Irrigate for Oral Health - Dimensions of Dental Hygiene (2024)

The mouth is an ideal environment for the formation andgrowth of microbial biofilm.Plaque, a type of bacterial biofilm, ismade up of multiple bacterial species that dwell on the surfacesof the teeth and soft tissues, and it contributes to a number of dental diseases. In orderto maintain oral health, plaque biofilm must be removed.¹ The two most recommendedmeans of removing plaque are toothbrushing and flossing. Toothbrushing is practicedby most people, but few use floss.^2,3 In order to increase the rate of interdental cleaningamong patients, effective and user–friendly techniques are strongly needed. This articlewill focus on the use of oral irrigation toimprove interdental cleaning.

The oral irrigator is a modality that caneffectively remove plaque and is simple touse. Since its introduction in the 1960s, useof the oral irrigator has become increasinglywidespread because of its proven efficacy.A number of studies have shown that oralirrigation is effective in reducing gingivitis^1–12and bleeding,^1–10 and is often recommendedfor patients with diabetes⁹ and dentalimplants,¹¹ as well as those who wear orthodonticappliances.^3,10,13 Oral irrigation iseffective because of its ability to penetratedeeper into periodontal pockets, disruptingbacteria in depths of up to 6 mm.^14,15

SCIENTIFIC EVIDENCE

The oral irrigator was first introduced in1962. The product’s efficacy, safety, and abilityto address a variety of patient needs aresupported in numerous clinical studies.^1–12Patients in periodontal maintenance,^6,7 thosewith orthodontic devices,^3,10,13 patients withdiabetes9 and dental implants,¹¹ and thosewho are non–compliant with flossing mayparticularly benefit from using an oral irrigator.^2,8,10 Daily oral irrigation reduces plaquebiofilm,^1,2,8–10 calculus,¹² gingivitis,^1–12 bleeding,^1–10 probing depth,^1,4,6,7 periodontalpathogens,^5,14,15 and a host of inflammatorymediators.^1,9

In an ex vivo (research conducted on tissuein an artificial environment) study thatused scanning electron microscopy, Gorur etal showed that the hydraulic forces generatedby an oral irrigator’s precise pulsation(1,200 per minute) and pressure (minimum60 psi) removed 99.9% of plaque biofilmfrom treated tooth surfaces both above andbelow the cementoenamel junction in 3 seconds.¹⁶ Cutler et al found that oral irrigationreduced the traditional markers of periodontaldisease (plaque, bleeding, and gingivitis)within 2 weeks. In addition, oral irrigationhad a regulating effect on the production ofinflammatory cytokines, which when overproduced,cause disease.¹ Measures taken8 hours post–irrigation (to prevent any dilutioneffect) found irrigation reduced the proinflammatorymediators interleukin–1 beta(IL–1ß), increased the anti–inflammatorycytokine interleukin–10 (IL–10), and maintainedthe bacteriocidal agent interferongamma(IFN–?), thus demonstrating theability of oral irrigation to inhibit diseaseactivity (Figure 1 and Figure 2).¹

These findings support the conclusions madeby Chavez et al who noted that improvementsin gingival health from irrigation mayinvolve specific host–microbiota alterations inthe subgingival environment.⁵

BENEFITS FOR PEOPLE WITH PERIODONTAL DISEASES

Periodontal treatments aim to remove subgingivalplaque so that healthy oral floramay be restored. Standard procedures forperiodontal therapy include root planing,scaling, and local or systemic antibiotic regimensthat, combined with meticulous selfcare,are intended to eradicate thesemicrobes. The benefits of flossing may belimited for peop

le with periodontal diseasedue to bone loss and other architecturalchallenges. Because of its ability to penetratedeep into a pocket17,18 and disrupt bacteriaup to 6 mm,^14,15 the oral irrigator maybe beneficial for people with periodontaldiseases. A study by Eakle et al included ninepatients who needed to have teeth extractedbecause of advanced periodontal disease.

The investigators discovered that pulsatingoral irrigation delivered an aqueous solutionapproximately half the depth of thepocket.¹⁷ Specifically, with the tip placed ata 90° angle, a 67% penetration of deeppockets, a 44% penetration of moderatepockets, and a 71% penetration of shallowpockets were achieved.¹⁷ Cobb et al andDrisko et al examined bacteria disruptionand both groups found that oral irrigationdisrupted bacteria up to 6 mm.^14,15 TheAmerican Academy of Periodontology hasfurther noted that one of the greatestadvantages of oral irrigation is that it helpspatients maintain the bacterial reductionattained during root planing.¹⁹

Previous research found that patients inperiodontal maintenance can significantlyreduce bleeding and inflammation with thedaily use of an irrigator.^1–12 Newman et alstudied periodontal maintenance patientswith 5 mm pockets and bleeding. Theyfound that daily irrigation reduced gingivitisby 18%, in addition to improving bleedingon probing and probing depth.⁷ Flemmiget al also studied periodontal maintenancepatients and reported that daily irrigationreduced bleeding by half throughout the6–month study period.⁶

Antimicrobial agents are routinely usedwith periodontal maintenance patients, andadding these agents to the oral irrigatormay enhance efficacy. One study comparedthe daily use of 0.06% chlorhexidine (CHX)irrigation, water irrigation, rinsing with0.12% CHX mouthrinse, and toothbrushingover 6 months. Results showed that theCHX irrigation was more effective thanwater irrigation, but daily irrigation withwater was more effective than daily rinsingwith a CHX mouthrinse in the reduction ofbleeding.⁴ This is most likely due to the factthat oral irrigation penetrates deeper intopockets than mouthrinsing.¹⁸

BENEFITS FOR PATIENTS WITH ORTHODONTIC APPLIANCES

Patients undergoing orthodontic treatmentface many challenges with plaque removal.Orthodontic devices serve as traps for bits offood and debris, potentially increasingmicrobial population on teeth surfaces andappliances alike. After orthodontic applianceshave been placed, increased numbersof Lactobacilli and Streptococci have alsobeen observed.¹¹

Patients with orthodontic appliancesmay avoid flossing because they find itdifficult. Sharma et al studied a group of106 patients with fixed orthodontic appliances.They found that those who used anoral irrigator with a specialized orthodontictip after manual toothbrushing were able toremove three times as much plaque as thosewho used a floss threader, and five times asmuch plaque as those who used a manualbrush only. The irrigation group reducedbleeding by 84.5% from baseline, 26% betterthan flossing alone.¹⁰

Hurst and Madonia completed a study on60 full–banded orthodontic patients age 10 to17 to determine the efficacy of oral irrigationin preventing the increase of microbial flora.¹³After 21 days, the researchers discovered thatdaily toothbrushing and daily oral irrigationprovided a 65% reduction in Lactobacilli andan 86% decrease in total aerobic bacteriasubgingivally. These reductions were maintainedfor another 63 days of the testingperiod. In contrast, those who brushed dailyand used an antimicrobial mouthrinse dailyshowed a 10% decrease in Lactobacilli and a25% decrease in total aerobic bacteria in thesubgingival area.

BENEFITS FOR PEOPLE WITH DIABETES

People with diabetes are at increased risk ofperiodontal diseases, especially those withoutproper glucose control. Poorly controlledor uncontrolled diabetes generallyresults in a greater incidence and severity ofperiodontal diseases.⁹ Even people who successfullymanage their diabetes may experiencemore bleeding and inflammation inresponse to the same amount of plaquebiofilm than people without diabetes.⁹Oral irrigation is one of the few modalitiesthat has been tested on people with diabetesin comparison to toothbrushing and flossing.Al–Mubarak et al conducted a 3–month studyon 56 subjects who had type 1 or type 2 diabetesfor at least 1 year and were on diabetesmedications for at least 6 months. Subjectsunderwent root planing and ultrasonic scalingfollowed by either routine oral hygiene self-careor manual brushing and twice–dailywater irrigation. The results showed that theoral irrigation group experienced a 44% betterreduction in inflammation and a 41% betterreduction in gingivitis than the oralhygiene only group. Those using oral irrigationalso had significant reductions in theplaque index. The investigators evaluated theserum levels of pro–inflammatory cytokinesand found that irrigation reduced the levels ofthese agents better than daily brushing andflossing.⁹

BENEFITS FOR PEOPLE WITH DENTAL IMPLANTS

Dental implants are successful only if the tissuessurrounding them remain healthy.¹¹The risk of implant failure is increased whenplaque biofilm accumulates and causesinflammation of soft tissues surrounding theimplants.¹¹ In order to protect this investment,meticulous self–care is required. Flosscan be difficult to maneuver aroundimplant prostheses. A study conducted byFelo et al found that people who used anoral irrigator with a specialized soft rubbertip at low pressure to deliver 0.06% CHXhad more significant reductions in plaque,gingivitis, and stain than those who rinsedwith 0.12% CHX. Notably, irrigation was87% more effective than rinsing in thereduction of bleeding. The presence of implants can negatively affect CHX’s substantivity,¹¹ but this study showed that irrigationmay overcome this barrier bydelivering the agent to greater subgingivaldepths, allowing for substantivity to thepocket epithelium.¹¹

CONCLUSION

In order to improve the efficacy of patients’self–care regimens, dental hygienists shouldeffectively educate patients on the variousproducts and methods available. Toothbrushing,followed by flossing, effectivelyreduces plaque when rigorously practiced,^4,5,7 however, many patients find flossingdifficult and it often can’t penetrateperiodontal pockets where plaque buildupbegins. Oral irrigation is an alternative toflossing that may be used as an adjunct totoothbrushing. Oral irrigation helps reducegingivitis and periodontal disease, as wellas offering particular health benefits topatients who have diabetes and dentalimplants and those who wear orthodonticappliances.⁹

DR. TIM EVANS/PHOTO RESEARCHERS INC

REFERENCES

1. Cutler CW, Stanford TW, Abraham C, CederbergRA, Boardman TJ, Ross C. Clinical benefits of oral irrigation for periodontitis are related to reduction of pro–inflammatory cytokine levelsand plaque. J Clin Periodontol. 2000;27:134—143.
2. Barnes CM, Russell CM, Reinhardt RA, PayneJB, Lyle DM. Comparison of irrigation to floss as an adjunct to tooth brushing: effect on bleeding, gingivitis, and supragingival plaque. J Clin Dent.2005;16:71—77.
3. Burch JG, Lanese R, Ngan P. A two–month studyof the effects of oral irrigation and automatic toothbrush use in an adult orthodonticpopulation with fixed appliances. Am J OrthodDentofacial Orthop. 1994;106:121—126.
4. Flemmig TF, Newman MG, Doherty FM,Grossman E, Meckel AH, Bakdash MB. Supragingival irrigation with 0.06% chlorhexidine in naturally occurring gingivitis I. 6 month clinical observations. J Periodontol. 1990;61:112—117.
5. Chaves ES, Kornman KS, Manwell A, Jones AA,Newbold DA, Wood RC. Mechanism of irrigation effects on gingivitis. J Periodontol.1994;65:1016—1021.
6. Flemmig TF, Epp B, Funkenhauser Z, et al.Adjunctive supragingival irrigation with acetylsalicylic acid in periodontal supportivetherapy. J Clin Periodontol. 1995;22:427—433.
7. Newman MG, Cattabriga M, Etienne D, et al.Effectiveness of adjunctive irrigation in early periodontitis: multi–center evaluation. JPeriodontol. 1994; 65:224—229.
8. Rosema NA, Hennequin–Hoenderdos NL,Berchier CE, Slot DE, Lyle DM, van der Weijden GA. The effect of different interdental cleaning devices on gingival bleeding. J Int AcadPeriodontol. 2011;13:2—10.
9. Al–Mubarak S, Ciancio S, Aljada A, et al.Comparative evaluation of adjunctive oral irrigation in diabetics. J Clin Periodontol.2002;29:295—300.
10. Sharma NC, Lyle M, Qaquish JG, Galustians J,Schuller R. The effect of a dental water jet with orthodontic tip on plaque and bleeding in adolescent patients with fixed orthodontic appliances. Am J Orthod Dentofacial Orthop.2008;133:565—571.
11. Felo A, Shibly O, Ciancio SG, Lauciello FR, HoA. Effects of subgingival chlorhexidine irrigation on perio–implant maintenance. Am J Dent. 1997;10:107—110.
12. Lobene RR. The effect of a pulsed water pressure–cleansing device on oral health. JPeriodontol. 1968;40:667—670.
13. Hurst JE, Madonia JV. The effect of an oral irrigating device on the oral hygiene of orthodontic patients. J Am Dent Assoc.1970;81:678—683.
14. Cobb CM, Rodgers RL, Killoy WJ.Ultrastructural examination of human periodontal pockets following the use of an oral irrigation device in vivo. J Periodontol.1988;59:155—163.
15. Drisko CL, White CL, Killoy WJ, Mayberry WE.Comparison of dark–field microscopy and a flagella stain for monitoring the effect of a water pik on bacterial motility. J Periodontol.1987;58:381—386.
16. Gorur A, Lyle DM, Schaudinn C, Costerton JW.Biofilm removal with a dental water jet.Compend Contin Dent Ed. 2009;30(SpecIssue):1—6.
17. Eakle WS, Ford C, Boyd RL. Depth of penetration in periodontal pockets with oral irrigation. J Clin Periodontol. 1986;13:39–44.
18. Braun RE, Ciancio SG. Subgingival delivery byan oral irrigation device. J Periodontol. 1992;63:469—472.
19. Position Paper: The role of supra– and subgingival irrigation in the treatment of periodontal diseases. J Periodontol.2005;76:2015—2027.

From Dimensions of Dental Hygiene. November 2012; 10(11): 54–56, 59.