A New Dimension in Subgingival Biofilm Removal - PPD September 2011

8/4/2019 A New Dimension in Subgingival Biofilm Removal - PPD September 2011

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The removal o biolm deposits rom

within the periodontal pocket is

recognised as being undamental

in reducing bacterial burden and down

regulating the pro-inammatory response

in the treatment o the periodontal diseases.

However, recolonisation o the periodontal

pocket by pathogenic bacteria occurs within

weeks o initial phase therapy, making

continuous and regular subgingival biolm

removal a prerequisite in the successulmanagement o periodontal disease1.

Repeated intervention, however, is not

without disadvantages in that a ne balance

exists between root surace debridement

and disturbance o the epithelial attachment

with loss o root substance. Repeated use o

traditional methods (hand scalers, curettes,

sonic and ultrasonic scalers) can result in

signicant loss o root substance and surace

smoothness2,3,4, thus limiting the requency o

such intervention.

Until now air polishing, with hand held

units such as the EMS Air-Flow Handy 2 unit

has only been indicated or supragingival

application. However, with the advent o

a commercially available glycine-based

prophylaxis powder (Perio Powder, Optident),

specically intended or subgingival use, a

new dimension in the removal o subgingival

plaque and biolm deposits has arrived.

AIR POLISHINGSurprisingly, air polishing is not a new

technology. Air polishing devices have been

used or almost 50 years5 and in contrast to

abrasive techniques, air polishing employs a

mixture o air, powder and water. Tis ne

jet is directed towards the tooth surace at an

air pressure o 4-8 bar and a water pressure

o 1-5 bar

6

leading to the removal o suracedeposits.

Until now the powder o choice has been

sodium bicarbonate (NaCOH3), however,

with a particle size o 200µm (micrometers)

it has proven too abrasive or subgingival

application. Compared to conventional

instrumentation, NaCOH3

appears to be

more eective in the supragingival removal o

plaque deposits and extrinsic staining7. Due to

its high abrasive quality it is contra-indicated

or root surace application and subgingival

deposits8.

ABRASION OF DENTAL TISSUESIntact enamel suraces appear not to be

signicantly aected by NaCOH3

air polishing

techniques, however, pits and ssures or

markings rom dental instrumentation appear

to be abraded more quickly and easily. EnamelCONT

PREVENTIVE CAREIN FOCUS

Hygienist Juliette Reeves looks at the benets ofered by a new treatment option or

subgingival plaque and biolm

A NEW DIMENSIONIN SUBGINGIVAL BIOFILM REMOVAL

Juliette Reeves is an expanded duties hygienist

and trained nutritionist with almost thirty years

experience. She qualifed rom Birmingham

Dental Hospital in 1981 and studied nutrition

with Patrick Holord rom 1995. She is a key

opinion leader or Phillips Oral Healthcare and

an ambassador or the Sunstar Oral Health

Foundation. Juliette has lectured and written

internationally or the last ten years and writes

regularly or the international dental press.She

is an editorial advisor to a number o dental

journals as well as senior UK tutor or the Swiss

Dental Academy and Clinical Director o Perio-

Nutrition.

www.perio-nutrition.com

Juliette Reeves


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suraces subjected to signicant plaque

colonisation and areas o demineralisation

(white spots) appear to be particularly

aected5,7,8.

Root suraces (cementum and root dentine)

are lower in hardness compared to enamel

and thereore the removal o subgingival

plaque deposits with NaCOH3

results in

substantial wear o the root surace9. In vitro

experiments on root suraces have shown

signicant deects o up >600µm ollowing air

polishing with NaCOH3

10.

Histological evaluation o the epithelium,

epithelial layers and base membrane o the

periodontal pocket have shown signicant

disruption o epithelial attachment and loss o basal membrane ollowing either hand scaling

or NaCOH3

in the removal o subgingival

plaque and associated micro organisms11.

Whilst NaCOH3

application is a useul and

ecient way o removing plaque and biolm

deposits rom supra gingival enamel suraces,it is thereore not indicated in the disinection

and maintenance o the periodontal pocket.

GLYCINEGlycine is a non-essential amino acid with

one o the simplest structures o all the

amino acids. Glycine is ound in proteins

o all lie orms, and is important in the

synthesis o proteins as well as adenosine

triphosphate (AP). Glycine is water soluble,

has a naturally sweet taste and is completely

biocompatible. Te choice o glycine is dueto its physical properties, in that it produces

very ne, round sof particles. In contrast

to NaCOH3, glycine has a particle size o

<63µm, making this powder ideal or use

along the gingival margins and in deep

subgingival pockets.

An in vitro evaluation o glycine powder

on subgingival cementum and dentine

showed that subgingival application resulted

in signicantly smaller deect depths

compared to NaCOH3

powder (19.6µm and

71.1µm respectively)12.

Laboratory test data also conrms that in

comparison to NaCOH3 in vitro evaluationo enamel surace roughness and enamel

wear afer treatment with glycine powder

was considerably less and resembled the

untreated enamel control surace13. An in

vitro evaluation and comparison o the

surace roughness o human enamel afer

air polishing with glycine powder and

conventional polishing procedures ound

that while conventional polishing leaves

grooves and scratches on the enamel surace,

glycine powder resulted in a smooth enamel

surace similar to untreated enamel

14

.

PLAQUE REMOVALA number o studies have evaluated

the plaque removal ecacy o glycine

powder and the subsequent eect on the

sof tissues. wo studies15,16 looked at

interdental plaque removal and buccal

and lingual sites respectively. Both studies

compared subgingival plaque removal

with glycine powder and traditional hand

instrumentation (curettes) in periodontal

pockets o 3-5mm in depth. Using a

split mouth design in 23 and 27 patientsrespectively, plaque samples were taken

beore and afer treatment with either glycine

powder or hand curettes. Plaque samples

were also taken rom untreated sites as a

negative control. Anaerobe cultivation was

utilised to assess the mean reduction o total

colony orming units (CFUs) immediately

afer treatment. In both studies test treatment

with glycine powder resulted in signicantly

greater reduction in CFUs at interproximal

sites (two times more) and buccal and lingual

sites (three times more) compared to handinstrumentation.

Additional study 17 has also shown

PREVENTIVECAREINFOCUS

Brought to you in partnership with Oral B ‘Continuing the care thats starts in your chair’

The Air Flow Perio Flow (Optident Ltd) for sub gingival applications: the soft p lastic tip is placed subgingivally making it easy toextend into deep pockets and clean around implants.

CONT


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that penetration o the pocket with

glycine powder is comparable to hand

instrumentation, with 80% debridement

o the root surace in pockets o 2-3mm

in depth and 65% in pockets o >4mm.

Previous studies on the debridement ecacy

o curettes and ultrasonic scalers have shown

that on average 66% o the root suraces

were plaque ree in pockets >4mm.

ATTACHMENT AND TISSUE TRAUMA

Te use o conventional NaCOH3 airpolishing powder has been shown to cause

signicant epithelial erosion with exposure

o the underlying connective tissue20,21. Te

use o glycine powder is however, associated

with minimal gingival irritation and increased

patient comort15,16. Tis nding has been has

also been conrmed by in vivo histological

examination o the gingival epithelium

ollowing subgingival debridement using an

air-polishing device (EMS Air-Flow Handy

or EMS Perio Master units) with glycine

powder

22

.Histological analysis revealed that in

comparison to hand instrumentation,

NaCOH3

powder and a negative control,

glycine powder exhibited a tissue appearance

comparable with the control specimens.

Epithelial attachment, keratinised layer and

base membrane all remained intact ollowing

the use o glycine powder or subgingival

biolm removal. Tis was in comparison to

hand instrumentation which displayed loss

o the keratinised layer and gingival epithelial

layer, loss o prominent papillae in the lamina

propria and strands o epithelial ridgesextending into the connective tissue due to

the stimulus o inammation.

PATIENT ACCEPTANCEFor periodontal therapy to be successul

regular maintenance and pocket disinection

is paramount. Tis is greatly inuenced by

patient acceptance, pain perception and post

operative comort.

Patient acceptance surveys conducted over

ve dental practices involving a total o 80

patients, indicate that treatment with glycineair polishing is widely accepted6. 70% o

patients reported either minimal discomort

or no pain at all with 76% o patients willing

to undertake the treatment again.

Further study 23 has also reported greater

patient acceptance and comort with

glycine air polishing compared to hand

instrumentation. Tis was a single blind,

randomised split mouth trial using a new

subgingival delivery system with glycine

powder compared to hand instrumentation

(curettes). No adverse eects were reportedin the test group with patients perceiving less

pain than the hand instrument group (0.9 vs

2.2 on a score o 1 to 10). reatment in the

test group was also completed three times

more quickly than the control group with

comparable microbial reduction.

CONCLUSIONSubgingival debridement is considered

essential in treating periodontitis and has

been shown to be pivotal in arresting disease

progression24. Biolm ormation occurs

rapidly in periodontal pockets ollowinginstrumentation and re-establishment o

pathogenic microbial ora occurs afer a ew

months ollowing treatment25, indicating

requent maintenance is required.

Regular and repeated debridement o root

suraces with hand instruments and or sonic/

ultrasonic instruments has been shown to lead

to root surace loss over time. Plaque removal

on enamel suraces can be accomplished

eectively with air polishing devices with little

or no abrasive eects. However, this method is

not indicated or root suraces as conventionalair-polishing powders (NaCOH

3) are highly

abrasive to root dentine and cementum,

which may become clinically signicant when

repeatedly perormed during maintenance

therapy due to its cumulative eects.

Te advent o a new glycine-based powder

or use with air polishing devices has

been shown to be suitable or root surace

debridement, causing little or no surace

loss, tissue trauma or patient discomort.

Reduction in pathogenic microbial colony

orming units is greater than with handinstrumentation in less time, less operator

atigue and greater patient comort and

compliance.

Precautionary measures or patients with

upper respiratory tract conditions remain the

same as conventional air-polishing powders,

however, since glycine was rst trialed in

2003, no adverse eects have been reported,

making it an eective method o removing

subgingival biolm rom the root suraces and

disinection o the periodontal pocket.

Considering the high level o patient

acceptance, biocompatibility and ecacy,the use o glycine powder or biolm

removal may greatly enhance the success o

periodontal maintenance therapy and has the

potential to oer signicant benets in the

supportive care o the periodontal patient.

Brought to you in partnership with Oral B ‘Continuing the care thats starts in your chair’

ppd

A full list of references is available.

Email [email protected]

To ask a question or comment on this article pl ease send

an email to: [email protected]

The Handy Perio handpiece and Air-Flow Master unit

PREVENTIVECAREINFOCUS

The EMS Air Flow Handy 2, Air Flow Perio Powder andthe EMS Perio Master are available from Optident - w ww.optident.co.uk

A New Dimension in Subgingival Biofilm Removal - PPD September 2011

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