Case report of bleeding and inflammation reduction
By Cristina Bordabeheres, RDH, BA
It is well-established that having diabetes (type 1 or 2) increases the risk for periodontal disease. People with diabetes have been shown to have more bleeding and inflammation than those without diabetes, even if the amount of plaque biofilm is similar. Poor glucose control also plays a critical role; those with the worst control often have the most severe periodontal disease.1
Research indicates that the periodontitis/diabetes relationship is bidirectional.1 Taylor et al. found that severe periodontal disease increases the risk of having poor glycemic control.2 Recent studies indicate that severe periodontitis may play a role in heart and kidney diseases as well as overall mortality.3,4 Saremi et al. found that people with severe periodontitis and type 2 diabetes had higher death rates from ischemic heart disease and nephropathy.3 Likewise, Schultis et al. found a higher incidence of nephropathy and end-stage renal disease in people with moderate or severe periodontal disease.4
Preop images taken in February 2011.
Pulsating water irrigation has a large body of evidence demonstrating a consistent ability to reduce bleeding and inflammation.5 Several studies have shown that people with periodontal disease who add water irrigation to routine oral hygiene have significantly better reductions in bleeding and gingivitis over those who don’t use irrigation.6 A study conducted at the University of Buffalo on the benefits of pulsating water irrigation on people with type 1 or 2 diabetes found that those who used the water irrigator had significantly less plaque biofilm, bleeding, and gingivitis than people who did not use an irrigator. The water irrigator also reduced serum levels of pro-inflammatory cytokines IL-1β and PGE2.7
The purpose of this case study is to evaluate the benefit of a pulsating water irrigator (Waterpik Ultra Water Flosser manufactured by Water Pik, Inc., of Fort Collins, Colo.) on the oral health of a patient with type 2 diabetes.
A 47-year-old male Caucasian presented to his dental practice in Elmwood Park, Ill., for a cleaning and examination on Feb. 21, 2011. His last prophylaxis was on Aug. 16, 2010.
Medical history — The patient has had type 2 diabetes for 14 years. He has been using insulin for the last 10 years due to poor glucose control. In October 2010, he began using an insulin pump. His last A1C reading was done in January 2011 and was 8.5.
He sees an endocrinologist every three months. He reports that he has swelling in his legs and that he has been told he has kidney problems. He also has high blood pressure and high cholesterol, and he takes medications for each of those conditions:
- Novolog insulin, type 2 diabetes, 50 units per day
- Vytorin 10, high cholesterol, 20 mgs per day
- Altace, high blood pressure, 1.25 mgs per day
Dental history — The patient is missing teeth numbers 1, 4, 12, 17, 32. Three of the missing teeth are wisdom teeth. Two are premolars, which were lost due to advanced carious lesions. He has a Class III occlusion.
Postop images taken in April 2011.
A full periodontal charting (see Figure 1) of all 27 teeth (162 sites) was completed on Feb. 21, 2011. At that time, 85 interproximal bleeding sites (52%) were detected, all with moderate to heavy bleeding. Twelve sites were recorded as having a probing depth of 5 mm, and 40 areas had a depth of 4 mm. All other areas were 3 mm or less.
Red halos were noted throughout, especially on the mandibular lingual. Light interproximal calculus was found on the mandibular anteriors. There was moderate plaque present, especially on the posterior buccal and lingual areas. Preop photos were taken.
The patient reported that he used a basic rechargeable toothbrush once daily in the evening. He did not use dental floss or any other type of interproximal cleaning device.
Treatment/self-care recommendations — The teeth were scaled using hand and ultrasonic instrumentation. The probing depth numbers were explained to the patient and the impact of inflammation and bone loss was discussed. It was recommended that the patient use a Waterpik Ultra Water Flosser. Instructions were given for the Classic Jet Tip. He was advised to use warm water and begin at the lowest setting, working up to the highest setting (10). The patient agreed to use the Water Flosser.
Follow-up visit — The patient returned on April 11, 2011, for a follow-up visit that included an exam and a prophylaxis following exam/data collection. Patient was still brushing only one time daily in the evening with the rechargeable power toothbrush. He reported that he had been using the Water Flosser with water twice daily on the highest setting. He stated he felt that the Water Flosser was very easy to use — easier than using the power toothbrush, which is why he is brushing only once a day. He said that with the Water Flosser, his mouth felt fresh and clean all of the time.
A full periodontal charting was taken and great improvement was noted. Tissue appearance was light pink and stippled on the facial. Lingual areas were a mix of stippling with some smoothness. Mandibular marginal tissue was less distended and bulbous. Only 7 sites (4%) bled upon probing. With the exception of the buccal area between 6 and 7, these bleeding sites were around crowns. Eleven of 12 probing depths of 5 mm were reduced to 3 mm. The other 5 mm sites were reduced to 4 mm. Of the 40 areas with a probing depth of 4 mm, 33 of those sites were now at 3 mm; one was at 2 mm and the other six remained at 4 mm. Twenty areas that had originally been 3 mm were reduced to 2 mm. One 3 mm site progressed to 4 mm. There were no red halos appearing on the tissue.
Discussion — This case study documents the beneficial effect of the Waterpik Water Flosser on the oral health of a patient with diabetes. Bleeding was reduced from 85 sites to seven sites in seven weeks. Gingival color and consistency went from red, distended, and bulbous to pink and stippled. The outcomes clearly support research findings regarding superior results for the Water Flosser’s ability to reduce bleeding and gingivitis.5,6,7 The results are also in support of studies showing the Waterpik Water Flosser as an effective alternative to string floss.8,9,10
Previously, the patient had not used string floss or any type of interproximal cleaning device. During the study time, the Water Flosser was the only other device he used in addition to his power toothbrush routine of once daily. Importantly, the patient found the Water Flosser very easy to use and was motivated by the way it made his mouth feel.
The Waterpik Water Flosser can help patients with diabetes control inflammation and is an easy and effective alternative to string floss.
A native of Chicago, Cristina Bordabeheres, RDH, BA, is a clinical hygienist and a 2008 graduate of William Rainey Harper College in Palatine, Ill. She is the Chair of the ADHA Diversity Committee. Bordabeheres is currently pursuing a master’s in business administration at Domincan University in River Forest, Ill.
1. Mealey BL, Oates TW. AAP-Commissioned Review: Diabetes mellitus and periodontal diseases. J Periodontol 2006; 77:1289-1301. Available at: http://www.perio.org/resources-products/pdf/lr-diabetes.pdf
2. Taylor GW et al. Severe periodontitis and risk for poor glycemic control in patients with non-insulin-dependent diabetes mellitus. J Periodontol 1996; 67:1085-1093.
3. Saremi A et al. Periodontal disease and mortality in type 2 diabetes. Diabetes Care 2005; 28:27-32.
4. Schultis WA et al. Effect of periodontitis on overt nephropathy and end-stage renal disease in type 2 diabetes. Diabetes Care 2007; 30:306-311.
5. Jahn CA. The dental water jet: A historical review of the literature. J Dent Hyg 2010; 84:122-128.
6. Husseini A et al. The efficacy of oral irrigation in addition to a toothbrush on plaque and the clinical parameters of periodontal inflammation: A systematic review. Int J Dent Hygiene 2008; 6:304-314.
7. Al-Mubarak S et al. Comparative evaluation of adjunctive oral irrigation in diabetes. J Clin Periodontol 2002; 29:295-300.
8. Barnes CM et al. Comparison of irrigation to floss as an adjunct to toothbrushing. Effect on bleeding, gingivitis, and supragingival plaque. J Clin Dent 2005; 16:71-77.
9. Sharma N et al. 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.
10. Rosema NAM et al. The effect of different interdental cleaning devices on gingival bleeding. J Int Acad Periodontol 2011; 13:2-10.
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