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Perio Reports

Perio Reports  Vol. 23 No. 11

Perio Reports provides easy-to-read research summaries on topics of specific interest to clinicians.
Perio Reports research summaries will be included in each issue to keep you on the cutting edge
of dental hygiene science.
New Tip for Air Polishing Reaches Subgingivally

Following periodontal therapy, subgingival microflora returns within days, necessitating periodontal supportive therapy (PST) visits every few months to maintain periodontal tissue health. Mechanical disruption of the subgingival microflora has long been accomplished with hand instruments. Scraping of the root surfaces removes cementum, creating irreversible hard tissue damage and in some cases, recession.

Air polishing traditionally uses a sodium bicarbonate powder that effectively removes plaque and stains from tooth surfaces, but damages gingival tissues when directed subgingivally. To solve this problem, a glycine powder was recently introduced that does not cause tissue trauma when directed subgingivally. To enhance subgingival cleaning, EMS designed a tip to direct the glycine powder subgingivally with lower jet spray flow and lower pressure than is used supragingivally.

Researchers at the University of Geneva in Switzerland compared air polishing with glycine powder using the new subgingival tip to hand instrumentation in 50 periodontal maintenance patients. These subjects all had at least two residual pockets measuring 5mm or more in two separate quadrants. Sites for each patient were randomly assigned to test and control treatments. This seven-day study measured subgingival microflora and bleeding upon probing.

Air polishing time averaged 30 seconds per site compared to curette use averaging 1.4 minutes per site. Bleeding upon probing was reduced for both groups, with greater reduction in the control group. No differences were observed for subgingival microflora between test and control groups. No tissue trauma was noted with air polishing. Patients preferred air polishing over curettes.

Clinical Implications: The new subgingival air polishing tip provides an alternative to hand instruments for PST.

Moëne, R., Décaillet, F., Andersen, E., Mombelli, A.: Subgingival Plaque Removal Using a New Air-Polishing Device. J Perio 81: 79-88, 2010.
Subgingival Debridement Effective with Air Polisher

Periodontal therapy patients are seen frequently for supportive periodontal maintenance visits to control subgingival microflora. This is usually done with curettes or power scalers. A new subgingival approach uses glycine powder in an air polisher.

Researchers at the University of Gothenburg in Sweden compared subgingival air polishing with glycine powder to ultrasonic scaling. Perio maintenance patients with two probing sites measuring 5 to 8mm in different quadrants were included in this two-month study. The control group was treated subgingivally with the EMS Piezon Master piezoelectric scaler set at 75 percent power with water coolant. The test group was treated with a new subgingival tip on the EMS Air-Flow air polisher with glycine powder.

Subgingival bacterial samples were collected before treatment, right after treatment, two days later and at 14 days. Clinical indices were taken before treatment, 14 days and at 60 days.

A total of 20 patients were treated with air polishing at a test site in one quadrant and ultrasonic scaling at a second site in another quadrant.

Both treatments resulted in significant reductions in subgingival bacteria immediately after treatment and two days later. By day 14, both groups returned to baseline levels of subgingival bacteria.

Clinical reductions in probing depths and bleeding scores were significant for both the treatment and control sites. Patients were also asked to rate comfort with each procedure. Air polishing was found more comfortable than ultrasonic scaling.

Clinical Implications: Subgingival air polishing with this new tip and glycine power could replace ultrasonic instrumentation during periodontal maintenance visits.

Wennström, J., Dahlén, G., Ramberg, P.: Subgingival Debridement of Periodontal Pockets by Air Polishing in Comparison with Ultrasonic Instrumentation during Maintenance Therapy. J Perio 38: 820-827, 2011.
Air Polishing Treats Peri-implantitis

Peri-implant mucositis is inflammation limited to the mucosa, while peri-implantitis is characterized by changes in bone levels plus bleeding. The three primary risk factors for peri-implantitis are poor oral hygiene, smoking and a history of periodontal disease.

Non-surgical treatment of peri-implant mucositis including mechanical instrumentation, ultrasonics and delivery of chemicals is usually successful in reversing the infection. Not so in cases of peri-implantitis which has unpredictable outcomes limited to six to 12 months.

The use of air polishing has not been an option with the traditional sodium bicarbonate powder because it damages implant surfaces. With the introduction of amino acid glycine powder, air polishing can now be used on implants.

Researchers at Heinrich Heine University in Dusseldorf, Germany, compared air polishing using glycine powder and the new subgingival Perio-Flow tip from EMS to the use of carbon curettes and subgingival delivery of chlorhexidine.

One month prior to baseline, the 30 patients with early to moderate peri-implantitis received a prophylaxis and oral hygiene instructions. This protocol was repeated at baseline and every two weeks for three months and then monthly for the next three months.

Both treatments resulted in reduced probing depths of half a millimeter. Bleeding was reduced more in the air polishing group, from 95 percent to 50 percent compared to a reduction from 95 percent to 84 percent in the curette and chlorhexidine group.

Clinical Implications: Air polishing with glycine powder using the new subgingival tip provides another option for treating peri-implantitis.

Sahm, N., Becker, J., Santel, T., Schwarz, F.: Non-Surgical Treatment of Perio-Implantitis Using an Air-Abrasive Device or Mechanical Debridement and Local Application of Chlorhexidine: A Prospective, Randomized, Controlled Clinical Study. J Clin Perio 38: 872-878, 2011.
Air Polishing and Laser Both Effective for Treating Peri-implantitis

Peri-implantitis is difficult to treat. Fortunately, the success rate of implant placement is around 95 percent. As more and more implants are placed, the incidence of peri-implantitis might increase, posing major treatment challenges. Implant surfaces and threads pose significant challenges to mechanical disruption of bacterial biofilm. In a recent consensus report it was concluded that traditional non-surgical therapy for peri-implantitis was not effective. Slightly better results are possible with the Er:YAG laser.

Researchers at Kristianstad University in Kristianstad, Sweden, compared the new EMS glycine air polishing powder with the EMS new disposable subgingival tip to the KaVo Laser 3 Perio laser for treating peri-implantitis with 21 subjects in each group over six months time.

All test subjects received a Philips Sonicare FlexCare power toothbrush, detailed oral hygiene instructions and new brush heads every three months.

Both groups showed significant healing with 25 percent of subjects in the laser group with average probing depth reductions of 1mm and 38 percent of those in the air polishing group showing a 1mm average probing depth reduction. Laser treatment resulted in improved health at 44 percent of implant sites and air polishing at 47 percent of sites.

Although both the laser and the air polishing did help some sites with severe peri-implantitis, neither therapy provided predictable treatment for severe peri-implantitis.

Clinical Implications: For severe peri-implantitis both air polishing with glycine powder using the disposable subgingival plastic tip and laser treatment using an Er:YAG might improve some lesions, but not with any degree of predictability.

Renvert, S., Lindahl, C., Jansaker, A., Persson, G.: Treatment of Perio-Implantitis Using an Er:YAG Laser or an Air-Abrasive Device: A Randomized Clinical Trial. J Clin Perio 38: 65-73, 2011.
Metronidazole Alone or with Amoxicillin – Which is Better?

Systemic metronidazole is an effective antibiotic against strict anaerobic bacteria, those characteristic of chronic periodontitis. In the late 1980s, Van Winkelhoff suggested an antibiotic cocktail combining metronidazole and amoxicillin for aggressive periodontitis, specifically Aa infections. In the late 1990s, the Van Winkelhoff cocktail also proved effective in the treatment of chronic periodontitis. Systemic antibiotics are combined with scaling and root planing (SRP).

Researchers at Guarulhos University in Sao Paulo, Brazil, compared SRP alone or combined with metronidazole alone or metronidazole and amoxicillin. They created two test groups and one control group, with 17 subjects in each. All subjects received four to six SRP visits using hand instruments under local anesthesia. Test subjects took assigned antibiotics three times daily for 14 days. Placebo pills were used so all subjects took the same regimen.

Clinical indices and subgingival plaque biofilm samples were taken at baseline and three months post therapy. All groups showed significant healing, but still had probing depths 5mm or deeper at three months. The SRP group began with an average of 40 sites 5mm or deeper and ended with 13, the metronidazole group began with 35 and ended with nine, the antibiotic cocktail group began with 39 and ended with five. Clinical attachment gains in pockets 7mm was 2mm in the SRP group, 2.7mm in the metronidazole group and 3mm in the cocktail group.

Clinical Implications: In non-smoking patients with chronic periodontitis, there are some short-term benefits from using metronidazole and amoxicillin with SRP.

Silva, M., Feres, M., Sirotto, T., Soares, G., Mendes, J., Faveri, M., Figueiredo, L.: Clinical and Microbiological Benefits of Metronidazole alone or with Amoxicillin as Adjuncts in the Treatment of Chronic Periodontitis: A Randomized Placebo- Controlled Clinical Trial. J Clin Perio 38: 828- 837, 2011.
Azithromycin Provides No Added Benefit over SRP Alone

Infections are often treated with antibiotics, and periodontitis is no exception. Metronidazole and amoxicillin are widely used, with some recent interest in azithromycin. This is a promising semi-synthetic, broad spectrum, bacteriostatic drug that is rapidly absorbed by cells. Drug concentrations at the site of inflammation are 10 to 100 times higher than in serum. Patient compliance is better with the once-daily dose for periods of three to five days.

Researchers at Guarulhos University in Sao Paulo, Brazil, compared SRP alone in 19 patients and SRP plus azithromycin once daily for five days in 19 patients. Clinical indices and subgingival plaque biofilm samples were taken at baseline, six and 12 months.

Full-mouth SRP was provided in four to six two-hour appointments over a two-week period using hand instruments under local anesthesia.

At the end of one year, both groups showed significant healing, with no differences between test and control groups, yet disease still remained. Despite ending the study with an average of three or four sites per patient that were 5mm or deeper with bleeding, the SRP group showed an average pocket depth reduction of 3.8mm. This is likely due to the number of very deep pockets at baseline. As the authors observed, "very deep sites" were converted to "deep sites" rather than being eliminated.

Clinical Implications: Good SRP and oral hygiene instructions are still the cornerstone of non-surgical therapy for chronic periodontitis. Antibiotics might be effective for some cases, but not all antibiotics will enhance healing.

Sampaio, E., Rocha, M., Figueiredo, L., Faveri, M., Duarte, P., Lira, A, Feres, M.: Clinical and Microbiological Effects of Azithromycin in the Treatment of Generalized Chronic Periodontitis: A Randomized Placebo-Controlled Clinical Trial. J Clin Perio 38: 838-846, 2011.
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