Can air polishing cause subcutaneous emphysema or gingival damage?

Yes, air polishing carries risks for both subcutaneous emphysema and gingival damage, though the magnitude of risk varies by powder type.

Regarding subcutaneous emphysema (SE), air-driven handpieces are implicated in 51% of SE cases identified in a systematic review of 135 cases, and air syringes account for a further 9% ^[1]. While that review focuses on handpieces used during extractions, the underlying mechanism - pressurised air forcing into soft tissue planes - is relevant to any air-driven device used intraorally. Dental extractions in the posterior mandible carried the highest risk, and use of air-driven handpieces in those sites is specifically cautioned against ^[1].

Regarding gingival damage, the choice of powder matters significantly. Studies assessing soft tissue effects found that sodium bicarbonate powder causes greater harm to gingival tissue compared to glycine powder, and that glycine powder air polishing produces less soft tissue modification even compared to instrumentation with curettes ^[2]. Subgingival use of air-polishing devices with appropriate powders such as glycine has the potential to enhance patient comfort and mitigate damage to periodontal structures, supporting better tissue healing ^[3]. Overall, air polishing devices used in supportive periodontal therapy appear capable of removing biofilm efficiently without causing significant damage to periodontal soft tissues when the correct powder is selected ^[4].

In summary, SE is a recognised, though uncommon, risk associated with pressurised air intraorally ^[1], and gingival harm is largely powder-dependent, with glycine being better tolerated than sodium bicarbonate or calcium carbonate formulations ^[2][3].