PREVENTIVE CARE IN FOCUS A NEW DIMENSION IN SUBGINGIVAL BIOFILM REMOVAL

Hygienist Juliette Reeves looks at the benefits offered by a new treatment option for subgingival plaque and biofilm
he removal of biofilm deposits from within the periodontal pocket is recognised as being fundamental in reducing bacterial burden and down regulating the pro-inflammatory response in the treatment of the periodontal diseases. However, recolonisation of the periodontal pocket by pathogenic bacteria occurs within weeks of initial phase therapy, making continuous and regular subgingival biofilm removal a prerequisite in the successful management of periodontal disease1. Repeated intervention, however, is not without disadvantages in that a fine balance exists between root surface debridement and disturbance of the epithelial attachment with loss of root substance. Repeated use of traditional methods (hand scalers, curettes, sonic and ultrasonic scalers) can result in significant loss of root substance and surface smoothness2,3,4, thus limiting the frequency of such intervention. Until now air polishing, with hand held units such as the EMS Air-Flow Handy 2 unit has only been indicated for supragingival application. However, with the advent of a commercially available glycine-based prophylaxis powder (Perio Powder, Optident), specifically intended for subgingival use, a new dimension in the removal of subgingival

plaque and biofilm deposits has arrived.

AIR POLISHING
Surprisingly, air polishing is not a new technology. Air polishing devices have been used for almost 50 years5 and in contrast to abrasive techniques, air polishing employs a mixture of air, powder and water. This fine jet is directed towards the tooth surface at an air pressure of 4-8 bar and a water pressure of 1-5 bar6 leading to the removal of surface deposits. Until now the powder of choice has been sodium bicarbonate (NaCOH3), however, with a particle size of 200m (micrometers) it has proven too abrasive for subgingival application. Compared to conventional instrumentation, NaCOH3 appears to be more effective in the supragingival removal of plaque deposits and extrinsic staining7. Due to its high abrasive quality it is contra-indicated for root surface application and subgingival deposits8.

Juliette Reeves

Juliette Reeves is an expanded duties hygienist and trained nutritionist with almost thirty years experience. She qualified from Birmingham Dental Hospital in 1981 and studied nutrition with Patrick Holford from 1995. She is a key opinion leader for Phillips Oral Healthcare and an ambassador for the Sunstar Oral Health Foundation. Juliette has lectured and written internationally for the last ten years and writes regularly for the international dental press.She is an editorial advisor to a number of dental journals as well as senior UK tutor for the Swiss Dental Academy and Clinical Director of PerioNutrition. www.perio-nutrition.com

ABRASION OF DENTAL TISSUES

Intact enamel surfaces appear not to be significantly affected by NaCOH3 air polishing techniques, however, pits and fissures or markings from dental instrumentation appear to be abraded more quickly and easily. Enamel

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to NaCOH3, glycine has a particle size of <63m, making this powder ideal for use along the gingival margins and in deep subgingival pockets. An in vitro evaluation of glycine powder on subgingival cementum and dentine showed that subgingival application resulted in significantly smaller defect depths compared to NaCOH3 powder (19.6m and 71.1m respectively)12. Laboratory test data also confirms that in comparison to NaCOH3 in vitro evaluation of enamel surface roughness and enamel wear after treatment with glycine powder was considerably less and resembled the untreated enamel control surface13. An in vitro evaluation and comparison of the surface roughness of human enamel after air polishing with glycine powder and conventional polishing procedures found that while conventional polishing leaves grooves and scratches on the enamel surface, glycine powder resulted in a smooth enamel surface similar to untreated enamel14.

PLAQUE REMOVAL
A number of studies have evaluated the plaque removal efficacy of glycine powder and the subsequent effect on the soft tissues. Two 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 of 3-5mm in depth. Using a split mouth design in 23 and 27 patients respectively, plaque samples were taken before and after treatment with either glycine powder or hand curettes. Plaque samples were also taken from untreated sites as a negative control. Anaerobe cultivation was utilised to assess the mean reduction of total colony forming units (CFUs) immediately after treatment. In both studies test treatment with glycine powder resulted in significantly greater reduction in CFUs at interproximal sites (two times more) and buccal and lingual sites (three times more) compared to hand instrumentation. Additional study17 has also shown

The Air Flow Perio Flow (Optident Ltd) for sub gingival applications: the soft plastic tip is placed subgingivally making it easy to extend into deep pockets and clean around implants. surfaces subjected to significant plaque colonisation and areas of demineralisation (white spots) appear to be particularly affected5,7,8. Root surfaces (cementum and root dentine) are lower in hardness compared to enamel and therefore the removal of subgingival plaque deposits with NaCOH3 results in substantial wear of the root surface9. In vitro experiments on root surfaces have shown significant defects of up >600m following air polishing with NaCOH310. Histological evaluation of the epithelium, epithelial layers and base membrane of the periodontal pocket have shown significant disruption of epithelial attachment and loss of basal membrane following either hand scaling or NaCOH3 in the removal of subgingival plaque and associated micro organisms11. Whilst NaCOH3 application is a useful and efficient way of removing plaque and biofilm deposits from supra gingival enamel surfaces, it is therefore not indicated in the disinfection and maintenance of the periodontal pocket.

GLYCINE
Glycine is a non-essential amino acid with one of the simplest structures of all the amino acids. Glycine is found in proteins of all life forms, and is important in the synthesis of proteins as well as adenosine triphosphate (ATP). Glycine is water soluble, has a naturally sweet taste and is completely biocompatible. The choice of glycine is due to its physical properties, in that it produces very fine, round soft particles. In contrast

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that penetration of the pocket with glycine powder is comparable to hand instrumentation, with 80% debridement of the root surface in pockets of 2-3mm in depth and 65% in pockets of >4mm. Previous studies on the debridement efficacy of curettes and ultrasonic scalers have shown that on average 66% of the root surfaces were plaque free in pockets >4mm.

ATTACHMENT AND TISSUE TRAUMA

The use of conventional NaCOH3 air polishing powder has been shown to cause significant epithelial erosion with exposure of the underlying connective tissue20,21. The use of glycine powder is however, associated with minimal gingival irritation and increased patient comfort15,16. This finding has been has also been confirmed by in vivo histological examination of the gingival epithelium following subgingival debridement using an air-polishing device (EMS Air-Flow Handy or EMS Perio Master units) with glycine powder22. 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 following the use of glycine powder for subgingival biofilm removal. This was in comparison to hand instrumentation which displayed loss of the keratinised layer and gingival epithelial layer, loss of prominent papillae in the lamina propria and strands of epithelial ridges extending into the connective tissue due to the stimulus of inflammation. The Handy Perio handpiece and Air-Flow Master unit

or no pain at all with 76% of patients willing to undertake the treatment again. Further study23 has also reported greater patient acceptance and comfort with glycine air polishing compared to hand instrumentation. This was a single blind, randomised split mouth trial using a new subgingival delivery system with glycine powder compared to hand instrumentation (curettes). No adverse effects were reported in the test group with patients perceiving less pain than the hand instrument group (0.9 vs 2.2 on a score of 1 to 10). Treatment in the test group was also completed three times more quickly than the control group with comparable microbial reduction.

CONCLUSION
Subgingival debridement is considered essential in treating periodontitis and has been shown to be pivotal in arresting disease progression24. Biofilm formation occurs rapidly in periodontal pockets following instrumentation and re-establishment of pathogenic microbial flora occurs after a few months following treatment25, indicating frequent maintenance is required. Regular and repeated debridement of root surfaces with hand instruments and or sonic/ ultrasonic instruments has been shown to lead to root surface loss over time. Plaque removal on enamel surfaces can be accomplished effectively with air polishing devices with little or no abrasive effects. However, this method is not indicated for root surfaces as conventional air-polishing powders (NaCOH3) are highly abrasive to root dentine and cementum,

PATIENT ACCEPTANCE
For periodontal therapy to be successful regular maintenance and pocket disinfection is paramount. This is greatly influenced by patient acceptance, pain perception and post operative comfort. Patient acceptance surveys conducted over five dental practices involving a total of 80 patients, indicate that treatment with glycine air polishing is widely accepted6. 70% of patients reported either minimal discomfort

which may become clinically significant when repeatedly performed during maintenance therapy due to its cumulative effects. The advent of a new glycine-based powder for use with air polishing devices has been shown to be suitable for root surface debridement, causing little or no surface loss, tissue trauma or patient discomfort. Reduction in pathogenic microbial colony forming units is greater than with hand instrumentation in less time, less operator fatigue and greater patient comfort and compliance. Precautionary measures for patients with upper respiratory tract conditions remain the same as conventional air-polishing powders, however, since glycine was first trialed in 2003, no adverse effects have been reported, making it an effective method of removing subgingival biofilm from the root surfaces and disinfection of the periodontal pocket. Considering the high level of patient acceptance, biocompatibility and efficacy, the use of glycine powder for biofilm removal may greatly enhance the success of periodontal maintenance therapy and has the potential to offer significant benefits in the supportive care of the periodontal patient. The EMS Air Flow Handy 2, Air Flow Perio Powder and the EMS Perio Master are available from Optident - www. optident.co.uk A full list of references is available. Email comments@ppdentistry.com To ask a question or comment on this article please send an email to: comments@ppdentistry.com
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