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1 HVE (Suction-evacuation) Suggestions for ultrasonics and glycine/air polishing HVE is a critical part of infection control when using these treatment modalities. The goal is to aspirate the plume before it leaves the oral cavity. Aspiration should occur opposite the Air Polishing tip. Posterior Anterior QUALITY ASPIRATORS Duncanville, TX Phone: (972) This is the set-up we used in the clinic. Using the surgical tubing adapter set with HVE and a short tip, allows for freedom of movement and placement not possible with standard tubing. 5. tubing adaptor set TASS $37.50 ST-HVE $38 Flip-A $54 STS 100 Disposable screen tip $14.96

2 Available at Hager Worldwide, (purchase through office dental supply company) BullFrog Ergo handpiece # B11171 Autoclavable $80-$90ea BullFrog Ergo Vac H.V.E. Handpieces (110 degree) Easily hold at top to retract with Pelotte tip. 4 Pelotte Plus tip Autoclavable 10/$32 Available in disposable 50/$46 Available at Widemouth adaptor # Autoclavable 25/$12 Vented 6 HVE tip VE-1121 Disposable 100/$5 Cut in half and insert widemouth into vented (slot) end, vent hole overrides suction, prevents tissue aspiration Autoclavable Angled HVE tips # Bag of 25 (blue) $12.00

3 MASS suction HVE tips #21-79 Disposable bag 100 $15.00 Perforations around the barrel to override suction. Available from local dental supplier - Practicon Practicon Angle-Ease Adjustable HVE tips- The adjustments on this tip make it easier for the single clinician to retract and suction in an ergonomic manner. Especially when used with Bull Frog. Available from local dental supplier - YOUNG DENTAL Vent-O-Vac Vented 3.5 HVE tips- Bag of 100 $27.00 Note: Can t be used with the widemouth adaptor as it covers the air slots. However, they work well even without it as they are shorter and easier to control.

4 Available from local dental supplier Crosstex, Pulpdent and others HYGOFORMIC Saliva Ejectors The curled shape holds soft tissue from being sucked in, multiple holes allow for faster, more complete evacuation of water/fluid. They fit into standard size saliva ejector adaptors via a short autoclaveable adaptor (shown). A bag of 100 ejectors comes with 5 adaptors. Available at Autoclaveable lightweight saliva ejector adaptor hose Can be placed in high speed evacuation hose, or saliva ejector hose via a Hygoformic adaptor. Unfortunately a standard HVE Evac tip is too big to fit in this hose. 42 or 48 $65 Suction Mirrors Available from local dental supplier - Practicon Micro-vac saliva ejector mirror Use for standard suction, disposable Box of 50 for $30.00.

5 Available from local dealer or online from many sites Autoclavable set with hose and adaptor for HVE and standard suction. Cost from $120 - $175 for set-up [GRAB YOUR READER S ATTENTION WITH A GREAT QUOTE FROM THE DOCUMENT OR USE THIS SPACE TO EMPHASIZE A KEY POINT. TO PLACE THIS TEXT BOX ANYWHERE ON THE PAGE, JUST DRAG IT.] PREPARED FOR YOU BY: Robin Cox ce4me@dhceinstitute.com

6 Slide 1 Robin D. Cox, BSDH, RDH, EPP OHSU School of Dentistry, Department of Periodontology Dental Hygiene CE Institute, Portland OR Slide 2 Course Objectives Clarify the origin and physical properties of glycine powder and use as a biofilm removal therapy. Describe safety, efficacy and benefits of glycine air polishing as a biofilm management treatment. State evidence based treatment recommendations for glycine air polishing. Define recommended techniques for using subgingival glycine powder air polishing. Slide 3 Glycine powder has recently become an effective treatment modality for biofilm disruption through air polishing technology. Evidence shows promising data for using Glycine Powder Air Polishing to manage and treat periodontal disease, implant maintenance and first stage treatment for diseases affecting the implant integrity.

7 Slide 4 Clinical and patient circumstances Scientific Evidence Patient value or preference TREATMENT DECISION Experience and judgement Slide 5 Slide 6 *ROTARY CUP AND POLISH *AIR POLISHING STAIN REMOVAL CORONAL POLISHING BIOFILM DISRUPTION *ULTRASONIC SCALING

8 Slide 7 *PURPOSE - Remove extrinsic stain and biofilm remaining on the tooth surface following scaling. *LIMITATIONS No therapeutic value; damages tooth structure; unsafe for many dental restorations Slide 8 *EXTRA FINE *FINE *MEDIUM 10% of all sales *COURSE 80% of all sales Covey, D.A., et al., Effects of a paste-free prophylaxis polishing cup and various prophylaxis polishing pastes on tooth enamel and restorative materials. General dentistry, (6): p Slide 9 Ditched root surface resulting from polishing paste and cup Pence, S.D., et al., Repetitive Coronal Polishing Yields Minimal Enamel Loss. Journal of Dental Hygiene, (4): p

9 Slide 10 Slide 11 *EFFECTIVE STAIN REMOVAL *BIOFILM DISRUPTION *SAFE FOR ROOT SURFACES *ADDITIONAL PROCEDURAL BENEFITS TIME CONSUMING Slide 12 *MOST EFFECTIVE STAIN REMOVAL *BIOFILM DISRUPTION *PRE-SEALANT PREPARATION LIMITATIONS omessy omaintenance

10 Slide 13 *Coronal stain removal Preparation for dental sealants 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): Slide 14 Slide 15

11 Slide 16 *Sodium bicarbonate *Calcium carbonate *Aluminum Hydroxide Slide µm Crystalline Angular shape Jagged edges Contains salt Salty taste Magnification X on_of_air_polishing.aspx Atkinson, D. R., et al. (1984). "The effect of an air-powder abrasive system on in vitro root surfaces." J Periodontol 55(1): Slide 18 Surface of a premolar after air-polishing with standard sodium bicarbonate. The nozzle of the air-polishing device was aimed with a constantly sweeping motion towards the cemento enamel junction for 20 s. While the enamel surface is unaltered, root damage is clearly visible. Arrows indicate the border between the instrumented and the noninstrumented area. Petersilka, G. J. (2011). "Subgingival air- polishing in the treatment of periodontal biofilm infections: Subgingival air- polishing." Periodontology (1):

12 Slide 19 Galloway, S. E. and D. H. Pashley (1987). "Rate of removal of root structure by the use of the Prophy-Jet device." J Periodontol 58(7): Slide 20 Microscopic detectable tissue change- Histological Score 1. No lesion: undamaged epithelium and connective tissue 2. Minor lesion: disruption of superficial epithelial layers, undamaged basal membrane 3. Medium lesion: superficial layers of the epithelium removed, basal membrane partially damaged 4. Severe lesion: epithelium and basal membrane completely removed, connective tissue exposed Simon, C. J., et al. (2015). "Efficacy of glycine powder air polishing in comparison with sodium bicarbonate air polishing and ultrasonic scaling - a double-blind clinico-histopathologic study." International Journal of Dental Hygiene 13:( (Electronic)). Slide 21 Particle size µm Crystalline Microspheres Safe on enamel Sodium free restrictions 1000x 55um, Air N Go PEARL 2500x

13 Slide 22 * *Particle size µm *Crystalline *Jagged *Safe on enamel only *Sodium free restrictions Slide 23 Composite Resin Glass Ionomer Gold Amalgam Johnson, W. W., et al. (2004). "The effects of a commercial aluminum airpolishing powder on dental restorative materials." Journal of prosthodontics 13(3): Slide 24 *Effective stain removal *Less abrasive than rotary cup and polishing *Requires less time *Better access to pits, fissures and interproximal areas *Reduction in operator fatigue *Good biofilm removal *Safe for enamel surfaces *Great for pretreatment of dental sealants

14 Slide 25 The most essential treatment aspect for all periodontal treatments. Health Maintenance Gingivitis Periodontal disease and maintenance Implant maintenance Peri-implantitis Implant mucositis Slide 26 Plastic scalers Specialty scalers Flossing tricks Ultrasonic tips and adaptations Flap surgery Slide 27

15 Slide 28 *BIOFILM REMOVAL * 5 seconds per site * Replaces polishing step *DISEASE PREVENTION * Prophylaxis * Periodontal maintenance * Implant maintenance *THEREPUETIC TREATMENT * Gingivitis * SRP * Implantitis * Mucositis Slide 29 *Biocompatible Amino acid *Simplest and smallest *Naturally sweet tasting *Used in dentistry since 2003 *Widely used in Europe *FDA cleared for subgingival use *No PD limit in Europe *10mm in Canada *5mm in USA Slide 30 *Glycine at 1000x *Glycine at 100x µm

16 Slide 31 Slide 32 PURPOSE Determine biofilm debridement effectiveness on root surfaces in different anatomical pocket depths (APD) RESULTS *100% up to 2mm apical to the gingival margin *60-80% at 2-3mm (average) *Median removal was 49.24% (50% of teeth had APD 6mm) *Biofilm debridement reduced as PD increased and leveled off to 30% at 6mm PD Flemmig, T. F., et al. (2007). "Subgingival Debridement Efficacy of Glycine Powder Air Polishing." Journal of periodontology 78(6): Slide 33 DISCUSSION Clinical pocket depth was found to be about 1 mm deeper than APD. The debridement results of GPAP were not affected by the presence of calculus. GPAP may replace curettes or ultrasonic scalers in shallow pockets. CONCLUSION GPAP removed most of the biofilm on root surfaces in all PD up to 4 mm. GPAP may replace traditional methods and the use of hand and ultrasonic scalers used strictly for calculus removal. GPAP takes only 5 seconds per site (4 per tooth) for a total of 9.3 minutes for 28 teeth. Flemmig, T. F., et al. (2007). "Subgingival Debridement Efficacy of Glycine Powder Air Polishing." Journal of periodontology 78(6):

17 Slide 34 PURPOSE Efficacy of subgingival plaque removal in supportive periodontal therapy comparing curettes scaling and GPAP RESULTS * Significant reduction in colony forming units for the GPAP group compared to curette group * Results found in PD of 3-5mm consistently CONCLUSION GPAP treatment is superior to curettes in treatment of periodontal maintenance patients for biofilm removal. Patient perceived GPAP treatment significantly more comfortable than curette group negative control positive control (curettes) test (subgingival air polishing) MEAN REDUCTION IN CFU (P<0.05) Petersilka, G. J., et al. "Subgingival plaque removal in buccal and lingual sites using a novel low abrasive air-polishing powder." ( (Print)) Slide 35 PURPOSE The study aimed to look at several aspects of using glycine in the periodontal pocket. The author looked at biofilm removal, safety on root surfaces and safety of the gingival pocket wall. RESULTS BIOFILM REMOVAL- the results show nearly all biofilm completely removed in PD up to 4mm. Biofilm reduction decreased and leveled off to 30% at 9mm. (5 seconds of tx per site, with nozzle aimed at coronal 1/3 of root into sulcus) A significant reduction in subgingival bacterial count was found in the GPAP group compared to the curette group. (Hand scaling end point was when no more plaque came up on the instrument). Petersilka, G. J. (2011). "Subgingival air- polishing in the treatment of periodontal biofilm infections: Subgingival air- polishing." Periodontology (1): Slide 36 RESULTS ROOT SURFACE-sodium bicarbonate powder resulted in 80% greater substance loss than glycine powder. (36 teeth, 20 seconds of treatment from varying distances of 2 6 mm away at low, medium and high psi.) 3D mapping of defect on root surface resulting from both powder types. Glycine- Minor abrasion of dentin with depth of 2 µm Sodium Bicarbonate- Deep, wedge shaped groove in excess of 50 µm deep Petersilka, G. J. (2011). "Subgingival air- polishing in the treatment of periodontal biofilm infections: Subgingival air- polishing." Periodontology (1):

18 Slide 37 RESULTS HISTOLOGICAL testing was done to evaluate the condition of the epithelial tissue it was evident that GPAP caused little to no epithelial damage. Signs of mild inflammation was noted in some samples. (80 teeth, 10 patients, 5 seconds of tx per site) A B C D (A) Epithelium without mechanical debridement. No signs of epithelial damage are visible. (B) Oral gingival epithelium directly after debridement using glycine powder air-polishing. No signs of epithelial damage are visible. (C) Oral gingival epithelium directly after treatment with sodium bicarbonate air-polishing. Discernible erosion of the oral gingival epithelium with exposure of the underlying connective tissue is present. (D) Oral gingival epithelium directly after hand instrumentation. Epithelial layers are almost completely removed leading to focal exposure of connective tissue. Petersilka, G. J. (2011). "Subgingival air- polishing in the treatment of periodontal biofilm infections: Subgingival air- polishing." Periodontology (1): Slide 38 *GPAP is safe and effective to use for the periodontal patient. *It may be a better option for treating pockets up to 5mm *It is as effective as hand scaling with insignificant root damage *Tx completed with greater ease and efficiency *5 seconds per site, mins for entire mouth *Patients report that treatment with GPAP is significantly more comfortable that hand scaling. *Hand scaling and/or ultrasonic devices should still be used for the removal of calculus when present. Petersilka, G. J. (2011). "Subgingival air- polishing in the treatment of periodontal biofilm infections: Subgingival air- polishing." Periodontology (1): Slide 39 PURPOSE Compare safety and efficacy of GPAP, Sodium Bicarbonate and ultrasonic scaling during periodontal maintenance therapy. RESULTS * GPAP reduced biofilm significantly greater than Sodium Bicarbonate * GPAP resulted in less epithelial damage than either SB or ultrasonic scaling * Biofilm reduction was equal for GPAP and ultrasonic scaling CONCLUSION GPAP is a more efficient material for biofilm removal compared to SB and virtually as effective as ultrasonic scaling. GPAP causes less gingival erosion vs. that resulting from ultrasonic scaling. * Simon, C. J., et al. (2015). "Efficacy of glycine powder air polishing in comparison with sodium bicarbonate air polishing and ultrasonic scaling - a doubleblind clinico-histopathologic study." International Journal of Dental Hygiene 13:( (Electronic)).

19 Slide 40 No instrumentation (1) Glycine AP (1) Sodium Bicarbonate (2 &3) Ultrasonic (Piezo) (2&3) Simon, C. J., et al. (2015). "Efficacy of glycine powder air polishing in comparison with sodium bicarbonate air polishing and ultrasonic scaling - a double-blind clinico-histopathologic study." International Journal of Dental Hygiene 13:( (Electronic)). AP was 5 sec. per site, 5 mm from tooth aimed into pockets 5mm. Ultrasonic scaling was done until no visible plaque showed on probe. Slide 41 PURPOSE Evaluate the effects of three distinct periodontal treatment methods in comparison with hand instrumentation on residual cementum of periodontal diseased teeth. CLINICAL RELEVANCE Cementum is a key component of periodontal tissues, and its preservation is of paramount importance for the quality of healing at completion of periodontal both non-surgical and surgical treatment modalities. Periodontal reattachment or new attachment as end result of therapy strongly relies on the presence of cementum after root instrumentation. Bozbay, E., et al. (2016). "Preservation of root cementum: a comparative evaluation of power-driven versus hand instruments." International Journal of Dental Hygiene: Slide 42 a. Ultrasonic scaling Piezoelectric Cementum is absent coronally. Has irregularities with scratches and gouges. b. Hand scaling Gracey Curettes No cementum remaining in treated area c. Ultrasonic scaling + AP Glycine Most cementum intact, grooves and irregularities present d. AP alone Glycine All cementum still intact CONCLUSION Hand scaling results in almost complete removal of cementum AP preserved the most cementum but failed to remove calculus Ultrasonic scaling with or without AP left sufficient intact cementum Ultrasonic and AP are most efficient in removing soft and hard deposits Bozbay, E., et al. (2016). "Preservation of root cementum: a comparative evaluation of power-driven versus hand instruments." International Journal of Dental Hygiene:

20 Slide 43 Above: Before and after treated with GAP Below: Before and after treated with Curettes Slide 44 Human Enamel POWDERS COMPARED EMS Sodium Bicarbonate Dentsply Aluminum Trihydroxide Dentsply Sodium Bicarbonate Osspray calcium sodium phosphosilicate KaVo calcium carbonate EMS glycine 25µm Barnes, C. M., et al. (2014). "An in vitro comparison of the effects of various air polishing powders on enamel and selected esthetic restorative materials." The Journal of clinical dentistry. 25(4): Slide 45 Hybrid composite Glass Ionomer

21 AP was 5 sec. per site. Slide 46 * Involving bone and gingival tissue * Marked by increased pocket depths * BOP and/or Pus * Involving gingival tissue * Marked by swelling * Apparent inflammation Slide 47 Glycine on Titanium Increased roughness in the titanium surface with SB treated group. GAP group did not result in any detrimental change in the quality of the surface. GAP group showed significantly less contamination (CFU) than SB group Cochis A, Fini M., Carrassi A, et al. Effect of air polishing with glycine powder on titanium abutment surfaces. Clin Oral Impl. Res 2013;24: Glycine & Mucositis Significant reduction in mean plaque score, BOP and number of periodontal pockets 4 mm in both groups. The percentages of diseased sites were significantly reduced for both groups GAP: 38% to 8% = 79% decrease Ultrasonic = 60% decrease Riben-Grundstrom, C., et al. "Treatment of peri-implant mucositis using a glycine powder air-polishing or ultrasonic device: a randomized clinical trial." Glycine & Implant Maintenance At 3 months, GAP treatment showed statistically significantly improved Bleeding Score (BS). At 6 months, GAP treatment statistically significantly improved indexes PD, PI, BOP and BS. GAP = 25% BS Curette & CHX = 14% BS Lupi, S. M., et al. "Air-abrasive debridement with glycine powder versus manual debridement and chlorhexidine administration for the maintenance of peri-implant health status: a six-month randomized clinical trial. LID /idh [doi]." Slide 48 Glycine on Titanium Air-polishing with glycine powder may be considered a better method of removing plaque from dental implants because glycine powder is less abrasive than sodium bicarbonate. Glycine powder appears to play a role in inhibition to bacterial recolonization of implants in short testing times of 24 hours. Cochis A, Fini M., Carrassi A, et al. Effect of air polishing with glycine powder on titanium abutment surfaces. Clin Oral Impl. Res 2013;24: Glycine & Mucositis Treatment with a glycine powder air-polishing or an ultrasonic device is effective in non-surgical treatment of peri-implant mucositis. Riben-Grundstrom, C., et al. "Treatment of peri-implant mucositis using a glycine powder air-polishing or ultrasonic device: a randomized clinical trial." Glycine & Implant Maintenance The maintenance protocol with glycine allows to maintain an adequate level of health of periimplant tissues with an extremely reduced chair time. Within the limits of the study, treatment with glycine seems appropriate in the maintenance of peri-implant health and more effective than the traditional treatment with plastic curette and chlorhexidine. Lupi, S. M., et al. "Air-abrasive debridement with glycine powder versus manual debridement and chlorhexidine administration for the maintenance of peri-implant health status: a six-month randomized clinical trial. LID /idh [doi]."

22 Slide 49 GLYCINE *Chemotherapeutic properties *Bacteriostatic or Bactericidal *Use in neurotransmitters *Schizophrenia *Memory function *Reduce brain damage during stroke *Healing ulcers *Maintaining blood sugar levels in diabetic patients ERYITHROL *Anti-cariogenic *Used regularly at therapeutic doses *Stain removal Slide 50 Slide 51 Glycine Powder Air Polishing *Safe on teeth, roots, tissue and all restorative materials *More effective for biofilm removal than hand instruments and is equally effective as ultrasonic instruments *It is more in line with the goal of periodontal therapy than hand scaling *It can be used to remove stain on root surfaces safely *It can t remove calculus *Patients prefer it to other treatments and do not find it unpleasant or uncomfortable *5 SECONDS PER SITE = minutes for full mouth biofilm removal *Unsurpassed treatment for implant care

23 Slide 52 ROUTINE TREATMENT SEQUENCE Biofilm Removal With GAP Ultrasonic Scaling All sites, 5 seconds per site Hard Deposits Only where indicated Air Polishing Stain Removal if needed Slide 53 Biofilm Removal With GPAP Ultrasonic Scaling Hard Deposits Air Polishing Stain Removal SRP TREATMENT SEQUENCE RE-EVAL GPAP biofilm removal Slide 54 *Full mouth decontamination with GAP is recommended for significant reduction of the bacterial load. *Labial and buccal mucosa, palate and tongue. *Periodontal maintenance and SPR *90 day study showed P. Gingivalis significantly lower in GPAP group compared to control group. Flemmig, T. F., et al. (2012). "Randomized Controlled Trial Assessing Efficacy and Safety of Glycine Powder Air Polishing in Moderate-to- Deep Periodontal Pockets." Journal of periodontology 83(4):

24 Slide 55 Tips for Air Polishing Pre-procedural rinse of Listerine or CHX Isolation of treatment area High Speed Suction Safety glasses for patient Non-petroleum lip balm Slide 56 Aspiration should occur opposite AP tip, and close to subgingival tip. Slide 57 * Immediate swelling & pain in gingival tissue * One in 666,666 * More cases reported with air-water syringe and high speed turbine * Deep pocket treatment * Requires 3mm of bone support Discontinue Use 3mm Resolves in 2-3 days Seek medical help difficulty swallowing or impaired vision

25 Slide 58 SUBGINGIVAL GLYCINE POWDER AIR POLISHING Slide 59 ACTEON EMS Slide 60

26 Slide 61 Supragingival stain removal use. For subgingival AP with Glycine or Eryithol. Slide 62 CLASSIC POLISHING & LOW ABRASIVE POWDERS Slide 63 ACTEON EMS

27 CLINICAL CASE PERIO easy Nozzle Slide 64 Slide 65 Deep and narrow Moderate-ease of access Slide 66 X-ray showing the positioning of the nozzle to the bottom of the sulcus Positioning of the PERIO easy nozzle for debridement of sub-gingival biofilm Clinical case Dr G. GAGNOT (France)

28 ACTEON Supra and Sub nozzles Slide 67 Slide 68 *Coronal stain removal Preparation for dental sealants 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): Slide 69 BEFORE AFTER Clinical case Dr G. GAGNOT (France) Patient: Smoker, severe periodontitis, patient did not want implants.

29 Slide 70 Patient Presents to Appointment Slide 71 Slide 72

30 Slide 73 Slide 74 Slide 75

31 Slide 76 Slide 77