by Carol A. Jahn, RDH, MS
Back in the early 1980s, when I was first practicing dental hygiene, my typical self-care recommendations were brushing and flossing, along with the occasional interdental brush for those in periodontal maintenance. I did not recommend a dental water jet because I had heard it did not remove plaque. If it didn’t remove plaque, why bother?
So I didn’t “bother,” until one day when I was confronted with something that bothered me. I had a visit from a patient in his mid to late 20s who was not very good about his home care. Being new and eager to the profession, I tried hard to convert him to my way of thinking: brushing and flossing. He was fairly regular about his visits, and one day when I saw him, I was sure I had succeeded. His mouth was cleaner and healthier. The gingivitis and bleeding had resolved. I was thrilled, and he knew it.
I immediately assumed he was flossing. I remember the smirk on his face when he told me that wasn’t the case. I asked him about many other plaque-removal products he might be using, and his answer was always no. “Tell me what you’re doing,” I begged. “I bought a Waterpik®,” he replied. This took me by surprise. The Waterpik wasn’t supposed to work. Besides, who told him to get a Waterpik? (Turns out it was his brother-in-law.) Now my ego was totally wounded.
The mind is great at rationalizing, and I immediately told myself that he had simply become more conscious of his home care after he got the Waterpik, and he was probably brushing better. I told myself I did do one thing right. So I kept my negative thoughts to myself and gave him positive feedback on how good his mouth looked. Of course, I was sure that the next time I saw him he would be back to his old ways.
I was wrong. He kept using the dental water jet, and his mouth continued to look great. I even took a leap of faith and started recommending the water jet to other patients, usually those I couldn’t get to do anything beyond brushing. As the 1980s and my career progressed, I began doing in-office irrigation after scaling and root planing (SRP) with regularity, followed by a recommendation for home use.
In the mid 1990s my career took a swing, and I found myself interviewing with Waterpik for an educational representative position. At the time, I thought I knew a lot about the product, and I was comfortable promoting it to my patients. I accepted the new position, but as I trained for it, I discovered just how much I didn’t know.
Like many dental hygienists at the time, I thought patients got the best results when irrigation was performed in conjunction with SRP, and that home irrigation was secondary. Turns out I had it backwards. Due to the anatomy of the sulcus and the physics of gingival crevicular fluid flow, chairside irrigation adds minimal benefit to an SRP. Simply put, any solution put into the pocket flows out too quickly to bind to teeth and tissue for any real lasting effect.1 On the other hand, having patients irrigate their own mouths at home on a daily basis is an effective way to sustain bacterial reduction produced by the SRP.2
In the early years (the late 1990s) of my career at Waterpik, the plaque issue was still a problem. When I talked with hygienists, some of them still believed that home irrigation was ineffective because it didn’t remove plaque. Others said they had seen great benefits from the device but were confused about how it could work if it didn’t remove plaque. Those were difficult questions to answer, because while there were some well-thought ideas about why this occurred, there was not yet a definitive answer.
It was about this time that the first studies linking poor oral health to heart disease and preterm, low-birth-weight babies began to emerge. A key piece in all of this was “host response” in both susceptibility to periodontal diseases and systemic conditions. Researchers were learning that some people, particularly smokers and those with diabetes, over-express hormone-like substances called cytokines. In the oral cavity, these cytokines destroy tissue and bone, and are systemically linked to blood vessel inflammation.3
One of the hypotheses that researchers had come up with regarding the effectiveness of irrigation despite minimal plaque removal was host response mechanisms. So, in a study that was ahead of its time, researchers at Baylor University in Texas tackled this very thing. They found that daily home irrigation not only reduced the traditional signs of periodontal disease (bleeding and gingivitis), but also decreased a very potent cytokine called interleukin 1-beta, or IL-1β. In fact, when the investigators looked at the reduction in bleeding, they found that it was correlated to this agent and not plaque reduction.4 Two years later, researchers at the University of Buffalo found similar results in a group of patients with both type 1 and type 2 diabetes.5
My career at Waterpik has now spanned 10 years. Dental hygienists are fully tuned in to the oral/systemic link, and the focus has shifted from plaque to inflammation. The dental water jet has been duly recognized as a key tool for reducing bleeding and gingivitis. When I talk with dental hygienists today, they ask for products to help patients reduce disease, not just plaque. They realize that years of flossing recommendations have fallen flat.
As it turns out, not only were clinicians asking us for viable alternatives to floss, we had many long-time dental water jet advocates telling us that the results convinced them it was a viable alternative to floss. The only way to know for sure was to conduct a clinical trial, so we did. Researchers at the University of Nebraska tested the Waterpik dental water jet with both a power and a manual toothbrush and compared it to a manual toothbrush and floss. They discovered that when combined with toothbrushing, the dental water jet was an effective alternative to traditional dental floss for reducing bleeding, gingivitis, and plaque, and in some cases it provided superior results for reducing bleeding and gingivitis. Significant improvements in oral health occurred regardless of toothbrush type, which increased the likelihood that patients currently using a power toothbrush could get further improvement by adding a dental water jet.6
The Waterpik dental water jet has been around for 45 years. In the opinion polls, it has often waxed and waned. On the scientific side, the research has been strong and consistent. It’s been tested and shown to be safe and effective on people in periodontal maintenance and those with gingivitis, crown and bridge, implants, orthodontic appliances, and diabetes.2,4,7,8 It has been demonstrated to improve clinical outcomes by reducing subgingival bacteria, plaque, calculus, bleeding, gingivitis, and stabilizing probing depth.2,4-8
The dental water jet is ahead of its time. It is a viable option for any patient, especially those who do little or nothing beyond brushing. As I talk to dental hygienists around the country, I know many feel the dental water jet has allowed them to take patient home care to a new level.
1 Hanes PJ, Purvis JP. Local anti-infective therapy: Pharmacological agents: a systematic review. Ann Periodontol 2003; 8:79-98.
2 American Academy of Periodontology Position paper: The role of supra- and subgingival irrigation in the treatment of periodontal diseases. J Periodontol 2005; 76:2015-2027.
3 Offenbacher S. Periodontal diseases: pathogenesis. Ann Periodontol 1996; 1:821-878.
4 Cutler C, et al. Clinical benefits of oral irrigation for periodontitis are related to reduction of pro-inflammatory cytokine levels and plaque. J Clin Periodontol 2000; 27:134-143.
5 Al-Mubarak, et al. Comparative evaluation of adjunctive oral irrigation in diabetes. J Clin Periodontol 2002; 29:295-300.
6 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(3):71-77.
7 Felo A, et al. Effects of subgingival chlorhexidine irrigation on peri-implant maintenance. Am J Dent 1997; 10:107-110.
8 Burch, et al. A two-month study of the effects of oral irrigation and automatic toothbrush use in an adult orthodontic population with fixed appliances. Am J Orthod Dentofac Orthop 1994; 106:121-126.
Carol Jahn, RDH, MS, is the manager of professional education and commucations for Water Pik, Inc. She provides continuing-education programs on periodontal disease and the oral systemic link and diabetes. She can be reached at [email protected].