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ORAL IRRIGATION

SPECIAL REPORT

This report was written by Tricia O'Hehir, Editor of Perio Reports which is published six times a year for the benefit of the dental hygiene community.

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Irrigation is back in the research headlines. If you aren't recommending oral irrigation to your patients, or using it yourself, it's time to start. Oral irrigation was occasionally suggested as an alternative for those who didn't floss, but now it should be considered a regular part of oral hygiene for everyone. The WaterPik® was first introduced in 1966 as a plaque and debris removal device. At that time, researchers were unable to show plaque removal capabilities. Since then it has taken a back seat to brushing and flossing and not really been accepted as a valuable part of plaque control. Contrary to the attitude taken by the profession, patients who used the WaterPik found it very effective and continued to use it, despite our lectures on the need for flossing. To our surprise, these patients always presented with better than average oral health. The recent resurgence of irrigation research has focused on plaque alteration rather than removal. Alterations of subgingival plaque have been measured both qualitatively and quantitatively as deep as 6 millimeters. Changes in the immune response are also evident, suggesting a mode of action other than plaque removal. When plaque is measured using disclosing solution, oral irrigation does not demonstrate a measurable reduction. Despite this lack of plaque removal, home oral irrigation is effective in controlling gingival inflammation, with reductions in gingivitis scores, bleeding scores, pocket depths and proinflammatory substances. Without removing plaque, oral irrigation seems to effect bacteria within the plaque, the thickness of the plaque and the immune response. In a recent study measuring changes in 4-7 millimeter interproximal areas that bled, reductions in bleeding upon probing, pocket depths and inflammatory cytokines, interleuken 1 (IL-1) and prostaglandin (PG-E2) were observed after just 14 days of using the WaterPik, in addition to regular oral hygiene.

RINSING VS ORAL IRRIGATION

Chlorhexidine rinse is the most effective anti-plaque agent now available. Rinsing however, does not reach subgingival or interproximal areas. In fact, it only goes about 1 millimeter below the margin on the surfaces it does reach. In more than one study, oral irrigation with water was more effective in controlling gingivitis than rinsing with chlorhexidine. Adding chlorhexidine to the WaterPik® improved results slightly over water, but isn't necessary to achieve better oral health. Water should be the first choice, saving chlorhexidine for patients with non responding areas. A three-month test in maintenance patients showed no difference between daily irrigation with water and daily irrigation with chlorhexidine. This deserves repeating. Daily oral irrigation with water is more effective in controlling gingivitis than rinsing with chlorhexidine. Although water irrigation shows no difference in stainable plaque, the toxicity and thickness of the plaque is altered by the irrigation, yet not detected by disclosing solutions. The original WaterPik research focused on water irrigation. Some of the various solutions evaluated currently include: antibiotics, chlorhexidine, fluoride, Listerine, oxygenating agents, quaternary ammonium compounds, salt water, Viadent, water and zinc chloride. Despite the work of hygienists to educate and instruct the public on the importance of effective plaque control, only 30% of patients perform adequate home care with brushes and some sort of interproximal aid. Brushes reach less than one millimeter below the gingival margin. Interproximal plaque control is essential to periodontal health, but only 35% of patients occasionally use dental floss, and only 2-15% floss daily. For these reasons, oral irrigation provides an alternative for control of gingival inflammation.

SAFETY

Years ago, it was thought that oral irrigation forced bacteria and toxins into the tissues, but that was never substantiated by research. A few isolated case reports created a generalized scare. In contrast, the safety of irrigation is shown repeatedly in studies measuring bacteremia potential. Systemically healthy patients are not subject to bacteremia of any greater degree than that measured following dental procedures, brushing, flossing, or chewing. Patients requiring antibiotic premedication, however, should be periodontally healthy before using home irrigation or any other interdental tools. Although the potential for physical injury exists, such documentation is not available. Isolated cases of tissue trauma resulting from improper use of home irrigators have been presented, as is the case with misuse of any homecare device. More than 20 years ago, concern was raised as to the potential for bacteremia following home irrigation. Subsequent studies have been unable to confirm those findings. Instead, researchers have demonstrated similar levels of bacteria within the tissue between test and control groups. The focus has now changed from irrigation as a cause of bacteremia to its potential in preventing such bacteremias. Despite the lack of evidence demonstrating any higher risk of bacteremia following home irrigation compared to other plaque control measures, introducing any mechanical plaque control procedure for untreated periodontal disease raises special concern for patients with systemic risk factors.

POCKET PENETRATION

Penetration of irrigation fluids is another area of controversy. When dyes and disclosing solutions are used to measure depth of penetration, the teeth must be extracted to do the measurements. Depending on the study, various levels of dye penetration are reported, from 50% to 100% of the depth of the pocket. Jet irrigation will reach 3 millimeters or half the depth of the pocket. The Pik Pocket™ tip on a jet irrigator will allow penetration to 80% of the probing depth, or 7 to 8 mm. Canulated needle tips on jet irrigators are only slightly more effective than the Pik Pocket. In-office use of syringes shows dye reaching the base of the pocket. Pocket architecture and the presence of calculus may explain the differences reported in studies measuring depth of penetration. Results must also be considered in light of the fact that measurements are made on the extracted teeth precluding any clinical evaluation. Measurements are made from the gingival margin to the connective tissue attachment, rather than to the epithelial attachment. Scores are then at least one millimeter more than the actual pocket depth. Results therefore underestimate actual penetration of the irrigation fluid. Supragingival irrigation controls bacterial levels before they can influence subgingival areas, since reduction of supragingival plaque will impede development of subgingival accumulations. Subgingival irrigation directly alters pocket microflora in an attempt to eliminate and control infection. Irrigation alone and brushing alone are not enough to control inflammation, but together, they consistently achieve enhanced periodontal health.

IRRIGATION FOLLOWING SUBGINGIVAL DEBRIDEMENT

When a single episode of irrigation followed debridement therapy, despite the solution uses, little benefit was demonstrated. Repeated irrigation, such as biweekly over 3 months following treatment, did demonstrate significant clinical results. In general, subgingival irrigation immediately following debridement therapy provided no added effect over subgingival debridement alone. The most significant results were measured in one study using povidone iodine during ultrasonic instrumentation with an Odontoson® ultrasonic scaler. The increased length of time the irrigant was in contact with the subgingival area or the combined effect of the antimicrobial and acoustic streaming may have contributed to the findings. The two most popular tips are the jet tip and the Pik Pocket by WaterPik. The traditional jet irrigator tip was designed for supragingival irrigation placing the tip close, yet not actually touching the tooth surface. The tip is not directed subgingivally, but aimed at a 90-degree angle to the tooth surface. The pressure of the water will take it subgingivally. Pik Pocket subgingival tips are designed to deliver water and antimicrobials directly into the pockets. The soft rubber tip has a small opening, allowing a controlled amount of fluid to penetrate the pocket. The soft tip is also comfortable to direct into the subgingival and interproximal areas. In pockets less than 6 millimeters, the Pik Pocket tip is more effective than both the standard jet tip and the cannula tip. In deeper areas, the cannula tip may be more effective.

IRRIGATION PLUS ROOT PLANNING

Irrigation combined with root planning has shown mixed results. Several studies showed no added benefit of irrigation combined with root planning, while others showed a slight synergistic effect. Other studies have shown equal effects between antimicrobial irrigation and saline or a placebo. At this time, data is insufficient to support the concept of routine antimicrobial irrigation in association with root planning. The effectiveness of antimicrobial irrigation in specific cases becomes diluted in a large study including cases that respond well to debridement alone. For practical purposes, non-responding cases may benefit significantly from site specific antimicrobial irrigation by either the therapist or the patient.

MAGNETIC IRRIGATION SYSTEMS

Some oral irrigators contain a magnetic component to change polarity of the water, resulting in reduced calculus accumulations on the lingual surfaces of the lower anterior teeth. Other irrigators are controlled by hand pumping rather than electricity and two are attached between the showerhead and the water pipe, allowing for oral irrigation while showering. An idea for the future is a full-mouth irrigation device to insure reaching all areas effectively and saving time.

ADA APPROVAL

The only irrigation device to receive ADA approval for reducing gingivitis and associated bacteria is the WaterPik®. It's time we consider oral irrigation as a viable alternative to flossing. The fact that oral irrigation with water is more effective in reducing inflammation and bleeding than rinsing with chlorhexidine is a major finding. Oral irrigation should be part of our daily routine as well as that of our patients.

REFERENCES

Vol. 1, #3

Cobb, C., Rodgers, R., Killoy, W.: Ultrastructural Examination of Human Periodontal Pockets Following the Use of an Oral Irrigation Device in Vivo. J of Periodontology 59: 155, 1987. Greenstein, G.: The Ability of Subgingival Irrigation to Enhance Periodontal Health. Compendium of Continuing Education in Dentistry 10: 327, 1988. Ciancio, S.: Oral Irrigation A Current Perspective. Biological Therapies in Dentistry 3: 33, 1988

Fleming, T., et al: Chlorhexidine and Irrigation in Gingivitis: 6 Months Correlative Clinical and Microbiological Findings. AADR Abstract #1612, 1989. Irrigation Update

Vol. 5, #1

Greenstein, G.: Supragingival and Subgingival Irrigation: Practical Application in the Treatment of Periodontal Diseases. Compendium of Continuing Education in Dentistry 13: 1098, 1992.

Vol. 5, #6

Shiloah, J., Hovious, L.: The Role of Subgingival Irrigations in the Treatment of Periodontitis. J of Periodontology 64: 835, 1993.

Vol. 3, #3

Greenstein, G.: Subgingival Irrigation - An Adjunct to Periodontal Therapy. Current Status and Future Directions. Journal of Dental Hygiene 64: 389, 1990.

Vol. 6, #6

Chaves, E., Kornman, K., Manwell, M., Jones, A., Newbold, D., Wood, R.: Mechanism of Irrigation Effects on Gingivitis. J of Periodontology 65: 1016, 1994.

Vol. 7, #4

Flemmig, T., Epp, B., Funkenhauser, Z., Newman, M., Kornman, K., Haubitz, I., Klaiber, B.: Adjunctive Supragingival Irrigation with Acetylsalicyclic Acid in Periodontal Supportive Therapy. J Clinical Periodontology 22: 427, 1995.

Vol. 4, #2

Itic, J., Serfaty, R.: Clinical Effectiveness of Subgingival Irrigation with a Pulsated Jet Irrigator Versus Syringe. J of Periodontology 63: 174, 1992.

Vol. 6, #2

Newman, M., Cattabriga, M., Etienne, D., Flemmig, T., Sanz, M., Kornman, K., Doherty, F., Moore, D., Ross, C.: Effectiveness of Adjunctive Irrigation in Early Periodontitis: Multi-Center Evaluation. J of Periodontology 65: 224, 1994.

Vol. 7, #3

Walsh, T., Ünsal, E., Davis, L., Yilmaz, Ö.: The Effect of Irrigation with Chlorhexidine or Saline on Plaque Vitality. J of Clinical Periodontology 22: 262, 1995.

Vol. 8, #3

Asari, A., Newman, H., Wilson, M., Bulman, J.: 0.1% / 0.2% Commercial Chlorhexidine Solutions as Subgingival Irrigants in Chronic Periodontitis. J of Clinical Periodontology 23: 310, 1996.

Vol. 4, #3

Walsh, T., Glenwright, H., Hull, P.: Clinical Effects of Pulsed Oral Irrigation with 0.2% Chlorhexidine Digluconate in Patients with Adult Periodontitis. J of C Periodontology 19: 245, 1992.

Vol. 3, #1

Brownstein, C., Briggs, S., Schweitzer, K., Briner, W., Kornman, K.: Irrigation with Chlorhexidine to Resolve Naturally Occurring Gingivitis. J of Clinical Periodontology 17: 588, 1990. Jolkovsky, D., Waki, M., Newman, M., Otomo-Corgel, J., Madison, M., Flemmig, T., Nachnani, S., Nowzari, H.: Clinical and Microbiological Effects of Subgingival and Gingival Marginal Irrigation with Chlorhexidine Gluconate. J of Periodontology 61: 663, 1990.

Vol. 5, #5

Johnson, K., Sanders, J., Gellin, R., Palesch, Y.: The Effectiveness of a Magnetized Water Oral Irrigator (Hydro Floss®) on Plaque, Calculus and Gingival Health. J of Clinical Periodontology 25: 316, 1998.

Vol. 12, #2

Cutler, C., Stanford, T., Abraham, C., Cederberg, R., Boardman, T., Ross, C.: Clinical Benefits of Oral irrigation for Periodontitis are Related to Reduction of Pro-Inflammatory Cytokine Levels and Plaque. J of Clinical Periodontology 27: 134-143, 2000.