To the powder, get set, go – a new prophylaxis trio

by Christin Bunn
First publication: Prophylaxe Journal 5 (2019)

With the slogan “Proxeo – prophy for professionals”, W&H presents its expanded portfolio for automatic plaque removal. Proxeo supports the complete preventive workflow on the basis of scientific recommendations for each patient and each indication. The three new prophylaxis powders are presented in the following article.

The Proxeo Aura air polishing system has been part of the W&H prophylaxis range since this year's International Dental Show (Fig. 1). The system concept that characterises all W&H product groups is also provided, so that the powders, handpieces and spray heads are ideally compatible and ensure thorough and gentle cleaning – supragingival and subgingival.

Usability and comfort

Before using the system, a decision should always be made, based on the clinical findings, about which powders should be used in which order and which indications should be covered (Fig. 2). Experience shows that the easier and more reliable a device is to use, the more frequently it will ultimately be used in practice. A special feature of the Proxeo Aura handpiece is that the working pressure for supragingival or subgingival work can be changed in seconds using the adjustment ring and thus all indications can be conveniently covered. The transparent powder chamber with a side opening makes it convenient to refill and easy to check the powder level.

Sounding out air polishing

Air polishing is the process of cleaning and polishing teeth and dental prostheses using a device that mixes air and water pressure with an abrasive substance.¹ In addition to the device used¹, the outcome of the air polishing² is predominantly affected by the abrasion potential of the powder.^1,2 This is determined by:

• Hardness, particle size and powder particle shape
  
• Contact time of the powder spray with the tooth surface
  
• Spray pressure
  
• Powder concentration and quantity
  
• Impact angle
  
• Powder type^1,2

Correct technique for successful treatment

Aside from selecting the right powder, the correct technique is also crucial for healthy, happy patients in the long term and minimal aerosol load in the room. Hand position, duration and tips for air polishing are covered below. The optimal impact angle of the spray jet onto the tooth surface depends on the powder used and whether the treatment is supragingival or subgingival. An impact angle of 90 degrees should only be implemented to deep clean the occlusal surfaces prior to a fissure sealing.³ When using sodium bicarbonate powders, the spray jet must never be at a right angle to the tooth surface and should be directed away from the gingival margin.² When using a glycine powder, the powder-water spray jet can be targeted directly at the sulcus if the pockets are shallow (up to approximately 3 mm)², e.g. using appropriate spray heads. In any event, the instructions for use from the appropriate manufacturer must be adhered to when using the powder.

The opening of the spray head should be approximately 3-4 mm away from the tooth surface.^2-4 The spray jet is generally applied in brushing or circular movements from the tooth neck to the occlusal surface – from red to white. Data from the literature and studies on the adequate treatment duration of a tooth surface range from a maximum of two3 to a maximum of five seconds.^4-6 It must also be ensured that the suction technique is carried out in such a way that as much of the spray aerosol is suctioned as possible. Practitioners and patients should wear eye and face protection.³

Powder types – an overview

Although the first air polishing powders were very aggressive, the development of a number of gentle powders has made air polishing a safe alternative. However, each powder is not suitable for each user. In addition, a distinction is made between water soluble, and a little or not water soluble. The basic substances of current air polishing powders are listed below together with their areas of application:

Fig. 3: The SOFT prophylaxis powder is based on sodium bicarbonate and has an average particle size of 40 μm. – Fig. 4: The SMOOTH prophylaxis powder is based on calcium carbonate, has a particle size between 45 μm and 75 μm, a neutral taste and is free from sodium and silicon (Si). – Fig. 5: The SENSITIVE prophylaxis powder is based on glycine, has an average particle size of 25 μm, is available in a sweetish taste and is water soluble. (Only available in the European Economic Area and in Switzerland.)

Sodium bicarbonate (SOFT powder, Fig. 3)

The first powder used for air polishing, but only for supragingival applications due to its high level of abrasiveness is sodium bicarbonate (NaHCO₃).² As its particle size is between 402 and a maximum of 250 μm^2,7,8, sodium bicarbonate is used, for example, for removing stubborn deposits and stains (such as smoker's plaque)^2,4, cleaning cavity margins prior to etching and preparing the tooth surfaces for bleaching.⁹ The individual crystals of the water soluble powder have an angular, irregular shape, and polishing should not be carried out more than twice a year. Due to the remaining rough surface, other polishing measures may be necessary subsequently², for example, using rotary polishing.

Calcium carbonate (SMOOTH powder, Fig. 4)

Calcium carbonate (CaCO₃) is another powder that is a little water soluble.² The spherically arranged crystals with particle sizes of between 45 and 100 μm form round particles, which produce a “roll effect” and thus less enamel damage even at unfavourable jet angles, as well as a low aerosol load.² The use of a calcium carbonate powder is indicated for cleaning restorative materials and fillings. In addition, it is the ideal aide for teeth cleaning with a sparkling finish, as well as gently cleaning brackets and fissures, and it also means that patients on a salt-free diet can still get the best possible treatment.

Glycine (SENSITIVE powder, Fig. 5)

One of the less abrasive, water soluble powders is based on glycine (C₂H₅NO₂).² Glycine is a naturally occurring amino acid with a particle size of maximum 63 μm.⁴ These powders have an extremely low abrasiveness and are suitable for supragingival treatment in cases of mild to moderate staining, for teeth polishing as well as supragingival and in the peri-implant area.² Glycine can be applied to dentine, cementum, in periodontal pockets, in periodontitis therapy, for peri-implantitis and implant surfaces. In addition, it has been demonstrated that air polishing with glycine and erythritol is comparatively gentle on soft tissues.^10,11

Prophylaxis for implant patients

The glycine-based powder is particularly important when it comes to implant care. Thanks to the SENSITIVE powder, the biofilm is ideal and it can be removed from titanium surfaces in a highly efficient manner without causing any damage. We will also look at peri-implantitis treatment. The powder can be of help in a surgical procedure and thanks to its resorbability it can be used safely in the surgical area. Thus any pathogenic biofilm can be quickly and effectively removed from the implant surfaces intraoperatively. In combination with photo-activated disinfection and subsequent augmentation, this is a promising approach because it facilitates the reliable decontamination of the surfaces.

Good patient acceptance of air polishing

Numerous studies document that air polishing is met with a high level of acceptance from patients.^5,12-15 Bleeding on probing can be reduced¹⁶, and pocket depths are shown to decrease after glycine air polishing.¹⁷ Low-abrasive powders do not demonstrably affect the root surface or the gums.¹⁸

Conclusion

The system allows you to always do your best work – even for prophylaxis. The Proxeo system is part of the integrated W&H Prophylaxis and Periodontology products portfolio, which is applied to a given individual patient profile. Targeted work in the supragingival and subgingival areas with powders that are gentle on the teeth is a convenient option for all indications and a broad target patient group.

Possible contraindications

Air polishing devices should only be used on patients with respiratory tract diseases or certain kidney and metabolic disorders following consultation with the doctor. The instructions for use of the respective powders and devices should also be consulted with regard to the use of certain medications or allergies to powder ingredients⁸. If there are contraindications to air polishing, the treatment should be changed to rotary polishing with the corresponding range of pastes.

References

1. Connect, O.-S.H.N.U.A. https://aaosh.org/aaosh-connect/. 2019.
2. D E A Deußen and A. Groß, Air-Polishing – vom Power-Cleaning zum Biofi lmmanagement – Teil 1. Prophylaxe Journal 2016(3): p. 14-17.
3. Hellwege, K.D., Die Praxis der professionellen Zahnreinigung und Ultraschall-Scaling. Eine Arbeitsanleitung für den Zahnarzt und sein Mitarbeiterteam. 2007: 3. Auflage. Thieme Verlag.
4. 6R Mohan, et al., Air Polishing: An Update. International Journal of Maxillofacial Research, 2015. 1(1): p. 22-34.
5. Petersilka, G.J., et al., Subgingival plaque removal in buccal and lingual sites using a novel low abrasive air-polishing powder. J Clin Periodontol, 2003. 30(4): p. 328-33.
6. Flemmig, T. and T.E. O´Hehir, How subgingival air polishing will turn dental hygiene upside down. Interview with Prof. Dr. Thomas Flemmig, in Dentaltown. 2014. p. 94-96.
7. Botti, R.H., et al., Effectiveness of plaque indicators and air polishing for the sealing of pits and fissures. Eur J Paediatr Dent, 2010. 11(1): p. 15-8.
8. Gutmann, M.E., Air polishing: a comprehensive review of the literature. J Dent Hyg, 1998. 72(3): p. 47-56.
9. W&H, Happy Patient - Happy Professional. Proxeo Aura. Product Brochure, 2019: p. 6.
10. Petersilka, G., et al., Evaluation of an ex vivo porcine model to investigate the effect of low abrasive airpolishing. Clin Oral Investig, 2018. 22(7): p. 2669-2673.
11. 17. ZMK-aktuell.de. Trehalose für supra- und subgingivales Pulverstrahlen. 2017 14.09.2017].
12. Moene, R., et al., Subgingival plaque removal using a new air-polishing device. J Periodontol, 2010. 81(1): p. 79-88.
13. Hongsathavij, R., Y. Kuphasuk, and K. Rattanasuwan, Clinical comparison of the stain removal efficacy of two air polishing powders. Eur J Dent, 2017. 11(3): p. 370-375.
14. Flemmig, T.F., et al., Randomized controlled trial assessing efficacy and safety of glycine powder air polishing in moderate-to-deep periodontal pockets. J Periodontol, 2012. 83(4): p. 444-52.
15. Wennstrom, J.L., G. Dahlen, and P. Ramberg, Subgingival debridement of periodontal pockets by air polishing in comparison with ultrasonic instrumentation during maintenance therapy. J Clin Periodontol, 2011. 38(9): p. 820-7.
16. P Schmage, B.B., I Nergiz, U Platzer, P Pfeiffer, Biofilm removal of ultrasonic driven devices with universal and periodontal intrument tips. Poster presentation. 2012.
17. Petersilka, G.J., et al., Subgingival plaque removal at interdental sites using a low-abrasive air polishing powder. J Periodontol, 2003. 74(3): p. 307-11.
18. Sculean, A., et al., A paradigm shift in mechanical biofilm management? Subgingival air polishing: a new way to improve mechanical biofilm management in the dental practice. Quintessence Int, 2013. 44(7): p. 475-7.