Efficacy of Air-polishing on Pain Perception and Compliance Rate to Periodontal/Peri-implant Maintenance Therapy: a 2-year Follow-up Randomized Controlled Clinical Trial
Phase: NA
Conditions: Peri-Implantitis, Peri-implant Mucositis
Sponsor: Universitat Internacional de Catalunya

 
 
 
SPECIFIC COMMISSION OF THE DOCTORAND - RESEARCH PLAN 
4. RESEARCH PROTOCOL 
 
Study Protocol: PER-ECL-2021-08 
Protocol Version: 2.0 
Version Date: 08/05/2022 
Presentation Date: 24/02/2022 
 
Main Researcher: - 
Secondary Researcher: - 
Tutor: - 
Departament: Periodontics 
Research Line: Diagnóstico, prevención y tratamiento de las enfermedades periodontales y periimplantarias. 
Research Title: Pain Perception during Supportive Periodontal Therapy – impact in compliance 
Peri-Implant Diseases 
In the last decades, replacement of teeth with dental implants became a very frequent procedure, and it is 
associated with high rates of implant survival (Albrektsson and Donos, 2012). However, the incidence of 
technical and biological complications seems to be frequent (Scwartz et al., 2018). Since the number of 
subjects receiving dental implants is growing continuously (Schimmel et al., 2017), preventing and effectively 
resolving peri-implant diseases on the long-term without compromising esthetic results have become one of 
the major endeavors of this field. 
In 2017, the World Workshop jointly held by the European Federation of Periodontology and the American 
Academy of Periodontology on the classification of Periodontal and Peri-Implant Diseases, defined peri-
implant disease as a pathological condition occurring in tissues around dental implants, characterized by 
inflammation in the peri‐implant connective tissue (ie, peri‐implant mucositis - PM), and progressive loss of 
supporting bone (ie, peri‐implantitis - PI) (Schwarz et al., 2018). The onset of peri‐implant diseases is 
characterized by the presence of etiological factors similar to those involved in the etiology of periodontal 
diseases and it might occur within the first three years of function in a non-linear and accelerating pattern 
(Derks et al., 2016). 
A recent systematic review and meta-analysis, performed by Jan Derks and colleagues in 2015, found a 
prevalence of 43% for PM and 22% of PI. Later on, in Spain, Rodrigo et al. (2018) observed similar PI 
prevalence’s with 24% of the subjects presenting bleeding on probing and radiographic bone loss ≥ 2mm 
after at least 5 years of function.  
The predictability of treatment of PI remains controversial, with evidence of results from several controlled 
clinical studies pointing out that nonsurgical treatment appears to be unpredictable with potential beneficial 
clinical outcomes limited to a period of 6–12 months (Renvert et al., 2008). However, in the last years, two 
12-month follow-up case studies demonstrated a novel protocol to address PI, with improved outcomes 
(Stein et al., 2018; Nart et al., 2019). Notwithstanding the above, at the moment, surgical treatment is still the 
standard of care, with a resective or regenerative approach depending on the morphology and anatomy of 

 
SPECIFIC COMMISSION OF THE DOCTORAND 
 
the bone defects resulting from the disease (Claffey et al. 2008). In spite of that, the predictability and long-
term stability of these procedures are still a matter of controversy (Teughels et al., 2006; Renvert et al., 2012; 
Chan et al., 2014; Serino et al., 2015). Therefore, efforts from the research community should be more 
directed towards prevention. 
Compliance to supportive periodontal therapy and prevention of peri-implantitis  
In the 3rd World Workshop, all the efforts taken after completion of the dental implant therapy were defined 
as supportive periodontal therapy (SPT), as opposed to periodontal maintenance, to highlight the importance 
of this phase of treatment. Moreover, in the same workshop, factors such as patients with history of chronic 
periodontitis, poor bacterial plaque control skills, and absence of regular maintenance care after implant 
therapy were recognized as being more likely to develop peri-implant diseases (Schwarz et al., 2018). This 
stress the idea that SPT is mandatory to prevent future breakdown of the disease.  
The rational for doing SPT is due to three main facts: i) bacterial plaque and its byproducts represent the 
primary etiological factor for further breakdown (Lang et al., 2008); ii) after being exposed to inflammation, 
tissues are more susceptible due to changes in gene expression that are not encoded by DNA itself (Martins 
et al., 2016); iii) recolonization with putative bacteria such as spirochetes and motile rods occurs as soon as 
4 to 8 weeks after active periodontal treatment (Mousques et al., 1980; Magnusson et al., 1984), highlighting 
the importance of frequent disruption of the biofilm.  
In this context, SPT can determine the failure to meet oral hygiene standards (Morrison et al., 1979). Several 
studies conducted in the 1980’s have clearly demonstrated that long-term therapeutic outcomes can be 
achieved if patients practice good oral hygiene and enroll in a regular supportive periodontal treatment after 
active periodontal therapy (Becker et al., 1984a; Becker et al., 1984b; Axelsson et al., 2004). Moreover, 
other studies concluded that without effective oral hygiene skills and a regular SPT program, the beneficial 
effects of various periodontal therapies would be compromised (Nyman et al., 1977; Axelsson et al., 1981). 
Nevertheless, even though SPT is considered to be crucial to maintain peri-implant health, classic studies 
have shown that patient’s adherence to SPT is not satisfactory (Wilson et al., 1984). Several studies have 
been carried out in different settings involving a considerable variety of cohorts of patients coming from both 
university and private practices in order to assess the factors that are associated with the lack of compliance 
with SPT (Ramseier et al., 2014, Perrell-Jones and Ireland, 2016). Identifying patients who are more likely to 
present a non-compliant pattern would help clinicians to focus their attention on these particular subjects, 
who mostly require a motivational strategy tailored to each individual risk profile (Amerio et al., 2019). The 
same publication pointed out that smoking habit and history of periodontal disease were found to be 
associated with patients´ compliance. Inadequate information/motivation was found as the main patient-
reported reason for non-compliance. 
Addressing the main reason for patients’ non-compliance is a research priority; however, studies in the 
literature are scarce. It’s crucial that clinicians understand the importance of supportive periodontal treatment 
to prevent the development and progression of peri-implant diseases (Schwarz et al., 2018). Therefore, 

 
SPECIFIC COMMISSION OF THE DOCTORAND 
 
missing or inadequate information given to patients after finishing the active periodontal treatment or the 
dental implant therapy is condemned to end. Patient motivation, nevertheless, is something external and 
depends mainly on patients’ phycological factors and personality traits (Komarraju et al., 2009). The main 
reason is going to be addressed in the first part of this research project. The second most frequent reason 
for patients to fail SPT on these questionnaires was bad experiences and dissatisfaction. It has been 
demonstrated that peri-implant probing, even in healthy tissues, caused significantly more pain/discomfort 
than periodontal probing (Ringeling et al., 2016; Stanner et al., 2017; Parvini et al., 2017). Such finding might 
be due to: 1) differences between periodontal and peri-implant tissues or, 2) on average, higher levels of 
inflammation are observed around dental implants than around teeth (Meyer et al., 2017).  
Considering these premises, one might suspect that a SPT visit to the dental office can be associated with a 
bad experience (Si et al., 2016), especially when these patients have one or more implants. Several 
debridement methods have been associated with better experiences around teeth. Less treatment 
discomfort was reported when comparing laser therapy with conventional therapy (Tomasi et al., 2006; 
Ratka-Kruger et al., 2012). Also, around teeth, air-polishing devices (APD) has been described as being 
significantly more comfortable and less painful than conventional instrumentation (Petersilka et al., 2003a; 
Petersilka et al., 2003; Möene et al., 2010; Wennström et al., 2011; Muller et al., 2014). An erythritol based 
air-polishing powder (Electro Medical Systems, Nyon, CH) have been recently introduced as a low abrasive 
powder (Hagi et al., 2013). Erythritol is a polyol used in food industry as an artificial sweetener. Its physical 
properties were shown to be comparable to glycine (Hagi et al., 2015). Moreover, when used during SPT, 
similar results in terms of clinical and microbiological outcome were demonstrated in comparison with hand 
instrumentation (Hagi et al., 2015). The efficacy of APD as monotherapy around dental implants, in the 
treatment of peri-implant diseases, have been addressed in a recent systematic review (Schwarz et al., 
2015) – comparable results were found between conventional devices and APD in terms of mucositis 
treatment and better outcomes regarding peri-implantitis. However, only one of the studies included in the 
review observed that “no complains or discomfort” were reported by any of the patients investigated (Ji et al., 
2014) – even though, no visual analog scale or other measurement scale was used for this purpose.  
To our knowledge, only one study compared pain/discomfort during SPT around dental implants (Menini et 
al., 2019). This study included only full-mouth implant-supported restoration and compared three 
debridement approaches: 1) glycine air polishing; 2) sodium bicarbonate air polishing and, 3) manual scaling 
with carbon-fiber curettes. Since they didn’t use a control group with ultrasonic devices, and no teeth were 
included in the study, it reduces its external validity. Nevertheless, they observed statistically significant 
better VAS scores for glycine group when compared with sodium bicarbonate air polishing. Leading to a 
possible effect of the size of the powder particles in the pain perception, which could be improved with the 
erythritol due to its even smaller particle size (Hagi et al., 2013).  
2. Background and current status of the topic: 
Implants have become a popular and widely used treatment option for treating partial and total edentulism. 
As the number of implants placed increases, so does the incidence of peri-implant mucositis and peri-

 
SPECIFIC COMMISSION OF THE DOCTORAND 
 
implantitis. Placing patients under SPT/maintenance care has been shown to prevent and treat such 
conditions. Despite SPT’s importance in prevention and infection control, adherence to scheduled SPT visits 
have been unsatisfactory. Understanding the reasons for non-compliance can help both the clinician and 
research community to address them by improving communication and/or patients experience to those visits 
thereby increasing compliance. 
3. Objectives: 
a) General objective 
Evaluate the patient reported outcomes to a different implant instrumentation method during SPT visits, as 
well as its impact in compliance rates. 
b) Specific objective 
1. To evaluate pain/discomfort during SPT around dental implants and teeth. 
2. To evaluate patient reported outcomes and clinical variables by decontamination during SPT 
with erythritol based air polishing powder (Air Flow Master, Air-Flow Plus, EMS, Nyon, 
Switzerland), at the first SPT and after 2 years. 
3. To evaluate the effect of erythritol based air polishing powder (Air Flow Master, Air-Flow Plus, 
EMS, Nyon, Switzerland) during SPT on the compliance rates after 1 and 2 years of follow-up. 
 
4. Hypothesis: 
a) General Hypothesis 
The proposed protocols, focused on the prevention of peri-implantitis, will result in an increase adherence to 
SPT by better understanding the specific factors related to non-compliance, specifically by improving the 
experience of patients to SPT visits.  
b) Specific Hypothesis 
1. SPT with conventional ultrasonic device will result in more pain/discomfort around dental 
implants than in teeth. 
2. SPT by means of an erythritol based air-polishing powder (Air Flow Master, Air-Flow Plus, 
EMS, Nyon, Switzerland) will result in better patient reported outcomes and same clinical 
outcomes, at the first SPT and after 2 years. 
3. SPT by means of an erythritol based air-polishing powder (Air Flow Master, Air-Flow Plus, 
EMS, Nyon, Switzerland) will result in the increase of the compliance rates after 2 year of follow-
up. 

 
SPECIFIC COMMISSION OF THE DOCTORAND 
 
 
5. Materials and Methods: 
Study Design  
The present research project is designed as a randomized controlled double-blind clinical trial with a 2-year 
follow-up. The reporting of this clinical trial will follow the Consolidated Standards of Reporting (CONSORT) 
guidelines. It is registered in ClinicalTrials.gov (…) 
Subject Selection 
The study will be performed after the approval of the Ethics Committee of the Universitat Internacional de 
Catalunya (UIC) and will be conducted according to the principles outlined in the Declaration of Helsinki and 
Ethical Conduct for Research with Human Beings.  
An aleatoric list of patients who have been enrolled in SPT at the Department of Periodontology of UIC and 
met the inclusion criteria will be generated – those patients will be called for SPT visit by the same 
investigator (E.R) 
Criteria for subject selection will be as follows:  
(1) Patients aged 18 to 80 years who are healthy; 
(2) Partially edentulous patients, rehabilitated with at least one dental implant in the maxilla or mandible; 
(3) No implant mobility; 
(4) Treated periodontal disease; 
(5) No systemic diseases that could influence the outcome of the therapy (i.e. uncontrolled diabetes, 
osteoporosis, bisphosphonate medication).  
(6) Non-smoker or light smoking status in smokers (<10 cigarettes/day).  
Pregnant, lactating women and non-collaborating patients will be excluded from the study.  
Sample Size Calculation 
The sample size will be calculated using changes in CAL as the primary outcome variable. Thirty patients (15 
subjects in each group) were necessary to detect a difference of  1 mm in CAL assuming a mean standard 
deviation (SD) of 0.9. This calculation assumes an alpha error of 0.05, a beta error of 0.2, and a statistical 
power of 80%. In addition, 12% of loss to follow-up was considered.  
Compliance Definition 
Patients will be grouped as regular compliers (RC), erratic compliers (EC), or non-compliers (NC), as 
described by Monje and cols. (2017). Complete compliance will be based on the longest SPT recall interval 
possible for each group.  

 
SPECIFIC COMMISSION OF THE DOCTORAND 
 
Groups: 
RC = 3- to 6-month recall interval (≥2 SPT/year) 
EC = 7- to 12-month recall interval (<2 SPT/year) 
NC = no recall interval program (no SPT/year) 
Patients who participated in a recall schedule but discontinued SPT in future appointments will be 
categorized as EC or NC according to their complianceduring the following years 
Considering the beginning of the COVID-19 Pandemic in early 2020 and the consequent lockdown between 
March and May of the same year, those patients unable to come to their programed SPT appointment due to 
the lockdown, but came right after the easing of the restrictions, will be consider as compliers – in a case-by-
case evaluation from the authors of the study. 
Study Visits 
a) SPT visit 
One calibrated investigator will consecutively call patients for SPT visits and will be responsible of enrolling 
the patients (T.R.A).  
The study variables will be recorded in a case report form (CRF) specially designed for the study. Each study 
patient will be assigned a numerical code comprising a 3-digit patient code (assigned correlatively as they 
are included in the study). Only the study investigator will be able to identify the patient by their code.  
Screening examination 
The clinician will review with the patient the Information and Medication History Forms and record the 
anthropometric, socio-demographic and clinical information. Candidates will undergo an oral pathology 
examination and a full-mouth manual probing using a periodontal probe PCP-UNC 15 (HuFriedy, Rockwell 
St, Chicago, IL) to determine their periodontal and peri-implant status. Presence or absence of plaque will be 
recorded after staining with an erythrosine disclosing dye (Plac-Control®, Dentaid SL, Cerdanyola, Spain). 
Finally, periapical radiographs (Dürr Dental AG, Bietigheim-Bissingen, Germany) of all implants will be taken 
using a paralleling cone technique and a film-holder (7mA- 60kV/20ms).  
The same calibrated examiner (E.R) will record clinical variables of mPI, BOP, PPD, MR and clinical 
attachment level (CAL). 
Oral hygiene instructions. 
Individualized instructions in proper oral hygiene measures will be given to all patients (E.R) enrolled in the 
study. Patients will be instructed to brush their teeth and implants twice daily to remove bacterial plaque with 

 
SPECIFIC COMMISSION OF THE DOCTORAND 
 
a low-abrasive dentifrice and to use specific cylindrical or conical brushes in the interproximal area. Patients 
will be indicated to brush under, around, and in the peri-implant crevice circumferentially. In those cases with 
no access for the interdental brush, patients will be instructed to use a floss threader or a specialized floss 
that has a built-in threader (Super Floss®, OralB®, Procter & Gamble, Cincinnati, OH, USA) and to wrap in a 
circle and move into the peri-implant crevice.  
Randomization and study groups 
Once oral hygiene instructions were provided, patients will be randomly assigned to the Test or Control 
groups. Allocation of patients will be decided following randomization tables with permuted blocks of four 
while the information will be concealed by using opaque envelopes, which will be labelled with the patient 
study number and only be revealed after oral hygiene instructions are provided. 
Debridement  
All the supragingival debridement will be performed by the residents of the Master’s Program in 
Periodontology at CUO – UIC (Sant Cugat del Vallès). Subjects will receive a session of full-mouth 
professional prophylaxis with: 
- Control group: an ultrasonic device (DTE-D5, Woodpecker®, Guilin, China) with a plastic tip (Hu-
Friedy®, Rockwell St, Chicago, IL, USA) and scaling with plastic curettes (Hu-Friedy®, Rockwell St, 
Chicago, IL, USA) around dental implants and a conventional metal tip for teeth will be used. 
- Test group: an erythritol based air-polishing powder (Air-Flow, EMS, Nyon, CH) during 5 seconds 
on each site (Schwarz et al., 2015).  
In those cases where implant-supported restorations do not facilitate oral hygiene access, the modification of 
the implant prosthesis in order to facilitate oral hygiene access will be performed using the protocol 
described in de Tapia et al., 2019.   
VAS 
After finishing the supragingival debridement around teeth, another calibrated examiner (T.R.A) will give the 
patients graded pain intensity on a visual analogue scale (VAS) (0 = no pain and 10 = extreme, unbearable 
pain), and then perform supragingival debridement around the dental implants and give VAS again.  Patients 
will be instructed to point at the VAS. 
Follow-up visits 
Patients enrolled in the study will be called for supportive periodontal therapy considering their SPT program 
and supragingival debridement will be performed accordingly to their group (control or test). All clinical 
variables will be re-examined by the same blinded examiner (C.V.) after the first SPT visit, at 1 year and 2 

 
SPECIFIC COMMISSION OF THE DOCTORAND 
 
years of follow-up. Additionally, a periapical radiograph of all implants involved in the study will be taken at 1 
year and 2 years of follow-up. Individual compliance will be registered as well in the CRF. 
Patients will be further motivated with respect to oral hygiene habits during the entire period of the study.  
2.5 Clinical and VAS examination 
A guidebook will be prepared to standardize procedures throughout the protocol, step by step, for all 
questionnaires and evidence collection. The data will be transferred to a computerized database. 
The study variables will be recorded in a case report form (CRF) specially designed for the study. Each study 
patient will be assigned a numerical code comprising a 3-digit patient code (assigned correlatively as they 
are included in the study). Only the study investigator will be able to identify the patient by their code.  
Anthropometric and socio-demographic data  
An initial questionnaire will be conducted to obtain information regarding age, race, gender, medical history, 
medication, and health behavior (smoking habits). Smoking behavior will be specified as 3 categories: never 
smoker, former smoker, or current smoker (light smokers: < 10 cigarettes/day). Patients will be asked about 
their tobacco smoke exposure in terms of consumption (i.e. the number of cigarettes consumed per day); 
duration (i.e. the number of years of smoking); and lifetime exposure (i.e. the accumulated exposure as 
formed by the product of consumption and duration: cigarette-years). In case of former smokers, patients will 
be asked about the smoke-free time following cessation.  
Clinical Parameters 
The following clinical parameters will be evaluated by the same examiner (T.R.A) using a manual periodontal 
probe PCP-UNC 15 (HuFriedy, Rockwell St, Chicago, IL):  
1. Full mouth plaque index (FMPI) will be assessed dichotomously at four sites per tooth (mesial, 
buccal, distal and lingual). Presence or absence will be recorded after staining with an 
erythrosine disclosing dye (Plac-Control®, Dentaid SL, Cerdanyola, Spain). Presence of plaque 
will be scored if an area of clearly stained material is present along the gingival margin and if this 
material can be removed with the side of the probe. The percentage of surfaces with plaque out 
of the total number of examined tooth surfaces will be calculated (O'Leary et al., 1972).  
2. Full mouth bleeding index (FMBI) will be assessed dichotomously as presence or absence of 
bleeding after 30 seconds of gently probing. The proportion of bleeding surfaces out of the total 
number of examined surfaces will be calculated (Ainamo and Bay, 1975).  
3. Full mouth PPD measured at six aspects around tooth.  
4. Gingival Recession (GR) will be recorded at six aspects per implant: mb, b, db, ml, l and dl. 
5. mPI (Mombelli et al., 1987) will be measured at six aspects around implants:  

 
SPECIFIC COMMISSION OF THE DOCTORAND 
 
Score 0 - no detection of plaque. 
Score 1 - plaque only recognized by running a probe across the smooth marginal surface of 
the implant. 
Score 2 - plaque can be seen by the naked eye. 
Score 3 - abundance of soft matter.  
6. mBI (Mombelli et al., 1987) will be assessed 30 seconds after 0.15 N force probing.  
Score 0 - no bleeding. 
Score 1 - isolated bleeding spots visible. 
Score 2 - blood forms a confluent red line on margin.  
Score 3 - heavy or profuse bleeding. This variable will be dichotomized in presence/absence 
of bleeding and will serve as the main variable.  
7.  SOP evaluated after assessing dichotomously the presence of suppuration within 30 seconds 
after gentle probing.  
8. Implant PPD, measured from the mucosal margin to the bottom of the probable pocket, 
determined at six aspects per implant: mb, b, db, ml, l and dl with a resin splint.  
9. MR at the implant will be recorded at six aspects per implant: mb, b, db, ml, l and dl.  
Outcomes of the study 
 
Main outcome; 
- 
Patient Pain/Discomfort (VAS) reported after decontamination during SPT. 
Secondary outcome;  
- 
Changes in the following clinical variables: FMPI, FMBI, PPD, GR, mPI, mBI, SOP, Implants PPD 
and MR after decontamination during SPT. 
- 
Compliance to SPT reported after decontamination during SPT. 
Intra-examiner reproducibility 
Reproducibility of clinical examinations will be conducted by the examiner (T.R.A), evaluating the Implant 
PPD and mBI in 5 patients, not involved in the study, on two separate occasions, 1 week apart. The intra-
class correlation coefficient and the kappa index will be calculated. Calibration will be accepted when 

 
SPECIFIC COMMISSION OF THE DOCTORAND 
 
measurements at baseline and at one-week evaluation will be within a difference of 0.5 mm >90% of the 
time. 
Withdrawal of consent 
The Patient Information Sheet will clearly state that the patient can withdraw from the study at any time 
without prejudice or explanation. Such withdrawal will be documented in the medical record file. Losses to 
follow-up are taken into account in the sample size calculations (12%).  
Statistical analysis 
Descriptive analysis 
Descriptive statistical methods (percentage and numbers on total) will be used to analyze the evaluated 
parameter 
Inferential analysis 
Data will be calculated at patient level and implant/tooth level. VAS score will be considered as the main 
outcome (quantitative).  
If the distribution is normal, the following tests will be used: 
- Binary categorical variables: T-Student / Fisher’s exact test; 
- Categorical variables with > 2 categories: ANOVA; 
- Quantitative variables: Simple linear regression / Pearson correlation coefficient. 
If it doesn’t follow normality: 
- Binary categorical variables: U of Mann-Whitney; 
- Categorical variables> 2 categories: H of Kruskal-Wallis; 
- Quantitative variables: Spearman's correlation coefficient. 

 
 Página 11 de 15 
 
 
Relevant Bibliography 
 
- 
Amerio, E. , Mainas, G. , Petrova, D. , Giner Tarrida, L. , Nart, J. and Monje, A. (2019), Compliance 
with Supportive Periodontal/Peri‐Implant Therapy: A Systematic Review. J Clin Periodontol. 
Accepted Author Manuscript. doi:10.1111/jcpe.13204  
- 
Axelsson P, Lindhe J. The significance of maintenance care in the treatment of periodontal 
disease. J Clin Periodontol. 1981;8:281‐ 294.  
- 
Becker, W., Becker, B. E. & Berg, L. E. (1984a) Periodontal treatment without maintenance. A 
retrospective study in 44 patients. J Periodontol 55, 505-509. doi:10.1902/jop.1984.55.9.505. 
- 
Becker, W., Berg, L. & Becker, B. E. (1984b) The long term evaluation of periodontal treatment and 
maintenance in 95 patients. The International journal of periodontics & restorative dentistry 4,54-
71.  
- 
Derks, J. & Tomasi, C. (2015) Peri-implant health and disease. A systematic review of current 
epidemiology. J Clin Periodontol 42 Suppl 16, S158-171 doi:10.1111/jcpe.12334.  
- 
Derks J, Schaller D, Håkansson J, Wennström JL, Tomasi C, Berglundh T. Peri-implantitis - Onset 
and pattern of progression. J Clin Periodontol 2016;43(4):383-388.  
- 
Fardal, O. (2006) Interviews and assessments of returning non-compliant periodontal maintenance 
patients. J Clin Periodontol 33, 216-220. doi:10.1111/j.1600-051X.2006.00891.x.  
- 
Fenol, A. & Mathew, S. (2010) Compliance to recall visits by patients with periodontitis - Is the 
practitioner 
responsible? 
Journal 
of 
Indian 
Society 
of 
Periodontology 
14, 
106-108. 
doi:10.4103/0972-124X.70829.  
- 
Magnusson, I., Lindhe, J., Yoneyama, T. & Liljenberg, B. (1984) Recolonization of a subgingival 
microbiota following scaling in deep pockets. J Clin Periodontol 11, 193-207.  
- 
Martins MD, Jiao Y, Larsson L, et al. Epigenetic modifications of histones in periodontal disease. J 
Dent Res 2016;95:215-222. 
- 
Mendoza, A. R., Newcomb, G. M. & Nixon, K. C. (1991) Compliance with supportive periodontal 
therapy. J Periodontol 62, 731-736. doi:10.1902/jop.1991.62.12.731. 
- 
Moene R, Décaillet F, Andersen E, Mombelli A. Subgingival plaque removal using a new air-
polishing device. J Periodontol 2010: 81: 79–88.  
- 
Morrison, E. C., Lang, N. P., Loe, H. & Ramfjord, S. P. (1979) Effects of repeated scaling and root 
planning and/or controlled oral hygiene on the periodontal attachment level and pocketdepth in 
beagle dogs. I. Clinical findings. J Periodontal Res 14, 428-437.  

 
 
 
12 
- 
Mousques, T., Listgarten, M. A. & Phillips, R. W. (1980) Effect of scaling and root planing on the 
composition of the human subgingival microbial flora. J Periodontal Res 15, 144-151. 
- 
Muller N, Moene R, Cancela JA, Mombelli A. Subgingival air-polishing with erythritol during 
periodontal maintenance: randomized clinical trial of twelve months. J Clin Periodontol 2014: 41: 
883–889.  
- 
Nart J, Pons R, Valles C, Esmatges A, Sanz-Martín I, Monje A. Non-surgical therapeutic outcomes 
of peri-implantitis: 12-month results. Clin Oral Invest 2019.  
- 
Perrell-Jones, C. & Ireland, R. S. (2016) What factors influence patient compliance with supportive 
periodontal therapy in a general practice setting? British Dental Journal 221, 701-704. 
doi:10.1038/sj.bdj.2016.904.  
- 
Petersilka GJ, Steinmann D, H€aberlein I, Heinecke A, Flemmig TF. Subgingival plaque removal in 
buccal and lingual sites using a novel low abrasive air-polishing powder. J Clin Periodontol 2003: 
30: 328–333.  
- 
Petersilka GJ, Tunkel J, Barakos K, Heinecke A, H€aberlein I, Flemmig TF. Subgingival plaque 
removal at interdental sites using a low-abrasive air polishing powder. J Periodontol 2003: 74: 307–
311.  
- 
Ramseier, C. A., Kobrehel, S., Staub, P., Sculean, A., Lang, N. P. & Salvi, G. E. (2014) 
Compliance of cigarette smokers with scheduled visits for supportive periodontal therapy. J Clin 
Periodontol 41, 473-480. doi:10.1111/jcpe.12242.  
- 
Ratka-Kruger P, Mahl D, Deimling D, Monting JS, JachmannI, Al-Machot E, Sculean A, Berakdar 
M, Jervøe-Storm P-M, Braun A. Er:YAG laser treatment in supportive periodontal therapy. J Clin 
Periodontol 2012: 39: 483–489.  
- 
Shah, R., Thomas, R., Bhandari, S. & Mehta, D. S. (2017) Influence of various factors on patient 
compliance after periodontal therapy: A pilot study. Journal of Indian Society of Periodontology 21, 
50-54. doi:10.4103/jisp.jisp_254_16. 
- 
Si, W., Wang, H., Li, Q., Zhao, X. & Pan, Y. (2016) Effects of different factors influencing clinical 
compliance of Chinese patients with chronic periodontitis. Quintessence international (Berlin, 
Germany : 1985) 47, 643-652. doi:10.3290/j.qi.a35701. 
- 
Stein JM, Hammacher C, Michael SS (2018) Combination of ultrasonic decontamination, soft 
tissue curettage, and submucosal air polishing with povidone-iodine application for non-surgical 
therapy of peri-implantitis: 12 month clinical outcomes. J Periodontol 89: 139– 147  
- 
Wennstrom JL, Dahl_en G, Ramberg P. Subgingival debridement of periodontal pockets by air 
polishing in comparison with ultrasonic instrumentation during maintenance therapy. J Clin 
Periodontol 2011: 38: 820–827.  

 
 
 
13 
- 
Wilson, T. G. J., Glover, M. E., Schoen, J., Baus, C. & Jacobs, T. (1984) Compliance with 
maintenance therapy in a private periodontal practice. J Periodontol 55, 468-473. 
doi:10.1902/jop.1984.55.8.468.  
 
 
a. Cronograma del estudio (se debe considerar claramente las etapas de 
reclutamiento y seguimiento. Por su sencillez, se sugiere el uso de un 
diagrama de Gantt). 
 
 
 
 
 
 
 
 
 
 
 

 
 
 
14 
b. Diagrama de flujo que cuente con una línea de tiempo de los sujetos del 
estudio (acorde a los grupos estudiados) 
 
 
 
 
 

 
 
 
15 
 
 
 
Investigador/a Principal 
Fdo: Dr./Dra. 
•
To evaluate pain/discomfort during SPT around dental implants and teeth. 
•
To evaluate patient reported outcomes and clinical variables by decontamination during 
SPT with erythritol based air polishing powder (Air Flow Master, Air-Flow Plus, EMS, 
Nyon, Switzerland), at the first SPT and after 2 years. 
•
To evaluate the effect of erythritol based air polishing powder (Air Flow Master, Air-Flow 
Plus, EMS, Nyon, Switzerland) during SPT on the compliance rates after 1 and 2 years 
of follow-up.