# Efficacy of Instruments for Professional Oral Hygiene on Dental Implants: A Systematic Review
## 4 Discussion  
Curette, scalers and air polishing are common and effective strategies applied for professional oral hygiene in order to prevent peri-implant inflammation [27]. However, as supported by the studies included in the present review, instrumentation of implant and prosthodonic components with curettes for biofilm management might present some disadvantages and air polishing devices with low-abrasive powders are increasingly gaining acceptance. Fifteen out of 19 studies included investigated the efficacy of air-polishing devices showing favorable outcomes. In particular, professional oral hygiene using glycine powder air polishing has been demonstrated to be clinically effective for plaque removal on dental implants but also highly accepted by patients [6; 7]. It may be considered a viable method to remove plaque from dental implants because glycine is less aggressive than powders like sodium bicarbonate powder, that might cause more alterations to the implant surface and is more aggressive on soft tissue, depending on its larger granulometry [7; 13]. Glycine powder air polishing resulted in a significantly higher reduction in plaque around implants [7; 11], and effective in reducing peri-implant inflammation [25]. In vitro studies showed that also tagatose powders could have cleaning potential with great results [21]. In addition, the combination of glycine and taurolidine could enhance effectiveness of plaque-removing procedures [31]. A study by [PERSON] et al. combined glycine with tricalcium phosphate: they seemed to be more effective than the control groups for biofilm removal on titanium and zirconium implant surfaces [30]. The application of air polishing with erythritol powder is another more recent alternative. It has the potential to efficiently remove biofilm from rough implant surfaces [29] and yielded clinical outcomes comparable with titanium curettes, stainless steel ultrasonic tip, or rubber cup polishing [23; 24]. Moving to other oral hygiene instruments, [PERSON] et al. demonstrated that dental lasers, ultrasonic scalers and titanium curette didn't remove all residual cement from any of the 3 implant surfaces in their in vitro study [19]. PEEK tip or stainless steel (SS) tip ultrasonic scaling are more effective in eliminating visible contamination according to other authors [20; 22; 28]. Further studies are needed about the application of dental laser such as Er: YAG laser in decontaminating Ti implant surfaces [26]. \begin{table}
\begin{tabular}{c c c c} \hline \hline  & & \multicolumn{2}{c}{**Level of Evidence Oxford**} \\ \hline \multirow{2}{*}{**Study**} & \multirow{2}{*}{**Reference Number**} & \multicolumn{2}{c}{**Degree of**} \\  & & **Recommendation** & **Level of Evidence** \\ \hline [PERSON] et al., 2021 & 19 & B & 2C \\ \hline [PERSON] et al., 2021 & 20 & B & 2C \\ \hline [PERSON] et al., 2021 & 21 & B & 2C \\ \hline [PERSON] et al., 2020 & 13 & B & 2C \\ \hline [PERSON] et al., 2019 & 22 & B & 2C \\ \hline [PERSON] et al., 2017 & 26 & B & 2C \\ \hline [PERSON] et al., 2017 & 28 & B & 2C \\ \hline [PERSON] et al., 2017 & 29 & B & 2C \\ \hline [PERSON] et al., 2015 & 31 & B & 2C \\ \hline [PERSON] et al., 2014 & 32 & B & 2C \\ \hline \hline \end{tabular} GRADE system: Moderate.  
\end{table} 
Table 4: Evaluation and classification of included in vitro studies through the Grading of Recommendations Assessment, Development and Evaluation (GRADE), graduation for the evidence level as per the Oxford Center for Evidence-Based Medicine. In order to help to lead to better biofilm removal and to reinforce proper oral and correct self-care regimens, [PERSON] et al. compared plaque index after 12 months of sonic vs. manual toothbrushing: the results showed no significant difference.