02 November 2026

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Comparison of treatment time and patient-reported outcomes between erythritol powder air-polishing and rubber cup polishing: a randomized crossover clinical trial.

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This peer-reviewed oral hygiene & prevention article summarizes clinical evidence from Odontology (2026). It focuses on findings that may help dental professionals evaluate treatment decisions, patient outcomes, or clinical protocols.

Abstract

Professional mechanical plaque removal (PMPR) is essential for the prevention of dental caries and periodontal diseases. Erythritol powder air polishing (EPAP) has recently gained attention as an alternative to conventional rubber cup polishing (RC); however, evidence regarding patient-reported outcomes (PROs), particularly using the cetylpyridinium chloride (CPC)-containing erythritol formulation available in Japan, remains limited. This randomized, single-center, two-period crossover clinical trial compared EPAP with RC in systemically healthy adults. Twenty-one participants received both interventions in a randomized sequence with a washout period of at least two weeks. The primary outcome was treatment time, while secondary outcomes included pain during treatment, taste, oral freshness, taste disturbance, discomfort, and overall treatment preference. Data were analyzed using linear mixed-effects models accounting for treatment, period, and sequence effects. Baseline plaque scores were comparable between interventions. EPAP required significantly less treatment time than RC, with adjusted mean treatment times of 438 s and 759 s, respectively, corresponding to a reduction of approximately 323 s (P < 0.001). No significant period or sequence effects were observed. No significant differences were detected between EPAP and RC for pain, taste, oral freshness, taste disturbance, discomfort, or overall treatment preference. Eleven participants preferred RC and ten preferred EPAP, with no significant difference in preference (P = 1.000). Within the limitations of this study, EPAP significantly improved the efficiency of supragingival plaque removal without compromising patient-reported outcomes or treatment acceptance. These findings support the use of the CPC-containing erythritol powder air-polishing system as an efficient alternative to conventional rubber cup polishing for professional supragingival biofilm management.

Key takeaway

Key takeaway: Because the evidence comes from a clinical trial design, the findings may be especially useful when comparing treatment approaches in daily practice.

Introduction from full text

Biofilms are naturally occurring accumulations of microorganisms, that are embedded in an extracellular polymeric matrix and adherent to biologic or non-biologic surfaces [ 1 ]. Microorganisms communicate via “quorum sensing”, they control virulence, motility, metabolism, production of antibiotics, exchange of genes, formation of biofilm [ 1 ]. Antimicrobials have no or limited efficacy against microorganisms in biofilms. They penetrate slowly or incompletely through the biofilm matrix [ 2 ]. Microorganisms respond to heterogeneous environment of biofilms by gene transfer leading to higher resistance and higher virulence; subpopulations consist of dormant and metabolically less active «persister» bacteria [ 2 ]. Consequently, mechanical removal of biofilms is still of major importance in any biofilm-associated disease.

One of the most prevalent biofilm-associated diseases is periodontitis, an inflammatory condition affecting the hard and soft tissue surrounding teeth. If left untreated, periodontitis leads to tooth loss. Nowadays, pathogenesis of periodontitis is thought as a dysbiosis of biofilm associated with deviated bacterial function [ 3 ] followed by an immuno-inflammatory host-mediated destruction of bone and connective tissues [ 4 ]. In this process Porphyromonas gingivalis , a gram-negative bacterium, was postulated being a key-stone pathogen [ 5 ]. A few other bacteria, e . g . Tannerella forsythia , Treponema denticola [ 6 ], and Aggregatibacter actinomycetemcomitans [ 7 ] may contribute. Moreover, bacteria within subgingival biofilms may serve as a link to systemic diseases, e.g. rheumatoid arthritis [ 8 ].

The primary goal in cause-related periodontitis treatment is to remove hard and soft bacterial deposits which should result in a smooth and biocompatible root surface to minimize bacterial adhesion and to facilitate fibroblast attachment. Since in vitro bacterial compounds (i.e. P . gingivalis lipopolysaccharide) stimulate expression of proinflammatory chemokine interleukin-8 in PDL fibroblasts [ 9 ] it can be anticipated that a minimized bacterial adhesion might prevent or reduce the inflammatory reaction of periodontal ligament (PDL) fibroblasts. Scaling and root planing (SRP), which includes the mechanical removal of biofilms, is an effective causative method for infection control in the treatment of periodontal disease [ 10 ]. A supportive maintenance program after initial therapy prevents the incidence of caries and further periodontal breakdown [ 11 ]. Based on the individual risk for disease progression, patients are seen for periodontal maintenance therapy at varying intervals ranging from three to 12 months [ 12 ]. Apart from repeated instruction and remotivation for the patients’ plaque control, the removal of subgingival bacterial deposits is one major therapeutical goal to maintain periodontal stability. Despite the introduction of machine driven sonic and ultrasonic scalers, the use of hand instruments (i.e. conventional Gracey curettes) is still widely spread in dental practice. Comparisons between hand instruments and sonic / ultrasonic scalers did not show a clear advantage for the machine driven instruments in terms of the clinical results [ 13 , 14 ]. On the other hand, the use of hand instruments may result in higher tooth hard-substance-loss [ 15 , 16 ]. Therefore, in order to prevent extensive tooth hard-substance-loss during periodontal maintenance, treatment modalities that combine both, a complete removal of the biofilm and a minimal tooth hard-substance-loss, should be preferred.

As a novel approach, air-polishing using low abrasive glycine powder was indicated to remove subgingival biofilm, and its abrasivity was demonstrated to be approximately 80% lower than that of the previously used bicarbonate air-polishing powder [ 17 ]. Clinical studies of patients in periodontal maintenance demonstrated comparable clinical results as when using hand instruments [ 18 , 19 , 20 ]. However, the patients’ acceptance was better and the treatment time was shorter [ 19 ]. Inconsistent microbiological results were reported, partially demonstrating a higher decrease of the total viable counts and of P . gingivalis [ 18 ], whereas in the study by Moëne et al. [ 19 ] bacterial counts were pronouncedly reduced in the group using hand instruments.

Apart from glycine, erythritol was recently introduced as a low-abrasive air-polishing powder [ 21 ]. Erythritol is a polyol and used in food industry as an artificial sweetener. Its physical properties were shown to be comparable to glycine [ 22 ]. Moreover, when used during supportive periodontal therapy, similar results in terms of clinical and microbiological outcome were demonstrated in comparison with hand instrumentation [ 22 ]. As of late, supplementation of the erythritol powder with chlorhexidine digluconate as an antimicrobial was available [ 23 ].

The lack of suitable in vitro models to evaluate traditional and newly developed treatment modalities for non-surgical treatment of periodontitis made us establish a multi-species biofilm pocket model to perform in vitro evaluation of repeated mechanical removal of biofilms. Thus, the aims of the present in vitro-study were: a) to establish a biofilm model which mimics the subgingival environment of a periodontal pocket and b) to use for the first time the new model to evaluate the most frequently used methods for biofilm removal ((i.e. hand instrumentation using curettes (CUR) and ultrasonication (US)) with recently developed ones (air-polishing using erythritol only (EAP) or supplemented with chlorhexidine (EAP-CHX)) in terms of biofilm removal and reformation, caused surface alterations, tooth hard-substance-loss, and the attachment of periodontal ligament fibroblasts.

Peer-reviewed source

Satoshi Sekino, Etsuko Murakashi, Tomohisa Ogawa, Yukihiro Numabe

Odontology. 2026

DOI: 10.1111/idh.12537

PMID: 42830345

PubMed: https://pubmed.ncbi.nlm.nih.gov/42830345/

Image: William Warby (Unsplash)