Benefits of water flossing for periodontal maintenance patients

Periodontal disease is one of the most common chronic conditions found in adults. In Australia, over 40% of adults aged 55 and over have moderate to severe periodontal disease.¹ Smoking, uncontrolled diabetes and poor oral hygiene are well-established risk factors for the development of periodontitis.² It has been associated with numerous systemic oral health conditions including cardiovascular disease,³ adverse pregnancy outcomes,⁴ cancer⁵ and cognitive decline.⁶

In November of 2018, the European Federation of Periodontology and the American Academy of Periodontology co-sponsored a World Workshop on the Classification of Periodontol and Peri-implant Diseases and Conditions. This resulted in an update in the periodontal classification system, the first since 1999. The new system includes multi-dimensional staging and grading to allow for a more comprehensive, sophisticated and personalised approach to the identification, treatment and arrestment of periodontal disease.⁷

The definition of periodontal health was also considered by the workshop participants and defined as:

"a state free from the absence of inflammation.⁸"

The authors further concluded that periodontal health can be restored to an anatomically reduced periodontium.⁸ Thus, while treatment is vital for arresting periodontal disease, it also means that regular maintenance visits and daily self-care is essential for the optimal maintenance of patients who have been treated for periodontal disease.

The Waterpik® Water Flosser (Figure 1) is a clinically proven tool for helping periodontal maintenance patients maintain good oral health.^9-12 Six-month studies conducted during the 1990s found that water flossing consistently reduced inflammation and improved the oral health of periodontal maintenance patients.^10-12 Water flossing has been shown to reduce BOP by half over a 6-month time frame.¹¹ People with the most BOP have been found to have the greatest reductions.¹⁰ When compared to rinsing with 0.12% chlorhexidine, water flossing with water was more effective at reducing BOP.¹²

Water Flossing has been found to be as effective as the local delivery of an antibiotic post scaling and root planing (SRP). Genovesi et al evaluated the difference between SRP followed by the local delivery of 1mg of minocycline into periodontal pockets and SRP followed by daily full-mouth water flossing with water for 30 days. The results demonstrated that both treatments effectively reduced bleeding on probing and improved pocket depth and clinical attachment at 30 days. There were no statistical differences between the groups, thus showing that the Water Flosser is an effective alternative to subgingival antibiotics for periodontal maintenance patients over a 30-day period.⁹

Evidence indicates that a Water Flosser has the potential to disrupt bacteria up to 6 mm in a periodontal pocket.^13,14 Studies documenting subgingival access in vivo for tooth brushing and flossing are limited. Conventional wisdom rather than scientific evidence says that toothbrushing typically reaches 1-2 mm and traditional dental floss up to 3 mm.

The Waterpik Water Flosser is supported by more than 70 published scientific studies and five decades of use by the public.

It has earned the American Dental Association (ADA) Seal of Acceptance. Despite evidence to the contrary, some dental professionals believe that the product can increase probing depth or destroy attachment. A six-week study by Goyal et al evaluated the effect of the Water Flosser on gingival and epithelial tissue at multiple pressure settings including 90 and 100. At the conclusion of the study, the Water Flosser was more effective at reducing probing depth and improving clinical attachment than manual brushing and flossing or manual brushing alone. All subjects were negative for trauma or other adverse conditions.¹⁵

In conclusion, the Waterpik Water Flosser is an ideal choice for helping periodontal maintenance patients improve and maintain good oral health.

References

1. Manton DJ, Foley M, Gikas A, Ivanoski S. et al. 2018 Australia's Oral Health Tracker: Tech-nical Paper, Australian Health Policy Collaboration, Victoria University, Melbourne.
2. Mariotti A, Hefti AF. Defining periodontal health. BMC Oral Health 2015, 15(Suppl 1): S6.
3. Lockhart PB, Bolger AF, Papanaou PN, Osinbowale O. et al. On behalf of the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, Council on Epidemiology and Prevention, Council on Peripheral Vascular Disease, and Council on Clinical Cardiology. Periodontal disease and atherosclerotic vascular disease: Does the evidence support an independent association? A scientific statement from the American Heart Association 2012. 125:00-00.
4. Offenbacher S, Katz V, Fertik G, Collins J. et al. Periodontal infection as a possible risk factor for preterm low birth weight. J Periodontol 1996; 67:1103-1113.
5. Michaud DS, Lu J, Peacock-Villada AY, Barber JR et al. Periodontal disease assessed using clinical dental measurements and cancer risk in the ARIC study. J Natl Cancer Inst 2018; 110:843-854.
6. Ide M, Harris M, Stevens A, Sussams R et al. Periodontitis and cognitive decline in Alz-heimer's disease. PLoS ONE 2016; 11(3): e0151081.doi:10:10.1371/journal.pone.0151081
7. Tonetti MS, Greenwell H, Korman KS. Staging and grading of periodontitis: Framework and proposal of a new classification system and case definition. J Periodontol 2018; 89*Suppl 1): S159-S172.
8. Lang NP, Bartold PM. Periodontal health. J Periodontol 2018; 89(Suppl 1): S9-S16.
9. Genovesi AM, Lorenzi C, Lyle DM, Marconcini S et al. Periodontal maintenance following scaling and root planing, comparing minocycline treatment to daily oral irrigation with wa-ter. Minerva Stomatol 2013; 62(Suppl. 1 No 12): 1-9.
10. Newman MG, Cattabriga M, Etienne D, Flemmig T et al. Effectiveness of adjunctive irrigation in early periodontitis: Multi-center evaluation. J Periodontol 1994; 65: 224-229.
11. Flemmig, TF, Epp B, Funkenhauser Z, Newman MG et al. Adjunctive supragingival irrigation with acetylsalicylic acid in periodontal supportive therapy. J Clin Periodontol 1995; 22: 427-433.
12. Flemmig TF et al. Supragingival irrigation with 0.06% chlorhexidine in naturally occurring gingivitis. I. 6-month clinical observations. J Periodontol 1990; 61: 112-117.
13. Cobb CM et al. Ultrastructural examination of human periodontal pockets following the use of an oral irrigation device in vivo. J Periodontol 1988; 59: 155-163.
14. Drisko CL et al. Comparison of dark-field microscopy and a flagella stain for monitoring the effect of a Water Pik on bacterial motility. J Periodontol, 1987; 58: 381-386.
15. Goyal CR, Qaqish JG, Schuller R, Lyle DM. Evaluation of the safety of a Water Flosser on gingival and epithelial tissue at different pressure settings. Compend Contin Ed Dent 2018; 39(Suppl 2): 8-13.