J Clin Periodontol 2011; 38: 820–827 doi: 10.1111/j.1600-051X.2011.01751.x

Jan L. Wennstro¨ m1, Gunnar Dahle´n2 Subgingival debridement of and Per Ramberg1 Departments of 1Periodontology and 2Oral microbiology & Immunology, Institute of periodontal pockets by air Odontology, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, polishing in comparison with Sweden ultrasonic instrumentation during maintenance therapy

Wennstro¨m JL, Dahle´n G, Ramberg P. Subgingival debridement of periodontal pockets by air polishing in comparison to ultrasonic instrumentation during maintenance therapy. J Clin Periodontol 2011; 38: 820–827. doi: 10.1111/j.1600-051X. 2011.01751.x.

Abstract Aim: The objective was to determine clinical and microbiological effects and perceived treatment discomfort of root debridement by subgingival air polishing compared with ultrasonic instrumentation during supportive periodontal therapy (SPT). Material and methods: The trial was conducted as a split-mouth designed study of 2- month duration including 20 recall patients previously treated for . Sites with probing pocket depth (PPD) of 5–8 mm and (BoP1) in two quadrants were randomly assigned to subgingival debridement by (i) glycine powder/air polishing applied with a specially designed nozzle or (ii) ultrasonic instrumentation. Clinical variables were recorded at baseline, 14 and 60 days post-treatment. Primary clinical efficacy variable was PPD reduction. Microbiological analysis of subgingival samples was performed immediately before and after debridement, 2 and 14 days post-treatment. Results: Both treatment procedures resulted in significant reductions of periodontitis- associated bacterial species immediately and 2 days after treatment, and in significant reduction in BoP, PPD and relative attachment level at 2 months. There were no statistically significant differences between the treatment procedures at any of the examinations intervals. Perceived treatment discomfort was lower for air polishing than ultrasonic debridement. Key words: air-abrasive; chronic periodontitis; Conclusion: This short-term study revealed no pertinent differences in clinical or non-surgical; periodontal treatment microbiological outcomes between subgingival air polishing and ultrasonic debridement of moderate deep pockets in SPT patients. Accepted for publication 21 May 2011

Conflict of interest and source of Because of the bacteriological aetiology instrumentation for elimination/suppres- funding statement of it is of paramount sion of the subgingival microflora at importance to maintain adequate infec- sites showing remaining or recurrent The authors declare that they have no tion control after active treatment of the clinical signs of pathology and (ii) rein- conflict of interest. The study was supported by a research disease. Thus, the patient is commonly forcement of self-performed supragingi- grant from Electric Medical Systems recalled with a 3–4 months interval for val infection control (Lang et al. 2008). (EMS, Nyon, Switzerland). supportive periodontal therapy (SPT) Frequently repeated mechanical instru- including (i) repeated mechanical mentation, however, may cause cumu- 820 r 2011 John Wiley & Sons A/S Subgingival debridement by air polishing 821 lated damage of the root surfaces (Zappa powder/air spry was delivered within ing subjects provided informed consent et al. 1991, Schmidlin et al. 2001), and the pocket (Fig. 1), but with the jet before the start of the study. the use of treatment modalities effective directed perpendicularly to the root sur- in removing biofilm but causing mini- face. In addition, with the use of this mal abrasion of the root surface would specially designed nozzle the effective Participants be preferable during SPT. working pressure was reduced com- Patients treated for moderate-advanced Subgingival air polishing (for review pared with that of supragingivally chronic periodontitis and involved in an see Petersilka 2011) has been suggested applied air polishing. The authors SPT programme at the Department of as a treatment approach for root debri- reported from a 7-day clinical trial , Sahlgrenska Academy dement. In a series of studies Petersilka involving SPT subjects with pockets at University of Gothenburg, Sweden, et al. (2003a, b, c, d) demonstrated that X5 mm that subgingival glycine pow- were invited for the study that was air polishing with a low abrasive amino der/air polishing with the new device conducted between August 2009 and acid glycine powder effectively was safe, perceived to be more accep- June 2010. The patients were eligible if removed biofilm on the root surface, table by the patients, and was more time meeting the following inclusion criteria: and that the tested powder caused sig- efficient than mechanical debridement nificantly less root surface abrasion than with hand instruments. Furthermore, on  Two periodontal sites in each of two the earlier commonly used sodium a microbiological level there were no jaw quadrants with PPD of 5–8 mm bicarbonate powder (Berkstein et al. differences between the two approaches and bleeding following probing. The 1987, Kontturi-Narhi et al. 1990, Agger for root debridement. pockets should not be located at et al. 2001). The authors also demon- Whether the deplaqueing and micro- furcation sites. strated that air polishing with glycine biological effects of glycine powder/air  No antibiotic therapy or subgingival powder applied supragingivally for 5 s polishing reported in the studies referred treatment within 3 months preceding in a direction towards the orifice of to above are of clinical significance the start of the trial. pockets with 3–5 mm in depth resulted needs to be validated by clinical assess-  No ongoing drug therapy that might in a statistically significantly greater ments. The objective of this investiga- affect the clinical signs and symp- reduction of subgingival bacterial tion involving subjects on SPT was toms of periodontitis and no require- counts than pocket/root debridement therefore to determine (i) clinical ment for prophylactic antibiotic with hand instruments (Petersilka et al. and microbiological effects and (ii) coverage during treatment. 2003c, d). In a subsequent publication perceived treatment discomfort of by the same research group (Flemmig et subgingival debridement by airflow The following criteria excluded sub- al. 2007) it was shown that with the use polishing with a low abrasive amino jects from participating: of this application method of powder/air acid glycine powder compared with polishing a median debridement depth ultrasonic instrumentation.  Diabetes mellitus, cancer, HIV, dis- of 2 mm was achieved and that at sites orders that compromise wound heal- with a clinical probing pocket depth ing, chronic high dose steroid (PPD) of  4 mm about 60% of the therapy, bone metabolic diseases, root surface was cleaned, while in dee- Material and Methods radiation or immune-suppressive per pockets the efficacy of root debride- This trial was conducted as a split-mouth therapy. ment decreased to about 40%. study of 2 months duration. Approval of  Pregnancy. In a recent publication by Moe¨ne et the study protocol by the Ethics Com-  Acute infectious oral lesions. al. (2010) a new air-polishing device mittee at University of Gothenburg (Dnr was described by which the glycine 749-08) was obtained and all participat- Following a screening examination, the patients were subjected to reinforce- ment of self-performed mechanical tooth cleaning and professional supra- gingival tooth cleaning with a rubber cup and a low-abrasive polishing paste. The study was initiated 1 week after the screening examination.

Interventions Test treatment comprised pocket/root debridement with the use of a low abrasive amino acid glycine powder (Air-Flows Perio Powder, EMS, Nyon, Switzerland) applied by the use of Perio-Flows hand-piece connected to an airflow unit (Air-Flow Masters, EMS). The settings for water and pow- der were approximately 75% of the Fig. 1. Mode of application for subgingival air polishing debridement with the specially maximum scale, and the powder cham- designed nozzle. ber was filled to the indicated maximum r 2011 John Wiley & Sons A/S 822 Wennstro¨m et al. level before each treatment to ensure Clinical assessments added and the suspensions boiled for reproducible conditions. A specially 5 min. After cooling, 800 ml 5 M ammo- designed nozzle for subgingival applica- At the baseline examination before nium acetate was added to each tube and tion (Perio-Flows Nozzle, EMS) was treatment, as well as at the 14- and 60- the samples further processed according used that directed the powder/air jet day follow-up examinations, the inves- to standardized procedures. The hybrids mainly towards the root surface while tigational sites were examined with formed between the bacterial DNA and the water exited at the tip of the nozzle respect to the following variables: the probes were detected by application (Fig. 1). Each periodontal pocket was of an anti-digoxigenin antibody conju- debrided for 2 Â 5 s. Before the start of  status – presence/ gated with alkaline phosphatase and the trial, the dental hygienist performing absence of plaque at the soft tissue incubation with a chemiluminiscent sub- the treatment procedures was specially margin. strate. Evaluation of the chemiluminis- trained in proper use of the airflow  MGB – presence/absence of bleed- cent signal was performed at a device. ing following angulated probing of LumiImagert Workstation by compar- The periodontal sites assigned to the the . ing the obtained signals with those of control treatment were debrided for 30 s  PPD – measured with a manual Hu- pooled standard samples containing 106 using a piezoceramic ultrasonic device Friedy PCP15 or 105 of each of the 12 studied micro- (EMS Piezon Masters 400, PerioSlim (Hu-Friedy Inc., Leimen, Germany) organisms. The obtained chemiluminis- tip, EMS) with power set to 75% and to the closest lower millimetre. cent units were transformed into a scale water as coolant.  RAL – probing depth assessed from of scores from 0 to 5 according to a fixed reference point on the tooth Papapanou et al. (1997), related to the (cemento-enamel junction or the low and high standards, respectively. In Study outline border of a restoration). addition, the specificity of each bacterial After a baseline microbiological and  BoP – presence/absence of bleed- probe was tested against species of the clinical examination, the patients were ing within 15 s following pocket panel. A site was considered positive for given repeated instruction in proper probing. the various microorganisms at a concen- supragingival plaque control measures tration X105 (score 2). at the investigational sites. The investi- One examiner, who was not involved gational sites were then debrided in the treatment of the patients, per- according to the randomization proto- formed the assessments at all time inter- Sample size col. Both test and control sites were vals. Before the start of the trial, the treated at the same visit. Local anaes- examiner had to prove his consistency in Based on power calculation for two-tail thesia was not used. After completed a pre-study calibration trial; a standard intra-individual comparison (GnPower treatment, subgingival plaque samples deviation for repeated PPD measure- 3; Faul et al. 2007), inclusion of 20 were again collected from both test and ments of o0.6 mm and a reproducibility patients (considering a risk of 10% control pockets. Mouthrinsing with a of 95% within Æ 1 mm. Corresponding drop-out) would allow the detection of 0.1% chorhexidine solution twice daily values for RAL were set to o0.8 mm a mean difference of 0.5 mm between for 1 min. during 14 days post-treatment and 90%. treatments in PPD change with a study was prescribed. power of 0.80, a error of 0.05 and with a The patients were recalled for standard deviation of 0.7 mm. Microbiological assessments repeated microbiological sampling 2 days post-treatment. Clinical and micro- Sampling of the subgingival microbiota biological examinations were repeated at each investigational site was per- Randomization at day 14. The study was terminated formed by the use of sterile curettes with a clinical re-examination at day 60. before and immediately after the treat- After verifying that a patient met the Following the completion of the study, ment, at 2 and 14 days post-treatment. criteria for inclusion, the subject was the patients were reassigned to the pre- Before sampling the supragingival area enrolled in the study and given a case viously used recall intervals for SPT. was cleaned by the use of cotton pellets. number. A person otherwise not The samples were analysed for the involved in the study performed the detection of , randomization of the treatments of Outcomes , Prevotella investigational pockets by quadrants, Primary clinical efficacy variable was nigrescens, Aggre- using a computer-generated randomiza- PPD reduction. Changes in relative gatibacter actinomycetemcomitans, tion table. The randomization code for attachment level (RAL) and bleeding , Treponema the patient number was available to the on probing (BoP) were considered sec- denticola, Parvimonas micra, Campylo- operator only to reveal the treatment ondary outcomes. The number of bacter rectus, Porphyromonas endodon- assignments. Investigational sites in ‘‘closed pockets’’ (PPD44 mm and talis, Prevotella tannerae and Filifactor one quadrant were assigned to the test BoP À ) as an endpoint of treatment alocis using the checkerboard DNA- and the sites in the other quadrant to the success (Wennstro¨m et al. 2005) was DNA hybridization technique and with control treatment. Treatment procedure evaluated for descriptive interpretation. whole genomic probes (Dahle´n & Leon- was in all patients to be initiated in the Plaque and marginal gingival bleeding hardt 2006). The samples were trans- quadrant with the lowest number. (MGB) scores were considered descrip- ferred to a tube containing 100 mlTE Throughout the study, the randomiza- tors of the patients’ standard of self- buffer (10 mM Tris-HCL, 1 mM EDTA, tion code was concealed for the exam- performed infection control. pH 7.6) and 100 ml 0.5 M NaOH was iner and the statistician. r 2011 John Wiley & Sons A/S Subgingival debridement by air polishing 823

Adverse events sumption varying between 5 and 20 RAL assessments revealed a mean cigarettes. All patients completed the improvement at day 60 of 0.6 mm in At the completion of the treatment ses- 2-month trial. both the air polishing and the ultrasonic degree of treat- sion the patients scored treated group. In the ultrasonic treated ment discomfort using a 100 mm visual group an improvement of RAL with analog scale (VAS) with ‘‘none’’ at the Clinical assessments X1 mm was observed at 18 of the sites left and ‘‘unbearable’’ at the right end as (45%), while the corresponding figure in verbal endpoints, and separate for the At baseline both the air polishing and the air polishing treated group was 19 two treatments. Any adverse events the ultrasonic debridement group (48%) (Table 2). There were no statisti- occurring during the treatment proce- showed a plaque frequency of o10% cally significant differences between the dures were recorded. Furthermore, the at target sites, and the standard of self- two treatment groups at any of the patients were interviewed at day 2 performed infection control remained examination intervals with regard to regarding any adverse post-treatment high throughout the observation period, probing assessments. events. although at the final examination (day 60) the plaque score was somewhat higher in the air polishing (17%) than Data handling and analysis Microbiological assessments in the ultrasonic treated group (7%). The percentage frequency of presence of MGB scores decreased in both treatment Numbers of sites positive for the various plaque, MGB and BoP at the various groups from approximately 40% at microbial species at the different exam- examination intervals were calculated baseline to 10% at the final examination. ination time points are given in Table 3. on a site level. For probing assessments Both treatment modalities resulted in a Before treatment the recovery rate var- (PPD, RAL) mean values were deter- significant reduction in BoP (Table 1); ied, depending on microbial species, mined for each individual and time from 100% at baseline to 25% for the between 0–26 sites (0–65%) in the air interval and then averaged for treatment air polishing and 30% for the ultra- polishing and 0–24 sites (0–60%) in the groups. Proportions of sites within var- sonic treated sites (between treatments ultrasonic group. There was a general ious categories of scoring units were p40.05). trend of reduced number of positive also calculated for data description. Tables 1 and 2 presents observed sites immediately after both air polish- Microbiological data were described alterations in probing assessments. At ing and ultrasonic debridement, as well with respect to frequency of sites with baseline the mean PPD of at the target as at day 2. At day 14 the recovery rates detectable levels of each of the 12 target sites was 5.8 and 5.7 mm in the air had returned to figures comparable to microorganisms (X105) and the total polishing and the ultrasonic treated those before treatment. As graphically sum of detection scores for each of the quadrants, respectively. Eighty-eight to presented in Fig. 2, a similar pattern of 12 microorganisms at each examination 92% of the pockets had a probing depth only a short-term reduction was evident interval (n 5 40 samples). The data were of 5–6 mm and 8–12% 7–8 mm. At the from the description analysis of the sum also analysed with respect to number of final examination (day 60) the mean of detection scores for each of the 12 sites positive for one or several of the PPD had decreased to 4.4–4.5 mm in microbial species at the various exam- bacteria belonging to the ‘‘red com- the two treatment groups. A PPD of ination intervals. With regard to the plex’’ (P. gingivalis, T. forsythia and 44 mm was found in 23 of 40 sites proportion of sites positive for one or T. denticola) and ‘‘orange complex’’ (P. (58%) in the air polishing and 25 of 40 more of the bacteria belonging to the intermedia, P. nigrescens, F. nucleatum, sites (63%) in the ultrasonic-treated ‘‘’’ or the ‘‘orange com- P. micra and C. rectus) as defined by group (Table 2). ‘‘Pocket closure’’ plex’’, early post-treatment reductions Socransky et al. (1998). (PPD44 mm and BoP À ) was reached were more marked for the ‘‘red com- Statistical analysis was based on in 19 sites (48%) in the air-polishing plex’’ in both treatment groups (Fig. 3). intra-individual comparison between group compared with 18 (45%) in the At baseline as well as at the post-treat- the two treatment procedures. Differ- ultrasonic treated group. ment examinations, none of the analyses ence in PPD and RAL between the treatment groups was tested by the use Table 1. Frequency (%) of bleeding on probing (BoP) positive sites and mean values (SD) on of the Student t-test. The McNemar test subject level for probing pocket depth (PPD) at baseline, 14 and 60 days post-treatment and for was utilized for statistical analysis of change in relative attachment level (RAL) at the follow-up examinations categorical variables. A p-value 0.05 o Ultrasonic debridement Air polishing debridement Significance was considered statistically significant. Data handling and statistical testing BoP (n 5 40) (n 5 40) were performed with the use of the Baseline 100% 100% NS SPSS 18 software package (SPSS Inc., Day 14 42% 40% NS Chicago, Illinois, USA). Day 60 30% 25% NS PPD (mm) (n 5 20) (n 5 20) Baseline 5.7 (0.62) 5.8 (0.70) NS Day 14 5.1 (0.79) 5.0 (0.71) NS Results Day 60 4.4 (0.93) 4.5 (0.87) NS Twenty recall patients, 14 females and RAL (mm) (n 5 20) (n 5 20) Change Day 14n 0.0 (0.77) À 0.2 (0.73) NS six males, with a mean age of 60 years n (range 40–71 years) agreed to partici- Change Day 60 À 0.6 (1.03) À 0.6 (0.69) NS pate in the study. Fifteen of the subjects nNegative value 5 RAL gain. were current smokers with a daily con- NS, not statistically significant. r 2011 John Wiley & Sons A/S 824 Wennstro¨m et al.

Table 2. Number of sites with probing pocket depth 44, 5–6 and 7–8 mm and change in relative follow-up period. Also for that reason attachment level (RAL) at the various examination intervals we selected SPT patients with only few Ultrasonic debridement Air polishing debridement sites in need of treatment, and a split- (n 5 40) (n 5 40) mouth design in order to reduce the number of subjects needed and to mini- Probing pocket depth 44 mm 5–6 mm 7–8 mm 44 mm 5–6 mm 7–8 mm mize variations in potential effect of Baseline – 37 3 – 35 5 confounding factors. Further, the risk Day 14 13 24 3 12 27 1 for cross-over effects should be minimal Day 60 25 14 1 23 15 2 n considering that only two pathological RAL change 4 À 1mm 0 X1mm 4 À 1mm 0 X1mm Day 14 8 19 13 10 25 5 pockets in each of two separate quad- Day 60 18 16 6 19 16 5 rants were used as investigational sites. Hence, these study conditions have to be n Negative value 5 RAL gain considered in the interpretations of the results. Table 3. Number of sites positive for the various microbial species (X105) before treatment (day Glycine powder/air polishing applied 0 Pre), immediately post-treatment (day 0 Post) and at days 2 and 14 supragingivally with a conventional air- Ultrasonic debridement Air polishing debridement flow device, and with the jet directed (n 5 40) (n 5 40) into the orifice of the periodontal pocket and parallel to the long axis of the root day 0 day 0 day 2 day 14 day 0 day 0 day 2 day 14 for 5 s, was reported to more effectively pre post pre post reduce the subgingival microflora than mechanical debridement with hand P. gingivalis 5 1 0 5 6 1 13 2 P. intermedia 18 7 5 24 16 11 7 15 instruments (Petersilka et al. 2003c, d). P. nigrescens 19 12 9 23 20 7 8 19 It was also demonstrated (Flemmig et al. T. forsythia 1402 6131 1 82007) from assessments on teeth A. actinomycetemcomitans 000 1 001 1extracted immediately following treat- F. nucleatum 6011140110ment that, with this mode of supragin- T. denticola 13 5 1 13 11 3 4 12 gival application of air polishing, a P. micra 6431994315median debridement depth of 2 mm C. rectus 7451271311was achieved. Considering this observa- P. endodontalis 24 13 9 32 26 15 20 25 F. alocis 100 4 200 2tion, Flemmig et al. (2007) proposed P. tannerae 95318122215that in sites with PPDX5 mm mechan- ical instrumentation might be superior. In the present clinical trial, as well as revealed any statistically significant dif- nificant microbiological differences in a recent study by Moe¨ne et al. (2010), ferences between the two treatment observed between the two treatment a specially designed nozzle was used groups. approaches. With respect to perceived and inserted subgingivally during air treatment discomfort, the patients polishing of periodontal pockets of 5– judged air polishing to cause less dis- 8 mm in depth, and by which the glycine Perceived treatment discomfort and comfort than ultrasonic debridement. powder/air jet was directed against the adverse events The study was designed to compare root surface. Moe¨ne et al. (2010) per- The evaluation of perceived treatment the clinical efficacy of two approaches formed subgingival bacterial sampling discomfort by the use of a 100 mm VAS to pocket/root debridement during SPT. by the use of paper points 2 days before immediately after completion of the In order to be able to properly evaluate treatment and 7 days post-treatment. treatment (Fig. 4) revealed low scores the effect of the subgingival debride- The authors reported a reduction in for both treatment modalities, but ment per se, careful means were taken to number of sites positive for six tested statistically significantly lower for air secure a high standard of supragingival microorganisms varying between 13% polishing than for ultrasonic debride- infection control. Hence, the patients and 43% at the follow-up examination, ment; median value 7.5 versus 15.0 were given instructions in proper and no significant differences compared (po0.05). No adverse events were ob- mechanical tooth cleaning before the with subgingival debridement with hand served or reported with any of the treat- initiation of the trial and were in addi- instruments. In the current study, in ment procedures. tion prescribed daily mouth rinsing with which the microbial sampling was per- a solution during the first formed with curettes in order to harvest 2 weeks post-treatment. A maintained the biofilm on the root surface, reduced high standard of oral hygiene through- microbial recovery rates and amounts of Discussion out the study period was confirmed by bacteria were observed immediately fol- The results of the present short-term low plaque scores and markedly reduced lowing debridement that were of similar trial revealed no clinically significant prevalence of marginal gingival bleed- magnitude as following ultrasonic instru- differences in treatment outcome ing (Table 1). mentation (Table 3 and Figs 2 and 3). between subgingival air polishing and Because of lack of clinical data with The microbiological effects were also ultrasonic debridement of moderate regard to the efficacy of subgingival air evident in samples taken after 2 days, deep periodontal pockets during main- polishing, we considered it appropriate whereas at the repeated sampling after tenance therapy. Neither were any sig- to limit the evaluation to a 2-month 14 days both the number of positive r 2011 John Wiley & Sons A/S Subgingival debridement by air polishing 825

Fig. 2. Microbiological assessments. Total sum of detection scores for the various microbial species and time intervals (n 5 40).

et al. 2007) of the potential of subgingi- val glycine powder/air polishing to remove biofilm on the root surface. Despite only short-term assessable microbiologic effects, the clinical assessments revealed significant reduc- tion in BoP, PPD as well as RAL in both the air polishing and the ultrasonic debridement group at the 60-day fol- low-up examination (Table 1). No bac- terial sampling was performed at the final examination but data from other studies show that improved clinical con- ditions are in fact associated with sig- nificant reductions of subgingival bacteria loads (Haffajee et al. 1997, Fig. 3. Number of sites positive to microbial testing divided by treatment and microbial complex ‘‘Red’’ and ‘‘Orange’’, see text) at the various time intervals (n 5 40). Darby et al. 2001). Hence, it is suggested that despite no significant differences relative to baseline in micro- biological assessments at day 14, the sites and the amounts of bacteria load polishing on the subgingival microflora subsequent improved tissue conditions were more or less comparable to corre- in 5–8 mm deep periodontal pockets, (reduction of inflammation) might have sponding data before debridement. and that this effect was not different affected the subgingival ecological Although different methods were used from that seen following mechanical environment and induced conditions for bacterial sampling (paper points debridement. In this respect, the findings less favourable for a disease-associated versus curettes), taken together the from the use of the specially designed subgingival microbiota. data from the two clinical trials indicate nozzle supports previous observations Change in PPD was considered the a short-term effect of subgingival air (Petersilka et al. 2003c, d, Flemmig primary clinical outcome variable in the r 2011 John Wiley & Sons A/S 826 Wennstro¨m et al.

analysis program for the social, behavioral, and biomedical sciences. Behavior Research Methods 39, 175–191. Flemmig, T. F., Hetzel, M., Topoll, H., Gerss, J., Haeberlein, I. & Petersilka, G. (2007) Subgingival debridement efficacy of glycine powder air polish- ing. Journal of Periodontology 78, 1001–1010. Haffajee, A. D., Cugini, M. A., Dibart, S., Smith, C., Kent, R. L. Jr. & Socransky, S. S. (1997) The effect of SRP on the clinical and microbiological para- meters of periodontal disease. Journal of Clinical Periodontology 24, 324–334. Hallmon, W. W. & Rees, T. D. (2003) Local anti- infective therapy: mechanical and physical approaches. A systematic review. Annals of Perio- dontology 8, 99–114. Hanes, P. J. & Purvis, J. P. (2003) Local anti-infective therapy: pharmacological agents. A systematic review. Annals of Periodontology 8, 79–98. Kontturi-Narhi, V., Markkanen, S. & Markkanen, H. (1990) Effects of airpolishing on removal and hard tissues as evaluated by scanning electron microscopy. Journal of Periodontology 61, Fig. 4. Perceived treatment discomfort as assessed on a 100 mm visual analog scale (VAS). 334–338. Lang, N. P., Bra¨gger, U., Salvi, G. E. & Tonetti, M. S. (2008) Supportive periodontal therapy (SPT). In present study. In this respect the two cases of air emphysema, which Lang, N. P. & Lindhe, J (eds). Clinical Perio- improvement were similar following ‘‘resolved within 4 days without further dontology and Implant Dentistry, 5th edition, pp. 1297–1317. Oxford: Blackwell Publishing Ltd. the two approaches for subgingival deb- sequelae’’, following subgingival gly- Moe¨ne, R., De´caillet, F., Andersen, E. & Mombelli, A. ridement and well in line with data cine powder/air polishing performed by (2010) Subgingival plaque removal using a new air- reported in systematic reviews on the general practitioners. With the specially polishing device. Journal of Periodontology 81,79– outcome of non-surgical mechanical designed nozzle used in the current 88. instrumentation (Tunkel et al. 2002, study, the jet is directed mainly towards Papapanou, P. N., Madianos, P. N., Dahlen, G. & Sandros, J. (1997) ‘‘Checkerboard’’ versus culture: van der Weijden & Timmerman 2002, the root surface and with reduced flow a comparison between two methods for identifica- Hallmon & Rees 2003). Also pressure compared with supragingivally tion of subgingival microbiota. European Journal with regard to ‘‘pocket closure’’ (PPD applied air polishing, which would low- of Oral Sciences 105, 389–396. 44 mm and BoP À ) as a successful er the risk for such an adverse event. Petersilka, G. J., Bell, M., Haberlein, I., Mehl, A., Hickel, R. & Flemmig, T. F. (2003a) In vitro endpoint of treatment the data indicated Furthermore, to minimize the risk edu- evaluation of novel low abrasive air polishing similar outcomes (45–48%) for two cation and training in the proper use of powders. Journal of Clinical Periodontology 30, treatment modalities of pocket/root deb- subgingival air polishing devices is 9–13. ridement. In the interpretation of the important. Petersilka, G. J., Bell, M., Mehl, A., Hickel, R. & Flemmig, T. F. (2003b) Root defects following air results, however, it should be recog- polishing. Journal of Clinical Periodontology 30, nized that the majority of sites treated 165–170. had a PPD of only 5–6 mm. Because Acknowledgements Petersilka, G. J., Steinmann, D., Ha¨berlein, I., Hei- subgingival pocket irrigation with water necke, A. & Flemmig, T. F. (2003c) Subgingival The authors thank dental hygienist plaque removal in buccal and lingual sites using a and antiseptic solutions lacks clinical novel low abrasive air-polishing powder. Journal of significant effects (Hanes & Purvis Gunilla Koch for her clinical work and invaluable contribution to the study. Clinical Periodontology 30, 328–333. 2003), the beneficial effects observed Petersilka, G. J., Tunkel, J., Barakos, K., Heinecke, A., with regard to subgingival air polishing Ha¨berlein, I. & Flemmig, T. F. (2003d) Subgingival plaque removal at interdental sites using a low- is most likely attributed to the use of the abrasive air polishing powder. Journal of Perio- glycine powder. Hence, the results indi- dontology 74, 307–311. cate that air polishing with glycine References Petersilka, G. J. (2010) Letter to the editor. Journal of powder is a valid treatment approach Periodontology 81, 962–963. Agger, M. S., Horsted-Bindslev, P. & Hovgaard, O. Petersilka, G. J. (2011) Subgingival air-polishing in to subgingival debridement of sites with (2001) Abrasiveness of an air-powder polishing the treatment of periodontal biofilm infections. moderate deep (5–6 mm) pockets during system on root surfaces in vitro. Quintessence Periodontology 2000 55, 124–142. SPT. However, in presence of subgingi- International 32, 407–411. Schmidlin, P. R., Beuchat, M., Busslinger, A., Leh- val and in the initial phase of Berkstein, S., Reiff, R. L., McKinney, J. F. & Killoy, mann, B. & Lutz, F. (2001) Tooth substance loss W. J. (1987) Supragingival root surface removal resulting from mechanical, sonic and ultrasonic root periodontal therapy hand/ultrasonic during maintenance procedures utilizing an air- instrumentation assessed by liquid scintillation. instrumentation should be selected as powder abrasive system or hand scaling. An in vitro Journal of Clinical Periodontology 28, 1058–1066. the primary approach to root debride- study. Journal of Periodontology 58, 327–330. Socransky, S. S., Haffajee, A. D., Cugini, M. A., ment. Dahle´n, G. & Leonhardt, A˚ . (2006) A new checker- Smith, C. & Kent, R. L. Jr. (1998) Microbial Considering the safety of subgingival board panel for testing bacterial makers in perio- complexes in subgingival plaque. Journal of Clin- dontal disease. Oral Microbiology and Immunology ical Periodontology 25, 134–144. air polishing no major adverse effects 21, 6–11. Tunkel, J., Heinecke, A. & Flemmig, T. F. (2002) A were observed in the current study or in Darby, I. B., Mooney, J. & Kinane, D. F. (2001) systematic review of efficacy of machine-driven previously reported studies (Petersilka Changes in subgingival microflora and humoral and manual subgingival debridement in the treat- et al. 2003c, d, Flemmig et al. 2007, immune response following periodontal therapy. ment of chronic periodontitis. Journal of Clinical Journal of Clinical Periodontology 28, 796–805. Periodontology 29 (Suppl. 3), 72–81. Moe¨ne et al. 2010). However, Petersilka Faul, F., Erdfelder, E., Lang, A-G. & Buchner, A. van der Weijden, G. A. & Timmerman, M. F. (2002) (2010) mentioned the knowledge of (2007) GnPower 3: a flexible statistical power A systematic review on the clinical efficacy of r 2011 John Wiley & Sons A/S Subgingival debridement by air polishing 827

subgingival debridement in the treatment of chronic Zappa, U., Smith, B., Simona, C., Graf, H., Case, D. & Institute of Odontology periodontitis. Journal of Clinical Periodontology 29 Kim, W. (1991) Root substance removal by scaling The Sahlgrenska Academy at University of (Suppl. 3), 55–71. and root planing. Journal of Periodontology 62, Gothenburg Wennstro¨m, J. L., Tomasi, C., Bertelle, A. & Dellase- 750–754. Box 450 ga, E. (2005) Full-mouth ultrasonic debridement SE 405 30 Go¨teborg versus quadrant as an Address: Sweden initial approach in the treatment of chronic perio- Jan L. Wennstro¨m dontitis. Journal of Clinical Periodontology 32, E-mail: [email protected] Department of Periodontology 851–859.

Clinical Relevance gingival air polishing are of clinical discomfort was lower for air polish- Scientific rationale for the study: significance needs to be validated. ing than ultrasonic debridement. Subgingival air polishing with low Principal findings: This 2-month Practical implication: Subgingival abrasive glycine powder has been study revealed no differences with glycine powder/air polishing with a shown to have deplaqueing and regard to clinical and microbiologi- specially designed nozzle may be microbiological effects comparable cal outcomes of subgingival debride- used as an alternative approach to to mechanical instrumentation. How- ment performed with glycine mechanical debridement of moderate ever, whether these effects of sub- powder/air polishing and ultrasonic deep periodontal pockets during instrumentation. Perceived treatment SPT.

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