by Terri Tilliss, RDH, PhD
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Oral health-care providers diagnose and treat oral diseases so that patients can achieve optimal oral health. Perhaps even more influential than in-office periodontal procedures are the daily oral hygiene practices of patients.
For those with periodontal disease – whether active or arrested – a consistently high level of oral hygiene is essential, since a history of periodontal disease puts them in the elevated risk category for additional destruction. The consistency element is the challenge, since maintaining oral health is a constant battle between bacteria and periodontal tissues.
To achieve optimal oral hygiene, the key is an effective device that people will use long-term since mechanical oral hygiene is still the gold standard for controlling periodontal disease.
The improvements in power toothbrushes over the last decade have resulted in high quality devices backed by compelling research. However, even the finest brushing device in the hands of a committed brusher with an effective technique cannot adequately address the critical interproximal areas.
Since dental floss was introduced nearly 200 years ago, oral health-care providers have consistently promoted or even pushed floss use, but flossing compliance has been an ongoing challenge. Routine use of dental floss has still not been embraced by the public. What a relief it would be for many dental patients if floss would just go away.
For two-thirds of them, it already has. They generally do not think about it, they do not use it, and they do not care that they do not use it except possibly during the regular scolding that they expect at dental visits. Since people find flossing difficult and time consuming, they prefer other approaches. A survey of health professionals, including dentists, found that the majority admitted to not flossing daily.
Recommending floss for all patients when there are other interproximal cleaning devices that are also beneficial and preferred by patients is not an evidence-based approach. It is preferable to suggest an alternate product that engenders better compliance – an effective device that is not conducive to regular use has little intrinsic value.
The Waterpik® Water Flosser parallels the benefits of floss and patients can comply with it long-term. The Water Flosser, previously known as the Waterpik® dental water jet, was recently renamed to reflect current research that has positioned it alongside floss in efficacy.
A 2007 study by Barnes demonstrated that a Water Flosser added to either manual or power toothbrushing was up to 93% more effective than a manual toothbrush and flossing at reducing bleeding, and was up to 52% better at reducing gingivitis. Similarly, a paper presented in 2010 at an international research conference showed that the Water Flosser used with manual brushing was two times more effective at reducing gingival bleeding than floss.
It is interesting that the Water Flosser and floss were equivalent in plaque biofilm removal. Why then was the Water Flosser superior at reducing bleeding? This finding can be explained by recognizing that it is not simply the amount of disclosable plaque that determines pathogenicity. A reduction in pro-inflammatory mediators explains the improvement in bleeding, while the amount of visibly disclosed plaque remains the same.
This immune pathway was demonstrated in a study where changes were seen in the components of the gingival crevicular fluid of periodontal patients who used the Water Flosser for two weeks. This was concurrent with a significant reduction in bleeding on probing. This study design differs from traditional oral hygiene device research, where plaque amount is viewed as the only important criterion, without addressing the disease-promoting alterations in the plaque.
It is compelling that inflammatory host mediators can be impacted by a device as simple to use and comply with as the Water Flosser. Biofilm research shows that there is a protective capsule surrounding the bacterial mass that contributes to its pathogenicity. The Water Flosser has actually been shown to eliminate this fibrin-like mesh capsule. The effects on the host mediators and the biofilm capsule address current concepts of periodontal disease etiology and demonstrate that daily use of the Waterpik® Water Flosser can impact the disease process.
Since traditional string floss has negative associations, patients are often receptive to learning about alternatives. It seems futile to continue to hope for floss compliance in patients who have never developed daily flossing behaviors.
Continuously promoting a behavior or product for which the patient has repeatedly demonstrated noncompliance can affect the credibility of the practitioner and frustrate patients, and prevent them from acquiring optimal oral health.
New enthusiasm for daily oral hygiene practices based upon current research findings may increase compliance. Practitioners can confidently recommend daily use of the Waterpik® Water Flosser based upon contemporary concepts of disease etiology.
Terri Tilliss, RDH, PhD, is a professor in the Department of Graduate Orthodontics at the University of Colorado School of Dental Medicine, where she assists residents with research projects, treats patients, and promotes oral health. Contact her at Terri.Tilliss@ucdenver.edu.
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