REVIEW ARTICLE

J B€ uhler M Amato R Weiger C Walter

Authors’ affiliations: J B€ uhler, M Amato, R Weiger, C Walter, Department of Periodontology, Endodontology and Cariology, School of Dental Medicine, University of Basel, Basel, Switzerland C Walter, Department of Oral Surgery, School of Dentistry, University of Birmingham, Birmingham, UK Correspondence to: C. Walter Department of Periodontology, Endodontology and Cariology School of Dental Medicine University of Basel Hebelstrasse 3 CH-4056 Basel, Switzerland Tel.: +41 61 2672628 Fax: +41 61 2672659 E-mail: [email protected]

A systematic review on the effects of air polishing devices on oral tissues Abstract: Objectives: Air-polishing devices are used for the instrumentation of the root surface. Their potential of harm to the hard and/or soft tissues needs to be considered during periodontal treatment. The objective of this systematic review was to analyse the effects of air polishing devices on oral tissues. Methods: The electronic databases MEDLINE, EMBASE and the Cochrane Library were screened for studies published through 18 November 2013. The surface modifications on human cementum, dentine or gingiva after the instrumentation were considered as outcomes. Results: Of the 1266 abstracts screened, 17 studies were included in the analysis. Different air polishing powders consisting of sodium bicarbonate, calcium carbonate, pumice or glycine were used in different ex vivo or in vitro settings. Thirteen publications reported data on the effects of air polishing devices on cementum and dentine. Hard tissue modifications, including defect depths and volume, caused by sodium bicarbonate or calcium carbonate powders were significantly greater compared to powders consisting of glycine. The soft tissue modifications using different modes of instrumentation were assessed in four publications. The data demonstrate less potential of harm to the gingiva after spraying with glycine powder compared to sodium bicarbonate powder or instrumentation with curettes. Conclusion: Glycine powder air polishing may be safely applied to human root surfaces and gingivae. Key words: air polishing; cementum; dentine; gingiva; glycine

Introduction

Dates: Accepted 27 November 2014 To cite this article: Int J Dent Hygiene DOI:10.1111/idh.12120 B€ uhler J, Amato M, Weiger R, Walter C. A systematic review on the effects of air polishing devices on oral tissues. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Several instruments and techniques, including hand instruments and ultrasonic scalers, are available and scientifically proven for periodontal therapy (1). To date, there are no sufficient alternatives to the mechanical deterioration of the oral biofilm. This multilayered ‘organized’ microbial community protects the bacteria from the attack by the host’s own immune system and from antimicrobial agents such as mouth rinses or local and systemic antibiotics (2, 3). During the instrumentation of the root surface, supra- and subgingival calculus and biofilm should be removed. However, treating the root surface for many years contributes to a significant removal of tooth substance (4, 5). Opposed to the first treatment phase, for many periodontia, the deterioration of the biofilm becomes the sole focus of attention in the regularly applied supportive periodontal treatment (SPT). Air polishing devices are suggested as an alternative for periodontal maintenance (6). Int J Dent Hygiene |

1

B€ uhler et al. Air polishing devices and oral tissues

The operating principle of these systems is based on compressed air that combines a powder medium with water that is delivered to the tooth surface (7). They were clinically applied in SPT, and some reports indicate promising results (8–10). Different powders, including sodium bicarbonate, calcium carbonate, bioactive glass, pumice or glycine, are available on the market (11, 12). The surface modifications of the treated root surface caused by the powders are of utmost importance for SPT. Technical parameters such as the consistency, grain size and shape of a powder as well as the mode of clinical application, including distance, angulation and treatment time, seem to affect the potential of harm of the individual powder. The aim of this systematic review was to analyse the effects of air polishing devices on oral soft and hard tissues with respect to periodontal treatment. The patient perception of periodontal therapy using air polishing devices was considered within a separate manuscript.

Materials and methods Protocols

The present systematic review considered the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) criteria (13, 14). The research questions were adapted using the Population, Intervention, Comparison, Outcomes (PICO) criteria (15). Focused PICO question

Box 1. Search terms used for PubMed-MEDLINE, EMBASE and the Cochrane Library

Search terms used for PubMed-MEDLINE, EMBASE and the Cochrane Library. The search protocols in the different databases were validated and created as identical as possible. Combinations of the search terms ‘Dental Prophylaxis/adverse effects’ OR ‘Dental Prophylaxis/instrumentation’ OR ‘Dental Prophylaxis/methods’ OR ‘Dental Prophylaxis/standards’ OR ‘Dental Polishing’ AND ((air AND polish*[OR subging*)) were applied. The following search terms were used: MEDLINE: ‘Dental Enamel’ [Mesh] OR ‘Dental Prophylaxis/adverse effects’[Mesh] OR ‘Dental Prophylaxis/instrumentation’ [Mesh] OR ‘Dental Prophylaxis/ methods’ [Mesh] OR ‘Dental Prophylaxis/standards’ [Mesh] OR ‘Dental Polishing’ [Mesh]) AND ((air [tiab] AND polish*[tiab]) OR subging* [tiab]. EMBASE: ‘enamel’/exp AND ‘preventive dentistry’/exp AND ‘mouth hygiene’/exp AND ‘dental equipment’/exp AND ‘procedures’/exp AND ‘gold standards’/exp AND ‘tooth brushing’/exp AND ‘dental surgery’/exp AND ‘periodontics’/exp. Cochrane Library: [Dental Cementum] explode all trees OR [Dentin] explode all trees AND [Periodontics] explode all trees OR [Periodontal Debridement] explode all trees OR [Dental Prophylaxis] explode all trees AND [Air Abrasion, Dental] explode all trees OR [Subgingival Curettage] explode all trees OR [Dental Polishing] explode all trees.

vivo. Review articles, case reports and clinical notes and comments were excluded. Only studies in German or English language were considered. No time restrictions were applied.

What are the effects of air polishing devices on human peri-

Study selection

odontal soft and dental hard tissues, such as dentine, cemen-

The combination of search terms resulted in a list of 1266 titles, that is 1252 titles from the electronic databases and 14 titles from the hand search (Fig. 1). The located titles and abstracts were screened for compliance with the inclusion criteria of the review by the authors (J. B., M. A.). A third reviewer (C. W.) resolved any disagreements and made the final decision. The data on patient perception of periodontal treatment using air polishing devices are presented separately.

tum and gingiva?

The effects of air polishing devices on soft and hard tissues such as gingival trauma and surface modifications on cementum and/or dentine were considered as primary outcome. Review of the current literature Information sources

The electronic databases MEDLINE, EMBASE and the Cochrane Library were searched for studies published prior to 18 November 2013. Moreover, the references of publications examined for inclusion were thoroughly analysed to search for additional studies. The search terms are shown in Box 1. Eligibility criteria

The selection of publications was limited to original studies that provided data validated with control groups on surface modifications on human cementum and/or dentine (defect depth, defect volume, surface roughness) and/or the state of the marginal gingiva (gingival erosion, gingival trauma) after the instrumentation using air polishing devices in vitro and ex 2

| Int J Dent Hygiene

Data collection process Data items

The following data were collected in data extraction files: (P) number of teeth, tooth type, type of tissue (I) setting (in vitro, ex vivo), device, (C) powders used, control treatments, measurements (O), and surface modifications, for example defect depth and volume, surface roughness, removal of root substance, gingival erosion and gingival trauma. Risk of bias in individual studies

The risk of bias of individual studies was evaluated using the modified items (e.g. randomization, concealment of

Identification

B€ uhler et al. Air polishing devices and oral tissues

PubMed-MEDLINE 554

EMBASE 51

Cochrane 651

Records after duplicates removed 1252

Screening

Hand search 14 Records screened 1266

Records excluded 1213

Eligibility

Final selection 24

Analysed

Fig. 1. Selection process of the studies included.

Full-text articles assessed for eligibility 51

Included

Excluded full-text articles 29

Effects on oral tissues 17

allocation) from the Cochrane Collaboration’s tool for assessing risk of bias (16) and the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) statement (17) (Appendix S2). Considering the adequacy in the respective studies, the studies were graded, and the percentage of positively graded items was calculated (16, 18) (Appendix S3). Summary measures

Most studies analysed surface modifications on cementum and dentine such as defect depth and volume after spraying with different powders. Surface roughness was assessed by two publications (19, 20), and another three studies analysed the removal of root substance (11, 21, 22). Soft tissue modifications such as gingival trauma and gingival erosion were evaluated in four publications (23–26). Synthesis of results

A great heterogeneity in setting parameters, spraying protocols and data analysis exists among the studies included in the review. Therefore, a meta-analysis was not appropriate and was not performed. However, to provide a limited synthesis of the evidence of the included data, a vote-counting method was applied (http://handbook.cochrane.org/chapter_9/ 9_4_11_use_of_vote_counting_for_meta_analysis.htm).

- No control groups: 2 - No data on surface modifications on periodontal soft and hard tissues or patient perception: 11 - Clinical notes and comments : 5 - Not published in German or English: 6 - Animal study: 2 - Not original study (review): 2 - Study not available: 1

Patient perception 9

Results Study selection

Fifty-one publications were selected for eligibility. The agreement between the reviewers was calculated using a Bayesian approach indicating a kappa value 0.795 and a credible interval (corresponding to a conventional confidence interval) of 0.773 < ICC < 0.816. This value represented a substantially strong agreement. Full-text analysis of the 51 publications, selected by at least one reviewer, led to exclusion of further 29 publications. The reasons for exclusion are summarized in Appendix S1. Of the remaining 24 publications, nine studies from the electronic search and eight additional publications satisfied the inclusion criteria. The studies were published in the period from 1984 to 2012. The remaining nine studies were analysed in a separate manuscript, that is the patient perception of periodontal treatment using air polishing devices.

Description of characteristics, results and quality assessment The study characteristics are summarized in Table 1, and the results related to the outcome parameter are outlined in Table 2. Int J Dent Hygiene |

3

B€ uhler et al. Air polishing devices and oral tissues

Table 1. Characteristics of included studies In vitro studies

Author (Year) Citation Number Tada et al. (2012) (32) Pelka et al. (2010) (12)

Tada et al. (2010) (31) Petersilka et al. (2003) (29)

Petersilka et al. (2003) (30)

Agger et al. (2001) (33) Bester et al. (1995) (28) Leknes et al. (1991) (20)

Lavigne et al. (1988) (19) Horning et al. (1987) (22) Berkstein et al. (1987) (21)

Galloway and Pashley (1987) (11)

Number of teeth Tooth type Tissue 96 n.r. Dentine 168 Maxillary and mandibular molars Dentine 36 n.r. Dentine 126 Canines, premolars, molars Root surface 270 Canines, premolars, molars Root surface 50 All tooth types Root surface 40 Third molars Dentine 30 Mandibular incisors Root surface 15 n.r. Root surface 15 n.r. Cementum 50 Incisors, canines, premolars Root surface 36 Maxillary and mandibular first, second and third molars Root surface

Setting

Device

Treatment Powder

Measurement

In vitro

Air Flow S2*

Sodium bicarbonate, glycine

Electron microanalyzer, 3D-measuring microscopy, SEM

In vitro

Handy Jet a*, Prophyflex 3†

Sodium bicarbonate, glycine, calcium carbonate

Laser scanning microscopy

In vitro

Handy Jet a*

Sodium bicarbonate, glycine

Electron microanalyzer, 3D-measuring microscopy, SEM

In vitro

Air Flow S1*

Sodium bicarbonate, powders A, B, C, D‡

Impressions, replicas, laser scanner, superimposition

In vitro

Prophy-Jet§

Sodium bicarbonate

Impressions, replicas, laser scanner, superimposition

In vitro

Prophyflex 2†

Sodium bicarbonate

Optical profilometer, SEM

In vitro

Siroflow¶

Sodium bicarbonate

Electronic digimatic indicator, SEM

In vitro

Air Flow*

Profilometer

In vitro

Prophy-Jet§

Sodium bicarbonate, sonic scaler**, rubber cup and pumice, rubber cup and chalk Ultrasonic + sodium bicarbonate, ultrasonic

In vitro

Cavi-Jet§

Sodium bicarbonate

Horizontal cross sectioning, light microscopy

In vitro

Prophy-Jet§

Sodium bicarbonate, curettes

Electronic point micrometer

In vitro

ProphyJet C-100§

Sodium bicarbonate, flour of pumice

Triplicate wax patterns of defect, average weight, SEM

Smoothness†† and cleanliness scores‡‡ in SEM

In vivo/Ex vivo studies

Author (Year) Citation Number Petersilka et al. (2008) (26)

4

| Int J Dent Hygiene

Number of patients Mean age Gender Tissue 10 47.4  11.3 y 8 F, 2 M Gingiva

Setting

Device

Ex vivo SPT§§

Air Flow S1*

Powder Treatment duration Glycine, sodium bicarbonate, curettes 14 day

Measurement Biopsy, light microscopy

B€ uhler et al. Air polishing devices and oral tissues

Table 1. (Continued) In vivo/Ex vivo studies

Author (Year) Citation Number €rzeler et al. Hu (1998) (27) € rhi Kontturi-Na et al. (1989) (25)

Mishkin et al. (1985) (23)

Weaks et al. 1984 (24)

Number of patients Mean age Gender Tissue 11 44–59 y 6 F, 5 M Root surface 20 20–50 y n.r. Gingiva 21 n.r. 3 F, 18 M Gingiva 53 n.r. n.r. Gingiva

Setting

Device

Powder Treatment duration

Measurement

Ex vivo EPT¶¶

Plaque Sweep***

Sodium bicarbonate, curettes, diamond burs†††

Light microscopy, Optical surface sensor system, SEM

Ex vivo PT‡‡‡

Air Flow*

Sodium bicarbonate†††

Impressions, epoxy resin casts, SEM

In vivo PT‡‡‡

Prophy-Jet§

Sodium bicarbonate, rubber cup and pumice 21 day

TI

In vivo PT‡‡‡

Prophy-Jet§

Sodium bicarbonate, rubber cup and pumice 12 day

TI

y, years; m, months; d, days; F, Females; M, Males; n.r., not reported; SEM, scanning electron microscopy; TI, trauma Index. *EMS. †KaVo, Brugg, Switzerland. ‡Water soluble salts with varying grain sizes. §Dentsply. ¶Siemens. **Syntex Dental Products, Inc., Valley Forge, PA, USA. ††1 = Smooth appearance, no nicking or marking; 2 = Relatively smooth appearance with minimal nicking and marking; 3 = Moderately smooth, but uneven grooves, pitting, or markings; 4 = Moderately rough with uneven grooves, pitting, or markings and some isolated fissures or fractures; 5 = Rough surface, with multiple irregular and abrupt fissures and fractures. ‡‡1 = Clean surface, no superficial, scattered surface; 2 = Relatively clean surface, with some superficial surface spicules of debris; 3 = Moderately clean surface, with a light layer of debris present in discrete patches; 4 = Moderately unclean surface, with continuous single layer of debris present; 5 = Unclean surface, with a dense matrix of multiple layers of debris covering surface. §§SPT: Supportive Periodontal Treatment, subgingival application of the air polishing powder. ¶¶EPT: Experimental Periodontal Treatment, application of the air polishing powder during open flap debridement with no previous instrumentation of the root surface. ***EMDA. †††Analysis directly after treatment. ‡‡‡PT: Prophylaxis Treatment, supragingival application of the air polishing powder.

Summary of characteristics (PICO) Population – number and characteristics of subjects and teeth

Two in vivo studies (23, 24), three ex vivo studies (25–27) and 12 in vitro studies (11, 12, 19–22, 28–33) were included in this systematic review. A mean age of the patients of 47.4  11.3 year was provided in one publication (26), and two studies provided an age range of 20–50 years (25) and 44 –59 years, respectively (27). All further studies declared no information about the age of included patients. All but two (26, 27) of the included in vivo and ex vivo studies stated that their patients were systemically healthy. Three studies did not provide any information about medication of the included patients (24, 26, 27), and two studies defined medication such as antibiotics as exclusion criterion (23, 25). Gingival status of the patients was stated as healthy gingiva in all but one (27)

included in vivo and ex vivo publications (23–26). In two studies, patients suffered from periodontitis (26, 27), and another study stated that the participants had no periodontitis (24). Patients were undergoing SPT (26) or prophylaxis treatment (23–25), or periodontal surgery (27). The number of patients in the included publications ranged from 10 (26) to 53 patients (24). The overall number of patients was 115 (Table 1). Additionally, three studies mentioned the sex of participants (23, 26, 27). The effects of air polishing devices on the gingiva were analysed in four studies (23–26). Analysed teeth varied from molars (11, 12, 28–30), premolars (21, 29, 30), canines (21, 29, 30) and incisors (20, 21). One study did include all tooth types (33), and four studies did not provide tooth type (19, 22, 31, 32). Before spraying of tooth surfaces with an air polishing device, surfaces were either cleaned with a rotary brush and pumice (29, 30) or a curette

Int J Dent Hygiene |

5

6

| Int J Dent Hygiene

Petersilka et al. (2003) (29)

Tada et al. (2010) (31)

Pelka et al. (2010) (12)

Tada et al. (2012) (32)

Author (Year) Citation Number

Defect depth: 2 mm spraying distance: sodium bicarbonate (68.967  12.184 lm) > glycine Ø25 lm (98.283  24.039 lm)* > glycine Ø65 lm (48.217  06.193 lm)* Defect volume: 3 mm spraying distance: sodium bicarbonate (0.027  0.003 mm3) > glycine Ø25 lm (0.025  0.004 mm3)* > glycine Ø65 lm (0.013  0.003 mm3)* 2 mm spraying distance: glycine Ø25 lm (0.026  0.009 mm3) > glycine Ø65 lm (0.015  0.004 mm3)* No major differences at greater spraying distances Crater-shaped defects in SEM Defect depth, defect volume: calcium carbonate  sodium bicarbonate > glycine*,‡ Prophyflex 3 > Handy Jet a*,‡ Increase of root defects with increasing treatment time for calcium carbonate* and sodium bicarbonate*,‡ Defect depth: 90° angulation: sodium bicarbonate (110.5  6.716 lm)  glycine Ø63 lm (88.667  7.737 lm) > glycine Ø100 lm (63.333  12.879 lm)* Defect volume: 90° angulation: sodium bicarbonate (0.043  0.004 mm3) > glycine Ø63 lm (0.024  0.003 mm3)* > glycine Ø100 lm (0.013  0.003 mm3)* No major differences at different angulations Crater-shaped defects in SEM Defect size: Sodium bicarbonate (163.1  71.1 lm) > A (17.9  10.9 lm)*, B (48.2  32.7 lm)*, C (92.5  57.9 lm)* and D (33.9  19.6 lm)*

Main outcome

In vitro studies

Table 2. Outcome of included studies

Glycine 0

0

0

n.a.

Sodium bicarbonate +

+

+

+

n.a.

n.a.

+

n.a.

Calcium carbonate

0

n.a. n.a.

n.a.

n.a.

Powder A

0

n.a.

n.a.

n.a.

Powder B

Rating of the potential of harm (vote counting method)

0

n.a.

n.a.

n.a.

Powder C

0

n.a.

n.a.

n.a.

Powder D

n.a.

n.a.

n.a.

n.a.

Chalk

n.a.

n.a.

n.a.

n.a.

Pumice

n.a.

n.a.

n.a.

n.a.

Curettes

n.a.

n.a.

n.a.

n.a.

Ultrasonic scaler

B€ uhler et al. Air polishing devices and oral tissues

Horning et al. (1987) (22)

Lavigne et al. (1988) (19)

Leknes et al. (1991) (20)

Agger et al. (2001) (33) Bester et al. (1995) (28)

Petersilka et al. (2003) (30)

Author (Year) Citation Number

Defect depth, defect volume: Instrumentation time had the strongest influence on defect depth (b-weight 0.57) and defect volume (b-weight 0.60)* Greater defect depth and defect volume with increasing amount of powder (b-weight 0.3)* (b-weight 0.49)* and water (b-weight 0.3)* (b-weight 0.28)* Distance negligible concerning defect volume (b-weight 0.04), but not defect depth (b-weight 0.44) No major differences at different angulations Defect depth: Exposed surface (484  196 lm) > unexposed surface (323  153 lm)* Crater-like defects in SEM Dentin removal: 40 s > 20 s* > 10 s* > 5 s*,‡ 5 s exposure: removal of smear layer, opening of dentinal tubuli Longer than 5 s exposure: obstruction of dentinal tubuli Surface roughness Ra†: Group 1: scaling (1.686  0.408) > sodium bicarbonate (1.410  0.329)* > chalk (1.198  0.265)* Group 2: scaling (1.549  0.291) > pumice (1.265  0.196)* > chalk (1.104  0.225)* Group 1  Group 2 Smoothness§: no treatment (4.58  0.71) < ultrasonic only (3.96  0.97)*  ultrasonic + sodium bicarbonate (4.17  1.09) Cleanliness¶: no treatment (3.79  0.98) < ultrasonic only (2.49  0.82)*, ultrasonic + sodium bicarbonate (2.50  0.74)* Cementum removal: 20 s exposure: (51.09  19.81 lm) 40 s exposure: (80.34  25.38 lm) 60 s exposure: (91.33  44.81 lm) Mean cementum removal: 18.56 lm per 10 s

Main outcome

In vitro studies

Table 2. (Continued)

Glycine n.a.

n.a.

n.a.

n.a.

n.a.

n.a.

Sodium bicarbonate +

+

+

+

0

+

n.a.

n.a.

n.a.

n.a.

n.a.

n.a.

Calcium carbonate

n.a.

n.a.

n.a.

n.a.

n.a.

n.a.

Powder A

n.a.

n.a.

n.a.

n.a.

n.a.

n.a.

Powder B

Rating of the potential of harm (vote counting method)

n.a.

n.a.

n.a.

n.a.

n.a.

n.a.

Powder C

n.a.

n.a.

n.a.

n.a.

n.a.

n.a.

Powder D

n.a.

n.a.

0

n.a.

n.a.

n.a.

Chalk

n.a.

n.a.

n.a.

n.a.

n.a.

n.a.

Pumice

n.a.

n.a.

++

n.a.

n.a.

n.a.

Curettes

n.a.

0

n.a.

n.a.

n.a.

n.a.

Ultrasonic scaler

B€ uhler et al. Air polishing devices and oral tissues

Int J Dent Hygiene |

7

8

| Int J Dent Hygiene

Root substance removal: 12 applications (simulating 3 years therapy): curettes (325.09 lm) > sodium bicarbonate (127.66 lm)* Root substance removal: Increase with increasing treatment time for both powders*,‡ 5–10 s exposure: pumice , > sodium bicarbonate* ‡ 15–60 s exposure: sodium bicarbonate  pumice‡ Crater-like defects, smear layer in SEM

Main outcome

Petersilka et al. (2008) (26) €rzeler Hu et al. (1998) (27)

Author (Year) Citation Number

n.a.

0

0 1 0

n.a.

n.a.

Powder B

Sodium bicarbonate

Potential of harm

0

0 1 0

n.a.

n.a.

Powder A

Surface roughness Ra† and Rt‡‡: Ra: Curettes (1.96  1.05)* > Curettes + diamond bur (1.18  0.34)* > Curettes + diamond bur + Sodium bicarbonate (0.78  0.12)* Rt: Curettes (12.84  5.33)* > Curettes + diamond bur (9.59  2.36)* > Curettes + diamond bur + Sodium bicarbonate (6.54  0.90)* Residual stain: No treatment (53.5  27.4%) > Curettes (4.2  2.1%)* > Curettes + diamond bur (2.0  0.9%)* > Curettes + diamond bur + Sodium bicarbonate (0.6  0.6%)*

1 1 1

n.a.

n.a.

Calcium carbonate

+

0 3 0

n.a.

+

10 12 0.8

Glycine

Sodium bicarbonate

Rating of the potential of harm (vote counting method)

Gingival erosion††: Curettes (scores 3 and 4) > sodium bicarbonate (scores 2 and 3)* > glycine (scores 1 and 2)*

Main outcome

In vivo/Ex vivo studies

Sum Number of studies analysing this treatment Score**

Berkstein et al. (1987) (21) Galloway and Pashley (1987) (11)

Author (Year) Citation Number

In vitro studies

Table 2. (Continued)

n.a.

0

Glycine

0 1 0

n.a.

n.a.

Powder C

0 1 0

n.a.

n.a.

0 1 0

n.a.

n.a.

Chalk

n.a.

+

++

2 2 1

n.a.

+

1 1 1

0

Curettes

n.a.

Ω

Pumice

++

Curettes

Powder D

n.a.

n.a.

Rubber cup/pumice

0 1 0

n.a.

n.a.

Ultrasonic scaler

B€ uhler et al. Air polishing devices and oral tissues

Gingival erosion§§: Score 0: baseline (40%) > after treatment (0%)* Score 4: baseline (0%) > after treatment (23%)* Increased erosive changes with presence of gingival inflammation: Score 0: baseline (13.3%) > after treatment (2.5%)* Score 4: baseline (0%) > after treatment (62.5%)* Gingival trauma: Baseline: sodium bicarbonate  pumice After treatment: sodium bicarbonate > pumice* After 7 day: sodium bicarbonate  pumice After 21 day: sodium bicarbonate  pumice‡ Gingival trauma¶¶: Pumice: baseline (0.21  0.13)  after treatment (0.23  0.16)  after 6 day (0.20  0.14) Sodium bicarbonate: baseline (0.22  0.15) < after treatment (0.75  0.37)*

Main outcome

0 1 0

n.a.

+

3 5 0.6

n.a.

n.a.

+

0

Glycine

Sodium bicarbonate

Potential of harm

4 2 2

n.a.

n.a.

n.a.

Curettes

1 1 1

n.a.

n.a.

n.a.

Ω

0 3 0

0

0

n.a.

Rubber cup/pumice

Ø, Diameter; n.a., not applicable; SEM, scanning electron microscopy. *P < 0.05. †Ra = (lm) profile roughness parameter, average roughness. ‡No numbers provided/data provided as figures. §1 = Smooth appearance, no nicking or marking; 2 = Relatively smooth appearance with minimal nicking and marking; 3 = Moderately smooth, but uneven grooves, pitting, or markings; 4 = Moderately rough with uneven grooves, pitting, or markings and some isolated fissures or fractures; 5 = Rough surface, with multiple irregular and abrupt fissures and fractures. ¶1 = Clean surface, no superficial, scattered surface; 2 = Relatively clean surface, with some superficial surface spicules of debris; 3 = Moderately clean surface, with a light layer of debris present in discrete patches; 4 = Moderately unclean surface, with continuous single layer of debris present; 5 = Unclean surface, with a dense matrix of multiple layers of debris covering surface. **Score: For this analysis, the treatments were compared in each study. The treatments causing statistically significant more harm received ‘+’ in increasing numbers for the comparison of the treatments in the respective study. The score was calculated by dividing the number of ‘+’ by the number of studies analysing this treatment. A higher score provides a proximate for the increased potential of harm. ††1 = No lesion: undamaged epithelium and connective tissue; 2 = Minor lesion: disruption of superficial epithelial layers, undamaged basal membrane; 3 = Medium lesion: superficial layers of the epithelium removed, basal membrane partially damaged; 4 = Severe lesion: epithelium and basal membrane completely removed, connective tissue exposed. ‡‡Rt = (lm) profile roughness parameter, maximum peak-to-valley height. §§0 = Healthy smooth epithelial surface; 1 = Only superficial abrasion or roughness on the epithelial surface; 2 = Scattered eroded or rough areas on gingival or mucosal surface; 3 = Severe erosion in the whole free gingival margin or in attached gingiva; 4 = Exudation on the eroded surface. ¶¶0 = No abrasion, no bleeding, no colour change; 1 = No noticeable epithelial abrasion, slight bleeding, slight colour change; 2 = Some epithelial abrasion, considerable bleeding, marked colour change; 3 = Marked abrasion exposing underlying tissue, profuse bleeding, and considerable colour change.

Sum Number of studies analysing this treatment Score**

Weaks et al. (1984) (24)

Mishkin et al. (1985) (23)

Kontturi€rhi Na et al. (1989) (25)

Author (Year) Citation Number

In vivo/Ex vivo studies

Table 2. (Continued)

B€ uhler et al. Air polishing devices and oral tissues

Int J Dent Hygiene |

9

B€ uhler et al. Air polishing devices and oral tissues

and rubber cup with abrasive (21), or they were scaled with ultrasonic devices (22). In one study, tooth surfaces were wiped dry with a gauze sponge (11), and in four studies, teeth were ground with abrasive paper (12, 28, 31, 32). Four studies did not treat the tooth surfaces before air polishing (19, 20, 27, 33). The effects of air polishing devices were analysed in four studies on dentine (12, 28, 31, 32) and in one on cementum (22). Eight studies did not further define the character of the ‘root surface’ (11, 19–21, 27, 29, 30, 33).

Surface modifications on cementum and dentine

Most publications reported defect depths (12, 30–33) defect volume (12, 30–32) or defect size (29) of cementum or dentine caused by air polishing powders. The amount of removed root substance was analysed by five studies (11, 21, 22, 28). Some other publications reported surface roughness values (20, 27) or scored smoothness and cleanliness of treated surfaces (19) or analysed the amount of residual stain (27). Details about the methods to assess surface modifications are described in Table 1.

Intervention – methods and measurements Methods

Outcomes – effects on dental hard and periodontal soft tissues Soft tissue modifications

Air polishing devices and powders

Devices: Different modes of powder application, including AIRFLOW devices (EMS SA, Nyon, Switzerland) (12, 20, 25, 26, 29, 31, 32), Cavi- or Prophy-Jet (Cavitron; Dentsply International, York, PA, USA) (11, 19, 21–24, 30), Prophyflex (KaVo, Biberach, Germany) (12, 33), Plaque Sweep (EMDA, Frankfurt, Germany) (27) or Siroflow (Siemens, Medical Engineering Group, Dental Sector, Bensheim, Germany) (28), were used. Powders: The different powders used in the publications consisted of sodium bicarbonate (11, 12, 19–33), glycine (12, 26, 31, 32), calcium carbonate (12) or pumice (11) (Table 2). The grain size of the different powders ranged between 25 lm (32) and 180 lm (11). Twelve publications did not provide data on the grain sizes of the powders used (19–24, 26– 30, 33). Treatment parameters. The effects of air polishing devices on periodontal tissues were analysed with respect to treatment time, angulation and distance from the nozzle to the treated surface. Several combinations of these parameters were tested in the included publications. The distances varied from 1 mm (22) to 8 mm (19). Six publications did not further reveal the spraying distance (20, 21, 25–28). Treatment time per tooth or surface ranged between 5 s (12) and 60 s (22). One publication stated the exposure time per dentition, which ranged between 5 and 10 min (25). Three publications did not provide data about exposure time (21, 23, 24). The angulations of the spraying nozzle varied between 45° (30) and 120° (22). Six publications did not further reveal the angulations of the spraying nozzle (19, 20, 24, 25, 27, 28). Assessments. Assessments of the effects of air polishing devices on oral tissues were accomplished using different methods. Soft tissue modifications

In one publication, biopsies of treated gingiva were analysed with a light microscope, and histological scores were applied (26). One publication quantified the gingival erosion by analysing epoxy resin replicas of treated gingival epithelium with a scanning electron microscope (SEM) (25). Two publications measured gingival trauma indices (TI) directly after spraying with air polishing devices, and six, respectively twelve days after therapy (23, 24). Two studies analysed gingival erosion (25, 26). 10

| Int J Dent Hygiene

Gingival trauma, gingival erosion

Histological scores ranging from 1 (no lesion) to 4 (severe lesion) from gingival biopsies were applied in one study (26). Significantly greater erosive changes of gingival epithelium after hand instrumentation with curettes (scores 3 and 4) and sodium bicarbonate powder (scores 2 and 3) compared to the sites treated with glycine powder (scores 1 and 2) (26) were documented. One publication showed that even short spraying with sodium bicarbonate caused severe erosion in the free gingival margin or in attached gingiva with exudation on the eroded surface in 23% of the treated sites (score 4) (25). These erosive changes increased significantly from 0% before treatment to 62.5% after treatment in case of gingival inflammation. In another study, the TI increased significantly from 0.22  0.15 to 0.75  0.37 after treatment with sodium bicarbonate powder, while treatment with a rubber cup and paste did not lead to an increase of TI (0.23  0.16 versus 0.21  0.13 at baseline) (24). Similar results without numerical data were shown in an additional publication (23). Surface modifications on cementum and dentine

Defect depth: Several studies reported that sodium bicarbonate air polishing caused crater-shaped defects on the root surface (12, 30–33). The defect depths after spraying with sodium bicarbonate powder were 68.967  12.184 lm with a distance of 2 mm, and a treatment time of 5 s (32). Defect depths were significantly greater with sodium bicarbonate powder compared to glycine powder (12, 31, 32) or other – not further specified – organic and inorganic salts (29). Increasing treatment time (11, 12, 28, 30), decreasing working distance and increasing powder emission (30) resulted in greater mean defect depths and increased root substance removal (Table 2). Defect volume: Significantly greater defect volumes were obtained when sodium bicarbonate was applied compared to glycine powder treatment (12, 31, 32). Defect volume was not increased with decreasing spraying distance (b-weight 0.04) (30). Different angulations induced no significant changes in defect depth or defect volume (30, 31). Root substance removal: Two studies showed that the application of sodium bicarbonate powder led to a substantial loss of dentine (127.66 lm per site over a simulated SPT of 3 years)

B€ uhler et al. Air polishing devices and oral tissues

(21) and cementum (18.56 lm per 10 s) (22). Two other studies stated similar findings, but did not provide numbers and showed data as figures (11, 28). Surface roughness: One publication reported that dentine polished with pumice after sonic scaling showed a similar reduction in roughness values (Ra 1.265  0.196) when polished with sodium bicarbonate powder (Ra 1.410  0.329) (20). Another study showed that there was no significant difference in smoothness scores (1 = smooth surface, 5 = rough surface) between dentine treated with an ultrasonic device (3.96  0.97) and similarly treated dentine that underwent adjunctive polishing with sodium bicarbonate powder (4.17  1.09) (19). The instrumentation of root surfaces with curettes (Ra 1.96  1.05) or instrumentation with curettes and subsequent polishing with a perio-diamond bur (Ra 1.18  0.34) leads to significantly higher roughness than root surfaces that were instrumented with curettes, polished with a perio-diamond bur and afterwards polished with sodium bicarbonate (Ra 0.78  0.12) (27). Cleanliness

Cleanliness scores (1 = clean surface, 5 = unclean surface) on dentine were significantly greater after treatment with an ultrasonic device and adjunctive sodium bicarbonate powder spraying (2.50  0.74) compared to no treatment (3.79  0.98) (19). However, there was no difference in cleanliness between dentine treated with an ultrasonic device followed by polishing with sodium bicarbonate powder compared to ultrasonic treatment alone (2.49  0.82). One study showed that the instrumentation of root surfaces with curettes, perio-diamond burs and sodium bicarbonate leads to significantly less residual stain (0.6  0.6%) than treatment with curettes and perio-diamond burs (2.0  0.9%), or instrumentation with curettes alone (4.2  2.1%) (27). Risk of bias

At least 43% of items relevant for quality assessment were considered in all included studies, except in three studies (Appendix S3). No study fulfilled all items for control of bias. The protocol of three studies was ethically approved. Eligibility criteria for included probands or teeth were mentioned in nine studies. All studies described the applied methods in detail. Examiner calibration and validation of reproducibility were not always reported. Variability of results was presented by means with standard deviations and/or range of individual values in 12 studies. Three studies reported data on all outcome variables in terms of number of participants or teeth and tooth sites, treatment time, working distance and control treatment.

Discussion This systematic review analysed the effects of air polishing on dental hard and periodontal soft tissues, that is dentine, cementum and gingiva. Seventeen publications satisfied the

inclusion criteria for the analysis. Four studies reported data on the outcome with respect to the state of the marginal gingiva (gingival erosion, gingival trauma). The surface modifications on cementum and dentine (i.e. defect depth, defect volume, surface roughness) were addressed in 13 studies. The synthesis of the available evidence using a vote-counting method provides a careful proximate revealing, that treatment with sodium bicarbonate is associated with gingival trauma (score: 0.6, Table 2) (23–26), and distinct defects on the root surface (score: 0.8) (11, 22, 28, 30–33). On the contrary, spraying with glycine powder seems to result in less gingival trauma (score: 0) (26) and less surface modifications on dentine (score: 0) (12, 29, 31, 32) compared to sodium bicarbonate and conventional therapy with curettes and ultrasonic devices. Additionally, one publication showed that spraying with sodium bicarbonate was more time efficient (3.23 s per surface) compared to scaling and root planing with curettes (10.185 s per surface) (21). Limitations

Several possible covariates need to be considered when comparing the data: 1 Due to the remarkable differences in the morphological, chemical and physical properties between animal and human oral hard and soft tissues (34), data were exclusively collected from studies performed in humans or using human tissues. 2 Any relevant work published in the English or German language and presenting pertinent information about the described outcome variables was considered for inclusion in the review. However, there may be other evidence, but for convenience, the search was limited to English and German publications and the grey literature was not actively searched. 3 The studies included in this review were published within the time frame from 1984 to 2012. Dental treatment concepts and/or materials have changed over time. The studies included in this analysis may reflect the development of air polishing devices with respect to content, shape and/or grain size of the powders and the areas for clinical use from supra- to subgingival application. 4 One important observation is that different air polishing devices were used in the included studies. This finding should be kept in mind when the state of the gingiva after the instrumentation or the surface modifications caused by a powder are interpreted. Several devices feature different technical parameters, such as different air pressure, powder delivery mechanisms or powder emission rates. Therefore, they may lead to different defect dimensions and treatment outcomes (12). 5 Different test settings were applied in the study designs of the publications analysed. Treatment parameters such as working distance and angulation of the spraying nozzle varied within a great range. It was demonstrated that working distance had an impact on defect depths and volume, that is decreasing working distance (30, 32) leading to a greater defect depth. However, different angulations did not seem to have a significant influence on defect depth and volume (30, 31). Int J Dent Hygiene |

11

B€ uhler et al. Air polishing devices and oral tissues

6 The treatment time varied from 5 s to 1 min (12, 22). Increasing treatment time had a strong effect on defect depth and volume (11, 12, 28, 30). The mean time for a single SPT session is about 45–60 min. This means that the time available for a tooth surface amounts to 5–20 s. Therefore, exposure times up to 20 s seem to be realistic and may represent SPT in the long term (30). 7 The effects of conventional instrumentation using curettes and ultrasonic devices on the root surface and the gingiva are well known and documented (4, 5, 26). In some studies, the instrumentation of the root surface was conducted using a combination of different instruments, such as sodium bicarbonate combined with ultrasonic scalers (19, 20), with curettes and with perio-diamond burs (27). As there were no control groups that analysed the effects of sodium bicarbonate alone, it is not possible to determine to what amount this combined treatment may affect the outcomes. 8 Most of the included studies in this review were not funded independently or were established in close cooperation with the manufacturer of the assessed products (12, 19, 20, 22–26, 28–33). This might raise the risk of bias.

Conclusion The level of evidence and the strength of recommendation of the included studies were evaluated according to the SORT grading (35, 36). The studies included for the surface modifications on periodontal soft and dental hard tissues (i.e. dentine, cementum) were performed in vitro and ex vivo, and only some studies were performed in vivo. Therefore, the strength of recommendation need to be considered as grade C, that is disease-oriented evidence. Consistent evidence suggests that sodium bicarbonate powders should not be used in periodontally affected dentitions because of their considerable potential of harm to cementum, dentine and gingiva (score: 0.8, score 0.6). There is consistent evidence demonstrating less potential of harm on soft and hard periodontal tissues of powders consisting of glycine (score 0, score 0). The level of evidence regarding the effects of air polishing devices on these oral tissues can therefore be considered as moderate, that is according to the definition: ‘we are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different’ (http://www.jclinepi.com/article/S0895-4356(10) 00332-X/fulltext).

Directions for further research The data from this review indicate that some powders are less harmful to the gingiva and cause minor surface modifications on dentine and cementum. However, consideration of the following parameters is suggested for future research: The use of: 1 human teeth or tissues 2 clinically relevant treatment protocols 12

| Int J Dent Hygiene

3 suitable methods for quantification of surface modifications with appropriate examination methods (i.e. measuring of profile and surface roughness).

Clinical relevance Scientific rationale for the study

Air polishing devices are applied in periodontally affected dentitions to remove supra- and subgingival biofilm. Principal findings

There is sufficient evidence demonstrating less potential of harm on soft and hard oral tissues for powders consisting of glycine compared to powders consisting of sodium bicarbonate. Practical implications

Sodium bicarbonate powders should not be used in periodontally affected dentitions because of their considerable potential of harm to cementum, dentine and gingiva.

Acknowledgements J. B€ uhler conducted parts of this research in partial fulfilment of the requirements for an MD degree from the University of Basel, Switzerland. The authors thank Dr. Mirko von Elstermann for assistance with the literature search.

Conflict of interest and sources for funding The author Mauro Amato declares no conflict of interest. An in vitro analysis of the effects of novel air polishing devices on human teeth is currently under preparation. The latter project is supported in part by an unrestricted grant by Electro Medical Systems (EMS), Nyon, Switzerland to Julia B€ uhler, Roland Weiger and Clemens Walter.

References 1 Walmsley AD, Lea SC, Landini G, Moses AJ. Advances in power driven pocket/root instrumentation. J Clin Periodontol 2008; 35: 22– 28. 2 Fux CA, Stoodley P, Hall-Stoodley L, Costerton JW. Bacterial biofilms: a diagnostic and therapeutic challenge. Expert Rev Anti Infect Ther 2003; 1: 667–683. 3 Socransky SS, Haffajee AD. Dental biofilms: difficult therapeutic targets. Periodontol 2000 2002; 28: 12–55. 4 Cadosch J, Zimmermann U, Ruppert M, Guindy J, Case D, Zappa U. Root surface debridement and endotoxin removal. J Periodontal Res 2003; 38: 229–236. 5 Ritz L, Hefti AF, Rateitschak KH. An in vitro investigation on the loss of root substance in scaling with various instruments. J Clin Periodontol 1991; 18: 643–647.

B€ uhler et al. Air polishing devices and oral tissues

6 Sculean A, Bastendorf KD, Becker C et al. Paradigm shift in mechanical biofilm management? Quintessence Int 2013; 44: 475–477. 7 Petersilka GJ. Subgingival air-polishing in the treatment of periodontal biofilm infections. Periodontol 2000 2011; 55: 124–142. 8 H€agi TT, Hofmanner P, Salvi GE, Ramseier CA, Sculean A. Clinical outcomes following subgingival application of a novel erythritol powder by means of air polishing in supportive periodontal therapy: a randomized, controlled clinical study. Quintessence Int 2013; 44: 753–761. 9 Flemmig TF, Arushanov D, Daubert D, Rothen M, Mueller G, Leroux BG. Randomized controlled trial assessing efficacy and safety of glycine powder air polishing in moderate-to-deep periodontal pockets. J Periodontol 2012; 83: 444–452. 10 Wennstr€ om JL, Dahlen G, Ramberg P. Subgingival debridement of periodontal pockets by air polishing in comparison with ultrasonic instrumentation during maintenance therapy. J Clin Periodontol 2011; 38: 820–827. 11 Galloway SE, Pashley DH. Rate of removal of root structure by the use of the Prophy-Jet device. J Periodontol 1987; 58: 464–469. 12 Pelka M, Trautmann S, Petschelt A, Lohbauer U. Influence of airpolishing devices and abrasives on root dentin-an in vitro confocal laser scanning microscope study. Quintessence Int 2010; 41: e141–e148. 13 Liberati A, Altman DG, Tetzlaff J et al. The PRISMA statement for reporting systemic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ 2009; 339: b2700. 14 Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol 2009; 62: 1006–1012. 15 Miller SA, Forrest JL. Enhancing your practice through evidencebased decision making: PICO, learning how to ask good questions. J Evid Based Dent Pract 2001; 1: 136–141. 16 Graziani F, Figuero E, Herrera D. Systematic review of quality of reporting, outcome measurements and methods to study efficacy of preventive and therapeutic approaches to peri-implant diseases. J Clin Periodontol 2012; 39: 224–244. 17 Pjetursson BE, Zwahlen M, Lang NP. Quality of reporting of clinical studies to assess and compare performance of implant-supported restorations. J Clin Periodontol 2012; 39: 139–159. 18 Schmidt JC, Sahrmann P, Weiger R, Schmidlin PR, Walter C. Biologic width dimensions–a systematic review. J Clin Periodontol 2013; 40: 493–504. 19 Lavigne CK, Nauman RK, Munley MM, Suzuki JB. In vitro evaluation of air-powder polishing as an adjunct to ultrasonic scaling on periodontally involved root surfaces. J Dent Hyg 1988; 62: 504–509. 20 Leknes KN, Lie T. Influence of polishing procedures on sonic scaling root surface roughness. J Periodontol 1991; 62: 659–662. 21 Berkstein S, Reiff RL, McKinney JF, Killoy WJ. Supragingival root surface removal during maintenance procedures utilizing an airpowder abrasive system or hand scaling. An in vitro study. J Periodontol 1987; 58: 327–330. 22 Horning GM, Cobb CM, Killoy WJ. Effect of an air-powder abrasive system on root surfaces in periodontal surgery. J Clin Periodontol 1987; 14: 213–220. 23 Mishkin DJ, Engler WO, Javed T, Darby TD, Cobb RL, Coffman MA. A clinical comparison of the effect on the gingiva of the Prophy-Jet and the rubber cup and paste techniques. J Periodontol 1986; 57: 151–154. 24 Weaks LM, Lescher NB, Barnes CM, Holroyd SV. Clinical evaluation of the Prophy-Jet as an instrument for routine removal of tooth stain and plaque. J Periodontol 1984; 55: 486–488.

25 Kontturi-N€arhi V, Markkanen S, Markkanen H. The gingival effects of dental airpolishing as evaluated by scanning electron microscopy. J Periodontol 1989; 60: 19–22. 26 Petersilka G, Faggion CM Jr, Stratmann U et al. Effect of glycine powder air-polishing on the gingiva. J Clin Periodontol 2008; 35: 324 –332. 27 H€ urzeler MB, Einsele FT, Leupolz M, Kerkhecker U, Strub JR. The effectiveness of different root debridement modalities in open flap surgery. J Clin Periodontol 1998; 25: 202–208. 28 Bester SP, de Wet FA, Nel JC, Driessen CH. The effect of airborne particle abrasion on the dentin smear layer and dentin: an in vitro investigation. Int J Prosthodont 1995; 8: 46–50. 29 Petersilka GJ, Bell M, H€aberlein I, Mehl A, Hickel R, Flemmig TF. In vitro evaluation of novel low abrasive air polishing powders. J Clin Periodontol 2003; 30: 9–13. 30 Petersilka GJ, Bell M, Mehl A, Hickel R, Flemmig TF. Root defects following air polishing. J Clin Periodontol 2003; 30: 165–170. 31 Tada K, Kakuta K, Ogura H, Sato S. Effect of particle diameter on air polishing of dentin surfaces. Odontology 2010; 98: 31–36. 32 Tada K, Wiroj S, Inatomi M, Sato S. The characterization of dentin defects produced by air polishing. Odontology 2012; 100: 41–46. 33 Agger MS, H€orsted-Bindslev P, Hovgaard O. Abrasiveness of an air-powder polishing system on root surfaces in vitro. Quintessence Int 2001; 32: 407–411. 34 Yassen GH, Platt JA, Hara AT. Bovine teeth as substitute for human teeth in dental research: a review of literature. J Oral Sci 2011; 53: 273–282. 35 Ebell MH, Siwek J, Weiss BD et al. Strength of Recommendation Taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. Am Fam Physician 2004; 69: 549– 557. 36 Phillips B. GRADE: levels of evidence and grades of recommendation. Arch Dis Child 2004; 89: 489. 37 Atkinson DR, Cobb CM, Killoy WJ. The effect of an air-powder abrasive system on in vitro root surfaces. J Periodontol 1984; 55: 13– 18. 38 Banerjee A, Hajatdoost-Sani M, Farrell S, Thompson I. A clinical evaluation and comparison of bioactive glass and sodium bicarbonate air-polishing powders. J Dent 2010; 38: 475–479. 39 Boyde A. Airpolishing effects on enamel, dentine, cement and bone. Br Dent J 1984; 156: 287–291. 40 de Boever JA, Van de Velde F. Aerosol-jet device for plaque removal. A clinical and scanning electron microscopy study. Dtsch Zahnarztl Z 1985; 40: 725–729. 41 Glenwright HD, Knibbs PJ, Burdon DW. Atmospheric contamination during use of an air polisher. Br Dent J 1985; 159: 294–297. 42 Holm G, Berger A, Henriksson E, Jonsson U, Rimen A. Air-Flow, a realistic alternative to polishing with rubber cups and paste. Tandlakartidningen 1985; 77: 915–918. 43 Hunter KM, Holborow DW, Kardos TB, Lee-Knight CT, Ferguson MM. Bacteraemia and tissue damage resulting from air polishing. Br Dent J 1989; 167: 275–278. 44 Janicki T, Sobczak-Kupiec A, Skomro P, Wzorek Z. Surface of root cementum following air-polishing with bioactive hydroxyapatite (Ca and P mapping). A pilot study. Acta Bioeng Biomech 2012; 14: 31 –38. 45 Kee-Nichol A. Air polishing technique and patient selection. Dentalhygienistnews 1990; 3: 6. 46 Kontturi-Narhi V, Markkanen S, Markkanen H. Effects of airpolishing on dental plaque removal and hard tissues as evaluated by scanning electron microscopy. J Periodontol 1990; 61: 334–338. Int J Dent Hygiene |

13

B€ uhler et al. Air polishing devices and oral tissues

47 Kozlovsky A, Artzi Z, Nemcovsky CE, Hirshberg A. Effect of airpolishing devices on the gingiva: histologic study in the canine. J Clin Periodontol 2005; 32: 329–334. 48 Logothetis DD, Gross KB, Eberhart A, Drisko C. Bacterial airborne contamination with an air-polishing device. Gen Dent 1988; 36: 496– 499. 49 Macfarlane DW. New hand instruments for subgingival scaling. Br Dent J 1974; 136: 381–382. 50 Makinson OF. Air-polishing systems. Clinical notes no. 3. Aust Dent J 1985; 30: 136. 51 Marumo Y, Suzuki A, Kimura S et al. Clinical evaluation of air polishing systems. Shigaku 1985; 73: 124–144. 52 Newman PS, Silverwood RA, Dolby AE. The effects of an airbrasive instrument on dental hard tissues, skin and oral mucosa. Br Dent J 1985; 159: 9–12. 53 Petersilka GJ. Subgingival air-polishing in the treatment of periodontal biofilm infections. Periodontology 2000 2011; 55: 124–142. 54 Petersilka GJ, Schenck U, Flemmig TF. Powder emission rates of four air polishing devices. J Clin Periodontol 2002; 29: 694–698. 55 Rateitschak-Pl€ uss EM. Problems with subgingival scaling instruments and root planning. Dtsch Zahnarztl Z 1985; 40: 715–720. 56 Rawson RD, Nelson BN, Jewell BD, Jewell CC. Alkalosis as a potential complication of air polishing systems. A pilot study. Dent Hyg (Chic) 1985; 59: 500–503. 57 R€ uhling A, Schlemme H, K€onig J, Kocher T, Schwahn C, Plagmann HC. Learning root debridement with curettes and power-driven instruments. Part I: a training program to increase effectivity. J Clin Periodontol 2002; 29: 622–629. 58 Sauro S, Watson TF, Thompson I. Dentine desensitization induced by prophylactic and air-polishing procedures: an in vitro dentine permeability and confocal microscopy study. J Dent 2010; 38: 411–422.

14

| Int J Dent Hygiene

59 Snyder JA, McVay JT, Brown FH et al. The effect of air abrasive polishing on blood pH and electrolyte concentrations in healthy mongrel dogs. J Periodontol 1990; 61: 81–86. 60 Stirrups DR. Methods of reducing bacterial contamination of the atmosphere arising from use of an air-polisher. Br Dent J 1987; 163: 215–216. 61 Uchida T, Suda Y, Motohashi K, Suzuki A, Marumo Y, Yokozuka S. The effect of an air polishing system on orthodontic materials and tooth surfaces. Shigaku 1986; 74: 377–390. 62 Van der Linde ES, Dreyer WP, K€ uhn IK, van Heerden JD. A comparative clinical study of an air polishing instrument. J Dent Assoc S Afr 1986; 41: 453–456. 63 Worrall SF, Knibbs PJ, Glenwright HD. Methods of reducing bacterial contamination of the atmosphere arising from use of an airpolisher. Br Dent J 1987; 163: 118–119. 64 Yanagimura M, Koike F, Satoh E, Wu CS, Hara K, Kawakami T. Application of an air-powder abrasive system in periodontal therapy and its effect on root surfaces. Nihon Shishubyo Gakkai Kaishi 1988; 30: 1168–1179. 65 Yu XQ, An YB, Luan QX. Effects of bio-glass in subgingival scaling and root planing. Beijing Da Xue Xue Bao 2011; 43: 40–43.

Supporting information Additional supporting information may be found in the online version of this article. Appendix S1. Excluded studies and reason for exclusion. Appendix S2. Scores for assessment of risk of bias. Appendix S3. Risk of bias of individual studies.