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CLINICAL EVALUATION OF THE PROPHY-JETTM IN ROUTINE PLAQUE
DEBRIDEMENT OF ORTHODONTIC PATIENTS
JEREMY M. ALBERT
A THESIS PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF SCIENCE
UNIVERSITY OF FLORIDA
I thank my wife Jacque for all of her support, patience, and sacrifices through my
many years in school. I look forward to our future together and all that it will bring.
I thank my daughter Alyssa, who alone is worth all the hard work and effort.
I thank my family for guiding me into the person that I am today and for giving me
the ability to be excellent.
I would like to thank the members of my committee-Dr. Wheeler, Dr. Dolce, Dr.
Towle, and Dr. McGorray. I would also like to thank all of the patients who participated
in the study; and the staff at the Graduate Orthodontic Clinic- Marie Taylor, Debbie
Walls, April Heritage, and JoAnn Ridgell-for their help in this project.
TABLE OF CONTENTS
A C K N O W L E D G M E N T S ............................................................................................... ii
ABSTRACT ..................................... ...... .............. iv
IN TR O D U C TIO N ............................................................................... ......... .
M A TERIALS AN D M ETH OD S............................................................. ............... 4
R E SU L T S ............................................................................... . 8
D ISC U S SIO N ...................................................... 14
CON CLU SION S...... ...... .......................... .............. ........ ........... 18
REFEREN CES ..................... ...... ............ .. .. .. ....... .......19
BIOGRAPH ICAL SKETCH ................................................. ..............21
Abstract of Thesis Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Master of Science
CLINICAL EVALUATION OF THE PROPHY-JETTM IN ROUTINE PLAQUE
DEBRIDEMENT OF ORTHODONTIC PATIENTS
Jeremy M. Albert
Chair: Timothy T. Wheeler
Major Department: Orthodontics
Orthodontic appliances, specifically brackets bonded to teeth, can accumulate
plaque, leading to gingivitis, enamel decalcification, and dental decay. Currently, plaque
removal in the orthodontic office is limited to tooth-brushing after wire removal.
A prospective randomized clinical trial was conducted to compare the
effectiveness of the Prophy-JetTM to that of tooth-brushing for removing dental plaque
and for maintaining oral health. We recruited 40 orthodontic patients with fixed
appliances showing poor oral hygiene to participate in the 6-month study. Patients were
randomly assigned to have one side of their mouth to be cleaned monthly with the
Prophy-JetTM; the contralateral side was brushed by the patient. Plaque Index (PI),
Papillary Bleeding Score (PBS), and Decalcification Index (DI) were assessed throughout
Significantly lower mean PI scores after cleaning were found for the Prophy-JetTM
(0.41 maxillary posterior, 0.08 maxillary anterior, 0.23 mandibular posterior, 0.05
mandibular anterior) versus tooth-brushing (1.85 maxillary posterior, 2.08 maxillary
anterior, 1.64 mandibular posterior, 1.78 mandibular anterior). Monthly PI and PBS
scores were not significantly different. However, changes in DI scores were significantly
less for the Prophy-JetTM teeth (mean difference= 0.27 mandibular posterior, 0.37
maxillary anterior, 0.18 mandibular anterior).
Results show that the Prophy-JetTM was more effective than tooth-brushing at
removing dental plaque for a single session. In addition, monthly cleaning with the
Prophy-JetTM were found to decrease the progression of enamel decalcifications in
patients with inadequate oral hygiene practices between visits.
Dental plaque has long been associated with dental decay and periodontal disease.
Fixed orthodontic appliances, specifically brackets bonded to teeth, can accumulate
plaque along their margins with teeth; and may interfere with effective plaque removal.
In addition, proper oral hygiene by these patients, while crucial to successful treatment,
can be difficult to maintain. Accumulated dental plaque in orthodontic patients has been
associated with enamel decalcification, enamel scarring, dental decay, and gingivitis. In
a study of decalcification incidence, 50% of orthodontic patients experienced an increase
in decalcification during treatment, with the highest incidence in the maxillary incisor
region and lowest incidence in the maxillary posterior region.1
Professional dental prophylaxis over the years has traditionally involved the use
of a rubber cup and abrasive paste for coronal polishing. The ultimate goal of this
procedure is complete removal of supragingival plaque and stain. However, the use of
rubber cup and abrasive paste is often laborious, time-consuming, and ineffective in
completely removing supragingival deposits, particularly around bonded orthodontic
Since its introduction to the dental marketplace in 1977, air-powder polishing
systems have been effective at removing stain and plaque.2 The design of the various
air-powder polishing systems, such as Dentsply's Prophy-JetTM, use a mixture of air,
water, and sodium bicarbonate to deliver a controlled stream of sodium bicarbonate
particles to the tooth surface. This slurry of powder and water debrides tooth surfaces of
plaque and stain by abrasion. Advantages of air polishers are rapid removal of tooth
deposits, less invoked hypersensitivity;3'4 less operator fatigue;5 and improved access to
pits and fissures.6 In a survey of 140 stain patients, 94% preferred the Prophy-JetTM
compared to hand instrumentation or ultrasonic scaling. Reasons cited by the patients
were that the Prophy-JetTM was more thorough, it required less chair time, and it was
more comfortable because no heat, scratching, or pressure were generated during the
Currently, plaque removal in the orthodontic office is limited for mainly to
tooth-brushing after wire removal. This method of plaque removal requires wire removal
and often relies on the patient's ability to effectively remove the plaque with a manual
tooth-brush. While the Prophy-JetTM has been shown to be effective in general dental
patients, its long-term effectiveness on orthodontic patients has never been studied.
By designing a study that includes long-term follow-up on the periodontal and
dental health of orthodontic patients, the potential benefits of routine Prophy-JetTM
cleaning could be explored not only for a single visit, but as a regimen for oral health
maintenance for orthodontic patients with oral hygiene concerns.
The purposes of this clinical trial were as follows:
* To evaluate the efficacy of the Prophy-JetTM in removing dental plaque in orthodontic
patients with arch-wires in place;
* To evaluate the long-term effects of monthly debridements with the Prophy-JetTM in
orthodontic patients with poor oral hygiene on gingivitis, decalcification, and plaque
* To compare the effectiveness of the Prophy-JetTM to currently used method of
MATERIALS AND METHODS
This study was designed as a prospective randomized controlled clinical trial.
Patients undergoing orthodontic treatment with brackets and wires in the maxillary and
mandibular arches were recruited from the Graduate Orthodontic Clinic at the University
of Florida College of Dentistry. Other selection criteria for inclusion in the trial were the
presence of extensive amounts of visually detectable plaque around the orthodontic
appliances as identified by the operator, good health with no current medications, and
willingness to sign informed consent. Patients were instructed to restrict home care to
floss and manual tooth-brushes; and were not allowed the use of any electric
tooth-brushes. The Institutional Review Board for research at the University of Florida
approved the study protocol before the study was begun.
Participants in the study were randomly assigned a side of the mouth that would
be cleaned monthly by the Dentsply Prophy-JetTM instrument for the duration of the
6-month study. The contralateral side was manually brushed by the patient at each
clinical visit. This randomization was created from a computer-generated sequence that
was followed for patient assignment. A mouth tray was placed on the tooth-brush side of
the mouth while using the Prophy-JetTM to prevent crossover spray. For participation in
the trial, patients were financially compensated and received a full mouth debridement
with the Prophy-JetTM at completion of the study.
The protocol for each clinical visit was designed based on a pilot study that was
conducted in 1999 at the University of Florida. This pilot study showed the effectiveness
of debridement with the Prophy-JetTM with arch-wires in place; therefore, arch-wires
were not removed for the present study. Patients were seen for a total of seven clinical
visits, the first consisting of a baseline examination of dental health parameters including
the collection of clinical indices. At this initial visit, Prophy-JetTM cleaning on the
assigned side and manual tooth-brushing on the contralateral side were performed, with
30 seconds allotted per arch for each method to make procedure time comparable.
Patients were then seen at monthly intervals for 6 months, at which times clinical indices
were recorded and the split-mouth cleaning was performed.
The labial surfaces of teeth bonded with brackets from the 2nd premolars forward
were included in this assessment. The following clinical indices were measured for this
Plaque. Plaque levels were assessed using the Turesky modification of the
Quigley-Hein Plaque Index (PI).8
0 = No plaque visible
1 = Separate flecks of plaque visible at the gingival margin
2 = A thin continuous band of plaque (up to 1 mm) at the gingival margin
3 = A band of plaque wider than 1 mm but covering less than one-third of the tooth
4 = Plaque covering at least one-third but less than two-thirds of the surface
5 = Plaque covering more than two-thirds of the surface
The PI was recorded at each monthly visit. In addition, the PI before and after
cleaning was scored at the baseline visit to compare mechanical cleaning effectiveness of
the Prophy-JetTM to that of manual tooth-brushing under the clinical conditions of the
Decalcifications. Decalcifications were assessed visually and tactilely with a
dental explorer and scored by using a modified version of the white spot lesion index of
Gorelick et al.1
0 = No white spot present
1 = Visible white spots without surface interruption (mild decalcification)
2 = Visible white spot lesion having a roughened surface but not requiring a restoration
3 = Visible white spot lesion with surface interruption (severe decalcification)
4 = Cavitation
The decalcification index (DI) was measured at baseline, 3 months, and 6 months
due to the slow, progressive nature of decalcifications.
Gingivitis. Gingivitis was assessed at each monthly visit using the Papillary
Bleeding Score (PBS) of Loesche.9 A Stimu-dentTM was used to stimulate the interdental
papilla, which is a common site of gingival inflammation for orthodontic patients.
Subsequent gingival bleeding was used as a measure of gingival health.
1 = No bleeding
2 = Slight bleeding
3 = Bleeding with flow
4 = Intermediate bleeding (copious)
5 = Spontaneous bleeding
A single operator performed all measurements and cleaning; thus, blinding was
not possible for the decalcification index, which was recorded after cleaning. Before
recruitment of patients for the Prophy-JetTM study, the operator was calibrated by a
calibrated dental hygienist on the three clinical indices (DI, PI, and PBS) and use of the
Prophy-JetTM to ensure consistency of results. Five orthodontic patients meeting the
inclusion criteria of the planned study were examined by operator and hygienist and
standardization and reproducibility of indices were demonstrated. These patients were
not included in the clinical trial.
Forty patients were recruited to participate in the study. The mean age was
18.1 + 9 y (range 11 to 56 y). The group was composed equally of 20 males and
20 females. In reference to use of a dominant hand, 35 patients were right-handed and
5 patients were left-handed. The assignment of sides of the mouth to be cleaned with the
Prophy-JetTM was 20 for the right side and 20 for the left side. For the right-handed
subjects, 17 had Prophy-JetTM on the left and 18 had Prophy-JetTM on the right; for
left-handed subjects, 3 had Prophy-JetTM on the left, and 2 had Prophy-JetTM on the right.
Over the course of the 6-month study, 5 patients were eliminated for missing
appointments or discontinuing orthodontic treatment. Thirty-five patients successfully
completed the study and were seen at all seven clinical visits.
Each patient served as a control: one assigned side of the mouth was cleaned by
the Prophy-JetTM for the duration of the 6 months. Changes that occurred during
treatment for PI, DI, and PBS on the two treatment sides were evaluated with the paired
t-test and the 2-sample t-test. Pearson correlation coefficients were used to evaluate for
relationships within the data set.
The difference in mean reduction in PI scores at the baseline visit (Figure 1)
between the Prophy-JetTM and tooth-brush was statistically significant for all four
quadrants, with the Prophy-JetTM having greater PI reduction (p < 0.0001). A sample
comparison of the cleaning effectiveness between the Prophy-JetTM and manual tooth-
brushing at the baseline visit is illustrated in Figure 2.
Change in DI scores from baseline to 6 months were significantly lower for the
Prophy-JetTM for the mandibular anterior and posterior, and the maxillary anterior
(p < 0.05). The maxillary posterior did not reach statistical significance (p = 0.26). The
mean DI scores are shown in Figure 3, and the differences between the two sides (with a
positive number indicating less decalcification increase for the Prophy-JetTM) are shown
in Figure 4. Figure 5 shows a sample photo comparison of both sides. Mean DI score
change did not differ significantly by gender or side of mouth selected for Prophy-JetTM
Plaque index (PI) changes from baseline to 6 months are shown in Figure 6 and
did not reach statistical significance (p = 0.07). Patient gender did not influence PI
scores; however, patients who received the Prophy-JetTM cleaning on the left side of
their mouth had a significantly greater difference in plaque levels between the two sides
(mean = 0.46 0.52) than those assigned to the right side (mean = 0.00 + 0.80).
Papillary Bleeding Score (PBS) changes from baseline to 6 months were not
significantly different (p = 0.46) and are shown in Figure 7. Mean PBS score change did
not differ by gender or side of mouth selected for Prophy-JetTM use.
Analysis via Pearson correlation coefficients (Table 1) indicated statistically
significant correlations of the changes in clinical indices between the Prophy-JetTM and
tooth-brush sides. DI, PI, and PBS were positively correlated between the two sides
(p < 0.005). In addition, for the Prophy-JetTM side, changes in DI were positively
correlated with changes in PI (p < 0.05).
M Before Cleaning
F After Cleaning
PJ TB PJ TB PJ TB PJ TB
Posterior Anterior Posterior Anterior
Figure 1. Plaque Index scores (mean + SE, n = 40) before and after cleaning at baseline
visit, by region. (PJ = Prophy-JetTM, TB = tooth-brush).
Significant at p < 0.0001
Figure 2. Study subject after cleaning at baseline visit. A) With Prophy-JetTM. B) With
tooth-brush. Disclosing solution has been used to reveal plaque.
* 6 months
PJ TB PJ TB
PJ TB PJ TB
Figure 3. Decalcification Index scores (mean + SE) at baseline and 6 months, by region.
(PJ = Prophy-JetTM, TB = tooth-brush).
Figure 4. Difference in Decalcification Index change (mean + SE, n = 35) by region.
Positive DI difference indicates less increase for Prophy-JetTM.
*Significant at p < 0.05
Figure 5. Study subject at completion of the six month trial. This illustrates the
decreased decalcification on the (A) Prophy-JetTM side compared to the (B)
7 -*- PJ Maxillary posterior
-3 PJ Maxillary anterior
3.50 -A- PJ Mandibular posterior
S-*-PJ Mandibular anterior
/ -e- TB Maxillary posterior
/ -- TB Maxillary anterior
3.00 -A- TB Mandibular posterior
--- TB Mandibular anterior
Figure 6. Monthly mean Plaque Index scores (n = 35) from baseline to 6 months, by
region. (PJ = Prophy-JetTM, TB = tooth-brush)
*Not significant at p = 0.07
1.50- -- PJ Maxillary posterior
-- PJ Maxillary anterior
1.30 -A- PJ Mandibular posterior
v -- PJ Mandibular anterior
a 1.10 -
S-- TB Maxillary posterior
0.90 -- TB Maxillary anterior
A- TB Mandibular posterior
0.70 -- TB Mandibular anterior
Figure 7. Monthly mean Papillary Bleeding Score from baseline to 6 months, by region.
(PJ = Prophy-Jet, TB = Tooth-brush)
*Not significant, p = 0.46
Table 1. Pearson Correlation Coefficients (R values) for Decalcification Index (DI),
Plaque Index (PI), and Papillary Bleeding Score (PBS).
ADITB ADIPJ A PITB A PI PJ APBSTB A PBS PJ
ADITB 1.00000 0.56192 0.19013 0.25993 -0.00457 -0.03324
(p=0.0004) (p=0.2739) (p=0.1316) (p=0.9792) (p=0.8497)
A DIPJ 1.00000 0.22428 0.36608 -0.10785 -0.06599
(p=0.1952) (p=0.0306) (p=0.5374) (p=0.7065)
A PI TB 1.00000 0.82883 -0.06343 -0.15548
(p<0.0001) (p=0.7174) (p=0.3725)
A PI PJ 1.00000 -0.08753 -0.21230
APBSTB 1.00000 0.55921
A PBS PJ 1.00000
(PJ = Prophy-JetTM, TB = Tooth-brush, A = change from baseline to visit 6)
The present study was conducted as a prospective randomized controlled clinical
trial on 40 orthodontic patients with full fixed appliances demonstrating visible
supragingival plaque. By selecting patients in orthodontic treatment with poor oral
hygiene, it was hoped that monthly Prophy-JetTM cleaning would minimize the
deleterious effects of plaque accumulation due to inadequate brushing or flossing at
home. However, this patient group may not be representative of orthodontic patients as a
whole. Other potential limitations include geographic sampling bias, lack of blinding due
to the single operator for decalcification index, effect of extraneous factors such as
manual dexterity for the patients, and selection of clinical indices
Previous studies investigated the use of the Prophy-JetTM on orthodontic patients.
Two studies by Barnes and Gerbo et al.10'11 investigated the application of air-powder
polishing systems in the orthodontic setting. The first study was conducted in two parts
with both using the Prophy-JetTM device. Part 1 showed that the Prophy-JetTM was more
effective in removing plaque around orthodontic appliances; and required less time than
traditional rubber cup/pumice prophylaxis. The investigators noted the clinical advantage
of lack of disturbance of orthodontic wires and elastic bands with the Prophy-JetTM.
Part 2 of the study was performed by the bonding of brackets with composite to ten
extracted maxillary central incisors and cementing of molar bands with zinc phosphate
cement to ten extracted mandibular first molars. The results indicated that, while both the
composite and zinc phosphate cement were exposed to the air powder spray, the surface
of the two materials maintained their integrity and their margins remained intact. The
authors concluded that use of air-powder spray had no detrimental effects on orthodontic
brackets or bands or their cementing agents. Other studies have suggested roughening
and/or wear of dental restorative materials such as amalgam, composite, and gold
foil;7'12'13'14 thus, it has been recommended to avoid prolonged direct exposure of these
materials to the compressed spray of slurry.
In the present study, the effectiveness of plaque debridement in a single visit by
the Prophy-JetTM was far superior to that of tooth-brushing. While PI scores were similar
on both sides before cleaning, the PI scores after cleaning on the Prophy-JetTM side were
less than the tooth-brush in all areas of the mouth (Figure 1). This portion of the study
was to verify previous reports of Prophy-JetTM cleaning efficiency and to give a statistical
comparison of the effectiveness of the selected cleaning methods under orthodontic
The lack of any effect by the Prophy-JetTM cleaning on monthly plaque levels
and gingival inflammation can be explained by the pathogenesis of periodontal disease
and the design of the study. The salivary pellicle forms within minutes to hours after
professional dental cleaning, and the initial colonizers are gram positive bacteria such as
Streptococcus and Actinomyces species.15 Over the following days, the plaque increases
in thickness and quantity as gram-negative cocci and gram-positive and gram-negative
rods and filaments increase their presence. The patients included in this study were
identified as having poor oral hygiene and the duration of time between monthly
appointments was more than enough time for plaque levels and gingivitis to return to
baseline levels. Any potential benefits of a professional cleaning would have to be
maintained by the patients in their home care in order to minimize the damaging effects
of plaque accumulation on the teeth and surrounding periodontium. However, poor oral
hygiene patients are the ones that would most benefit from additional hygiene measures.
Therefore, we chose to study this group. The interval of one month between cleaning
was selected as the minimum amount of time between most clinical visits for orthodontic
Over the 6-month study, it was shown that the Prophy-JetTM significantly
decreased the formation and/or progression of decalcifications. It should be noted,
however, that the decalcification process was not entirely avoided. From baseline to
6 months, the mean DI scores for the Prophy-JetTM increased from 0.71 to 0.74 in the
maxilla and 0.56 to 0.66 in the mandible. However, the tooth-brush side experienced a
significantly greater increase over the six months from 0.65 to 0.95 in the maxilla and
0.44 to 0.79 in the mandible. Thus, while formation and/or progression of
decalcifications was not entirely prevented, the thoroughness of the Prophy-JetTM
cleaning at monthly visits in some manner significantly disrupted the decalcification
process. Possibilities for this include interference in the colonization of certain bacteria
into the developing plaque on the tooth surface. Although there are more than 300
species of bacteria in plaque, most have no cariogenic potential.16 Primary etiologic
bacteria in dental caries include Streptococcus mutans and Streptococcus sobrinus, with
Lactobacilli as a secondary invader involved in caries progression in enamel.17 Thus,
even in the presence of unaltered plaque levels and gingivitis, the monthly debridement
by the Prophy-JetTM may have altered the bacterial load by physical disruption and
prevent more deleterious organisms from colonizing and promoting the decalcification
The correlation of the changes in the three clinical indices from baseline to 6
months reinforces the importance of the patient's involvement in oral health maintenance.
The R values of 0.56 for Decalcification Index, 0.83 for Plaque Index, and 0.56 for
Papillary Bleeding Score indicate positive correlation between the changes that occurred
on the Prophy-JetTM and tooth-brush sides. Any changes for the indices on one side were
paralleled by the contralateral side. This is not unexpected since this was a split-mouth
study. Additionally, the positive correlation between PI changes and DI changes for the
Prophy-JetTM side demonstrates that if the patients were able to maintain the decreased
plaque levels by the Prophy-JetTM cleaning, those patients experienced less increases in
decalcifications on that side. Obviously, adequate home care is critical in maintaining
oral hygiene and preventing decalcifications. For the present study, the Prophy-JetTM
proved to be useful on patients that were poorly compliant with oral hygiene in
preventing the excessive formation of decalcifications.
This prospective clinical trial was designed to evaluate the effects of Prophy-JetTM
cleaning as compared to conventional tooth-brushing during office visits on orthodontic
patients with poor oral hygiene. Based on the findings of this study, the following
conclusions were reached:
* The Prophy-JetTM is more effective than the tooth-brush at removing plaque in
orthodontic patients for a single visit setting.
* Over the course of six months, the monthly Prophy-JetTM cleaning significantly
reduced the progression and/or formation of enamel decalcifications, even in the
presence of unaltered monthly plaque levels and gingivitis.
* Maintenance of adequate oral hygiene at home is essential to minimizing the
deleterious effects of plaque accumulation, including decalcifications.
* The Prophy-JetTM is an effective supplement to oral health maintenance during
orthodontic treatment for poor oral hygiene patients.
The mechanism for the decalcification reduction remains unclear, but could be
attributed to interference in the colonization of certain bacteria by the monthly cleaning.
Future studies may be designed to investigate this hypothesis by examining the
differences in bacterial strains present on each side. Other factors may also be explored
to minimize decalcifications and gingivitis, such as fluoride supplements, mechanical
tooth-brushes, or increased frequency of professional cleaning.
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Jeremy Matthew Albert was born in Huntsville, Alabama, and raised in Tarpon
Springs, Florida. He attended the University of Florida for his undergraduate study, with
a B.S. in nutritional science. He was then admitted to the University of Florida College
of Dentistry for his dental education and graduated with honors from dental school in
2000, obtaining a Doctor of Dental Medicine degree. After graduation, Dr. Albert
continued his dental education at the University of Florida earning a Master of Science
degree with a certificate in orthodontics in May 2003.