Does Air Particle Abrasion ACTUALLY Improve Clinical Outcomes? – PDP190

Protrusive Dental Podcast

Air Particle Abrasion!

Images of Sandblasted teeth look cool but does it ACTUALLY improve clinical outcomes?

What are the indications? When is it genuinely critical to use?

More pragmatically, are there any decent alternatives eg. roughening with a bur?

Air particle abrasion, a technique used to prepare tooth surfaces for bonding, has sparked considerable debate among professionals. This episode discussed its effectiveness, implications, and best practices with Dr. Veronica Pereira de Lima.

https://youtu.be/oTGQBTyuY-k

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Protrusive Dental Pearl:

Two advantages of slicing off a corner of the rubber dam are:

1. Anterior Dam Stabilization: By flossing the cut piece through the front teeth, it acts as a makeshift wedge, securely fastening the dam in place without the need for traditional wedjet.
2. Simplified Orientation: This technique aids in aligning the rubber dam properly, streamlining the entire setup process for more efficient dental work.

Check out ‘Quick and Slick Rubber Dam’ online course (on-demand) only available via the Ultimate Education Plan on Protrusive Guidance

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:

• 00:44 Protrusive Dental Pearl
• 04:16 Dr. Verônica Pereira de Lima Introduction
• 07:07 Journey of Dentistry in Brazil
• 08:34 Academia vs Clinical Practice
• 09:20 Journey about PhD and Work Surrounding Air Particle Abrasion
• 11:12 Importance of Air Particle Abrasion to Clinical Dentistry
• 15:57 Health Concerns Regarding Air Abrasion Particles
• 18:10 Air Abrasion Contraindication
• 20:13 Size of the Microns – Clinical Guidelines
• 22:25 Pragmatic Approaches in Clinical Practice
• 24:28 Cojet as an Air Abrasion Particle
• 27:37 Improper Use of Air Abrasion
• 30:07 Air Abrasion Guidelines Regarding Different Ceramics
• 31:40 Alternatives to Air Abrasion
• 33:29 Dr. Veronica’s Personal Guidelines – Air Abrasion Protocol and Unit
• 40:27 Learning with Dr. Veronica

Access the CPD quiz either on your browser or by downloading our mobile app. For the full educational experience, our Ultimate Education Plan gives you access to all our courses, webinars, and exclusive monthly content.

If you love this episode, be sure to watch Immediate Dentine Sealing Tutorial Part 1 – PDP173

Click below for full episode transcript:

Jaz's Introduction: Air particle abrasion for the restorative dentist. How important is it? Hello, Protruserati. I'm Jaz Gulati and welcome back to the Protrusive Dental Podcast. In this episode, I'm joined by Dr. Veronica Pereira de Lima.

Jaz’s Introduction:
She was the lead author and a systematic review in 2020 that looked into air particle abrasion and the significance for improving dentine bonding. Some of the key questions that we cover in this episode are how important actually is it? What micron of sand and which sand should we be using? Is there any benefit of CoJet? CoJet is like this sand with silica embedded into it.

Does that really make a difference? And ultimately at the end of the podcast, we will answer the question. If you don’t have it at the moment, are you really missing out? And the answer actually might surprise you.

Dental Pearl
Every PDP main episode, I give you a Protrusive Dental Pearl. Today’s pearl, very fitting with air particle abrasion, because when do we use air particle abrasion? Well, we use it a lot when it comes to adhesive dentistry. And for adhesive dentistry, rubber dam isolation is often favourable. Now, I’m no rubber dam police, but I’m an avid user of rubber dam. And the tip I want to pass on to you today is, are you using things like Wedjet? You know, those stretchy silicon type strings that you use to anchor your rubber dam?

And the terminal tooth for example, you’re using a clamp on the molar and then all the way to an incisor, maybe you’re using like a Wedjet or something to secure your rubber dam. Well, instead of using two clamps or a clamp and a Wedjet, I like to use a clamp. And my favorite clamp is a soft clamp.

Why? Because it’s softer. It’s kinder. I don’t need to give a lingual anesthesia. As you guys know, I’m a huge fan of buccal, articain infiltrations, even for lower molars. But that’s a whole other episode. In fact, we’ve done that episode already. Do check out PDP 143 if you’re interested in that. But back to rubber dam.

So rubber dam, what I will do, instead of using a Wedjet, I will cut a corner of the rubber dam. Okay, now this serves two purposes. One is, once I’ve put the rubber dam on, I’ve got a clamp on one side, and I’ve got the little cut piece, that little triangle of dam that I cut away from the rubber dam.

Well, that I can now floss through the anterior contacts, for example, if I’m doing a quadrant, and now the rubber dam is secured by a clamp on one side and by this makeshift Wedjet, using the dam basically to secure it. And it’s super simple. It saves the environment so we don’t have to buy an additional product to secure the rubber dam anteriorly.

And sometimes the contacts are tight enough that you don’t need anything. You just have to floss it through and it stays. But if you want that extra security, you floss through, you stretch and you floss through this piece, this little corner, this triangle of rubber dam. Now, the second benefit here is you try and cut the corner which represents the quadrant.

So, for example, if I’m isolating the lower left quadrant, then when I punch my holes on the lower left quadrant, let’s say I’m doing the second molar, first molar, pre molars, canine, and lateral incisor, for example, right? On the lower left side is where I’m going to cut my triangles. Why? Because you know when you sometimes put your clamp on, and then you put your dam on, and by the time you’ve got the dam through some of the contacts, and then your nurse is helping you, and you get the frame on, and then you’re thinking, hmm, which corner of the dam goes on which part of the frame?

Sometimes it happens, and sometimes what ends up happening is you end up confusing it, and you’ve kind of got this like twisty, funky rubber dam thing going on. Now, because you have the cut corner on the lower left, you know that the cut area of dam is the lower left, and you just put that on to the lower left corner of the frame. Now, you’re much less likely to make this funky rubber dam mistake because it’s aided you in orientation.

So two benefits of cutting the corner of the rubber dam. One is that you can floss it through to secure your dam anteriorly instead of Wedjets. And two is it helps with your orientation. It just makes the process slicker. And talking of slicker, if you’d like to improve in rubber dam, check out the quick and slick rubber dam webinar that I did.

It’s available on Protrusive Guidance platform. That’s www.protrusive.app. And then there’s 30 plus clinical videos. These range from like two minutes all the way to 15 minutes of tricky cases, loads of different quadrants, anterior, upper left, upper right. All the mouth, basically the entire mouth uncut videos of rubber dam, which so many of you messaged to say it’s really elevated your rubber dam game. So those who are interested, check out quick and slick rubber dam available on Protrusive Guidance. Now let’s join the main episode and I’ll catch you in the outro.

Main Episode:
Dr. Veronica Pereira de Lima, welcome to the Protrusive Dental Podcast. How are you?

[Veronica]
Hi, Jaz. Thanks for having me. Yeah, I’m doing great.

[Jaz]
You are in the Netherlands, but you are from Brazil. And I want to unpack a little bit about that. Actually, I want to unpack your story. I always like to learn our guest story and like why you went into academia, how much clinical you do, what is your future research interests? I have so many questions in my mind already before you can just unpack the air particle abrasion.

But I just want to point out that you’re the first of a guest that I sought out on LinkedIn. I read your paper. I read some study that you were involved in with to do with air particle abrasion. I found that you’re doing a PhD and I thought, okay, I must reach out to you to have this geeky discussion that we’re going to have today.

So thank you for accepting my spam message on LinkedIn that led to a chain of events to book out time in your super busy diary to record today for the benefit of dentists. So Veronica, tell us about your journey from South America to Europe.

[Veronica]
Yeah, it’s a quite a journey. So yeah, I’m actually from a city called Manaus, which is a capital of Amazonas, which is way in the north of Brazil. Think of Amazon. So there is where I did my bachelor and master studies and where also started developing my interest for research, of course. With some limitations, like resources and stuff. And that’s why there was also no PhD in dentistry in my city back then. And then I decided, okay, I would like to go for a PhD and then I had to move out of Manaus and went way, all the way to the South of Brazil to a city called Pelotas.

And then that’s where I started my PhD. It was not specifically in restorative dentistry, but it was a bit more like in dental materials, more broad area. And during this time, of course, I was really mainly focused on research, not so much in the clinical practice, because of my PhD there, because of the partnership that was between the universities of Pelotas and in Nijmegen in the Netherlands.

I came up here this for a period of a year, stayed 14 months and then decided later after I finished my PhD to stay here. And now it’s-

[Jaz]
Amazing.

[Veronica]
Yeah. Yeah. Quite a journey when you think about it. And then, after I finished my PhD two years ago, here in the Netherlands, I decided to, okay, I want to go back to the practice. So then I had to learn Dutch. And do the whole validation recognizing of my diploma here, which was quite another particular journey, but which I’m happy to, I might happen to have finished it. And so now I am also licensed as a dentist in the Netherlands and I’m practicing part time and working at the university on teaching and research at the University of Amsterdam.

[Jaz]
What a nice balance. What a nice balance you have there in terms of practice and academia. I have this perception of a Brazilian dentist that generally, like, I see a lot of literature from Brazil. So I feel as though that dentistry in Brazil has a strong culture of academia. Is that perception correct, you think?

[Veronica]
No, I think so. I think we just, we’re a big country. We have a lot of universities each state has a few universities and usually research is mainly done in public universities. So yeah, if you think about it and that’s why maybe you can see so much of our publication of research there. And I think it’s just growing in the last couple of years. Yes.

[Jaz]
It’s definitely something I’ve seen in when I’ve been looking for literature that a lot of from Brazil pops up. And I also have this perception that lots of South American dentists in general like to go to the States and to do like further study, PhD, that kind of stuff. Whereas you went transatlantic. Did you consider the USA as well as when you were looking at options?

[Veronica]
I was honestly, when I went for my PhD, I was quite open to anywhere. I just wanted to also experience some international opportunities and see other how dentistry is done in other places and research in other places.

But I think when the opportunity came for the Netherlands, the topic was also very interesting. It was in the tooth wear, but also with the restorative aspect of it. Not that I’ve done any restorative procedures, but more like following up results of the patients which are treated for tooth wear and yeah, it was just like, that’s a nice thing. I would like to go and it’s a very interesting topic. So it was pretty much what happened and the opportunities that came my way.

[Jaz]
Good. And now that you are like doing two roles, the clinical practice and academia, do you have a favorite child in that regard? Do you favor one more than the other?

[Veronica]
Oh, it’s really hard to tell. I can say during the time that I was not back at academia, so after my PhD and I was only at the practice, although I was not fully as a dentist, I was kind of under supervision. So it’s a different story. I really miss academia. I really miss parts of just writing and doing research. And also, yeah, what’s new for me, it’s more also a teaching role. So yeah, I can say that now I’m quite satisfied with the balance.

[Jaz]
Good. Well, I’m glad you’ve achieved this balance. I think it’s a nice thing to have. And I’m just happy that I found someone to discuss a geeky topic of air particle abrasion. So tell me about your PhD and how you got into work surrounding air particle abrasion.

[Veronica]
Yeah. It’s also like sometimes, research ideas, they don’t come when you want it. They just show up to you. And of course, when you’re doing a PhD, sometimes that can come from you or from your supervisor. In this case, it was an idea from my supervisor.

We came, yeah, I was thinking about this topic. What do you think? We could make like a systematic review. And see what’s there. And of course, initially we wanted to do something like with clinical studies, but that was not possible. And then we decided to say, okay, let’s do it with in-vitro studies, with the laboratory study.

So not with patients, but in the lab, and that was not another level of challenge because then you have a variety of studies, but yeah, it was really at the beginning of my PhD. So my second year, I was not with the idea, clear idea of what I wanted to do for my thesis yet, but I said, okay. Sounds interesting.

Let’s do it. I also did that with two bachelor students at the time. We were working together on this. So it was quite an immersive topic back then, which it’s funny because even though the paper was published in 2021. The research, the search, was done in 2018, 2019, so it’s quite some time ago already. But yeah, so-

[Jaz]
But it’s still a very much a hot topic. I see air particle abrasion questions from our community all the time. So some of those things I want to pick apart. So for example, the first broad question I want to ask is, from what you’ve read and the research that you’ve done and also in clinical practice, how important do you think it is for a restorative dentist now, 2024 we’re recording, is it really, I mean, clinically, I would say my clinical experience that I don’t want to practice without it.

I love air abrasion. I love the biofilm removal. I love the confidence it gives me my bonding, but I want to know is that perhaps false confidence? What does the literature say about the importance of air particle abrasion when it comes to clinical dentistry?

[Veronica]
Yeah, that’s very, very interesting question. So I was surprised to see that even though a few years have passed since the research was done, but it’s still quite relevant. I could not find, at least on my last search, any other meta analysis related to it, because unfortunately, there is also a lack of primary studies on that. So you don’t have clinical studies really focusing on that.

It’s more of like a side outcome that is still relevant. And there are quite some things I have the impression the same as you. Some things are a bit like a feeling of the dentist, of the clinicians. Yeah, it feels good to work with it. And I also worked with it. So yeah, I can, I understand the feeling, but in terms of evidence, there’s no like a strong clinical evidence that says, oh yeah, we doubt it.

Your adhesion is not going to be good. Or with it, your addition is going to be amazing. So it’s something that so far we can say it doesn’t improve a lot, but also it doesn’t harm your addition. So I think I would say in that case, when you have something like this. And it just like, if you know, that’s an extra step, but if you’re good about it and then you, yeah, it gives you confidence and say go for it.

So how important it is. It definitely can be an additional step for several procedures related to adhesion, either direct or indirect procedures. Definitely. For example, if you go for immediate dentine sealing that you can definitely use also air abrasion at the later stage, but yeah, just knowing that.

If for some reason you cannot have that or don’t have access to it. Yeah. I don’t think that’s going to be the difference to make your procedures, your adhesion or any worse than someone that does.

[Jaz]
Certainly Veronica. I mean, I speak to lots of dentists who don’t use it and they say, look, my composites aren’t falling off. My composites are still in there and I don’t use their abrasion. And that’s the argument they said. My most compelling argument I found was when I first learned, probably 2013, 2014, I saw this lecture series from Dr. David Clark as part of the biofilm, and he talked about when you start plaque disclosing teeth, and you look at the plaque, and no matter what you use, if you use an ultrasonic scaler, if you use just the brush and the prophy paste, when you disclose again, you will always find plaque.

The only way he found that the biofilm was removed fully and there was no plaque being disclosed any longer was from air abrasion. Sometimes we’ll never be able to find evidence per se about how much difference it makes. But if you go back to the foundations of what we’re trying to do, the foundations of adhesive dentistry is having a clean substrate.

So that’s why the main conference I get just having clean substrate so that you get the best substrate to bond to and also the least likelihood of getting staining around the margins as well. What are your thoughts on that?

[Veronica]
Yeah, definitely. I mean, if you have ever have done it clinically, you can clearly see, for example, if you have your matrix, everything placed, and you’re going to do air abrasion afterwards, and then you can see clearly.

So, for example, if there is any contamination. That’s also much more clear as well. So for example, yeah, I don’t know, saliva, blood, whatever. You can clearly see after you do that step of air abrasion. So that gives you more also, yeah, let’s say control of your field. But I definitely think that is a two things that are related that because air abrasion is going to promote like this mechanical cleaning, as you said, the removal of any contaminations or incontaminants that are the surface that you’re going to make the adhesion.

But also, of course, the mechanical roughness that it produces that also helps increasing the adhesion area, surface area for the adhesion. So definitely, although, yeah, as you said, not because something is not, yet based on if this doesn’t mean that we have to discard it, it’s just, yeah, maybe after in some years we’ll have that, but I definitely recognize the same benefits that you mentioned. Yes.

[Jaz]
Okay. Well, in that realm, some other applications that we have for air abrasion, obviously, like for example, if you’re bonding zirconia, the APC protocol, the A stands for air particle abrasion. It’s part of the APC protocol bonding to zirconia. That’s another reason to have it in your toolkit. The other reason is when a crown comes off, and it’s loose and it’s still in a condition to bond it.

To get rid of the cement on the intaglio surface, my favorite word in dentistry, intaglio, to get rid of the cement in the inside surface, air abrasion, I found just brilliant to do that. The downside, I mean, exactly. When you’re using like a bur, you might be gouging out the internal surface of the ceramic.

When you’re using ultrasonic scaler, it’s a very slow process. And so there are other benefits that we have. The downside of that is perhaps some health concerns. I know I’m jumping the gun here, but that particle. You see it in the air. My beard is always filled with air particle abrasion, because I’m using it so much.

So did you find any data or have you come across any data about the health concerns about the use of aluminum oxide, for example, which is one of the most common particles used for air particle abrasion? Should we be worried about it?

[Veronica]
Yeah, I did check about it. I could not find any like recent evidence about some paper from 2003 and 1999. Yeah, if you think of the air abrasion used chair side, so just for intraoral use with proper suction device and proper individual protection like as mask and this kind of stuff, it seems to be below safety thresholds. It’s just so tiny, so very little that yeah, it’s not believed to really to be a cause of concern.

I do think that, for example, if you’re going to use outside of the mouth, for example, in a crown or something like that, that you want to clean up, then I know that it can be really messy and can create a lot of particles. Especially because, in that case, I don’t know, maybe you can ask someone to use the suction device, but I think it’s a bit tricky.

So I would say for that purpose would be better to use. There is a type of special air abrasion device, that maybe something that the labs would use as well. It comes in a little box so you can put your hands inside it and then you’ll have a little bit more of controlled environment and then the particles are not going to come off of your face. So then I would definitely suggest that. But again, in that sense, there is no specific studies only about the simulating, the chair sides exposure in that case. Yeah. It seems to be. It’s still safe, let’s say.

[Jaz]
Well, good point regarding the suction. Also, a lot of times we use it under rubber dam isolation, which will help to some degree. Now, I am going to confess that I also use it without rubber dam, in the mouth, okay? And so, things get very gritty, and so I say to my patient, okay, it’s going to feel like a car wash in the mouth, let me go away, wash it away. And so, it’s a very messy stuff. Are there any concerns that you have, as in part of the experience or research, about using air abrasion in the mouth without rubber dam isolation. I’m not condoning it, but I’m just being very real world with you that me and some clinicians do use it like that. Is there a massive contraindication?

[Veronica]
No, although of course, in that case, you really need to be more, I think, cautious and aware of not directing it to soft issues. I’ve seen happening once with a colleague that a little bit. I think went on the size of the cheeks of the patient, huh? On the inside and it got a little bit of a reaction which it was nothing crazy, but there’s not about much about it in the literature but I would definitely say even without a rubber dam you can make a proper control of it with suction. So I think definitely and really be aware of not directing it to soft tissues.

[Jaz]
It’s careful judicious use of it obviously. With that, just a clinical tip for those listening. When we’re using air abrasion in the mouth and when you wash it, there’s still always some particles of sand exactly at the margin and inside the cavity still. So what I always do is I go around with the ultrasonic scaler and that’s when I get the clean surface because I’m using the magnification.

That’s just a little thing that I found to be very important. So every adhesive procedure, I always have air abrasion, but I also have the ultrasonic scaler set up so that I can scale around. Otherwise you do, if you don’t use magnification, you’re not realizing there’s a little particles of aluminum oxide still there. So just a little tip there for everyone.

[Veronica]
And definitely is also, that’s just adding up to it. That’s actually also important for the adhesion itself. Okay. Often people do also the etching afterwards. I mean, there’s some variations in there. There’s a jumping a little bit of a head, there’s no like fixed protocol about it, but it’s very important also to remove the residual of the oxide afterwards. Because otherwise that can also be a little bit against what we wanted, which is improve the adhesion. If there’s a layer of particles of it on steel on the surface. Yeah, for sure.

[Jaz]
That’s right. So getting rid of all the debris. Now, speaking of the debris and the size of particles, is there much, I mean, I think you’ve said conclusively, we don’t have enough data because I see some papers that are pro air abrasion and also some papers that actually no difference and that kind of stuff.

So overall your systematic review, show that, okay, overall, we don’t know if it really is a massive plus point, but are there any variations within 27 microns and 50 microns, which is commonly the two most common particles use? I’ve also seen 90 micron on the market. Any clinical guidelines you can suggest in terms of when is it right to use each particle size?

[Veronica]
Yeah, no, there is unfortunately no answer to that question. No direct answer on the literature about that. Most of the studies that we included in the review. They were using particles that were equal or higher of greater than 30 microns, micrometers. But also for the little bit below that, overall, you don’t find the big difference in the effect of these particles, except for certain comparisons.

And also they were not in the long term. Because when you think of adhesion, it’s not that you, if you reach a high adhesion at the same, like today. It does, you really need to look at in the long term. So after aging and stuff, what’s going to represent and that information we don’t have yet. So I would say if you stick to this most, let’s say commercial, yeah. Frequently used, like for example, 27 to maximum 50, I think you are in the safe side.

[Jaz]
Lots of dentists actually say, lecturers say that they like 27 microns for cavity because it’s not too abrasive. So if you’re close to the pulp and whatnot, so, it will do the biofilm removal It may be make a nicer surface under the scanning electron microscope. It looks prettier, but maybe it doesn’t achieve the better bond strength. But it’s certainly they like what they see under the microscope or under the scanning electron microscope and then for 50 microns for actual like the intaglio surface of crowns and resin bond bridges which makes sense. Pragmatically though what I do, and this is just pragmatically and some other conditions, I’m just not in the enjoyment phase of switching sands.

I don’t like, oh, now is this I have to switch it. It’s a step too much. So I use 50. And that way with the 50, I can use it aggressively on restorations and metal and stuff and removing cement where I need to. But when I’m doing it on teeth, I’m favoring this like, soft sandblasting. So being a little bit further distance away from the cavity and being very careful to aim the sort of the beam, if you like, of the sand to exactly where I want to go and just being careful about that. In your clinical experience or what you’ve seen colleagues do, what you’ve read, is there a good pragmatic approach in practice that you think?

[Veronica]
I think what you’re saying that you kind of try to compensate a little bit of size of the particle, for example, with the distance. And I think that’s also a good idea in case you either don’t want to, or don’t have the conditions of changing the particles. I think definitely we need to be more mindful about when we are doing it in the mouth on a tooth substrate, because it does cut a lot and it cuts even more when it’s hard tissue. So for example, you already finish your, usually, you finish your bur preparation. So you remove the carious dentine or whatever that you’re working on. And you’re almost reaching that stage that is that hard dentine that’s healthy. So that you don’t want to remove more than you should. So then you have to be, yeah, you cannot be too enthusiastic with the air abrasion because in that case you can really remove more than what’s needed.

So I think it’s definitely good that you take these measures and yeah, it’s really like, so you have some factors that can influence the air abrasion effect. So we have particle size, you have pressure, you have distance, you have angle, and you have time just to mention a few, okay? So all of these, they going to play a role of course, but we don’t know what’s the effect of them because some of the studies, they are so different. They use so many things.

[Jaz]
It’s difficult to study all these grammaticals.

[Veronica]
It’s really different, difficult to compare them. So we can, because we need to first be able to compare so we can say which is better or not. But I think you’re definitely on the good direction that you’re balancing it a little bit with the particle size and stuff.

[Jaz]
And with the use of air abrasion, some other clinical protocols I’ve seen is when you’re trying to bond to existing composite, virtually all the clinical expertise that I’ve seen says that, okay, a good step to activate, reactivate the composite. It’s ready to silanate and then re bond a new composite to old composite. But air particle abrasion is used a lot. And then in particular, I’ve read some research about the use of cojet, a particular type of sand. Have you studied or looked into CoJet?

[Veronica]
Yes. So it’s one of the particles used. So you have just maybe people that are not familiar with it, but the difference with the CoJet is that it’s first of all, it’s a branded name, huh? From, it’s a 3M-

[Jaz]
I think, it’s a 3M product.

[Veronica]
Yeah, it’s 3M. And then you have not only the oxide, the alumina oxide, but you also have silicon and that’s especially the silica. It’s what helps with if you’re going to use, for example, a repair, if you want to use a sealant, then you can improve the bonding to the sealant because of the silica.

So in case of repairs. Because there is already some evidence that for repairs, it’s nice to use a sealant. And then if you use something that’s going to improve the bone into sealant, then you have an extra. So either you can do something to roughen that surface. For example, it doesn’t need to necessarily be air abrasion.

You could also do that with a bur, for example. But then you have, with only air abrasion, without being CoJet, you’re going to still going to have the benefit of the roughening of the surface. So you’re going to improve the quality of that surface for adhesion. But then if you use the CoJet, you also have the benefit of the silica and then you have better adhesion to the better bonding to the ceiling for repairs or for like if you’re bonding to metal or yeah, also zirconium also on the other types of materials that are not only composites that can be a benefit too.

[Jaz]
And to use CoJet, and this is, excuse my English, I’ve never used it. Is it just a matter of just buying the powder or do you have to buy the whole kit for the air abrasion unit as well? I’m not sure.

[Veronica]
Yeah, good question. I also, I’m also not sure about it. I know that in a lot of studies when they use CoJet, they combine it with a special type of hand piece or something. So I’m not sure if it’s compatible with any type of what with system. So yeah. Yeah, we need to check that.

[Jaz]
It’ll be good to look into it. And as part of the research, I’ll look into it for this podcast before we release it. It’ll be good to know because if it is showing promising data for when you are bonding to old composite. And that’s a lot of what we do in modern dentistry, trying to be conservative, minimally invasive, refreshing, old composite is part of what we do. And also with aging populations, we’re probably doing it more and more in the future. Therefore, if this really is the magic sand, if you like, then maybe we should just be stocking it and buying it.

But however, if there’s cost concerns that you need to get a brand new unit, then that might tip the balance. So I will look into that. It’d be interesting to know more about a CoJet, but I’ve definitely seen that it’s a quite encouraging data. What I’ve seen. Any times that you’ve come across in your findings about when we should avoid it? Are there any scenarios that we could be doing harm by using air abrasion or perhaps the improper use of air abrasion?

[Veronica]
Yeah. It’s really difficult to tell, but I could think of a few. So for example, you can use airbrasion if you have just that superficial enamel caries. That’s like, imagine some type of situation where you just use sealant, you not go for the full restoration.

And in those cases, it can be useful to use a little bit of abrasion. Fine. But you cannot use it, for example, if you want to, yeah, diagnose caries. I don’t know why would you do someone used that, but I’m just saying that I found an example.

[Jaz]
People used to, I mean, Veronica, we know that people used to use a fissure bur. They’d be like, hmm, let me see if it’s carious. It’s back in the day. They’d stick a fissure bur in and open it up and then see, ah, is it carries or not?

[Veronica]
So, yeah. So yeah, so there is a good example. So I could not think like, why would someone do that? But maybe people think, yeah, because I’m going to dry it and then I can see, I don’t know, but that would not be a good case for using air abrasion. Other than that also, as I said, you need to be aware that with air abrasion you’re not going to be able to have that tactile feeling of the cavity of the tissue, so you need to be aware of that, avoid it if you really think maybe that you’re already like really it can also be because you’re in a deep and you don’t want to expose, there’s a risk there, so you should avoid it in that case.

Also, if you cannot have proper isolation or protection in, of your field. And I’m not talking necessarily of rubber dam, because sometimes you can also have it like with other ways. So, if you cannot have that, you should also avoid the air abrasion. And another thing that I found very interesting, I think is also a good point.

You should not replace the etching, for example, with air abrasion. So skip a step and only use the air abrasion because of what we said before of this mirror layer. And the debris. So that’s not the way to go. So you can add it as an additional step, but should not replace that. It doesn’t replace that. No, no.

[Jaz]
Absolutely. And I think the other one I could think of is just be careful if anyone’s doing zirconia bonding. Air particle abrasion is a reasonable thing as part of the protocol for the APC protocol. But. if you’re doing it too aggressively, are you causing micro cracks in that zirconia, for example, that’s a concern.

So a term I’ve seen is soft sandblasting being used and the other one would be lithium disilicate. For example, I know plenty of colleagues who air abrade lithium disilicate. Any stance you have on that? Because last time I read the Ivoclar guidelines, Emax, for example, it’s a glass ceramic. They specifically say, do not air abrade, but I know some clinics who do and they don’t seem to have any fractures of the ceramic.

It’s just that because I read it in Ivoclar. Anything that I have that’s Emax, I don’t do it because I feel as I’m trying to follow the instructions for that. Any guidelines on different ceramics and air abrasion?

[Veronica]
Yeah, I don’t know. I’m not familiar with this recommendation from Ivoclar, but I can tell that yeah. With lithium disilicate you have not a great problem with bonding because you can just condition it and without having the risk of creating of any-

[Jaz]
Surface irregularities and microcaps.

[Veronica]
That’s damage to your, ceramic, with zirconia is definitely needed because then you do have a problem. So you do need to have to do something to increase your possibilities with adhesion. So, that’s a very interesting example. What I know is for the glass ceramics, yeah, it’s just not needed. You can just do the proper conditioning with the fluoridic acid and then, you can reach a good bone strength.

[Jaz]
Well, lots of colleagues don’t have air abrasion and I feel the number one question I get from the Protruserati community is, I don’t have air abrasion. Can I just use my Prophy Jet instead, like the polishing powders, very much softer stuff. Now, based on what you’ve said so far, because the data doesn’t strongly support the use of air particle abrasion, then really maybe they could just be using for the biofilm removal aspect, just be using the softer powders that are more for the biofilm.

Is there anything that you know about in terms of alternatives to air abrasion that people use and they can consider?

[Veronica]
Yeah. I think if you think of only the biofilm, I even go further with the pumice. So just know some like polishing with the pumice, that’s not going to leave any residue behind. But also if you think of the micromechanical effect of roughening the surface, then I would just go for like, for example, for roughening with the burr. Yeah, that too should also work. So for example, if you have like an old composite and you’re going to make a repair or something like that, you want to reactivate, remove that externally, and then have like a new layer on under it.

So I’ll definitely go also with the bur. And even if you don’t have air abrasion, for example, if it’s not a composite, if it’s like a sclerotic dentine that’s very hard and dentine, you can also activate a little bit the surface with the bur. But again, that’s an alternative. Even though, for example, in the paper we saw that when there was a difference favoring the Arab region, it was for some particles and for some pressure, yes.

It was usually when it was compared to either to hand excavators or with burs. So sometimes actually in those case, and I’m not saying I’m not going to generalize it, but some of my, let’s say sub comparisons, we found the difference than the air abrasion was better than those mediums. But yeah, if you don’t have it.

That’s what I was saying. If you don’t have it, you’re going to use what you have and not think that because you don’t have it, you’re going to have a too bad of an addiction. It’s not like that. I think it’s if you take care of other important details and steps on your clinical procedure, you can still reach a good, effective adhesion.

[Jaz]
If someone’s listened to this episode and they’re now feeling like they’re a little bit more knowledgeable about the guidelines for air particle abrasion. And just like a lot of research, we don’t have the answers. What was your personal reflection guideline in terms of if someone’s sitting on the fence, and they’re thinking, should I spend this equipment budget on an air particle abrasion unit?

It’s a two part question here. One, do you think they should do it? Or maybe because the evidence says it doesn’t significantly improve bond strengths that much, maybe just to skip it and continue to use the bur. That’s part one. And part two is any data on the more fancier units like, Aquacare, the crystal marks, any comment on those? So part one, if someone’s not using air particle abrasion at all, is it time that they invest or maybe should they save their money and buy another gizmo instead?

[Veronica]
Yeah, it’s a good question. I would say, air abrasion is definitely another tool in the dentist toolkit. So, the same thing, for example, yeah, can you be a dentist without magnification? Or, is it really something that the people that use it there’s a lot of benefits, but if you don’t have it, doesn’t mean that you cannot do dentistry, not necessarily, because we all kind of start without it. So it’s a bit-

[Jaz]
I like that. I actually love that. Because I love that Veronica, because I don’t trust any dentist that doesn’t use loops. That’s just my fact. Okay. I don’t trust if you don’t use magnification, I would not let you near anywhere near my mouth or my family’s mouth. And actually, if I was going to have an adhesive procedure or my family member was having adhesive procedure. And if I started working in a new clinic, my requirements are always the same.

I need air particle abrasion, I need rubber dam. If I don’t have these two things, I refuse to work in this clinic and that has worked well every time I go to a clinic and they always supply those things. So that’s my personal stance. Again, the literature doesn’t support it, but I like the comparison.

Okay. Literature maybe can’t support that a dentist who uses magnification crowns will last longer than a dentist who doesn’t use magnification, for example, right? So maybe the literature won’t support it, but in terms of how we perceive it and what do we feel in the absence of literature, because literature is one third of evidence based dentistry, right? It’s patient experience, patient values, and we have to consider that as well. Yes.

[Veronica]
Yes. Very much. It might get there. We might get there. And yeah, no, I’m out about getting heavy answers, but of course, sometimes you have questions that are more urgent to be answered. So there is also that, but yeah, it’s just to give it, I thought, yeah, just now if it’s a good example, so I would say if you have the means to do it, I think you might really like it, enjoy it and see the benefits and the quality of work and also, yeah, a bit of pleasure and fun that you have using it. That’s about the part one then. So yeah.

[Jaz]
And part two the fancier ones. The Aqua Care. The crystal marks. They had the water jet with them.

[Veronica]
That’s the thing. I had the opportunity of also working with Aqua Care and it was fine to me as well, but I don’t know any comparison terms of brands of devices of that. I just felt that okay, it was good, but I was also used. Let’s say in one room in the practice they have Aquacare in the other room they have another type and I was just used to the one that was in my room and I was happy with it. So I could not see from the clinical perspective, like personal perspective, I could not see like a huge difference, honestly. So, yeah.

[Jaz]
I think that the fans of Aquacare and Crystal Marks, these systems with the water, and there are some cheaper systems out there as well with water, I think twofold. One is that they’re less messy. It’s less messy, it’s easier to clean up because of the whole water with it as well. There seems to be, virtually none, I’m told, in the air and they feel better about the whole safety aspect, right?

So that makes sense. And, but there is also the, is it called Sylc maybe?, the bioactive glass, maybe the bioactive beads that come with a particular AquaCare that seems to have some promising soft tissue responses. That I’ve seen some lectures talk about and maybe there’s something in that, but yeah, I’ve never had any compelling evidence research, but it’s one of those things that I’m going to say that just like you said, if you have the means, right, if you have the means and if you can buy the best loops, the highest magnification you can afford, great. But if you only got the brand that you can afford and that will do good for now, I think that’s a good way to go. But to use something is better than using nothing in my opinion.

[Veronica]
Yes, yes. Yeah, I know that there was some studies that used also the glass beams in the review, but it was just not much. It was just, in that time, it was just a minority of the studies, huh? So as I said, science and evidence, they also need time. So maybe in a few years, we’re going to have more studies that’s used to test those equipments and those other particles so that they can maybe have a different, yeah, interesting, more new information.

[Jaz]
Veronica, you’re a true academic in the sense that we’ve ended the podcast with the usual sentence that you read at the end of every dental paper ever, which is we need more time, we need more papers, we need high quality studies, but it’s so true.

[Veronica]
Yeah, unfortunately, yeah, sometimes like, I mean-

[Jaz]
It’s the same conclusion every time, but this is the reality of it. We don’t have the clinical trials.

[Veronica]
Exactly. I mean, I’m not even saying clinical trials because honestly, not everything, like imagine clinical trials really need to be like a major important question. Some things are perfectly fine to be also evaluated in the lab. If you wanna compare, for example, different materials, like different composites, different these waves, yeah.

You don’t need to necessarily do it in the patient because some concepts are the same, but you wanna, so just see like a tiny details of differences in the bone strengths of that’s perfectly suitable to be tested in the lab. So, I think that’s the case also for air abrasion, but yeah, more studies are needed.

[Jaz]
Watch this space. More studies are needed. Oh, Veronica. Well, thanks so much for having this geeky discussion. It’s something that the community has asked for a long time in terms of more, just a geeky one about air particle abrasion. My personal stance, as I’ve said, is I’m very pro it, but I just want to, and I’m happy to have you say in this podcast that, look, we need more data.

It’s not as nice as you’re saying, Jaz, and I appreciate that. And that’s what the study said, and we can’t argue with the studies, but let’s see what time tells. Personally, the clinical satisfaction I get outweighs any of that. And I know that it’s not doing any harm, but the whole biofilm removal, but when I didn’t have the air abrasion, I was using Pumice, right. And I got by fine as well. So there are some considerations for that as well.

[Veronica]
Yeah. And even though we don’t have that big fat, yes or positive or go ahead, but we definitely also don’t have it yet, a big fat no. So I think, that’s why like sometimes you also need to balance it a little bit. Are there many risks?

Are there many harms that might be overcoming like positive effects? We don’t see that very much so far in a regarding to air abrasion. So I’ll say In this case, it’s okay to go with your feeling, because we might have some more definite definitive answers in the future. But just for now, we also don’t have many major red flags.

[Jaz]
So good. And are you happy for me to share your systematic review with the community in the download section in the show notes?

[Veronica]
No problem.

[Jaz]
Amazing. I will do that. And just tell us what are you working on next? Like what’s what’s next on the horizon academically for you? What are you researching next?

[Veronica]
Yeah, right now I’m at the Department of Cariology at the ACTA at Tech, from a University of Ment Amsterdam. So, yeah, right now it’s a little bit still very early stages, a bit of qualifications needed and yeah, still developing some work on the tool for, but in terms of research is still open for possibilities. And I will come soon.

[Jaz]
Good, good. Well, as a community, we wish you all the best. Thanks for giving the time. If anyone wants to send some love your way and a thank you, and maybe a geeky question, how would you accept that? How would you welcome that?

[Veronica]
Yeah, no, yeah. I’ll be happy to receive that. And I’m always quite active on my research gate page. So yeah, people will sometimes reach out for publications. I do my best to respond really quite fast to send the papers and stuff. And also, yeah, as you could see, also linked in. So yeah.

[Jaz]
I’ll link them to the research gate and honestly wishing you all the best with the future research endeavors and your new life in the Netherlands.

[Veronica]
Thank you. Same to you.

Jaz’s Outro:
Well, there we have it, guys. Thank you so much for listening all the way to the end. I’d like to thank our guest once again, Veronica Pereira de Lima, for being geeky and being kind enough to accept my invitation. Protrusive is all about the geeky and kind dentist. That’s you.

Now, if you want to find the home of the geekiest and kindest dentist in the world, you want to head to Protrusive Guidance. There, under this episode, you can answer some questions in the quiz to get some CPD. You’ve done the hard work of listening to this episode already, so why not get 40 minutes of CPD for this?

One of the five questions for this episode is this. Which of these factors determine the cutting efficiency of air particle abrasion? So which of these factors determine the cutting efficiency of air particle abrasion? Is it A, the particle size? Is it B, the pressure? Is it C, the distance away from the substrate? Is it D, the time of air abrasion? How long are you actually air abrading for? Or is it E, all of the above?

Now that was an easy one, I know. There’s a few others there. If you can answer those, you’ve got yourself a certificate which Mari, our CPD queen, will email to you. In fact, Mari will send you quarterly certificates and an annual review of all your activity within Protrusive.

I want to thank Team Protrusive, so Erika the Producer, Mari the CPD Queen, Krissel, Rakesh, Nav, Emma, who will help with the premium notes, and Gian for his video wizardry. Do me a favor before you go, whatever platform you’re listening on, consider giving it a like, a thumbs up, a subscribe, whatever button you can click on, please click on it.

It really helps the podcast grow, so I can continue to bring cool and geeky content to benefit us all. Thanks so much once again, I’ll catch you same time, same place, next week. Bye for now.