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DOI 10.1007/s00784-014-1317-z
ORIGINAL ARTICLE
Received: 31 March 2014 / Accepted: 8 September 2014 / Published online: 21 September 2014
# Springer-Verlag Berlin Heidelberg 2014
for instrumentation during SPT [16–18]. In 2003, air polishing (dv50)=50 % of the particle’s volume is smaller than this
powders containing glycine were introduced for SPT [19]. value and 50 % is bigger. The following grain sizes of the
They show promising results in vitro and clinically. Less powders were provided by the manufacturer:
abrasiveness of early introduced powders containing glycine
compared to those containing sodium bicarbonate or calcium (A) Sodium bicarbonate (AIR-FLOW CLASSIC, EMS SA,
carbonate was reported [15, 20–22]. Clinical results in partic- Nyon, Switzerland), grain size distribution: dv50=62 μm,
ular highlight consistently the minor discomfort compared to dv90=150 μm
conventional instrumentation using curettes or ultrasonic de- (B) Glycine (AIR-FLOW SOFT, EMS SA, Nyon,
vices [18, 23–25]. However, to what extent these powders Switzerland), grain size distribution: dv50=49 μm,
may modify human tooth surfaces or increase surface rough- dv90=146 μm
ness has not been sufficiently documented. A quantification of (C) Glycine (AIR-FLOW PERIO, EMS SA, Nyon,
surface modifications with validated examination methods Switzerland), grain size distribution: dv50=21 μm,
(i.e. measuring profile and surface roughness) is lacking [26, dv90=51 μm
27]. The aim of this study was an analysis of the root surface
roughness of human teeth after air polishing with powders An air polishing device (AIR-FLOW Master, EMS SA,
containing glycine or sodium bicarbonate. Nyon, Switzerland, standard handpiece) was installed in an
automated apparatus to accomplish instrumentation under
defined and standardized conditions. Powder and water set-
Material and methods tings were standardized to 50 % of the maximum level. A
dynamic pressure of 1.8 bar was used. The air polishing
Preparation of dentin discs powders were applied using different exposure times (5 s,
10 s), distances (2 mm, 5 mm) and angulations (45°, 90°).
The study protocol was approved by the Ethics Committee of Every setting was carried out five times. In order to document
Basel (Ref. Nr. EK:135/10). One hundred twenty anonymised the powder emission [28], the powder chamber was weighted
caries-free extracted maxillary and mandibular third, second using a precision balance (PG503-S DeltaRange, Mettler
and first molars stored in a solution of water mixed with Toledo, Greifensee, Switzerland) before and after instrumen-
chlorhexidine (0.1 %) were obtained from the tooth bank at tation of each disc.
the school of dental medicine of the University of Basel. Only
teeth with unaltered root surfaces, i.e. no caries or calculus and
no signs of previous periodontal instrumentation or damage Analysis of surface modifications
due to extraction, were used. The root surfaces were sectioned
into square dentin discs of approximately 2×2 mm and a Immediately after exposure to the air polishing powder, the
thickness of 1 mm and stored in 4 °C saline solution for no discs were cleaned with a water spray for 10 s and then dried
longer than 30 days. The discs were glued on aluminium stubs with an air spray. The surface modifications after instrumen-
(Stiftprobenteller, Plano GmbH, Wetzlar, Germany) with a tation were quantified using software-based roughness mea-
cold curing adhesive (DELO-AUTOMIX 1895 2K-Epoxy, surements (Tactile Stylus Hommel Tester T1000, cantilever
DELO, Landsberg, Germany). The discs were instrumented Typ TKK 50, Hommel & Seitz, Germany) and related to the
using Gracey curettes (Deppeler, Rolle, Switzerland) with untreated sides of the discs. Every side of the disc (treated and
overlapping strokes, i.e. 10 strokes in one direction followed untreated) was scanned three times over a distance of 1.5 mm
by 10 strokes in the opposite direction. The effect of instru- each.
mentation was analysed with magnifying glasses (×2.5 mag- Three defined parameters of surface roughness were
nification). One half of the disc served as untreated control and analysed: the Pa value (i.e. the arithmetical mean deviation)
was protected with a circumferential secured silicone layer is defined as the arithmetic average of the unfiltered raw
(AFFINIS light body, Coltène Whaledent, Altstätten, profile (DIN EN ISO 4287, Berlin, Germany) [27], the Pt
Switzerland). Dentin discs were randomly assigned into 24 value (i.e. the average maximum height of the profile) is
different treatment groups. defined as the sum of the largest profile peak height and the
largest profile valley within an evaluation length (DIN EN
Application of air polishing powders ISO 4287, Berlin, Germany) [27] and the Rz value (i.e. the
maximum height of the roughness profile) is defined as the
The effects of three different powders on human root surfaces sum from the height of the highest profile peak and the depth
were analysed. Numerical values of particle sizes of the pow- of the lowest profile valley within a sampling length (DIN EN
ders used are given in volume. The symbol “dv” describes the ISO 4287, Berlin, Germany) [27]. As Pa and Pt are surface
particle size distribution (“d”=diameter, “v”=volume), i.e. profile values, they can paraphrase the depth of a surface
Clin Oral Invest (2015) 19:877–885 879
a b c d
10 10
1 1
Powder Powder Powder Powder Powder Powder Powder Powder Powder Powder Powder Powder
A B C A B C A B C A B C
5.61 ± 10.75 ± 11.01 ± 1.47 ± 12.95 ± 13.05 ± 12.90 ± 7.95 ± 8.55 ± 8.70 ± 11.98 ± 10.56 ±
untreated untreated
1.18 1.13 0.69 0.08 1.67 1.63 1.63 1.00 1.34 0.97 1.35 1.42
17.43 ± 14.35 ± 27.56 ± 27.83 ± 21.50 ± 20.99 ± 22.45 ± 13.63 ± 13.87 ± 41.52 ± 21.34 ± 19.92 ±
treated treated
1.71 1.59 3.01 3.42 4.05 2.69 3.01 3.31 1.47 4.06 4.25 1.91
Fig. 1 Surface profile value Pa analysis. The raw data (μm) for the of the untreated surfaces (±2SEM) for the following combinations of
treated and untreated surfaces are shown in the first two lines of the table. parameters: angulation of 45°: a exposure time of 5 s, b exposure time of
Bars represent the results of the linear mixed effects models analysis 10 s, and angulation of 90°: c exposure time of 5 s, d exposure time of
represented as geometric mean ratio (GMR) of Pa subtracted to the mean 10 s
Fig. 2 Surface profile value Pt analysis. The raw data (μm) for the treated untreated surfaces (±2SEM) for the following combinations of parame-
and untreated surfaces are shown in the first two lines of the table. Bars ters: angulation of 45°: a exposure time of 5 s, b exposure time of 10 s,
represent the results of the linear mixed effects models analysis repre- and angulation of 90°: c exposure time of 5 s, d exposure time of 10 s
sented as geometric mean ratio (GMR) of Pt subtracted to the mean of the
differences in GMR with more pronounced effects caused by powders were negligible. Therefore, the powders may have
powder A for the distance of 2 mm. There were no significant similar effects on human root surfaces. As roughness and not
differences between the GMR for powders B and C (p>0.05) substance loss has been assessed in the present study, infer-
at both distances. ence on the abrasiveness of the assessed powders is not
possible by implication. It may be that one instrumentation
method results in a rougher surface but does remove less
overall root substance than another method that leaves behind
Discussion a smoother surface. However, the effects on periodontal soft
tissues are also relevant and may be affected by the grain size
The results of this in vitro study demonstrate significant of the powder. A study analysing human gingival biopsies
differences in terms of three surface roughness parame- after treatment with a glycine powder (dv90=63 μm) showed
ters, i.e. Pa, Pt and Rz, between air polishing powders significantly less gingival erosions compared to instrumenta-
containing sodium bicarbonate and glycine of different tion with curettes or sodium bicarbonate [32]. Although the
grain sizes. powder used in that particular study is from a different man-
All powders were compared to each other and all caused ufacturer, the data might be comparable to some extent with
alterations of the root surface in vitro. However, significantly powder C (dv90=51 μm) used in this study. The distinct
less pronounced effects occurred after treatment with glycine effects of powders B and C on human gingiva are unknown
on root surfaces of human teeth compared to the powder and remain open for further research. In addition, powder C
consisting of sodium bicarbonate. The glycine powders varied was evaluated clinically with respect to patient perception.
in terms of grain size distribution. The differences with regard The results of these clinical studies reveal that a treatment
to the parameters analysed between the two tested glycine with this powder was perceived as significantly more pleasant
882 Clin Oral Invest (2015) 19:877–885
Powder
A
Powder
B
Powder
C
Powder
A
Powder
B
Powder
C
1. Sufficient evidence shows differences in terms of chemi-
cal, physical and morphological properties between hu-
untreated
4.07 ± 3.90 ± 4.93 ± 4.17 ± 4.65 ± 3.93 ± man teeth and teeth from other mammalians [42].
0.21 0.30 0.29 0.26 0.32 0.21
Therefore, only human molar teeth were used for the
9.47 ± 6.21 ± 7.32 ± 5.25 ± 6.10 ± 5.93 ± experiments. The teeth were stored in a solution of water
treated
0.58 0.46 0.43 0.28 0.38 0.35
mixed with chlorhexidine (0.1 %) [21]. The matter of
GMR: GMR: GMR: GMR: storage medium is widely discussed in the literature and
1.46 1.51 0.97 0.85
95% CI: 95% CI: 95% CI: 95% CI: several solutions, including chlorhexidine, chloramine,
Powder A - -
1.26 - 1.30 - 0.83 - 0.73 -
1.70 1.74 1.12 0.98
artificial saliva, saline and thymol, for storage were sug-
p=0.029 p=0.013 p=0.967 p=0.497 gested [14, 15, 20–22, 43]. The storage of extracted
GMR: GMR: GMR: GMR:
1.46 1.03 0.97 0.88
human teeth for in vitro studies needs to be kept in mind,
Powder B
95% CI:
-
95% CI: 95% CI:
-
95% CI: since it might affect the physical properties of teeth
1.26 - 0.89 - 0.83 - 0.76 -
1.70 1.20 1.12 1.02 [44–46]. However, no scientifically accepted consensus
p=0.029 p=0.979 p=0.967 p=0.652 regarding the best storage medium is available currently.
GMR: GMR: GMR: GMR:
1.51 1.03 0.85 0.88 The effect was taken into account in terms of an analysis
95% CI: 95% CI: 95% CI: 95% CI: of Vickers hardness of a subsample of teeth analysed in
Powder C - -
1.30 - 0.89 - 0.73 - 0.76 -
1.74 1.20 0.98 1.02 this research. The results show a Vickers hardness range
p=0.013 p=0.979 p=0.497 p=0.652
very similar to recent studies [31]. In addition, the biolog-
Fig. 3 Surface profile value Rz analysis. The raw data (μm) for the ical variance of physiological properties of human teeth
treated and untreated surfaces are shown in the first two lines of the table. was considered by the amount of teeth used in this study
Bars represent the results of the linear mixed effects models analysis
represented as geometric mean ratio (GMR) of Rz subtracted to the mean and the presentation of data using 95 % confidence
of the untreated surfaces (±2SEM) for the following combinations of intervals.
parameters: a distance of 2 mm and b distance of 5 mm 2. The root surface was scaled with the aid of Gracey cu-
rettes in order to simulate a root surface after non-surgical
compared to hand instruments and/or ultrasonics [23, 24]. periodontal treatment using standard procedures. No
Such data are currently not available for powder B. grinding of the tooth discs with manufactured devices
There is an ongoing scientific controversy regarding the was performed to create a flat facing. Unevenness and
aim of the instrumentation of the root surface [26, 33]. roughness of the tooth surface represent biological vari-
Histological evidence demonstrates cellular attachment be- ance and occur before and after treatment. Powders ap-
tween junctional epithelium and dental calculus [34]. plied on a standardized surface may bias the effects
Historically, a smooth, hard and decontaminated root surface caused by distinct powders [20, 21].
is requested by several authors in order to prevent the docu- 3. The powders analysed were specially designed for the
mented enhanced bacterial adhesion on rough surfaces [13, device used in the study, and the powder emission rate
34–36]. However, a consensus regarding the requested was recorded. In order to provide a controlled emission of
roughness/smoothness after instrumentation in terms of phys- the powders, the powder chamber was filled to the max-
ical surface roughness values is lacking to the best of our imum level before every treatment of a tooth disc [28].
knowledge. Several hand instruments with different modified Data from this analysis showed that the powder emission
tips including Gracey curettes and ultrasonic scalers were for the three powders included in this study was predict-
developed for instrumentation of the root surface during able. However, an unpredictable powder emission was
non-surgical or even surgical treatment [35, 37, 38]. The detected for powders that were not intended for the device
periodontal scaling procedure causes some undesirable side according to the manufacturer. Preliminary data on a
effects [10, 12], leading to efforts for reducing the fourth powder (Sylc Prophy Therapy, OSspray Ltd.,
Clin Oral Invest (2015) 19:877–885 883
a b c d
e f g h
i j k l
Fig. 4 a–l Representative SEM images of the surface modifica- bicarbonate or two different powders containing glycine were
tions. The modifications of the root surfaces of human teeth after analysed using SEM, and three-dimensional images were calculat-
treatment with air polishing powders containing sodium ed. Distance of 2 mm, angulation of 90°
London, UK) were therefore excluded after the value and Recently, a nozzle for subgingival application was introduced
mode of powder emission were taken into account [47]. In to the market and evaluated clinically [23, 24]. The different
addition, the parameters powder and water were set to a delivery methods may differ in terms of root surface defects,
medium level and the air pressure was held constant. and the results of this study may therefore be applied to the
4. For the registration of surface alterations after air standard handpiece only.
polishing, different validated surface roughness parame- The clinical situation differs from this in vitro analysis. A
ters were analysed [27]. The parameters Pa, Pt and Rz are clinical or ex vivo analysis is challenging and may be limited
ISO standardized and are commonly used in the field of due to ethical reasons. In the clinical use of air polishing, the
surface physics to determine the quantitative characteri- distance and angulation of the nozzle as well as the treatment
zation of surface deviations. The data of this analysis are time are not constant and may vary among the different
therefore comparable according to this standard [26, 27]. surfaces of the different teeth in the dentition. In addition,
In addition, three-dimensional scanning electron micros- for standardization and comparison, the handpiece was locked
copy was performed for the visualization of the defects into a fixed position. In a clinical practice, the handpiece is
(Fig. 4a–l). The images from the latter aspect are in line usually in motion during treatment and the air polishing spray
with data generated using 3D measuring microscopy and will not affect a defined area for a supposed treatment time of
micro-computed tomography [21, 48]. As the surface 5 or 10 s [25]. However, the effort applied in this investigation
profile values Pa and Pt depict the depth or the maximal may provide the possibility for a careful translation to the
defect depth of a surface defect over a defined distance, clinical situation, i.e. keep the handpiece in motion. An addi-
the standardized surface roughness analysis from this tional clinically relevant finding from our analysis was that an
in vitro study may be comparable to some extent with increase in surface alterations occurred for either powder with
investigations using defect depth and defect volume mea- an increase in treatment time, a decrease in working distance
surements [14, 15, 20, 21, 27, 48]. and an angulation of 45°.
surfaces. The surface roughness was analysed using the vali- 11. Draenert ME, Jakob M, Kunzelmann KH, Hickel R (2013) The
prevalence of tooth hypersensitivity following periodontal therapy
dated and standardized parameters Pa, Pt and Rz. All investi-
with special reference to root scaling. A systematic review of the
gated powders altered the root surface according to these three literature. Am J Dent 26:21–27
parameters. However, remarkable and significant differences 12. Ritz L, Hefti AF, Rateitschak KH (1991) An in vitro investigation on
occurred between the powders. There were less effects detect- the loss of root substance in scaling with various instruments. J Clin
Periodontol 18:643–647
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13. Cadosch J, Zimmermann U, Ruppert M, Guindy J, Case D, Zappa U
compared to a powder containing sodium bicarbonate. Within (2003) Root surface debridement and endotoxin removal. J
the limits of this in vitro investigation, reason for a well- Periodontal Res 38:229–236
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Acknowledgments Parts of this research were conducted by J. Bühler effect of the vector scaler system on human teeth: a systematic
in partial fulfilment of the requirements for an MD degree from the review. Int J Dent Hyg 6:154–165
University of Basel, Switzerland. Special thanks to S. Galli and P. 17. Ratka-Krüger P, Mahl D, Deimling D, Monting JS, Jachmann I, Al-
Schaffner (Basel) for manufacturing the apparatus and preparing the Machot E, Sculean A, Berakdar M, Jervøe-Storm PM, Braun A
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Conflict of interest The author Fredy Schmidli declares no conflict of 18. Sculean A, Bastendorf KD, Becker C, Bush B, Einwag J, Lanoway
interest. This project is supported in part by an unrestricted grant by C, Platzer U, Schmage P, Schoeneich B, Walter C, Wennström JL,
Electro Medical Devices (EMS) Nyon, Switzerland, to Julia Bühler, Flemmig TF (2013) A paradigm shift in mechanical biofilm man-
Roland Weiger and Clemens Walter. agement? Subgingival air polishing: a new way to improve mechan-
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