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Plaque Disclosing Agent As a Guide for Professional Biofilm Removal: a Randomized Controlled Clinical Trial

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Plaque Disclosing Agent As a Guide for Professional Biofilm Removal: a Randomized Controlled Clinical Trial Received: 16 August 2019 | Revised: 1 April 2020 | Accepted: 23 April 2020 DOI: 10.1111/idh.12442 ORIGINAL ARTICLE Plaque disclosing agent as a guide for professional biofilm removal: A randomized controlled clinical trial Magda Mensi1,3 | Eleonora Scotti1,3 | Annamaria Sordillo1 | Raffaele Agosti1 | Stefano Calza2 1Section of Periodontics, School of Dentistry, Department of Surgical Abstract Specialties, Radiological Science and Public Objectives: To evaluate through computer software analysis, the efficacy of the use Health, University of Brescia, Brescia, Italy of a plaque disclosing agent as a visual guide for biofilm removal during professional 2Department of Molecular and Translational Medicine, University of Brescia, Brescia, mechanical plaque removal in terms of post-treatment residual plaque area (RPA). Italy Methods: Thirty-two healthy patients were selected and randomized in two groups 3U.O.C. Odontostomatologia - ASST degli Spedali Civili di Brescia, Brescia, Italy to receive a session of professional mechanical plaque removal with air-polishing fol- lowed by ultrasonic instrumentation with (Guided Biofilm therapy—GBT) or without Correspondence Magda Mensi, Section of Periodontics, (Control) the preliminary application of a plaque disclosing agent as visual guide. The School of Dentistry, Department of Surgical residual plaque area (RPA) was evaluated through re-application of the disclosing Specialties, Radiological Science and Public Health, University of Brescia, P.le Spedali agent and computer software analysis, considering the overall tooth surface and the Civili 1, 25123 Brescia, Italy. gingival and coronal portions separately. Email: [email protected] Results: A statistically and clinically significant difference between treatments is observed, with GBT achieving an RPA of 6.1% (4.1-9.1) vs 12.0% (8.2-17.3) of the Control on the Gingival surface and of 3.5% (2.3-5.2) vs 9.0% (6-13.1) on the Coronal, with a proportional reduction going from 49.2% (P-value = .018) on the former sur- face to more than 60% (P-value = .002) on the latter. Conclusion: The application of a plaque disclosing agent to guide plaque removal seems to lead to better biofilm removal. KEYWORDS air-polishing, biofilm, dental biofilm, oral hygiene, plaque disclosing 1 | INTRODUCTION growth of biofilm, leading to its diversification in distinct areas even of the same tooth.2 The oral cavity is the natural habitat of a heterogeneous pop- The regular disruption of biofilm through professional mechan- ulation of bacteria.1 Both soft and hard surfaces are the sub- ical plaque removal and home oral hygiene is a critical point in the strate where microorganisms adhere and grow, forming the oral prevention of caries and periodontal disease.5-8 Professional me- biofilm.1,2 chanical plaque removal in cariology involves biofilm and calculus Biofilm quantity and complexity increase with time and affect removal from the supra-gingival area while, in periodontology, it the environment, leading to the development of caries, gingivitis2,3 extends to the sub-marginal space.8 While manual and ultrasonic and periodontitis,4 according to individual susceptibility and risk fac- instrumentation constitutes the traditional professional mechani- tors. Vice versa, the environment and local factors can influence the cal plaque removal procedure, air-polishing with low-abrasiveness © 2020 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Int J Dent Hygiene. 2020;00:1–10. wileyonlinelibrary.com/journal/idh | 1 2 | MENSI ET AL. powder is of more recent introduction and is regarded as a promising Civili di Brescia, Department of Odontostomatology (Brescia, way to manage supra- and sub-gingival biofilm, with advantages in Italy). The patients showed no sign of periodontal disease but pre- terms of time and comfort.9-11 The clinical results during periodontal sented a Plaque Index27 (PI) exceeding 25% and required profes- maintenance therapy are comparable with the ones obtained via tra- sional oral care (professional mechanical plaque removal and oral ditional scaling and root planing.10,12 hygiene instructions). Regardless of the instruments used and time, complete biofilm The inclusion criteria were as follows: removal from hard surfaces is hardly achievable.13,14 The aim of pro- fessional mechanical plaque removal is to keep the bacterial pop- • Systemically healthy patients ulation below the “critical mass,” that is where an equilibrium with • No missing anterior teeth the host can exist.15 Being individual tolerance highly variable and • ≥18 years of age non-definable,16 it is essential to keep oral biofilm level as low as • PI27 > 25% possible. • No smoking or smoking <10 cigarettes/d Oral biofilm is mostly colourless. Disclosing tablets and liq- • Need for professional oral care (professional mechanical plaque uids can allow its visualization for clinical and research purposes.17 removal and oral hygiene instructions) Disclosing is proven to ensure complete cleaning of molar occlusal surfaces before sealants,18 increase biofilm control on dentures,19 The exclusion criteria were as follows: allow a more efficient debridement of root surfaces during peri- odontal resective surgery20 and, in case of agents able to identify ac- • Presence of periodontal disease, defined as >3 mm of clinical at- id-producing bacterial populations, assist in caries risk assessment.21 tachment loss at any site The ability to see the biofilm can also improve patients education • Presence of fix retainers and motivation and guide their self-performed oral hygiene.22-24 To • Presence of orthodontic appliances date, no studies are available involving the use of plaque disclosing • Prosthetic rehabilitation of anterior sextants agents as a guide for the clinician during professional mechanical • Pregnant and lactating patients plaque removal. • Unwillingness to undergo the proposed protocol In the research field, application of disclosing agents and sub- sequent photograph software analysis can be used as an advanced All the participants signed written informed consent before the plaque quantification tool,25,26 allowing to overcome classic plaque beginning of the study. indices limitations, such as variability between different examiners and centres.17 Comparisons between planimetric methods and con- ventional indices show that the former ones are more precise, objec- 2.2 | Intervention tive, sensitive and reproducible, and can detect even small changes in plaque area.17,25,26 A total of 32 eligible subjects were randomized in two groups: the The aim of the present study was to evaluate through computer test group received a session of professional mechanical plaque re- software analysis—also known as planimetric plaque analysis—the moval guided by the application of a plaque disclosing agent as a efficacy of the use of a plaque disclosing agent as a visual guide for visual guide for the clinician (named by the authors Guided Biofilm biofilm removal during professional mechanical plaque removal and Therapy—GBT), while the Control group received the same profes- compare it with the same procedure without any visual aid in terms sional mechanical plaque removal procedure without any visual aid. of post-treatment residual plaque area (RPA). After the placement of a lips and cheeks retractor (OptraGate®, Ivoclar Vivadent) and the collection of Plaque Index (PI),27 the pa- tients were allocated to one of the groups (GBT or Control) via ran- 2 | STUDY POPULATION AND domization list and numbered opaque envelopes. In the GBT group, METHODOLOGY the plaque disclosing agent (MIRA-2-TON® 60 mL bottle, HAGER WERKEN) was then applied by the operator with a micro-brush to 2.1 | Study design and population cover the entire tooth surface and thoroughly rinsed with water (Figure 1). The present study was a single-blinded, randomized, controlled In both groups, professional mechanical plaque removal was clinical trial with 2 parallel groups, conducted in accordance with performed with an air-polishing device (Air-flow Master Piezon® the Helsinki Declaration and approved by the Ethics Committee of EMS). The protocol follows the glycine powder air-polishing (GPAP) Spedali Civili di Brescia, protocol number 2636. principles outlined by Flemmig et al11 but with the use of the more Thirty-two (32) systemically healthy subjects were selected recently introduced erythritol powder (PLUS powder® EMS) and in- from the population afferent to the Dental School “Clinica volves supra-gingival and sub-gingival biofilm removal via air-polish- Odontoiatrica Lidia Verza,” University of Brescia, Department of ing as the first step. The erythritol powder was preferred due to its Radiological Science and Public Health, within the ASST Spedali similar physical properties, the clorhexidine content (0.3%) and the MENSI ET AL. | 3 FIGURE 1 Application of the disclosing agent before the therapy, palatal view (A), buccal (B) and lingual (C) FIGURE 2 Post-therapy, palatal view (A), buccal (B) and lingual (C) recent evidence of its safety and efficiency.10,12 At completion, cal- culus removal was performed with a piezoceramic device (Air-flow 2.3 | Image analysis Master Piezon® EMS) and a slim tip (PS® EMS) only if hard deposits are present. The clinical photographs were processed by an operator blinded to In the GBT group, the session ended when no visible disclosing the group allocations through ImageJ software (National Institutes agent was left (Figure 2), while in the Control group it ended when of Health). The area
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