Abstract
Context:
Tooth surface polishing is an integral part of periodontal therapy. Enamel and cementum show a smooth surface clinically after debridement with the naked eye, but numerous surface irregularities can be detected microscopically. Air polishing is safe and effective when used by trained professionals.
Aims:
The aim of the study is to evaluate and compare the surface roughness of cementum by using an air polishing device and conventional root planing with hand instruments.
Materials and Methods:
A total of 45 extracted teeth stored in saline were divided into three groups randomly – Group A (conventional root planing), Group B (hand instrumentation and air polishing), and Group C (air polishing alone) – with 15 samples each. Samples were evaluated for surface roughness by using profilometer. Six parameters were checked for surface roughness.
Statistical Analysis Used:
The data were collected, charted, and analyzed using one-way ANOVA with post hoc LSD method for pairwise comparisons.
Results:
Least amount of surface roughness was achieved with Group C when compared with Group A and Group B. These differences were statistical significant (P < 0.0001).
Conclusions:
Air polishing can effectively smoothen the root surface by removing surface irregularities which are produced hand/ultrasonic instruments. Profilometer can be effectively used to measure the surface roughness.
Keywords: Air polishing, profilometric analysis, scaling and root planing
INTRODUCTION
Periodontitis is a chronic infectious disease and is responsible for tooth loss. According to the WHO, periodontitis affects 10%–15% of the world adult population.[1]
Treatment of mild and moderate periodontitis can be achieved by nonsurgical periodontal therapy. However, adequate plaque control is necessary ever after completion of therapy.[2,3]
Scaling can be defined as “instrumentation of the crown and root surfaces of the teeth to remove plaque, calculus, and stains from these surfaces,” and root planing can be defined as “A treatment procedure designed to remove cementum or surface dentin that is rough, impregnated with calculus, or contaminated with toxins or microorganisms.[4]
Tooth polishing is defined as “the removal of plaque, calculus, and stains from the exposed and unexposed surfaces of the teeth by scaling and polishing as a preventive measure for the control of local irritational factors.”[5] Polishing reduces surface roughness which prevents further plaque accumulation.[6]
Air polisher is noninvasive and effective when used by trained professionals. Air polishing minimizes operative fatigue and effectively removes stains and plaque biofilm in less time.[7] Sodium bicarbonate powder was the only formulation available from the late 20th century till the early 21st century for air polishing. However, at present, several air polishing abrasive powders are commercially available. Powder characteristics, e.g., size, shape, and hardness, substantially influence the abrasiveness of the jet stream.[8]
The aim of the study was to evaluate and compare the surface roughness of cementum by using an air polishing device and conventional root planing with hand instruments.
MATERIALS AND METHODS
The present study was carried out on 45 human extracted teeth comprising of incisors, canines, and premolars from the outpatient department of oral and maxillofacial surgery and from the general dental practitioners in Navi Mumbai area. The cause for extraction was periodontally affected hopeless prognosis teeth. Ethical clearance was obtained from the Intuitional Ethical Committee with protocol reference no. IEC210122019 Version No. 001.
The teeth were randomly divided into three groups so that 15 teeth were present in each group.
Group A - Conventional root planing using area-specific curettes.
Group B - Conventional root planing using area-specific curettes and air polishing.
Group C - Air polishing alone.
Following materials and instruments were used in the study:
Piezoelectric Scaler (EMS PM100, Germany)
Gracey Curettes (Hu Friedy, Germany)
Air Polishing Device (Prophy Mate, NSK, Japan)
10% formalin and normal saline
Air Polishing Powder (EMS air-flow)
Airotor with straight diamond bur.
The technical specification of the air polisher (Prophy Mate) used was water pressure: 0.2–0.44 MPa, air pressure: 0.3–0.4 MPa, water spraying amount of working head: 30 ml/min, and sandblasting amount of working head: 2.4 G to 3.2 g/min (NSK, Nakanishi INC., Japan).
After the tooth was extracted, it was washed under running water for 1 min and then it was transferred and maintained in 10% formalin. All the extracted teeth were scaled by a calibrated operator by using the ultrasonic device (EMS PM100, Germany) with light lateral pressure to remove residual calculus and tissue tags. On visual inspection, the surface appeared smooth and clean which denoted satisfactory scaling.
The teeth were initially embedded in a rectangular stone block, and the proximal surface was examined using a magnifying glass to detect the anatomical cementoenamel junction (CEJ) [Figure 1].
Figure 1.
Prepared tooth specimen
Once the CEJ was determined, a measuring caliper was used to make a mark on the proximal surface side of the tooth. The caliper was set at 5 mm and measured from the CEJ in apical direction [Figure 2]. Marking was made using a graphite pencil at the 5 mm mark [Figure 3].
Figure 2.
Measuring 5 mm apical from cementoenamel junction
Figure 3.
Marking 5 mm from cementoenamel junction with pencil
Once the pencil marking was made, it was converted into a horizontal indented line using an airotor fitted with a straight diamond bur. This line denoted the apical extent of the experimental area, and all the procedures were done coronal this line and up to the CEJ [Figure 4].
Figure 4.
Horizontal indentation made with the bur
The required side was placed upward and based on each group, the experiment was conducted.
The air polishing particles used was EMS Air Flow® Perio which was a glycine-based powder. The particle size of the powder was 45–60 μm and had a less chiselled surface structure.
Group A underwent root planing with area-specific Gracey curettes until a smooth surface was obtained visually [Figure 5].
Figure 5.
Instrumentation with Gracey's curette
Group B underwent root planing and air polishing which was conducted for 20 s at 90° angulation with the nozzle 3–4 mm away.
Group C underwent air polishing alone in the same manner as the previous group [Figure 6].
Figure 6.
Air polishing of tooth specimen
Once the procedures were completed, each of the tooth block were washed and dried using a three-way air syringe of the dental unit. They were then placed in zip lock bag with saline and transported to the laboratory on the same day for profilometric analysis (IIT, Powai, Mumbai).
Profilometer was used to evaluate the surface roughness of a material. It is a cost-effective and time efficient method which uses a laser beam to evaluate the surface roughness [Figure 7].
Figure 7.
Profilometric analysis machine
Each tooth block (n = 45) was mounted on a profilometer (Alicona, Austria). The machine was adjusted and calibrated to move the stylus not more than 5 mm apico-coronally between the CEJ and the indented line. With the movement of the stylus, an illustrative graph appeared on the screen of the computer. The graph was then subsequently recorded and printed [Figure 8]. A three-dimensional image of the surface was also recorded [Figure 9].
Figure 8.
Profilometric image showing surface roughness with graph
Figure 9.
Three-dimensional image obtained from profilometer
The data were collected, charted, and analyzed using one-way ANOVA with post hoc LSD method for pairwise comparisons. All data were entered into a Microsoft Office Excel (version 2016) in a spreadsheet which was prepared and validated for the data form. Data were entered and checked for errors and discrepancies. The “MedCalc Statistical Software” version 18.11.3 (MedCalc Software bvba, Ostend, Belgium; https://www.medcalc.org; 2019) was used to analyze the data.
RESULTS
The results showed that polishing decreased the surface roughness on the tooth surface after root planing.
Throughout the study, the parameters assessed were as follows:
Ra – Average of roughness profile
Rp – Maximum peak height of roughness profile
Rv – Maximum valley height of roughness profile
Rmax – Maximum peak to valley height of roughness profile within the sampling area.
On analysis of the Ra [Table 1], the mean surface roughness in Group C was 0.50 ± 0.07. For Group A, the mean surface roughness was 1.29 ± 0.16 while for Group B exhibited a mean roughness of 0.97 ± 0.04. In intergroup comparison, Group C showed the best result with respect to average roughness profile; this was followed by Group B and Group A. The difference between the three groups was highly significant [P < 0.0001; Table 2].
Table 1.
Root roughness profile
| Polishing method (mean±SD) | |||
|---|---|---|---|
|
| |||
| Conventional RP (Group A) | Air polishing + conventional RP (Group B) | Air polishing (Group C) | |
| Ra | 1.29±0.16 | 0.50±0.07 | 0.50±0.07 |
Ra – Average of roughness profile; RP – Root planing; SD – Standard deviation
Table 2.
Intergroup comparison of average roughness profile
| Dependant variable | Polishing method | Polishing method | Mean difference | SE | Significant |
|---|---|---|---|---|---|
| Ra | Conventional RP (Group A) | Air polishing Air polishing + conventional RP |
−0.794892-0.322925 | 0.037685 0.037685 |
<0.0001 <0.0001 |
| Air polishing + conventional RP (Group B) | Air polishing Conventional RP |
0.471967-0.322925 | 0.037685 0.037685 |
<0.0001 <0.0001 |
|
| Air polishing (Group C) | Conventional RP Air polishing + conventional RP |
−0.794892-0.471967 | 0.037685 0.037685 |
<0.0001 <0.0001 |
P<0.0001. Ra – Average of roughness profile; RP – Root planing; SE – Standard error; P < 0.0001
On the analysis of Rp [Table 3 and Figure 10], the mean peak height of Group C was found to be 1.71 ± 0.24 whereas for Group A, the mean peak height was 4.16 ± 0.05. For Group B, the peak height was attained at 4.33 ± 0.81. While during intergroup comparison, Group C showed the best result with respect to the mean maximum peak height followed by Group A and Group B. No significant difference was found between Group A and Group B (one way ANOVA with post hoc LSD method for pairwise comparisons) [ P = 0.364; Table 4].
Table 3.
Maximum peak height of roughness profile
| Polishing method (mean±SD) | |||
|---|---|---|---|
|
| |||
| Conventional RP (Group A) | Air polishing + conventional RP (Group B) | Air polishing (Group C) | |
| Rp | 4.16±0.05 | 4.33±0.81 | 1.71±0.24 |
Rp – Maximum peak height of roughness profile; RP – Root planing; SD – Standard deviation
Figure 10.
Profilometric image showing maximum peak height
Table 4.
Intergroup comparison of maximum peak height of roughness profile
| Dependant variable | Polishing method | Polishing method | Mean difference | SE | Significant |
|---|---|---|---|---|---|
| Rp | Conventional RP (Group A) | Air polishing Air polishing + conventional RP |
2.454327-0.16330 | 0.177906 0.177906 |
<0.0001 0.364 |
| Air polishing + conventional RP (Group B) | Air polishing Conventional RP |
2.617627-0.16330 | 0.177906 0.177906 |
<0.0001 0.364 |
|
| Air polishing (Group C) | Conventional RP Air polishing + conventional RP |
−2.454327-2.617627 | 0.177906 0.177906 |
<0.0001 <0.0001 |
P<0.0001. Rp – Maximum peak height of roughness profile; RP – Root planing; SE – Standard error; P = 0.364
On analysis of the Rv [Table 5 and Figure 11], the mean valley height Group C was found to be 1.85 ± 0.29 wherein for Group A, it was 4.06 ± 0.15 and for Group B was 3.63 ± 0.30. While in intergroup comparison, Group C showed the least valley height followed by Group B and Group A. The difference between the three groups was highly significant [P < 0.0001; Table 6].
Table 5.
Maximum valley height
| Polishing method (mean±SD) | |||
|---|---|---|---|
|
| |||
| Conventional RP (Group A) | Air polishing + conventional RP (Group B) | Air polishing (Group C) | |
| Rv | 4.06±3.63 | 3.63±0.30 | 1.85±0.29 |
Rv – Maximum valley height of roughness profile; RP – Root planing; SD – Standard deviation
Figure 11.
Profilometric image showing maximum valley height
Table 6.
Intergroup comparison of valley height
| Dependant variable | Polishing method | Polishing method | Mean difference | SE | Significant |
|---|---|---|---|---|---|
| Rv | Conventional RP (Group A) | Air polishing Air polishing + conventional RP |
2.209947-0.427687 | 0.093348 0.093348 |
<0.0001 <0.0001 |
| Air polishing + conventional RP (Group B) | Air polishing Conventional RP |
1.782260-0.427687 | 0.093348 0.093348 |
<0.0001 <0.0001 |
|
| Air polishing (Group C) | Conventional RP Air polishing + conventional RPa |
−2.209947-1.782260 | 0.093348 0.093348 |
<0.0001 <0.0001 |
P<0.0001. Rv – Maximum valley height of roughness profile; RP – Root planing; SE – Standard error; P < 0.0001
On analysis of Rmax [Table 7], the data obtained showed that the least value of 3.38 ± 0.51 was obtained for Group C, followed by 7.02 ± 0.46 for Group B and 7.13 ± 1.09 for Group A. While in the intergroup comparison, Group C showed the best result with respect to the maximum peak to valley height of roughness profile within the sampling area followed by Group B Group A. No significant difference was between Group A and Group B (one way ANOVA with post hoc LSD method for pairwise comparisons) [P = 0.689; Table 8].
Table 7.
Maximum peak to valley height of roughness profile
| Polishing method (mean±SD) | |||
|---|---|---|---|
|
| |||
| Conventional RP (Group A) | Air polishing + conventional RP (Group B) | Air polishing (Group C) | |
| Rmax | 7.02±0.46 | 7.13±1.09 | 3.38±0.51 |
Rmax – Maximum peak to valley height of roughness profile within the sampling area; RP – Root planing, SD – Standard deviation
Table 8.
Intergroup comparison of peak to valley height
| Dependant variable | Polishing method | Polishing method | Mean difference | SE | Significant |
|---|---|---|---|---|---|
| Rmax | Conventional RP (Group A) | Air polishing Air polishing + conventional RP |
3.643280-0.109727 | 0.272332 0.272332 |
<0.0001 0.689 |
| Air polishing + conventional RP (Group B) | Air polishing Conventional RP |
3.753007-0.109727 | 0.272332 0.272332 |
<0.0001 0.689a |
|
| Air polishing (Group C) | Conventional RP Air polishing + conventional RP |
−3.643280-3.753007 | 0.272332 0.272332 |
<0.0001 <0.0001a |
P<0.0001. Rmax – Maximum peak to valley height of roughness profile within the sampling area; RP – Root planing, SE – Standard error; P = 0.689
DISCUSSION
The objective of periodontal therapy is to reduce bacterial deposits and calculus on tooth surfaces and also prevent further plaque accumulation.[9,10] Studies have shown that scalers, curettes, and ultrasonic instruments are effective in removing plaque and calculus but do not produce a smooth tooth surface. Traditional polishing techniques by using rubber cups and polishing brush do not achieve expected results. Our study showed that the surface roughness is least with air polisher. This result was confirmed by a standard profilometric analysis.
Polishing with rubber cup and brushes is the most prevalent method practiced, it is gradually being replaced by an air-powder polishing devices such as Prophy-Jet. Previously Prophy-Jet was known to cause gingival tissue damage and loss of cementum, which was attributed to large particle size of polishing powder.[11] This was attributed to the larger particle size used in the past. Air polishing has an advantage to reach inaccessible areas on the tooth surface compared to a rotary device.
In contrast to our study, polishing with rubber cup was found to be more effective to as compared to air polisher and bristle brush. This could be attributed to the large and irregular particle size of air polishing powder.[12]
In contrary to our study, Petersilka et al. reported that air polishing causes loss of exposed cementum and dentin. Hence, they recommended selective use of air polishing. This effect could be due to larger particle size of air polishing powder.[13] Galloway and Pashley reported similar results after using Prophy-jet.[14]
Particle size of <60 μm used by us in the current study has proved to cause least hard and soft tissue damage. Studies conducted by Leknes and Lie and Patil et al. also demonstrated reduced surface roughness as well as debris on both enamel and cementum surfaces.[15,16] Similar results for root surface were seen in the present study. Weaks et al. have studied the efficiency of Prophy-Jet along with its effects on marginal gingiva and showed that the soft-tissue trauma was not significant.[17]
The shape of the powder particles has a great role in achieving the desired smooth surface. The polishing powder particles used in our study have a more uniform structure, nontoxic, biocompatible organic salt crystals that slowly dissolve in water. The abrasiveness of this powder on human teeth is approximately 80% lower compared to first-generation powders. The maximum depth of the resultant surface abrasion did not exceed 2 μm. No clinically visible changes in the hard tissues following air polishing therapy were evident.[18]
In our study, we have used profilometer to assess the surface of cementum. Profilometer is a device used specifically to evaluate surface roughness of any material. Studies done by Kayahan et al. and Cuesta et al. have used profilometer to evaluate surface roughness in metallurgy.[19,20] The advantage of using profilometer is that its inexpensive when compared to scanning electron microscope (SEM) and relatively takes short time for evaluation. Profilometric analysis does not require elaborate preparation of sample as SEM such as sputter coating and sample sectioning. The results can be analyzed and obtained rapidly when compared to SEM. It uses laser guidance to accurately map the surface of any material.
Profilometer can be used to study surface roughness and topography. The disadvantages of using a profilometer are that measurements are limited to the area of the tip, viscous material cannot be measured, and highly angulated surfaces cannot be measured.[19] According to our study, Group C (air polishing) has been found to be more effective and least damaging to the tooth surface.
Studies have shown that without the administration of local anesthesia, patients described that treatment with glycine powder air polishing is significantly more comfortable than with hand instruments or ultrasonic instruments.[21] Polishing of tooth surface after scaling and root planing is most neglected, air polishing can effectively remove plaque and smoothen the root surface thereby achieving best outcome of periodontal therapy.
CONCLUSIONS
From this study, we can conclude that air polishing (Group C) can effectively smoothen the root surface by removing surface irregularities which are produced by hand/ultrasonic instruments when compared to conventional root planing (Group A) and combination of air polishing and conventional root planing (Group B). Newer generation air polishing powder is effective and does not cause damage to soft and hard tissue. The findings of this study could be substantiated and corroborated with larger sample size and evaluation of multiple tooth surfaces.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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