery model.

DEFINITION

Tooth Polishing:

The American Academy of

Periodontology defines it as [in relation to

oral prophylaxis] “the removal of plaque,

calculus and stains from the exposed and

unexposed surfaces of the teeth by scaling

and polishing as a preventive measure for

the control of local irritational factors.”11

Selective polishing:

The process of cleansing and

polishing tooth surfaces to remove

extrinsic stains that may remain after

scaling using a latex-free cup and or bristle

brush on a prophylaxis angle attached to a

low- speed handpiece or with an air-

powder polishing device, and an

appropriately selected abrasive agent;

however, cleansing and polishing are

omitted on surfaces already stain free.12

Air polishing:

The process of cleansing and

polishing the dentition and dental

restorations using a device that mixes air

and water pressure with an abrasive agent

such as sodium bicarbonate powder,

aluminum trihydroxide, calcium sodium

phosphosilicate powder, or calcium

carbonate powder to remove extrinsic stain

remaining after scaling.12

MECHANICS

The air powder polisher handpiece

attaches either directly to the air/water

connector on the dental unit or as a

separate unit or in combination with

ultrasonic scalers. By activating the foot

control, the handpiece nozzle propels the

slurry on the tooth surface.13 It operates by

delivering fine slurry of pressurized air,

water and abrasive powder from a special

reservoir against the tooth surface [Weaks

et al. 1984]. The abrasive powder contains

finely powdered sodium bicarbonate to

which tricalcium phosphate is added [up to

0.8% by weight] to improve flow

characteristics. Earlier, air dent machine

which uses alumina or dolomite was

used.13

The stand-alone type of APD [SA

APD] working principle is based on

mixing air and powder by swirling, and the

hand-piece type of APD [HP APD]

air/powder mixture is created by the

carburetor technique and swirling

[Petersilka et al. 2002]. The amount of

powder released in different powder

settings of APD depends on the way the


24

pressurized air is led through the powder

chamber, resulting in high variability in

powder emission rates at different powder

settings between the APDs [Petersilka et

al. 2002].

The abrasive property of the slurry

delivered from APD is determined by the

particle’s velocity, hardness and shape

[Momber & Kovacevic 1998, Petersilka et

al. 2003b], and design principles of the

APD [Petersilka et al. 2002].

INDICATIONS FOR AIR POLISHING

Heavily smoking stain on the teeth

Staining due to coffee or tea

To remove fine tartar that are still

attached to the teeth surface after

scaling

POWDERS USED7

Sodium bicarbonate [NaHCO3]

Glycine

Calcium sodium phosphosilicate

[CaNaO6PSi]

Calcium carbonate [CaCO3]

Aluminum trihydroxide [Al[OH]3]

Inorganic salts

Erythritol [[2R,3S]-butane-1,2,3,4-

tetraol]15

Sodium bicarbonate–based powders

[NaHCO3]:

It was the first powders to be used in air

polishing technology. They are specially

processed to form a powder with a particle

size of up to 250 μm. Studies on air

polishing with NaHCO3 based powders

have demonstrated its ability to be more

effective at supragingival stain removal,

less fatiguing to the operator and more

time efficient than conventional rubber–

cup polishing.10,16

Glycine:

It is a naturally– occurring amino acid;

water–soluble with a non– salty taste.

Studies have shown that the particle size of

glycine is 63 μm or less, close to 4 times

smaller than the particles in NaHCO3 and

that it produces significantly less surface

damage on restorative materials than

NaHCO3 powders [Pelka et al].

Calcium sodium phosphosilicate

[CaNaO6PSi]:

It is a bioactive glass, which is a chemical

compound of naturally occurring elements

which include calcium, phosphorus, silica

and sodium. Bioactive glass has shown to

promote the regeneration of damaged tooth

surfaces creating an enamel–like layer

when used in dental products and to have a

more profound whitening effect as a

polishing agent when compared to

NaHCO3. Studies have shown that

properties associated with bioactive glass

allow CaNaO6PSi to reduce dentinal


25

hypersensitivity by occluding dentinal

tubules as well as remove plaque biofilm

and stain.

Calcium carbonate [CaCO3]:

It is a powder with spherically

agglomerated crystals. Study results

indicate the efficiency and effectiveness of

CaCO3 for stain removal and the defects

produced on root dentin were greater than

that of NaHCO3. More clinical studies are

needed to determine the effectiveness and

abrasivity potential of CaCO3.

Aluminum trihydroxide [Al[OH]3]:

It is an alternative air polishing powder for

patients on sodium restricted diets and its

particles are harder but comparable in size

to sodium bicarbonate. Studies determined

that aluminium trihydroxide should be

avoided on cast restorations, luting

cements, glass ionomers and resin

composites [Johnson et al].

Erythritol [[2R,3S]-butane-1,2,3,4-

tetraol]:

It is a suger alcohol [or polyol]. A recent

study was conducted to evaluate repeated

subgingival air-polishing in residual

pockets with an erythritol powder

containing 0.3% chlorhexidine and it was

concluded that repeated subgingival air-

polishing reduced the number of pockets

>4 mm similar to ultrasonic debridement.

Erythritol is suggested to be safe and it

even induced less pain than ultrasonic

debridement when used subgingivally.15

The abrasiveness of the air-polishing

powders differ based on their physical

characteristics and the polishing device

used, and these characteristics are as

follows:12

Hardness: The hardness of

abrasives is ranked using Mohs

Hardness Scale, a standard 10-

point scale of mineral hardness

with talc 1 the softest and diamond

10 the hardest.

Particle size [grit]: The smaller

[finer] the grit, the smaller the

scratches, which means the shinier

the tooth or restoration surface will

be after polishing.

Particle shape: Small, spherical-

shaped particles abrade slower than

large, angular, irregular shaped

particles.

Agent contact time

Applied pressure [force, load,

measured in pounds per square

inch [psi]]

Concentration and quantity

Abrasiveness: Manufacturers of

Glycine, Calcium sodium


26

phosphosilicate and Calcium

carbonate claim these powders are

less abrasive than traditional

Sodium bicarbonate–based

powders.

TECHNIQUE14

Air polishing has been found to be

more effective than traditional polishing at

stain and supragingival plaque biofilm

removal. New, less abrasive powders are

enabling the selective use of air polishing

on cementum and dentin and a variety of

restorative materials without concern for

unnecessary damage.

A. EQUIPMENTS REQUIRED

1. Air polishing powder and

low-abrasive toothpaste.

2. Air-polishing device and

toothbrush.

3. Dental floss or tape.

4. Mouth mirror, air-water

syringe.

5. Disclosing solution.

6. Lubricant.

7. Saliva ejector and high-

volume evacuation [HVE]

tip.

8. Safety glasses.

9. Personal protective

equipment [PPE].

10. Preprocedural antimicrobial

mouth rinse.

B. STEPS

1. Preparation & Positioning

Evaluate patient’s health and

pharmacologic history to

determine need for antibiotic

premedication.

Explain patient about the

procedure, remove contact

lenses if patient is wearing.

An anti-microbial rinse,

application of a lubricant to the

lips, placement of safety

glasses or a drape over the

nose and eyes of the patient,

and placement of a plastic or

disposable drape over the

patient's clothing should be

taken care off.

A moistened 2x2 gauze square

is placed over the tongue or lip

in the area being polished.7

Assemble high-speed

evacuation and saliva ejector.

Verify that slurry exits from

device tip when held outside

the mouth; adjust saliva ejector

as necessary.

Operators should use universal

precautions, including

protective apparel, a face

shield or safety glasses with

side shields, gloves, and a

well-fitting mask with high-

filtration capabilities.7


27

2. Grasp

Use modified pen grasp.

Rest handpiece in V of hand.

Have all fingers in contact as a

unit.

Tuck excess cord around

pinkie finger, if desired.

3. Fulcrum

Use external soft tissue

fulcrum.

4. Adaptation, Angulation &

Stroke

Activate foot pedal by pushing

halfway down for water and all

the way down for combined

air-water-powder spray.

Pivot nozzle to surface being

polished with the tip directed

at a 60 [degrees] angle to the

tooth for anterior teeth, 80

[degrees] for posterior teeth,

and a 90 [degrees] for occlusal

surfaces of teeth.7

At about 3 to 4 mm from tooth

surface and at correct

angulation, use constant rapid

circular sweeping motions,

from proximal to proximal.

Polishing two to three teeth at

a time by fully depressing the

foot pedal, then rinsing the

teeth and tongue by pressing

the foot pedal half way

increases efficiency and

minimizes the saline taste.7

Cupping the lip with the

forefinger and thumb allows

the water to pool in the

vestibule for easier evacuation

and minimal aerosol

dispersion.

Surfaces without stain are

cleaned with a toothbrush and

low-abrasive toothpaste.

Polishing for five seconds or

less per tooth is usually

adequate to remove most

stains.

5. Other

Rinse with water; floss all

teeth [or have patient do so and

evaluate their flossing

technique].

Evaluate effectiveness with

disclosing solution,

compressed air, and good

lighting.

Provide professionally applied

topical fluoride treatment.

Advised patient not to eat,

drink, or rinse for 30 minutes.

EFFECTIVENESS & EFFICIENCY7

Studies on air polishing confirm

that conventional methods of polishing

[rotating cups, brush cones and abrasive


28

pastes] are less effective and more time

consuming at stain and plaque removal

than modern APDs and it ensures thorough

plaque biofilm and debris removal from

pits and fissures of teeth, prior to

placement of sealants.

Glycine Powder Air Polisher

[GPAP] was suggested to replace hand

instruments as well as sonic and ultrasonic

scalers for subgingival plaque biofilm

removal in shallow pockets and has also

shown a significantly greater reduction in

subgingival bacteria compared to hand

instrumentation [p<0.05]. Recently,

advancements in nozzle design have

afforded more effective subgingival

delivery. Few studies have been conducted

on the effectiveness of these various

models. A recent study quantified the

powder emissions of APDs at different

settings to evaluate the accuracy of powder

emission over time depending on the

powder amount in the chamber and the

powder setting, and concluded that

efficacy of air polishing depends on the

amount of powder present in the powder

chamber. Therefore, clinicians are

encouraged to refill the powder chamber

before each treatment session.

Manufacturers recommend monitoring

powder levels frequently to assure

adequate powder throughout a treatment

procedure.

Effects on Soft Tissues7

APD slurry is usually aimed at the

tooth surface close to the gingival margin.

The effect of the APD jet on gingival

mucosa has been reported in a few studies

based on clinical observations in humans

[Weaks et al. 1984, Newman et al. 1985,

Mishkin et al. 1986], scanning electron

microscopy [SEM] examination of

positive replica prepared from gingiva

impressions following air polishing

[Kontturi-Na¨rhi et al. 1989] and

microscopic examination in rabbit mucosa

[Newman et al. 1985]. Clinical studies

have shown that APD induces localized

trauma to the gingiva that heals within 6

days [Weaks et al. 1984, Mishkin et al.

1986]. Earlier studies indicated some

gingival bleeding and a salty taste

followed use, but no significant gingival

trauma within a week or 2 after

treatment.16 Recent studies have confirmed

these findings.7

Kozlovsky et al conducted a study

in dogs and suggested that the extent of

damage to the gingival tissue is positively

correlated with the time of exposure to

APD and concluded that the APD should

be used no more than 5 to 10 seconds per

tooth surface, with overlapping strokes to

minimize the extent of epithelial erosion

and to prevent the possibility of total

exposure of the underlying connective

tissue. Five to 20 second intervals of air–

polishing application are the working

parameters used in most of the studies.

Glycine–based powder causes less


29

gingival erosion than hand instruments and

NaHCO3 when treated for <5seconds and

is the only abrasive that has been studied

for its ability to clean plaque biofilm in

subgingival pockets <5 mm. In vivo

studies have indicated that it is safe and

caused no substantial gingival damage.

Effects on Enamel, Cementum and

Dentin7

The effect of APD on tooth hard

tissues has been investigated in several

studies.16 Tooth enamel is minimally

affected by the abrasive powder as shown

with the use of profilometer scans

[Willmann et al. 1980]. However, the

action of the APD on the root structure can

cause substantial cementum and dentin

loss, which is almost linearly related to the

amount of time the area is subjected to the

spray [Galloway & Pashley 1987]. The

mode of use of the device, i.e., overlapping

brush strokes or stationary position while

dwelling on the tooth surface, powder

setting of APD and various working

parameter combinations, cause different

root surface abrasion [Berkstein et al.

1987, Galloway & Pashley 1987, Jost-

Brinkmann 1998, Petersilka et al. 2003b].

Studies have found air polishing to

be safe on enamel with no significant loss

of enamel and less abrasive than rubber–

cup polishing.16 Studies did conclude

however that caution was warranted during

use on cementum and dentin to avoid loss

of tooth structure and it was recommended

that air polishing be limited to enamel.16

Agger et al confirmed these findings in a

recent study which used scanning electron

microscopy [SEM] and laser profilometry

to evaluate the abrasiveness of NaHCO3

on root surfaces. Recent studies have

continued to confirm the safety of air

polishing with NaHCO3 on enamel and

however, more importantly, the reduction

in abrasivity on supragingivally exposed

cementum and dentin with use of the new

air polishing powders has been shown.

Pelka et al found the smallest root surface

damage depths and volume losses with the

use of GPAP compared to NaHCO3 and

CaCO3.

Petersilka et al also studied the

influence different working parameters had

on root damage and determined which

parameters out of time, distance,

angulation and water- powder settings

minimized root damage and found that

instrumentation time had the strongest

influence on resulting defect volume

compared to the powder and water

settings. Distance between instrument

nozzle and root surface was found

negligible in this study. It was concluded

that air polishing with NaHCO3 may not

be safe for use on exposed root surfaces.

Tada et al examined the abrasiveness of

glycine powder on dentin with particle

diameters of 63 μm and 100 μm,

respectively. The larger diameter powder


30

resulted in less damage. He also studied

the effect nozzle distance had on dentinal

defects during air polishing and found that

a spray distance of 6mm from the nozzle

surface of the air polisher to the dentin

surface using a 45 degree angle produced

the shallowest defect depths. Tada et al

hypothesized that the larger particle size

may not have had time to reach maximum

velocity when exiting the nozzle head to

strike the dentin.

Effects on Restorative Materials,

Sealants, Orthodontic Appliances and

Implants7

Previous studies evaluated the

effects of air polishing with NaHCO3 on

restorative materials and suggested caution

or complete avoidance of composites and

porcelain veneers.16 There was however

differences in the studies, so Gutmann

concluded that clinicians should follow

manufacturers’ recommendations when

using air polishing on restorative

materials.16 Recent studies using new

powders are limited but have indicated that

during air polishing, restorative materials

such as composites and porcelain veneers

experience a small but noticeable material

loss. A study revealed that on microscopic

examination of the air polished amalgam

surfaces did not show evidence of any

macro cracks or chips, composite surfaces

did not have evidence of cavities or

craters, and porcelain ceramic surfaces did

not have evidence of any chips or increase

in pore size and he concluded that use of

20 psi during air polishing was more

effective in reducing abrasion on

restorative surfaces than 60 psi used in

earlier studies.

Air polishing on polymer

composite material with glycine powder

showed a smoother after appearance with

smaller surface defects than that of

NaHCO3 powder which produced large

depressions on the surface. Giacomelli et

al found similar results on nanohybrid

composite resin with glycine powder

producing smaller surface defects [1 to 2

μm wide] than NaHCO3 [5 to 10 μm

wide]. It was also found that air polishers

enhanced the bond strength of sealants

compared to traditional polishing, allowing

for deeper penetration of the sealant resin

into the enamel surface.16 According to the

previous studies air polishing is the most

efficient method for stain and plaque

removal around orthodontic bands,

brackets and arch wires. However, a recent

study found air polishing with NaHCO3

caused higher frictional resistance on both

metal and ceramic brackets and concluded

that air polishing with NaHCO3 should not

be used in the slots of ceramic or metal

brackets. SEM was used to determine

differences in the effect of NaHCO3 and

GPAP on orthodontic appliances. Marginal

surface changes on arch wire and metal

brackets were observed however there


31

were no significance differences between

the 2 powders and glycine proved to be the

powder of choice when it came to cleaning

plastic brackets.

Previous studies found air

polishing to be effective on implants,

finding surfaces were generally smooth,

plaque formations inhibited and bacteria

completely removed.16 A recent study of

patients with peri–implantitis found

glycine powder significantly reduced

bleeding on probing 6 months after

treatment when comparing it to patients

who were treated with mechanical

debridement using curettes and

chlorhexidine.

HEALTH CONCERNS AND SAFETY7

Contraindications:16

Sodium– restricted diet

Hypertension

Respiratory illness

Infectious disease

Renal insufficiency

Addison’s disease

Cushing’s disease

Metabolic alkalosis

Medications such as mineral

corticoid steroids, antidiuretics or

potassium supplements.

More recently, products have been

introduced that do not contain sodium,

therefore, can be used in patients such

as sodium– restricted diet,

hypertension or renal insufficiency.

Products without sodium are GPAP,

CaCO3 and Al[OH]3.

Calcium sodium phosphor-silicate

powder [Sylc™; OSspray, London,

UK] has a very small amount of

sodium mixed with the particles and

there have been no medical

contraindications associated with its

use, however it is not recommended

for patients with silica allergies. Air

emphysema, subcutaneous facial

emphysema and pneumoparotitis have

been reported, from aerosols produced

during air polishing.

The Jet–Shield™, an aerosol

reduction device, formally marketed by

DENTSPLY [York, Penn] are

available in market since 1998; a study

has evaluated the effectiveness of the

Jet–Shield™ which showed

significantly fewer mean quantity of

colony–forming units generated when

using the Jet–Shield™, compared to

not using this aerosol reduction device.

This study suggested that an aerosol

reduction device be used during air–

powder polishing.

ADVANTAGES17

It minimizes the operator and

patient fatigue.

It is time saving and effective.

Dentinal sensitivity is diminished


32

following the use of prophy‑jet,

which may be explained by the fact

that bicarbonate crystals may block

the tubular opening.

It removes plaque from areas that

are otherwise difficult to reach.18

DISADVANTAGES17

They should be cautiously used in

patients with restricted sodium

diets, respiratory, renal or

metabolic disease, infectious

disease, children, diuretics or long

term steroid therapy, and those

having titanium implants.

Another drawback is the aerosols

generated by air‑polishing may

present an infection control hazard.

ALTERNATIVE USE16

Since the introduction of the air polisher

for stain removal, many studies have been

conducted to evaluate its usefulness in

other dental procedures, including

Periodontal therapy

Orthodontics

Restorative dentistry

Implants

Occlusal sealants

TRENDS AND FUTURE RESEARCH

The growing body of research

related to the effective removal of

subgingival plaque biofilm is a significant

advancement in air polishing. Glycine–

based powder may become the air–

polishing powder of choice due to its low

abrasiveness on gingival tissues, tooth

structure, restorative materials and its

potential to clean both supragingival and

subgingival surfaces. Future research

should continue to explore ways to reduce

aerosol production, improve safety for all

restorative materials and all patients,

regardless of their medical condition.16

CONCLUSION

Air polishing has been studied

extensively and, when used appropriately,

provides a safe, efficient and contemporary

approach to achieving a variety of

treatment goals. This review has provided

evidence of the usefulness of air polishing

in contemporary practice. New polishing

powders are less abrasive and have the

potential to transform the dental hygiene

recall appointment for patients with

minimal periodontal involvement.

REFERENCES

1. Carols Solís Moreno, Javier D

Sanz-Moliner, Andrés Pascual La

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Alemany. In Vitro Evaluation of

the Root Surface Microtopography

Following the Use of Two

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CE, Hirshberg A. Effect of air-

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TF. Antimicrobial effects of

mechanical debridement.

Periodontol 2000 2002;28:56-71.

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Vestri A, Polimeni A.

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Concepts, Cases and

Competencies. Missouri: Elsevier;

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14. Michele Leonardi Dardy, Margaret

M. Walsh. Dental hygiene theory

and practice. Part 1. Ch 27.

Management of extrinsic &

intrinsic stains. 2010. Elsevier.

15. Muller N, Moene R, Cancela JA,

Mombelli A. Subgingival air-

polishing with erythritol during

periodontal maintenance. J Clin

Periodontol 2014; 41: 883–889.

16. Gutmann, Marylou Everett. Air

polishing: a comprehensive review

of the literature. Journal of Dental

Hygiene. June 1998.

17. Madhuri Alankar Sawai, Ashu

Bhardwaj, Zeba Jafri, Nishat

Sultan, Anika Daing. Tooth

polishing: The current status.

Journal of Indian Society of

Periodontology. March 2015.1-6

18. Boyde A. Airpolishing effects on

enamel, dentine, cement and bone.

Br Dent J 1984;156:287‑91.

1.Dr Ranjana Mohan

Professor and Head,

Department of

Periodontology, Teerthankar

Mahaveer Dental College &

Research Center, Moradabad,

India.

2.Dr Zoya Chaowdhary

Post Graduate Student,

Department of

Periodontology, Teerthankar

Mahaveer Dental College &

Research Center

3.Dr Vandana Sharma

Private Dental Clinic,New

Delhi

4.Dr. Rohit Rai,

Private Dental Clinic,New

Delhi

Email: [email protected]

mailto:[email protected]

r air polishing: an update e v i

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