Journal of Dentistry 46 (2016) 36–41

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Journal of Dentistry
journal homepage: www.intl.elsevierhealth.com/journals/jden

The effect of air-abrasion on the susceptibility of sound enamel to acid

challenge
O. Johnson Kinga , H. Millya,b , V. Boyesa , R. Austina , F. Festya , A. Banerjeea,c,*
a
Tissue Engineering & Biophotonics Research Division, King’s College London Dental Institute at Guy’s Hospital, King’s Health Partners, London, UK
b
Restorative Dentistry, Dental Institute, Damascus University, Syria
c
Head of Department, Conservative & MI Dentistry, King’s College London Dental Institute at Guy’s Hospital, King’s Health Partners, London, UK

A R T I C L E I N F O A B S T R A C T

Article history: Objective: To evaluate the effect of air-abrasion using three abrasive powders, on the susceptibility of
Received 29 October 2015 sound enamel to an acid challenge.
Received in revised form 16 January 2016 Methods: 40 human enamel samples were flattened, polished and assigned to 4 experimental groups
Accepted 20 January 2016
(n = 10); a: alumina air-abrasion, b: sodium bicarbonate air-abrasion, c: bioactive glass (BAG) air-abrasion
and d: no surface treatment (control). White light confocal profilometry was used to measure the step
Keywords: height enamel loss of the abraded area within each sample at three stages; after sample preparation
Enamel
(baseline), after air-abrasion and finally after exposing the samples to pH-cycling for 10 days. Data was
Air-abrasion
pH-cycling
analysed statistically using one-way ANOVA with Tukey’s HSD post-hoc tests (p < 0.05). Unique prismatic
Alumina structures generated by abrasion and subsequent pH cycling were imaged using multiphoton excitation
Sodium bicarbonate microscopy, exploiting strong autofluorescence properties of the enamel without labelling. Z-stacks of
Bioactive glass (BAG) treated and equivalent control surfaces were used to generate non-destructively 3-dimensional surface
Acid erosion profiles similar to those produced by scanning electron microscopy.
Profilometry Results: There was no significant difference in the step height enamel loss after initial surface air-abrasion
compared to the negative control group. However, a significant increase in the step height enamel loss
was observed in the alumina air-abraded samples after pH-cycling compared to the negative control
(p < 0.05). Sodium bicarbonate as well as BAG air-abrasion exhibited similar enamel surface loss to that
detected in the negative control group (p > 0.05). Surface profile examination revealed a deposition effect
across sodium bicarbonate and BAG-abraded groups.
Conclusion: This study demonstrates the importance of powder selection when using air abrasion
technology in clinical dentistry. Pre-treating the enamel surface with alumina air-abrasion significantly
increased its susceptibility to acid challenge. Therefore, when using alumina air-abrasion clinically,
clinicians must be aware that abrading sound enamel excessively renders that surface more susceptible
to the effects of acid erosion. BAG and sodium bicarbonate powders were less invasive when compared to
the alumina powder, supporting their use for controlled surface stain removal from enamel where
indicated clinically.
ã 2016 Elsevier Ltd. All rights reserved.

1. Introduction sound tooth surface. In air-abrasion, abrasive particles are emitted

from a nozzle in an air stream and aimed at the tooth surface. These
Minimally invasive dentistry (MID) advocates the maximum particles impact the hard tooth surface at high velocity, resulting in
preservation of intact and repairable dental hard tissues through the transfer of kinetic energy and the resulting physical removal of
minimising the unnecessary alteration of healthy tooth structure adherent extrinsic surface stains/debris [2]. Air-abrasion elimi-
[1]. Ideally, dental polishing techniques aim at removing surface nates bone vibration and minimises a rise in tissue temperature
stains efficiently and selectively without altering the underlying and consequently, reduces the unpleasant characteristics associ-
ated with the use of conventional mechanical instruments [3,4].
However, air-abrasion can result in alterations in an intact enamel
* Corresponding author at: King’s College London Dental Institute, Floor 26, surface due to its lack of clinical tactile feedback during use leading
Tower Wing, Guy’s Dental Hospital, London Bridge, London SE1 9RT, UK. to operator over-use on the tooth surface concerned [5]. Hence, air-
Fax: +44 207 188 1577/7486.
abrasion operating parameters should be subjected to precise
E-mail address: [email protected] (A. Banerjee).

http://dx.doi.org/10.1016/j.jdent.2016.01.009
0300-5712/ ã 2016 Elsevier Ltd. All rights reserved.
 O. Johnson King et al. / Journal of Dentistry 46 (2016) 36–41 37

control, and the polishing powder should be minimally invasive, brass sample former (Syndicad Ingenieurbüro, München,
not damaging sound tissue whilst still efficient at surface stain Germany). The outer enamel layer was removed using a water-
removal at the same time [6,7]. cooled rotating polishing machine (Meta-Serv 3000 Grinder-
Historically, different air-abrasion powders have been used in Polisher, Buehler, Lake Bluff, Illinois, USA) using a sequential
clinical practice including alumina, calcium carbonate, glycine and polishing protocol; 180-grit silica carbide disk (Versocit, Struers
sodium bicarbonate. Bioactive glass 45S5 (BAG) powder has been A/S, Copenhagen, Denmark) for 5 s, 600-grit for 10 s, 1200-grit for
introduced due to its unique properties such as antibacterial 20 s, 2400-grit for 30 and 4000-grit for 45 s, followed by 3 min of
effects, remineralisation potential and selective removal of softer ultrasonication to remove the smear layer at the enamel surface.
diseased/damaged tooth structure [8,9]. A summary of the This standardised polishing protocol permitted the removal of
properties of a selection of clinical powders currently available approximately 400 mm from the outer enamel layer.
can be found in Table 1. To the authors’ knowledge, there are no Each samples’ surface topography was scanned prior to surface
previous published studies assessing the susceptibility of dental air-abrasion, after surface air-abrasion and after subsequent pH-
enamel to acid challenge following the air-abrasion procedures cycling, using non-contact white light confocal profilometry
using BAG powder. Therefore, the aim of this study was to compare (XyrisTM 4000 WL, TaiCaanTM Technologies Ltd., Southampton,
the effect of three different powders (sodium bicarbonate, alumina UK) with a 10 mm step-over distance and 10 nm vertical resolution.
and BAG) on the susceptibility of sound dental enamel to The quantification flatness of the profilometry system used in this
subsequent acid challenge. The assessment was conducted in study was calibrated using the National Physical Laboratory optical
vitro using white light confocal profilometry, a “gold standard” flat. The maximum of the flatness error in the present system is
method for assessing enamel surface loss [10], and multiphoton 0.5 mm. Therefore, the baseline required flatness of the samples
excitation fluorescence to examine surface topography. Two null included in the present study was the step height value of less than
hypotheses investigated in this study were (i) the use of air- 0.5 mm.
abrasion has no effect on increasing the susceptibility of dental A standard scan area (3 mm  2 mm) was selected on the
enamel to acid challenge when compared to a negative control enamel sample surface, including the targeted area in the centre
group, and (ii) there is no difference in the level of mineral loss surrounded by sound enamel acting as an internal sample
using different powders. reference level (control). The resulting topographic images were
analysed using surface metrology software (Boddies v1.81,
2. Materials and methods TaiCaanTM Technologies Ltd., Southampton, UK) by levelling the
reference peripheral sound enamel areas to a “zero” plane. The step
Extracted, caries-free human molars were collected using ethics height of the lesion surface in relation to the sound enamel level
approval reviewed by the East Central London Research Ethics was obtained by averaging five measurements taken within each
Committee (Reference 10/H0721/55), stored in refrigerated de- sample. The differences in the enamel step height for each sample
ionised water and used within a month from extraction. One buccal were calculated between pre-abrasion and post-abrasion, and
enamel slab from each tooth was sectioned using a diamond- between and post-abrasion and post-pH-cycling (Fig. 1).
wafering blade (XL 12205, Benetec Ltd., London, UK). Forty enamel An AquacutTM clinical air-abrasion unit (Velopex, Harlesden,
slabs were included in this study after inspecting the integrity of UK) was used to treat the enamel surface for 5 sec using the
the surface using a confocal tandem-scanning microscope (TSM) following operating parameters: air pressure, 60 psi; powder flow
(Noran Instruments, Middleton, WI, USA), with an 20 air rate dial, 3 g/min; nozzle angle, 90 ; nozzle-surface distance, 3 mm
objective in reflection scanning mode. The samples were included and the internal nozzle diameter, 600 mm [6]. The samples were
face down in acrylic resin using a hard-anodized aluminium and allocated into four experimental groups (n = 10) according to the

Table 1
The advantages and disadvantages of a selection of commercially available clinical air polishing/abrasion powders.

Powder Advantages Disadvantages

Alpha alumina - Efficient removal of extrinsic stains [5] - Non-selective, highly abrasive on tooth structure [11]
(Al2O3) - It is an inert powder and therefore, does not have a beneficial
effect on tooth structure [12]

Aluminium - Useful in patients on sodium restricted diets [13] - Avoid using on glass ionomers, resin composites, luting cements
trihydroxide and cast restorations [14]
(Al(OH)3)
Bioactive glass - With the correct parameters, can effectively remove extrinsic stains [5] - Potentially longer clinical time required for its use
(BAG) - Bioactive and biocompatible.
- Reduces dentine hypersensitivity [15]
- Greater whitening effect and increased patient comfort when compared to
sodium bicarbonate [23]

Calcium - Efficient and effective stain removal demonstrated however more clinical - Greater defects produced on radicular dentine when compare to
carbonate studies required to determine abrasive potential [13] sodium bicarbonate [16]
(CaCO3)
Glycine - Produces less surface damage on restorative materials when compared to
sodium bicarbonate powders. [16]
- Removes plaque more efficiently than hand instruments [17]

Sodium - Efficient removal of extrinsic stains [18] - Prolonged use on cementum, dentine and composite is
bicarbonate contraindicated as can result in excess tissue removal [12,19]
(NaHCO3) - Does not remove stains as effectively as BAG, increased dentine
hypersensitivity [23]
38 O. Johnson King et al. / Journal of Dentistry 46 (2016) 36–41

Fig. 1. A diagram showing the experimental stages and the step height measurements steps.

Table 2
The experimental groups and composition of applied air-abrasion powders.

Group Treatment Composition

a Aluminaa Particle size distribution: 27.5 mm
Aluminium oxide (alpha-alumina)
c Sodium bicarbonateb Particle size distribution: 35 mm
NaHCO3
b Bioactive glass (BAG)c Particle size distribution: 30–60–90 mm
SiO2: 45%, CaO: 24.4%, Na2O: 24.6% and P2O5: 6%
d Control No surface treatment
a
Aquacut, Velopex, Horesham, UK.
b
Prophy Jet, Dentsply, UK.
c
Sylc, OSspray, Ltd., UK.

air-abrasion powder, alumina, sodium bicarbonate and BAG, with Chameleon Vision II) coupled to an inverted microscope. Samples
their compositions described in Table 2. The negative control were imaged using a 40 (1.3NA) oil immersion objective (Nikon)
samples remained untreated. Following air-abrasion, the samples and excited at 810 nm. The laser power at the sample was
were rinsed thoroughly with de-ionised water and then submitted measured as 19 mW and the image format was 256  256 pixels
to pH-cycling. Before commencing the pH-cycling, the reference with a pixel size of 321 nm.
areas of sound enamel adjacent to the abraded area were coated Surface profile images of enamel topographies were generated
with two layers of nail varnish for protection. The samples were using Image J software (imagej.nih.gov/ij/) from the compilation of
submitted to a pH-cycling regimen for 10 days to mimic acid z-stack images (xyz plane) acquired sequentially in 0.5 mm
erosion as follows; demineralisation for 6 h each day in a buffer increments beginning away from the sample surface and extend-
solution (40 ml/tooth) containing 75 mM acetic acid, 2.0 mM Ca ing to 60 mm beneath the surface. Following air-abrasion and
(NO3)2 and 2.0 mM KH2PO4 (pH 4.3). Remineralisation for 17 h subsequent pH-cycling, three points, spaced at least 300 mm apart
overnight in remineralisation solution (20 ml/tooth) containing were examined on the both control and test areas of each
20 mM Hepes, 130 mM KCl, 1.5 mM CaCl2 and 0.9 mM KH2PO4 (pH specimen.
7). The pH-cycling was carried out at 37  C [20].
The step height difference measurements were analysed 3. Results
statistically using SPSS statistical package (Version 20, SPSS
Inc/IBM, Chicago, IL). Data were tested for normality using The means and standard errors of the step height enamel loss
Histogram/Q–Q plots/Shapiro–Wilk tests. One-Way ANOVA with measurements after surface air-abrasion and after commencing
Tukey’s HSD post-hoc tests were conducted to calculate significant pH-cycling are shown in Fig. 2. The difference in step height after
factors at p < 0.05. surface air-abrasion compared to the pre-abrasion measurement
Imaging of the specimens was performed using an in-house showed no statistically significant differences compared to the
manufactured Two-Photon system. Excitation was provided by a positive control group (Fig. 2A, p > 0.05). The enamel surface
tuneable (680–1080 nm) (140 fs) Ti:sapphire laser (Coherent, treated with alumina air-abrasion exhibited the highest step
 O. Johnson King et al. / Journal of Dentistry 46 (2016) 36–41 39

surfaces, which is likely indicative of a surface deposition of the

aforementioned abrasive powders.

4. Discussion

This study reported the results from the comparison between

three different air-abrasion powders used in clinical practice
(alumina, sodium bicarbonate and 45S5 BAG) and their effect on
the susceptibility of treated sound enamel surfaces to a further acid
challenge, as would occur in the oral environment. The air-
abrasion operating parameters used in this study have been shown
to minimise the selective removal of bulk enamel using this
technology [6]. The results of this study demonstrates that air-
abrasion of sound enamel surfaces increases the enamel surface
loss after pH-cycling. This might result from the surface
modification following air-abrasion, with increased roughness of
the enamel surface, examined using laser profilometry [21]. The
roughened enamel surface exhibits a greater exposed damaged
area, which in turn, might increase the susceptibility of dental
enamel to acid challenge, as reported in this study. The pH-cycling
protocol conducted in this study is a well-documented in-vitro
method to assess the susceptibility of the dental hard tissue to acid
challenge [20,32]. An in-situ study is still required to figure the
long-term effect of air-abrasion on the susceptibility of sound
enamel to erosion, whereby multi-biological factors involve in the
erosive process such as enzymes, salivary proteins, pellicle and
clinical clearance products.
Alumina powder has a significantly higher microhardness
(2100 KHN) compared to that of enamel (340 KHN) [22]. This helps
explain the statistically significant level of damage of the enamel
surface reported in this study when using alumina powder.
Alumina powder is more clinically suited for cutting rather than
polishing purposes. Using both sodium bicarbonate (approx.
170 KHN) and BAG (420 KHN) powders generated similar levels
of enamel loss with no statistical differences when compared to
the positive control group (no abrasion treatment). This finding
helps to support their clinical use to clean enamel surfaces when
Fig. 2. Bar graphs show step height difference measurements (mean  SE) after air- using air-polishing technologies. Indeed, in a clinical trial with a
abrasion (A) and after pH-cycling (B). No statistically significant differences patient subgroup with poor oral hygiene, BAG air-abrasion was
observed between the four experimental groups after air-abrasion. (*) indicates more clinically and statistically effective at stain removal than
statistically significant differences in step height measurements between alumina
sodium bicarbonate [23]. Another advantage of using BAG powder
and the negative control group after pH-cycling.
over sodium bicarbonate is the chemical reactivity of BAG in the
presence of aqueous solutions such as water or saliva that leads to
height value (2.7  1.7 mm, mean  SE) followed by sodium the formation of hydroxyapatite (HA) structures [24,25]. Treating
bicarbonate air-abrasion (0.9  0.5 mm), BAG air-abrasion BAG particles with an aqueous solution causes a leaching and
(1.3  0.6 mm) and the positive control group (0.5  0.1 mm). exchanging of BAG ions with those in the solution and that in turn
After pH-cycling, a significant increase in step height measure- increases the interfacial pH followed by breaking Si O Si bonds
ments was noted in all experimental groups when compared to the and forming a Si(OH)4 layer. Calcium and phosphate ions are
“post-abrasion” measurements (Fig. 2-B, p < 0.001). The greatest released from BAG, at this stage, to form an amorphous CaP layer,
increase in step height was observed in the alumina group which is crystallised to HCA [26]. The chemical, mechanical and
(71.3  13.9 mm), which was statistically significant in comparison ultra-structural analyses of enamel surfaces treated with BAG
to the control (28.3  7.8 mm) (p = 0.007). The control group particles have showed that BAG can remineralise an enamel
showed less step height value change in comparison to the substrate [27–29].
sodium bicarbonate air-abrasion (57.3  3.8 mm) and to the BAG After tooth eruption, changes occur in the outermost enamel
air-abrasion (45.8  5.9 mm), but with no significant differences layer as it becomes hypermineralised due to the interactions
between them (p > 0.05). between fluoride and salivary ions during the dynamic balance of
Three-dimensional surface reconstructions, shown in Fig. 3, de- and remineralisation processes in the oral environment
revealed the surface topography of the specimens. The control [30,31]. Removing the outermost enamel layer prior to studying
enamel surfaces (Fig. 3a) exhibited intact, rounded prismatic enamel mineral change is a well-documented procedure that
structures, 3–5 mm wide. When intact enamel is subject to pH- reduces the variation between the biological samples [32–34].
cycling, removal of prism core material becomes apparent, yielding Protecting part of the sound enamel using a layer of nail varnish is
organised horseshoe-shaped structures (Fig. 3b). When subject to an accepted in-vitro protocol to help establish a reference level
alumina air-abrasion prior to pH cycling, horseshoe-like structures when analysing the 3D profilometry images [35–37]. Profilometry
similar to those seen in the control are formed (Fig. 3c). No such is the “gold standard” method in assessing the surface loss,
prismatic structures were identifiable on the surfaces of either providing objective quantitative information about the surface
sodium bicarbonate (Fig. 3d) or BAG-abraded (Fig. 3e) enamel topography [38,39].
40 O. Johnson King et al. / Journal of Dentistry 46 (2016) 36–41

Fig. 3. Representative 3-dimensional reconstructions of sound (a) and pH-cycled (b) enamel surfaces with corresponding enamel surfaces that were subjected to air-abrasion
using alumina (c), sodium bicarbonate (d) or BAG prior to PH cycling, from oblique and transverse (insert) perspectives.

Bioactive glass has been advocated to treat patients with alumina powder, supporting their use for the controlled cleaning of
dentine hypersensitivity, with varying formulations and carrier enamel where indicated clinically.
vehicles tested including dentifrices [40] and air-polishing
powders [41]. The proposed mechanism of action of the reduction 6. Clinical relevance
in hypersensitivity relates to dentine tubule occlusion and its
subsequent reduction in permeability [23]. This is a common Care should be taken when using bicarbonate/BAG air-abrasion
clinical problem seen in those where the exposed dentine is clinically, that only the surface to be treated is abraded to minimise
initiated and propagated due to active dental erosion, for example collateral micro-damage, the procedure lasts for just the pre-
from common dietary acids such as citric acids in fruits and requisite time required to remove the stain and no longer and the
beverages [42]. However, the present study has demonstrated that patient is advised to refrain from acidic food and drink for a few
the use of certain powders delivered via air-abrasion technology hours after the procedure. A high concentrated fluoride varnish
have the potential to cause significant clinical damage to the may be used to condition the air-abraded surface immediately
remaining enamel of those individuals who are susceptible to after treatment to reduce the surface susceptibility to further acid
ongoing dental erosion. The statistically significant increase in the erosive attack, especially in those susceptible patients already
acid erosion of enamel after alumina abrasion in comparison to suffering from dentine hypersensitivity caused by erosion.
BAG demonstrates the clinical importance of careful clinical
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