A New Dimension in Subgingival Biofilm Removal - PPD September 2011
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Transcript of A New Dimension in Subgingival Biofilm Removal - PPD September 2011
8/4/2019 A New Dimension in Subgingival Biofilm Removal - PPD September 2011
http://slidepdf.com/reader/full/a-new-dimension-in-subgingival-biofilm-removal-ppd-september-2011 1/4PPDSeptember 2011 85
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