Received: 13 January 2020 | Revised: 6 July 2020 | Accepted: 10 October 2020

DOI: 10.1111/idh.12481

ORIGINAL ARTICLE

Research on dental plaque removal methods for efficient oral

prophylaxis: With a focus on air polishing and rubber cup
polishing

Bo-young Park1 | Minjung Kim2 | Junghyun park2 | Ju-Hui Jeong1 |

Hiejin Noh3

1
Department of Dental Hygiene, The
Graduate School, Yonsei University, Abstract
Wonju, Republic of Korea
Objectives: This study was conducted to compare the plaque control effectiveness of
2
Boa Dental Clinic, Seoul, Republic of
Korea
rubber cup polishing with that of air polishing during oral prophylaxis procedures and
3
Department of Dental Hygiene, Wonju to investigate the effect of the order of air-polishing application on the efficiency of
College of Medicine, Yonsei University, oral prophylaxis.
Wonju, Republic of Korea
Methods: The study included adult patients (≥20 years of age) who had visited the
Correspondence dental clinic for oral prophylaxis. A total of 173 subjects were divided into three
Hiejin Noh, Department of Dental
Hygiene, College of Medicine, Yonsei groups (scaling followed by rubber cup polishing, SR; scaling followed by air polish-
University, 20, Ilsan-ro, Wonju, Gangwon- ing, SA; and air polishing followed by scaling, AS) based on sex, age, oral health sta-
do, 220-701, Republic of Korea.
Email: nohh14@[Link] tus, oral hygiene status, and indications and contraindications according to the oral
prophylaxis method. The analysis of variance (ANOVA) was used to determine the
Funding information
EMS Electro Medical System difference in oral prophylaxis time, residual deposits rate, subjects and dental hygien-
ist satisfaction.
Results: The total scaling time was shorter in the AS group (15.4 ± 6.9 minutes) than
in the SA (18.7 ± 5.5 minutes) and SR groups (19.9 ± 6.2 minutes) (p < 0.05). The
rate of residual deposits was significantly higher in the SR group than in the AS or
SA groups (p < 0.05). The satisfaction level of dental hygienists was higher in the
AS group (8.8 ± 1.0 points) and the SA group (8.4 ± 1.0 points) than in the SR group
(6.2 ± 1.3 points).
Conclusion: During oral prophylaxis, dental plaque removal using air polishing re-
quires a relatively longer time when compared to rubber cup polishing, but it can bet-
ter eliminate dental plaque. In addition, we found that dental plaque removal using air
polishing prior to scaling reduced the total scaling time.

KEYWORDS
air polishing, oral prophylaxis, rubber cup polishing, scaling

© 2020 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Int J Dent Hygiene. 2020;00:1–7.  [Link]/journal/idh | 1

2 | PARK et al.

1 | I NTRO D U C TI O N 2.2 | Baseline evaluation

To date, various studies have been conducted to compare the ef- One dentist performed all evaluations to determine the subjects’
ficiencies of hard instruments and ultrasonic instruments for oral teeth statuses and periodontal health statuses. Evaluation catego-
prophylaxis1 and to compare the plaque removal effects of rubber ries included the following: the number of natural teeth, the num-
2,3
cup, bristle brush, and air polishing. Oral prophylaxis is considered ber of artificial teeth, the number of missing or non-erupted teeth,
efficient when it provides complete care in a safe and relatively rapid the number of filled teeth, clinical attachment level and Periodontal
manner, with minimal discomfort for both the patient and the health- Index.7,14,15
1,4
care provider. Two dental hygienists determined the subjects’ oral hygiene sta-
Traditional oral prophylaxis involved tooth scaling using an ul- tuses after staining the intraoral dental plaque biofilm and calculus
trasonic scaler or periodontal instrument, followed by coronal pol- with a disclosing solution (GC Tri Plaque). Evaluation categories in-
ishing.5,6 Kim et al. reported that plaque control through a self-care cluded the Simplified Debris Index (S-DI), Simplified Calculus Index
device prior to teeth scaling reduced the time required for both ul- (S-CI) and residual deposits.16 Inter-observer agreement between
trasonic scaling and tooth cleaning.7 Nonetheless, self-care devices the two dental hygienists was represented by a Cohen's kappa value
are more frequently used in home settings than in dental clinics, and of 0.289 (p < 0.05).17
the effectiveness of plaque control equipment commonly used in
dental clinics (ie rubber cup polishing and air polishing) has not been
investigated. 2.3 | Group selection method
Dental plaque removal methods used in dental clinics include
not only self-care devices, but also hand instruments and powered The study subjects were divided into three groups based on the
instruments. 8,9 Powered instruments require less time and effort oral prophylaxis method used. After oral examination, the subjects
10
than hand instruments. Among the powered instruments, rubber deemed appropriate for this study were equally distributed into
cup–polishing and air-polishing instruments are often utilized for the groups after taking the following factors into consideration:
the removal of tooth stains and dental plaque.4,11 Previous studies sex, age, oral health status, oral hygiene status, and indications
have reported that air polishing causes less damage to the tooth and contraindications according to the coronal polishing method.
surface and provides a greater plaque removal rate when com- Overall, there were 60 patients in the SR group (scaling followed
pared to rubber cup polishing.11-13 In contrast, a study by Patil by rubber cup polishing), 57 patients in the SA group (scaling fol-
et al. showed no differences in the plaque control effectiveness lowed by air polishing) and 56 patients in the AS group (air polish-
of different methods, including rubber cup polishing, air polishing ing followed by scaling).
2
and bristle brush.
This study was conducted to compare the plaque control ef-
fectiveness of rubber cup polishing with that of air polishing 2.4 | Oral prophylaxis
during oral prophylaxis procedures and to investigate the effect
of the order of air-polishing application on the efficiency of oral Oral prophylaxis was divided into the scaling process (ultrasonic
prophylaxis. scaling and manual scaling) and the plaque control process (rubber
cup polishing and air polishing). All subjects were treated using
the same ultrasonic scaler, air flow (AIR-FLOW Master Piezon;
2 | M E TH O D S EMS, Nyon, Switzerland), air-flow powder (AIR-FLOW PLUS; EMS,
Nyon, Switzerland), abrasive for rubber cup polishing (Proxyt Fine;
2.1 | Subjects Ivoclar Vivadent, Schaan, Liechtenstein), rubber cup (ECODEN
RUBBER CUP; DMAX, Gwangju, Korea) and hand pieces (X-Smart;
The study included adult patients (≥20 years of age) who had vis- Dentsply Maillefer, Ballaigues, Switzerland). The cordless hand
ited the dental clinic in Seoul, South Korea, for oral prophylaxis piece used for rubber cup polishing was set at ≤3000 RPM, and
between September 2018 and March 2019 who had at least 20 the selected abrasive (Proxyt fine) had a relative dentine abrasion
natural teeth, were not undergoing orthodontic treatment and had (RDA) value of 7, thus resulting in no damage to the enamel.18,19
indications for oral prophylaxis. Using G*Power 3.1 software, the The powder selected for air polishing was erythritol-based, allow-
recommended sample size was 159; thus, 176 patients were as- ing for removal of the supragingival and subgingival biofilm with-
sessed to account for a 10% dropout rate. After excluding the data out damage to the teeth. 20
from three cases with inadequate information, 173 cases were in- In the SR group (rubber cup polishing), only natural teeth with-
cluded in the final analysis. This study was approved by the Ethics out artificial fillings were assessed.15 In the SA and AS groups (air
Committee for Research of Yonsei University, Wonju College of polishing), all functional teeth, including those with dental resto-
Medicine (CR317136). Written informed consent was obtained rations, were assessed.15 A fluoride rinse was provided after all
from all of the study participants. treatments.
PARK et al. | 3

2.5 | Postoperative assessments subjects in the SR group, 57 subjects in the SA group and 56 subjects
in the AS group (Table 1).
The time required for oral prophylaxis was measured for all treat-
ment processes. The total scaling time was calculated by adding the
times required for ultrasonic scaling and manual scaling (indepen- 3.2 | Subjects’ oral health conditions according
dently measured). The time required for plaque control was meas- to oral prophylaxis method
ured separately for rubber cup polishing and air polishing. Lastly, the
time required for oral prophylaxis was calculated by adding the total The mean numbers of functional teeth in the subjects were
scaling time and the time required for plaque control. 29.3 ± 2.2 in the SR group, 28.7 ± 2.4 in the SA group and 28.3 ± 2.3
After the completion of oral prophylaxis, all of the subjects’ tooth in the AS group, and there was a significant difference in the num-
surfaces were stained using a disclosing solution (GC Tri Plaque, ID ber of functional teeth between the SR group and the AS group
Gel) to assess the level of residual deposits. Surfaces were dichot- (p < 0.05). However, there were no significant differences in the
omized into either buccal and lingual surfaces or interproximal sur- number of natural teeth or the number of teeth treated with rub-
faces for the assessment. Any residual deposits detected during the ber cup polishing or air polishing. The subjects’ mean Periodontal
examination were removed, and the time required for this evaluation Index was 0.0 ± 0.1, and the mean number of teeth with a clini-
was not included in the time of oral prophylaxis. cal attachment level of ≥4 mm was 0.1 ± 0.3. The Debris Index
Immediately after all procedures, a survey was provided to both was ‘poor’ in all three groups, while the Calculus Index was ‘fair’
the patient and the dental hygienist to evaluate their satisfaction in all three groups. On average, the last scaling appointment was
levels. The points ranged from 0 (extremely unsatisfied) to 10 (ex- 15.5 ± 13.2 months prior, and 17.9% of the subjects were smokers
tremely satisfied). (Table 2).

2.6 | Statistical analysis 3.3 | Differences in the times required for oral
prophylaxis using different methods
Analyses in this study were performed using PASW Statistics 18.
General characteristics of the subjects were summarized using a fre- The time required for ultrasonic scaling was shortest in the AS
quency analysis. The oral health conditions of the subjects were ana- group (9.4 ± 4.4 minutes), followed by the SA group (11.3 ± 3.9
lysed using analysis of variance (ANOVA). Differences between the minutes) and the SR group (12.5 ± 5.7 minutes). Post hoc analysis
teeth cleaning methods regarding the rate of residual deposit, time of showed that the AS group required less time than the SR group for
oral prophylaxis and satisfaction levels of patients and dental hygien- ultrasonic scaling, and the difference was statistically significant
ists were also assessed using ANOVA. For the rate of residual deposits, (p < 0.05).
4.8% of the measurements were considered outliers; these values were Similarly, the total time required for scaling was shortest in the
replaced with the maximum observed value.21 Statistical significance AS group (15.4 ± 6.9 minutes), followed by the SA group (18.7 ± 5.5
was set at p < 0.05, and 95% confidence intervals (CIs) were calculated. minutes) and the SR group (19.9 ± 6.2 minutes). Post hoc analysis
showed that the AS group required a shorter total scaling time
than the SR group, and the difference was statistically significant
3 | R E S U LT S (p < 0.05).
The time required for plaque control was shortest in the SR group
3.1 | General characteristics (6.4 ± 2.1 minutes), followed by the SA group (7.9 ± 2.0 minutes) and
the AS group (8.5 ± 2.7 minutes). Post hoc analysis confirmed that
In this study, 43.4% of the subjects were male and 56.6% were fe- the time required for plaque control was shorter in the SR group
male. The subjects’ ages were evenly distributed among the age than in the SA and AS groups, and the difference was statistically
groups of 20-29 years, 30-39 years and ≥40 years. There were 60 significant (p < 0.05) (Table 3).

TA B L E 1 Per cent distribution of

Variables Range Total SR SA AS
subjects by general characteristics, n(%)
Sex Male 75 (43.4) 30 (50.0) 28 (49.1) 17 (30.4)
Female 98 (56.6) 30 (50.0) 29 (50.9) 39 (69.6)
Age 20-29 63 (36.4) 32 (53.3) 17 (29.8) 14 (25.0)
30-39 53 (30.6) 21 (35.0) 15 (26.3) 17 (30.4)
40≤ 57 (32.9) 7 (11.7) 25 (43.9) 25 (44.6)
Total 173 (100) 60 (34.7) 57 (32.9) 56 (32.4)
4 | PARK et al.

TA B L E 2 Subjects’ oral health

Variables Total SR SA AS p§∬
conditions according to oral prophylaxis
No. of functional 28.8 ± 2.3 29.3 ± 2.2b 28.7 ± 2.4ab 28.3 ± 2.3a 0.04* method (Mean±SD)
teeth
No. of natural 27.3 ± 3.0 28.0 ± 2.8 27.1 ± 3.1 26.7 ± 3.0 0.06
teeth
No. of coronal 28.3 ± 2.5 27.9 ± 2.8 28.7 ± 2.4 28.3 ± 2.3 0.27
polishing teeth
No. of teeth 0.1 ± 0.3 0.1 ± 0.4 0.1 ± 0.3 0.0 ± 0.1 0.60
with clinical
attachment
level 4 ≤
Periodontal Index 0.0 ± 0.1 0.0 ± 0.1 0.0 ± 0.0 0.0 ± 0.0 0.53
Debris Index†,‡ 2.2 ± 0.4 2.2 ± 0.4 2.2 ± 0.4 2.3 ± 0.5 0.29
Calculus Index†,‡ 1.1 ± 0.4 1.2 ± 0.4 1.1 ± 0.4 1.2 ± 0.4 0.56
Latest tooth 15.5 ± 13.2 16.1 ± 13.7 14.3 ± 13.5 16.2 ± 12.4 0.68
scaling (month)
Smoking 31 (17.9) 16 (26.7) 9 (15.8) 6 (10.7) 0.07
Total 173 (100) 60 (34.7) 57 (32.9) 56 (32.4)
ab
*ANOVA, p < 0.05, Scheffe
†,‡
Debris Index, Calculus Index score: o=excellent, 0.1 ~ 0.6=good, 0.7 ~ 1.8=fair,
1.9 ~ 3.0=poor(ref)

TA B L E 3 Differences in the times

SR SA AS p
required for oral prophylaxis using
Scaling different methods (Mean±SD).
Ultrasonic 12.5 ± 5.7b 11.3 ± 3.9ab 9.4 ± 4.4a 0.00*
Manual 7.4 ± 3.1 7.4 ± 3.2 6.0 ± 4.1 0.06
b b a
Total 19.9 ± 6.2 18.7 ± 5.5 15.4 ± 6.9 0.00*
a b b
Plaque control 6.4 ± 2.1 7.9 ± 2.0 8.5 ± 2.7 0.00*
Oral prophylaxis† 26.3 ± 5.9 26.6 ± 6.3 23.9 ± 7.5 0.06
†
Oral prophylaxis time: total scaling time +plaque control time.
*ANOV, p < 0.05, ab Scheffe.

3.4 | Differences in the rates of residual deposits TA B L E 4 Differences in the rates of residual deposits based on
based on oral prophylaxis method oral prophylaxis method (Mean±SD).

SR SA AS p
The AS group had the lowest rate of residual deposits on all assessed b a a
Buccal 19.0 ± 7.3 11.7 ± 6.2 10.4 ± 6.8 0.00*
surfaces (10.4 ± 6.8% [buccal], 12.0 ± 6.4% [lingual], 16.8 ± 9.6% [in-
Lingual 19.9 ± 7.0 b 13.3 ± 6.3a 12.0 ± 6.4a 0.00*
terproximal]), followed by the SA group and the SR group. Post hoc
b a a
Interproximal 38.4 ± 9.8 18.7 ± 10.1 16.8 ± 9.6 0.00*
analysis confirmed that the SR group had a higher rate of residual de-
posits than the SA group and the AS group on all assessed surfaces *ANOVA, p < 0.05, ab Scheffe
†
(buccal, lingual and interproximal), and the difference was statisti- Residual deposits rates (%): the number of teeth surface on residual
deposits / the number of subject teeth surface for oral prophylaxis ×
100.
cally significant (p < 0.05) (Table 4).

3.5 | Differences in the satisfaction levels of the 9.6 ± 0.9 in the AS group). On the other hand, the dental hygien-
subjects and dental hygienists according to oral ists’ satisfaction level was highest in the AS group (8.8 ± 1.0), fol-
prophylaxis method lowed by the SA group (8.4 ± 1.0) and the SR group (6.2 ± 1.3).
Post hoc analysis confirmed that the SR group had significantly
The subjects’ satisfaction levels were uniformly high in all three lower satisfaction levels than the SA or AS groups (p < 0.05)
groups (9.6 ± 0.8 in the SR group, 9.6 ± 0.9 in the SA group and (Table 5).
PARK et al. | 5

4 | DISCUSSION the marginal gingiva. 26 This may lead to a difference in the times
required for the two procedures.
Our results show that the total scaling time was shorter in the AS When compared to rubber cup polishing, air polishing is more
group (15.4 ± 6.9 minutes), whose subjects underwent dental plaque convenient to use and more effective for supragingival plaque re-
removal using air polishing before scaling, than in the SA (18.7 ± 5.5 moval. 25 The rate of residual deposits after completion of oral pro-
minutes) and SR groups (19.9 ± 6.2 minutes), and the difference phylaxis was significantly higher in the SR group than in the AS or
was statistically significant (p < 0.05) (Table 3). Similarly, the time SA groups (p < 0.05). More specifically, the rate of residual deposits
required for ultrasonic scaling was shorter in the AS group (9.4 ± 4.4 on the interproximal surfaces differed significantly in the SR group
minutes), whose subjects underwent air polishing, than in the SR when compared to the other two groups (Table 4). Nonetheless,
group (12.5 ± 5.7 minutes), whose subjects underwent rubber cup the difference between the AS and SA groups, in which the order
polishing (p < 0.05) (Table 3). There was no difference between the of procedures differed, was not examined. Air polishing involves
AS and SA groups regarding the time required for ultrasonic scaling, spraying a powder onto the tooth surface, which allows powder
implying that the order of procedure does not significantly affect to reach areas that are otherwise difficult to access (ie grooves,
the time required for ultrasonic scaling. These findings contradict malaligned teeth, and orthodontic brackets). 27,28 However, rubber
those of a previous study by Kim et al., which showed that dental cup polishing involves rubbing the bottom portion of the rubber
plaque removal with a self-care device before the scaling procedure cup on the tooth surface, making it harder to reach those diffi-
reduced the time required for ultrasonic scaling.7 Lastly, total scal- cult-to-access areas. 29
ing time was significantly shorter in the AS group, whose subjects Smoking can stain both the natural teeth and artificial prosthet-
underwent dental plaque removal prior to scaling, when compared ics.30 Nicotine stains caused by smoking can infiltrate the enamel,
to the SA and SR groups, whose subjects underwent scaling prior to making it more difficult to remove dental plaque. 26 The abra-
polishing (p < 0.05). Minimizing the time of dental procedures not sive(Proxyt fine) used for rubber cup polishing in this study had an
only alleviates the patients’ burden but also reduces the economic RDA value of 7, which is similar to the abrasiveness of normal tooth-
burden of dental clinics and social expenses. 22 With longer proce- paste.31 Products with RDA values of ≥83 are required to remove
dure times, dental hygienists are at a higher risk of developing work- nicotine stains.32 Similarly, the air polishing powder(AIR-FLOW
23
related musculoskeletal disorders. PLUS Powder) used in this study is used for biofilm and young-calcu-
The time required for plaque control was shortest in the SR lus removal, but is not recommended for stain removal.6 Therefore,
group (6.4 ± 2.1 minutes) (Table 3). On the other hand, both the SA the low-level abrasives used in this study may have hindered dental
(7.9 ± 2.0 minutes) and AS groups (8.5 ± 2.7 minutes), whose subjects plaque removal, as there were highly abrasive deposits (ie stains) on
underwent air polishing, required longer times compared with the SR the tooth surfaces.
group, whose subjects underwent rubber cup polishing. Moreover, Although the AS group, whose subjects underwent plaque con-
since the difference between the times required for plaque control trol followed by scaling, had a shorter tooth cleaning time and a
in the SA and AS groups was not examined, the difference in the lower rate of residual deposits, the patients’ levels of satisfaction
time required for air polishing based on oral hygiene status could not were similar among all three groups. However, the satisfaction level
be confirmed. Although previous studies have compared the times of dental hygienists was higher in the AS group (8.8 ± 1.0 points)
required for rubber cup polishing and air polishing,10,24 it is difficult and the SA group (8.4 ± 1.0 points), whose subjects underwent air
to assume that these results will be identical when using up-to-date polishing, than in the SR group (6.2 ± 1.3 points), whose subjects
tools and equipment. When using rubber cup polishing, it is relatively underwent rubber cup polishing (p < 0.05) (Table 5). Rubber cup
easy to adjust the pressure, contact time, RPM and abrasiveness de- polishing and air polishing have different modes of action and dif-
pending on the level of residual deposits on the tooth surface.15 In ferent assessment time-points for the determination of tooth sur-
contrast, air polishing involves spraying an air-water-powder using a face cleaning status.15,25,33 Therefore, the dental hygienists’ tool
25
fixed power and pressure ; therefore, the exposure time can vary preference may have affected their level of satisfaction. In addition,
depending on the level of residual deposits on the tooth surface. the groups that underwent air polishing had shorter overall times of
Furthermore, while rubber cup polishing is applied via a patting or oral prophylaxis compared with the group that underwent rubber
brushing motion, air polishing is applied in a circular motion along cup polishing,10 which may have positively influenced their level of
satisfaction.

TA B L E 5 Differences in the satisfaction levels of the subjects In this study, all subjects were recruited from a single dental
and dental hygienists according to oral prophylaxis method (0-10 clinic in Seoul, South Korea, and the majority of subjects had healthy
points) (Mean±SD). oral conditions. The times required for oral prophylaxis and the rates
of residual deposits may have also been affected by the subjects’
SR SA AS p
overall or oral health conditions. Nevertheless, we were not able to
Subjects 9.6 ± 0.8 9.6 ± 0.9 9.6 ± 0.9 0.98
validate the study outcomes in diverse cohorts of patients to elim-
Dental hygienist 6.2 ± 1.3a 8.4 ± 1.0 b 8.8 ± 1.0 b 0.00* inate various risk factors, which is a limitation of the study. In a fu-
*ANOVA, p < 0.05, ab Scheffe. ture study, it is necessary to investigate the difference in the time
6 | PARK et al.

required, the rates of residual deposits and the satisfaction level and dental hygienists of THE BOA DENTAL CLINIC for their help
according to oral prophylaxis methods for patients with various oral in this study.
conditions or symptoms.
In addition, the Cohen's kappa value of 0.289 (p < 0.05) represent- C O N FL I C T O F I N T E R E S T
ing inter-observer agreement between the two dental hygienists does The authors declare no conflict of interest.
not show a very high degree of agreement. However, this kappa value
is still in the ‘fair’ category, meaning it will not negatively affect the AU T H O R C O N T R I B U T I O N S
study outcomes.17 Our results confirm that, despite the longer overall Bo-Young Park and Hiejin Noh conducted the data analysis and the
time required, the use of air polishing for dental plaque removal can paper writing. Min-Jeong Kim and Jeong-Hyeon Park collected the
better reduce the rate of residual deposits when compared to rubber data. Ju-Hui Jeong performed most of the registrations. All authors
cup polishing in a cohort of subjects with relatively good oral health were involved in the preparation and design of the study.
conditions. Another significant aspect of this study is that we exam-
ined the effect of the order of procedures on total scaling time. ORCID
Bo-young Park [Link]
Minjung Kim [Link]
5 | CO N C LU S I O N junghyun park [Link]
Ju-Hui Jeong [Link]
During oral prophylaxis, dental plaque removal using air polish- Hiejin Noh [Link]
ing requires a relatively longer time when compared to rubber cup
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