by Lynne H. Slim, RDH, BSDH, MSDH
Y ou would think that, having been married to an Englishman for 28 years, I would visited England more frequently in the springtime. When my kids were very young, we lived in England for about six months but left to return to our home in Georgia just as the daffodils were about to pop open. This year David and I decided to spend Easter in England, surrounded by our English relatives and friends. Despite the hectic traveling schedule, we managed to spend a couple of days in Edinburgh, Scotland, amid the elegance of beautifully maintained gardens and its huge castle, which dominates the city. Like typical tourists, we walked our feet off while immersing ourselves in the history of the Old Town. The weather in Edinburgh was unusually warm and sunny, and we stayed in a lovely hotel that faced the North Sea.
Upon inspecting the “loo” (the English word for a bathroom or toilet) in our hotel room, I discovered the usual toiletries like shampoo and body lotion, but I was immediately taken with a small box of breath freshener called “Snog Me Senseless.” Only the the British, with their dry sense of humor, could have thought up that name! On the back of the box, the breath spray is described as “quickly giving the kiss of life to your love life.” A warning is also included, stating that a nasty whiff of bad breath often results in your date running away and never meeting you again.
There’s lots of miscellaneous stuff I’m always eager to talk about in my column, but I’ve decided to leave my discussion of dental hygiene in the UK until my next column ... so stay tuned! Instead, I’m going to focus on a subject that has been bugging me lately, and one that is often misunderstood. Am I going to talk about “bloody” mouth fresheners (bloody is another English expression) or something along those lines? No, what’s been bugging me is a discussion that I read and responded to online in an Internet chat group. The topic was oral irrigation, and I was somewhat disappointed not to read any posts about the science that supports the recommendations. I felt an urgency to respond, because I have read a lot of the research on adjunctive oral irrigation and I get frustrated when dental hygienists don’t consider it (or add it to the equation) when making clinical decisions.
Just how important is it for clinicians to be skilled at interpreting the literature and differentiating between strong and weak evidence?
Is evidence-based decision-making all about using systematic reviews of randomized controlled research trials, or is it broader in scope, including practitioner expertise (easily found in Internet chats), patient preferences, other practicalities, and cost considerations? At times when we don’t have systematic reviews due to a lack of interest or funding for a given topic, we must rely on prevailing trends to make the best decisions for our patients.
I just finished reading an excellent Canadian article on evidence-based practice and the professionalization of dental hygiene, one of those original articles that I strongly recommend to all hygienists, including students, because it gives us plenty to think about.1 The author understands the intent of evidence-based practice and reminds us that its purpose is to improve health outcomes. She also says: “To properly serve the oral health needs of the public, it is this author’s opinion that there must be a principal focus on the creation and implementation of a culture of evidence-based dental hygiene practice.”1
OK, so let’s apply evidence-based decision-making to adjunctive (self-applied) oral irrigation and see where it leads us.
I’d like to cite the ADHA’s practice guidelines or position papers on a topic like this, but we don’t yet have any. In looking at evidence, I used a couple of Academy of Periodontology (AAP) resources along with a collection of research articles compiled for me by Waterpik, Inc. Here’s what I found when looking at clinical outcomes ...
The AAP found that several studies consistently demonstrated improved periodontal outcomes when water or chlorhexidine (in different concentrations) was used in addition to toothbrushing.2 According to the AAP, the greatest benefit was reported in patients with inadequate interproximal cleansing and those with gingivitis and overall poor oral hygiene.2 Also, some evidence suggests that the dental water jet removes loosely adherent periodontal pathogens and that it’s also possible, depending on the pressure setting, that dental water jets can also help inhibit the formation of early biofilms. With adequate pulsation and pressure, perhaps targeting the gelatinous matrix is one effective strategy for biofilm control. We have brushes that can mechanically disrupt biofilms in shallow pockets and supragingivally, so perhaps a dental water jet used on a medium to high power setting helps keep biofilms disorganized and unattached. Once established, however, biofilms are extremely resistant to water pressure, as seen in industrial biofilms that foul water pipes and even dental unit waterlines. Periodontal pathogens that reside in mature biofilms exhibit extreme tolerance to antimicrobial agents of any kind, including antibiotics.3 There is no scientific evidence that the dental water jet removes stubborn, well-established, subgingival biofilms and calculus (no kidding), but there is weak evidence that oral irrigation combined with toothbrushing reduces bleeding, gingival inflammation, and supragingival plaque more effectively than dental floss.4 Adjunctive irrigation is also associated with a greater reduction of proinflammatory cytokines in the gingival crevice, but we don’t know if reduction of these substances in the gingival crevice signifies a continuing improvement in periodontal health.2
Clinicians Chime In
According to a recent small sampling of hygienists’ opinions about adjunctive home oral irrigation, many report positive results of oral irrigation in their patients.5 When patients cannot or will not floss, about 51 percent of hygienists indicate that they recommend daily oral irrigation, and 75 percent of hygienists have seen reductions in gingivitis and bleeding in these patients too. More research needs to be done in this and other areas of clinical dental hygiene, and the ADHA needs to lead the way in developing practice guidelines in an attempt to further encourage evidence-based dental hygiene decision-making. The Canadian Dental Hygienists’ Association already has a series of position statements on several topics, and the ADHA needs to publish the same.
To Add Or Not To Add An Antimicrobial
When I recommend adjunctive oral irrigation to my patients, most want to know if they should add an antimicrobial agent to the water bath. First, I tell them that there’s no strong evidence that the addition of an antimicrobial agent to the bath water is superior to water alone, but I usually recommend one anyway. The only agents that have some research (although weak) to support their use are chlorhexidine (CHX) in various dilutions (five parts water to one part CHX, two parts water to one part CHX, and one part water to one part CHX), essential oils, and bleach (0.5 percent). Since I’ve never had a patient agree to use bleach (and I don’t blame them one bit), I suggest a variety of antimicrobials that taste good and appeal to the patient. For example, my cost-conscious patients like the idea of adding a low-cost antimicrobial like an essential oil. My patients who are dedicated to naturopathic approaches to wellness prefer mouthrinses with “natural” ingredients like herbs and essential oils. For patients with spontaneous bleeding, I like to recommend CHX, but I may also have them rinse with 0.12 percent CHX. The important point to remember about the addition of an antimicrobial agent to a water bath is that these antimicrobials don’t penetrate biofilm.
The Pik Pocket® subgingival irrigation tip penetrates 90 percent of the depth of pockets that range from 1 mm to 6 mm in depth, and 64 percent in pockets that are 7 mm or greater in depth.6
As the wellness movement continues to grow, clinicians will discover that patients are desirous of any and all products that keep them healthier and more attractive. Like “Snog Me Senseless” breath fresheners and mouthrinses with “natural” ingredients, powerbrushes, interdental piks and brushes, and dental water jets are available for patients who take the message of oral biofilms seriously. If you’re one of those clinicians who is in a finger flossing, manual toothbrushing rut, remember that the sky’s the limit when you customize oral hygiene care. Move beyond the finger flossing/manual toothbrushing days of yesteryear and get patients excited about new approaches to oral biofilm control.
1. Cobban SJ. Evidence-based practice and the professionalization of dental hygiene. Int J Dent Hygiene 2004; 2:152-160.
2. American Academy of Periodontology: The role of supra and subgingival irrigation in the treatment of periodontal diseases. J Periodontol 2005; 76:2015-2027.
3. Cunningham AB, Ross RJ. Biofilms: the hypertextbook. Montana State University http://www.erc.montana.edu/biofilmbook.
4. Barnes CM. Comparison of irrigation to floss as an adjunct to toothbrushing: effect on bleeding, gingivitis, and supragingival plaque. J of Clin Dent 2005; 16(3):71-76.
5. O’Hehir TE. Hygienists’ opinions about oral irrigation. Hygienetown 2007; 3(4):8-9.
6. Braun RE, Ciancio SG. Subgingival delivery of an oral irrigation device. J Periodontol 1992; 63:469.
About the Author
Lynne H. Slim, RDH, BSDH, MSDH, is a practicing hygienist/periodontal therapist who has more than 20 years’ experience in both clinical and educational settings. She is also president of Perio C Dent Inc. (Perio-Centered Dentistry), a practice-management consulting firm that specializes in creating outstanding dental hygiene teams. Lynne is a member of the Speaking and Consulting Network (SCN) that was founded by Linda Miles, and has won two first-place journalism awards from ADHA. Lynne is also owner/moderator of a periodontal therapist yahoo group: http://yahoogroups.com/group/periotherapist. She can be contacted at [email protected].