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Centuries ago, dentistry identified mineral deposits, such as calculus, as the main cause of dental disease. Further research then recognised bacterial infections in the roots and the periodontium as the cause of periodontitis. So, what was the logical solution? To remove calculus completely. Today, we know that calculus has a porous surface that provides a niche environment for bacteria and endotoxins. Endotoxins are not absorbed into the calculus, and they can be easily removed. However, extensive removal of calculus is contra-indicated and counterproductive.
When I started out as a dentist over 40 years ago, prophylaxis was still in its infancy. At my university, there was minimal literature on everyday oral hygiene. An eye-opening moment for me was during a visit to Prof. Jan Lindhe in Gothenburg in Sweden. There, we studied cases of periodontitis for which almost everyone recommended complete dentures. We then saw images of the same patients ten years later—they still had their natural teeth, solely thanks to prophylaxis. The thing that made me opt for prophylaxis in dentistry was the birth of my first daughter. I would never have been able to forgive myself if she had developed a dental disease. This private passion for preventative dentistry and the vision of Prof. Per Axelsson and Lindhe have stayed with me to this day. Although my children’s and grandchildren’s teeth are healthy, I do see many unhealthy teeth in people in my own generation.
Forty years ago, there was a limited understanding of biofilm, individual diagnostics and individual prophylaxis. We removed calculus twice a year, but only introduced individual diagnostics and treatment in 1994. Today, we know the value of prophylaxis. One major reason is that we have a greater understanding of the causes of the most prevalent dental diseases. The trigger for cavities, gingivitis, periodontitis, peri-implant mucositis and peri-implantitis is always biofilm and not calculus. However, the amount of biofilm is not the determining factor; rather, it is the biofilm’s ecological make-up, type and balance.
Biofilm is a microbial, organised collection of microorganisms. The microorganisms are embedded in a matrix of extracellular polymer substances that the microorganisms produce themselves. Microorganisms in biofilm show a different phenotype regarding growth rate and gene expression compared with suspended living cells. Dental plaque is a kind of biofilm, and since biofilm forms an adhesive layer, special effort is required to disrupt and remove it.
Currently, there are two avenues available for the manual destruction of oral biofilm, everyday manual biofilm management and professional manual biofilm management. In professional manual biofilm management, we have a range of tools available, including manual debridement with handheld instruments and classic surface polishing, as well as debridement with sonic and ultrasonic instruments, such as air polishing systems. Most dental practices still clean the surface of the teeth with manual tools. In initial therapy, after the use of the PIEZON, we sometimes still use manual tools, though never for maintenance therapy. The correct use of these manual tools is technically challenging and requires good tactile ability and extensive training. The treatment itself is very time-consuming and tiring for the practitioner, but indispensable for non-surgical treatment of deep pockets caused by periodontitis. The procedure often leads to oversensitive roots and aesthetically displeasing and noticeable recessions. Manual tools are not well received by patients either and often cause dental practitioners’ hand and arm ligaments to tire. These reasons have led to the need for new tools to be used at regular intervals.
… or contemporary?
Axelsson and Lindhe began to use ultrasonic tools in their maintenance therapy. This technology broke through in the 1980s as bulky ultrasonic tips, which were replaced with fine tips based on periodontal probes. I can still remember the introduction of gentler piezoceramic ultrasonic devices—a true scientific and technological innovation. Only this ultrasonic technology allowed linear, low-pain movements. A consensus paper on this topic, published during the EuroPerio7 congress in Vienna in Austria in 2012, can be summarised as follows:
- Piezoceramic technologies have proven effective for manually removing build-up.
- They can be used universally (both sub- and supragingivally) to remove mineralised build-up and bacterial biofilm.
- They are gentle on soft tissue.
- They allow for shorter treatment times.
- They are less painful for the patient.
- They can be used after a short training period.
Today, we know even more. Powder jet devices can be used to remove sub- and supragingival biofilm and staining more efficiently and quickly. Low-abrasion powder based on glycine or erythritol and new subgingival nozzles perform exceptionally well. The literature on powder and water jet technology with low-abrasion powders in biofilm management, compared with manual and ultrasonic tools, highlights the benefits of this new technology. Furthermore, air polishing with low-abrasion powder removes more bacteria than manual and ultrasonic tools do. Many studies have shown that air polishing can remove supragingival build-up and stains much more effectively than classic polishing methods can. This applies to soft tissue, hard tissue and restorative materials. Therefore, subgingival air polishing with low-abrasion powder is sufficiently gentle to be suitable for use on all dental tissue.
A short guide to powder
The most commonly used powders are sodium bicarbonate, glycine and erythritol. Sodium bicarbonate is a white crystalline powder with a range of applications in food and medicine, and it breaks down at temperatures above 56 °C. In wet conditions, sodium bicarbonate, a hydrogen carbonate anion, can neutralise acids. This property explains its central role as the most important blood buffer, since it can regulate the acid-alkali balance in the human body.
Glycine is the simplest stable amino acid that can be made by the human body, where it acts as a radical catcher and neurotransmitter. Glycine is found in almost all foods that contain protein, as it is a common building block of almost all types of protein. Glycine is also found in collagen, an important component of tendons, bone, skin and teeth. Glycine is an approved dietary supplement with no maximum dose, as it supports various bodily functions. In the food industry, it is often used as a flavour enhancer or humectant. Studies from 2008 onwards have shown that air polishing with glycine powder does not irritate the gingivae.
Since 2012, we have almost exclusively used erythritol, a white crystalline powder with a pleasantly sweet taste. Erythritol is found in small amounts in nature, for example in honey, wine grapes, melons and mushrooms, and it is produced by the fermentation of natural sugar. Owing to its sweet taste, erythritol is used as a sweetener to replace sugar. It has almost no calories when absorbed by the human body and is suitable for people with diabetes. Oral bacteria are not able to metabolise erythritol, so it is not cariogenic. Various studies have shown that only glycine and erythritol powders do not change the surface structure of composite fillings and that erythritol powder produces no changes on glass ionomer surfaces.
Guided Biofilm Therapy
Guided Biofilm Therapy (GBT) perfectly combines air polishing devices and low-abrasion powders. Developed in collaboration with universities and dental practices, GBT is a concept designed for contemporary prophylaxis. Based on decades of scientific knowledge and evidence, GBT is the next step in prophylaxis. The eight steps that comprise GBT can be adapted to suit the treatment and patient, from patients in initial therapy to patients in maintenance therapy. It is for healthy patients and for patients with dental caries (especially in the initial stages), gingivitis, periodontitis, peri-implant mucositis or peri-implantitis.
The GBT concept ensures a systematic, quality-orientated approach, covering greeting of the patient, diagnostic data collection, everyday oral hygiene advice, professional tooth cleaning, the dentist’s final diagnosis and check-ups, and chemically supported plaque removal, as well as recalls. Alongside the disclosing of the supragingival biofilm, the process of professional tooth cleaning has changed considerably. The contemporary approach begins with sub- and supragingival biofilm removal using air polishing technology with AIRFLOW POWDER PLUS. This erythritol-based powder guarantees targeted, gentle, risk-orientated removal of the biofilm to support the initial diagnosis. This is followed by the targeted and minimally invasive removal of mineralised build-up with PIEZON NO PAIN. This approach has many additional benefits, including short treatment times and maximum comfort for both the technician and the patient. With GBT, we can finally carry out professional biofilm management effectively, gently, safely, quickly and without pain.
For the best results, it is especially important to use the correct devices and tools, such as GBT. Currently, there are a few new products on the powder market. However, in addition to the powders’ properties and scientific evidence that these powders are biocompatible and do not cause damage, it has become increasingly important for powders to be compatible with dental devices. This requirement has been addressed by Switzerland-based EMS, who has not only significantly contributed to the development of GBT but also provided suitable devices and tools (including the AIRFLOW PROPHYLAXIS MASTER, AIRFLOW POWDER PLUS, AIRFLOW handpiece, PERIOFLOW handpiece, PERIOFLOW nozzle and PIEZON NO PAIN).
The scientific knowledge and technological progress for a paradigm change in professional prophylaxis have now been established. Now is the time to integrate these developments into our everyday practice for the well-being of our patients and ourselves.