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Subgingival Debridement of Periodontal Pockets by Air Polishing in Comparison to Ultrasonic Instrumentation During Maintenance Therapy

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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 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 chronic periodontitis. Sites with probing pocket depth (PPD) of 5–8 mm and bleeding on probing (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 periodontal disease 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 Periodontology, 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 Oral hygiene 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
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