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Pay attention to the research and be open to new ideas for today's patients.

The tissue is the issue: An honest look at oral inflammation management in the 21st century

April 30, 2024
Taking an honest look at how you treat your patients, and having an open mind about current research, can lead dental hygienists to new therapies that patients will appreciate.

In dental hygiene school, I learned how to articulate my instruments into anatomical findings, and I worked tirelessly to leave behind a “glass-smooth” root surface. Sound familiar? If you’re anything like me, you were taught that the critical success of our work is rooted (pun intended) in our ability to root plane everything from granulated deposit to necrotic cementum.

Like many of you, I spent a large portion of my dental hygiene training learning every rotation in the handle of a Gracey 11/12 and every bend in the Gracey 13/14 to juxtapose my money makers to tear into my patients’ cementum. With visions of hockey skates gliding across ice (I went to school in Minnesota), I graduated into the ranks of dental hygienists, an army of root-smoothing heroes with a firm handshake and some premature back problems.

What was I missing?

Current theory reveals that periodontal inflammation results from an interaction between potent biofilm dense with disease-producing microorganisms and the immune system of the host.1 Even more concerning are the data points that conclude the bacterial invasion into gingival epithelial cells permit disease-producing bacteria to avoid the cutting edge of our equipment.

These pathogens nestle easily into the ulcerated, friable sulcular epithelium of patients who trust us and believe we’re using modalities to best meet their dental health-care needs.

Graphic micrographs of gingival tissue immediately following SRP display hundreds of disease-producing bacteria colonizing the gingival epithelial cells, releasing enzymes to corrode epithelium and leaving behind waste products that decay delicate tissues.2 They barge into the blood vessels like P. gingivalis is a bracelet-donning teen and the vital organs of the body are hosting an unending Taylor Swift concert of epic proportions.

The tissue is the issue

Disease of the oral cavity’s soft tissues impacts the largest portion of the patient population. From the irreversible nature of periodontitis seen in approximately 47.2% of the adult population to the reversible display of gingival inflammation observed in nearly 93.9% of patients,3,4 it’s safe to say that bacterial invasion into the soft tissue has become a silent epidemic.

Patients suffering from soft tissue infections present with complications, including gingivitis, periodontitis, and peri-implant disease. Patients who present with varying levels of disease provide an opportunity for prudent clinicians to recognize key warning signs as infectious and inflammatory components invading the soft tissue, entering the bloodstream and elevating the risk of systemic disease.

Put pressure on periodontal pathogens

New data suggests there’s been success moving away from one dimensional therapies aimed to only debride the hard tissue and embracing progressive therapies designed to address hard and soft tissue complications. While standard therapies of floss, wooden sticks, and interdental brushes had appropriate efficacy on hard tissue, water flossers have introduced a way to efficiently address gingival wound care.

Moving water through a pulsating motion to control infection within open and weeping oral wounds demonstrates evidence-based support of both hard and soft tissue debridement for optimal disease management. Patients presenting with oral diseases have shown critical improvements in their oral health and oral wound management with the use of water flossers.5

Gingivitis patients: Poor flossing compliance and the data from “flossgate” indicating that flossing is not supported by research have drawn attention to the true root cause of this reversible disease: bacteria into the soft tissue.6 In fact, water flossing outperforms sonic and oscillating electric toothbrushes in removing biofilm and improving gingival health, and it’s significantly more effective in biofilm removal than interdental brushes.7-9 What’s more, water flossing is 33% more effective at biofilm removal and twice as effective in reducing gingival bleeding than string floss. Water flossing delivers a high-level advantage over bleeding tendencies, positioning water flossing as a leading therapy in the reversal of gingival wounds.10-12

Periodontal patients: The ramifications of clinical attachment loss pave the way for plaque retentive anatomical variances. These challenges alone are reason to pivot from string to hydraulic pressurized water designed to reach beyond 6 mm probing depths in an attempt to disrupt and dislodge the sticky matrices of newly formed biofilm.13 Water flossing also serves as a highly successful and cost-effective alternative to subgingival antibiotics. This was observed in a study comparing water flossing to subgingival minocycline delivery, where there was a 76% reduction in bleeding tendency in the minocycline group, and the water flossing group benefitted from an 81% reduction in bleeding tendency.14

Water flossing offers a solution for improved compliance to a population of periodontal patients whose compliance around oral hygiene measures is critical. Data observing water flossing with a diluted chlorhexidine rinse in the reservoir demonstrated better clinical attachment levels and improvement in probing depths when compared with rinsing simply with a full-strength chlorhexidine solution. The best part is the water flossing group presented with significantly less staining than the rinsing group.15

Peri-implant disease patients: Dental patients often believe string floss is the optimal solution for oral health measures. They want to find ways to ensure as close to a biofilm-free implant surface as possible. The decontamination of dental implant services through a water flossing mechanism is twice as effective as the C-shape flossing method.16

While concerns about flossing remnants around implants have led to conversation about optimal modalities, water flossing with diluted chlorhexidine demonstrates significant reductions in plaque, gingival inflammation, and bleeding tendency, and water flossing with or without diluted chlorhexidine solution offers a safer and effective means of reducing the severity of peri-implant mucositis when compared with brushing and interdental cleaning.17,18 It’s safe to say that we don’t want to give implant patients a suboptimal home-care routine of flossing when water flossing offers superior benefits and lasting results.

The goal is optimal oral health

The renewed focus of interdental, intrafurcal, and transanatomical home-care modalities helps dental professionals extend their reach beyond the dental chair to empower patients to partner with the dental professional for optimal oral health.

As research examines the root cause of disease, the infection care needed for open oral wounds, and the role of oral biofilms in systemic disease, one key concept is clear: dental floss has been “wrapped around our fingers” for far too long.

The oral-systemic link has taught us that oral disease is more than simply warning patients that “you should receive treatment so that you don’t have heart problems.” It’s taking the opportunity to critically scrutinize how we manage not only plaque retentive hard tissue sites, but how we address periodontal lesions as the open oral wounds they truly are.

Through the integration of home-care products targeting infectious open oral wounds, we have an opportunity to progressively support our patients, not only in oral health, but also in systemic health.


1. Heitz-Mayfield LJ, Trombelli L, Heitz F, Needleman I, Moles D. A systematic review of the effect of surgical debridement vs. non-surgical debridement for the treatment of chronic periodontitis. J Clin Periodontol. 2002;29(Suppl 3):92-102.

2. Thurnheer T, Belibasakis GN, Bostanci N. Colonisation of gingival epithelia by subgingival biofilms in vitro: role of "red complex" bacteria. Arch Oral Biol. 2014;59(9):977-986. doi:10.1016/j.archoralbio.2014.05.023.

3. Eke PI, Zhang X, Lu H, Wei L, Thornton-Evans G, Greenlund KJ, Croft JB. Predicting periodontitis at state and local levels in the United States. J Dent Res, 2016;95(5):515-522. doi.10.1177/0022034516629112

4. Li Y, Lee S, Hujoel P, Su M, Zhang W, Kim J, De Vizio W. Prevalence and severity of gingivitis in American adults. Amer J Dent. 2010;23(1):9.

5. Mancinelli‐Lyle D, Qaqish JG, Goyal CR, Schuller R. Efficacy of water flossing on clinical parameters of inflammation and plaque: A 4‐week randomized controlled trial. Internat J Dent Hyg. 2023;21(4):659-658. doi:10:1111/idh.12770

6. Claydon NC. Current concepts in toothbrushing and interdental cleaning. Periodontol 2000. 2008;48:10-22. doi:10.1111/j.1600-0757.2008.00273.x

7. Goyal CR, Qaqish JG, Schuller R, Lyle DM. (2018). Comparison of a novel sonic toothbrush with a traditional sonic toothbrush and manual brushing and flossing on plaque, gingival bleeding, and inflammation: A randomized controlled clinical trial. Compend Contin Ed Dent. 2018;39(2).

8. Lyle DM, Qaqish JG, Goyal CR, Schuller R. Efficacy of the use of a water flosser in addition to an electric toothbrush on clinical signs of inflammation: 4-week randomized controlled trial. Compend Contin Ed Dent. 2020;41(3):170,177.

9. Lyle DM, Goyal CR, Qaqish JG, Schuller R. Comparison of water flosser and interdental brush on plaque removal: a single-use pilot study. J Clin Dent. 2016;27(1):23-26.

10. Goyal CR, Lyle DM, Qaqish JG, Schuller R. Evaluation of the plaque removal efficacy of a water flosser compared to string floss in adults after a single use. J Cln Dent. 2013;24(2):37-42.

11.  Rosema NA, Hennequin-Hoenderdos NL, Berchier CE, Slot DE, Lyle DM, van der Weijden GA. The effect of different interdental cleaning devices on gingival bleeding. J Int Acad Periodontol, 2011;13(1):2-10.

12. Barnes CM, Russel CM, Reinhardt RA, Payne JB, Lyle DM. Comparison of irrigation to floss as an adjunct to tooth brushing: effect on bleeding, gingivitis and supragingival plaque. J Clin Dent. 2005;16(3):71.

13. Verma A, Singh ST, Lall A. Water flosser: a boon for periodontal health. Indian J Comprehen Dent Care (IJCDC). 2017;7(1):938. https://openurl.ebsco.com/EPDB%3Agcd%3A13%3A10165661/detailv2?sid=ebsco%3Aplink%3Ascholar&id=ebsco%3Agcd%3A125527821&crl=c

14. Genovesi AM, Lorenzi C, Lyle DM, et al. Periodontal maintenance following scaling and root planing. A randomized single-center study comparing minocycline treatment and daily oral irrigation with water. Minerva Stomatologica. 2014;1.

15. Jain R, Chaturvedi R, Pandit N, Grover V, Lyle DM, Jain A. Evaluation of the efficacy of subgingival irrigation in patients with moderate-to-severe chronic periodontitis otherwise indicated for periodontal flap surgeries. J Indian Soc Periodontol. 2020;24(4):348.

16. Magnuson B, Harsono M, Stark PC, et al. Comparison of the effect of two interdental cleaning devices around implants on the reduction of bleeding: a 30-day randomized clinical trial. Compend Contin Ed Dent. 2013;34(8):2-7.

17. Felo A, Shibly O, Ciancio SG, Lauciello FR, Ho A. Effects of subgingival chlorhexidine irrigation on peri-implant maintenance. Am J Dent. 1997;10(2):107-110.

18. Bunk D, Eisenburger M, Häckl S, et al. (2020). The effect of adjuvant oral irrigation on self‐administered oral care in the management of peri‐implant mucositis: A randomized controlled clinical trial. Clin Oral Implants Res. 2020;31(10):946-958.

Editor's note: This article appeared in the April/May 2024 print edition of RDH magazine. Dental hygienists in North America are eligible for a complimentary print subscription. Sign up here.

Katrina M. Sanders, MEd, BSDH, RDH, RF, is a clinical dental hygienist, author, and international speaker. She serves periodontal patients as the clinical liaison for Hygiene Excellence & Innovation for AZPerio and is the founder, CEO, and keynote speaker for Sanders Board Preparatory. Sanders is published in various publications including RDH magazine and Today’s RDH and is an advisory member for Modern Hygienist and the Dental Academy of Continuing Education. Recently, she proudly accepted the 2023 Denobi Award for Clinical Excellence and Innovation in dentistry.