Trisha E. O`Hehir, RDH
Did you receive a Water Pik® when you graduated from dental hygiene school? If you graduated in the late 1960s, you did - a present from what is now Teledyne Water Pik. I know it was marketing, but I still appreciated the thoughtful gesture, probably because I was so happy to be graduating.
Home irrigation was new in the 1960s and suggested only for patients undergoing orthodontic treatment or who had areas of food impaction. But it was definitely not considered as an alternative to dental floss. If patients used a Water Pik, they were urged to floss daily. We were also warned in school about the dangers of systemic bacteremia due to the irrigation forcing bacteria into the tissues.
Plaque alteration becomes the positive benefit
Intuitively, hygienists knew that home irrigation worked. They looked at the results on their patients. Rarely, if ever, was a bacteremia linked to home irrigation. It took 20 years for research to confirm what hygienists knew. Daily home irrigation is both effective and safe for controlling gingivitis and bleeding.
Oral irrigation has taken a back seat to dental floss and other interproximal tools since early studies revealed it was unable to remove visible plaque. Despite the inability to remove visible plaque, irrigation effectively controlled gingivitis. However, those first studies evaluated plaque removal and did not really focus on tissue response.
More recently, the old studies have been repeated. The effects of irrigation on gingival health and bleeding have been examined, rather than simply looking at plaque removal. The positive effects of irrigation appear to be due to alterations of plaque bacteria rather than plaque removal.
Several ideas have been suggested. Irrigation appears to empty bacterial cells without breaking the cell wall. Plaque thickness is reduced, but this is not seen when disclosing solutions are used. Dilution of bacterial toxins occurs. The loosely adherent bacteria are flushed from the pocket. Oral irrigation may stimulate the immune response. Any or all of these concepts may explain the effectiveness of daily home irrigation.
We do know that loosely adherent bacterial plaque is more toxic than attached plaque. It`s also easily rinsed from both supragingival and subgingival areas, so the concept of flushing these bacteria from the pocket with daily irrigation makes sense. Dilution of toxins would also contribute to tissue healing.
For many reasons, quite different from those of traditional mechanical plaque removal, home irrigation is an important oral hygiene tool.
The safety of irrigation has been 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 even chewing. Patients requiring antibiotic premedication, however, should be periodontally healthy before beginning irrigation therapy. This is true with the introduction of any oral hygiene aid.
Evolution of home irrigation continues
Back in the 1960s we only had one home irrigation device, the Water Pik. Things have changed not only with the Water Pik, but also with the introduction of other products to the market. Home irrigation now includes:
- The traditional jet irrigation.
- Subgingival tips such as the Pik Pocket.
- Canulas for either the Water Pik machines or for disposable syringes or plastic bottles.
- Shower and faucet attachments which use positive water pressure.
- Magnetic devices which alter the charge of the water.
- Uniquely designed travel irrigators.
The traditional home irrigation tip is called the jet tip and is designed to be used supragingivally with the water flow reaching subgingivally. The tip is simply aimed at the tooth surface or directly interproximally, moving slowly around both facial and lingual surfaces. To test the depth of fluid penetration, a disclosing solution was used with a jet-tip irrigator around teeth prior to extraction, showing penetration of about 3 millimeters or an average of half the pocket`s depth.
The most popular subgingival tip is the Pik Pocket by Water Pik, a soft rubber tip which directs a finer stream of water. The tip can be inserted into the sulcus or pocket for greater depth of penetration. The study using disclosing solution found the Pik Pocket tip to reach 7 to 8 millimeters or an average of 80 percent of the pocket`s depth. Penetration of irrigation fluids may, in fact, be deeper than estimated by this research. Measurements on the extracted teeth were made to the periodontal ligament without consideration of the junctional epithelial, which ranges from a few cells to a few millimeters in width, or the plaque-free zone, which has been shown to be one millimeter wide.
Canula tips open either on the side or the end of the blunt needle, but one hasn`t been shown to be better than the other. Patients must have good manual dexterity to effectively use these tips. These tips were found to be just slightly better than the Pic Pocket tip when used on a Water Pik machine. When the canula tip on the Water Pik was compared to a disposable syringe using the same tip, better healing was noted with the Water Pik than with the syringe. This study measured healing rather than fluid penetration.
Another variation on the market is the magnetic water treatment device. Some Eastern European countries and China have magnetically treated their general water supply to control deposits and corrosion in the water pipes.
This concept has been adapted to a home irrigation device which is sold by Oxyfresh distributors. The magnetically treated water produces an electrolysis reaction which favors precipitation of salts within the water rather than on the tooth surfaces, resulting in less calculus accumulation. Only one study has been reported on this device. Bleeding and gingivitis information were not included.
For those wanting the convenience of a shower irrigator, the Shower Floss? is available. This simple system is inserted between the showerhead and the water pipe. A divert valve allows water to flow to the irrigator at the same time the shower is being used.
If choosing from a wide variety of devices and tips is not enough to confuse you, there is also the consideration of using water or an antimicrobial agent. Water remains the best first choice. It has proven better than irrigation with several other antimicrobials. Although home irrigation was shown to be better than rinsing with chlorhexidine, irrigating with chlorhexidine was more effective for reducing gingivitis and bleeding. But chlorhexidine does result in staining and greater calculus accumulation.
New research has changed our thinking on home irrigation. Hopefully, future research in this area will answer the many new questions we have.
Trisha E. O`Hehir, RDH, is a senior consulting editor of RDH. She also is editor of Perio Reports, a newsletter for dental professionals that addresses periodontics.