Interdental Cleansing

By Jacquelyn L. Fried, RDH, MS

In March 2008, the Standards for Clinical Dental Hygiene
Practice were adopted by the Board of Trustees of the American Dental Hygienists Association. The two stated purposes
for this document are (1) to assist dental hygiene clinicians
in the provider-patient relationship and (2) to educate
other health care providers, policy makers and the public
about the clinical practice of dental hygiene. To access the
full standards document, go to www.adha.org/downloads/
adha_standards08.pdf. The following article on interdental
cleansing contains references that link back to the standards
document. Readers who would like greater understanding
of the standards are encouraged to read it alongside a copy
of the standards document and make their own links to the
information in the article. Readers who do so are encouraged
to share their insights with Access.

p4 Definition of

nterdental cleansing is necessary for the

Dental Hygiene
attainment of optimal oral health. Since
Practice
most toothbrushes have limited access to
proximal surfaces of teeth, measures for
interdental cleansing must be included in dental hygiene care
plans. Interdental spaces are areas where bacteria can accumulate, multiply and remain undisturbed. Undisturbed plaque
biofilm can cause gingival inflammation and bleeding and
increase the risk for and progression of periodontal disease.
Accessing interdental areas can be challenging for patients.
A myriad of devices designed to access interdental spaces
are available for consumer purchase. Examples of interdental
aides on the market include dental floss and tape, water jets,
interdental brushes and tips, and plastic or wooden picks.
Products can vary according to comfort, cost, ease of use,
consumer acceptance and effectiveness in reducing bleeding, gingival inflammation and the composition and quantity
of biofilm accumulations. With so many options available,
patients need a professionals guidance to determine what
choices to make. Dental hygienists can assist by offering recommendations that are
p6 Dental Hygiene
individualized and based on patients needs Process of Care
and abilities.
This article will address why the Water Flosser (also
known as an oral irrigator or dental water jet) is a viable and
useful adjunct for interdental cleansing. Research examining the effectiveness of the Water Flosser when compared to
toothbrushing alone, to string (dental) floss in conjunction
with toothbrushing, and with another powered interproximal
type device will be explored. The Water Flossers mechanisms
of action, benefits, versatility and suitability for specific target
groups and the general public also will be discussed.

Research Studies
Water Flosser and Dental Floss
For almost five decades, oral irrigation and its effects
on interdental cleansing, tissue health and the potential for
bacteremia, as well as in reducing calculus, plaque, gingival
inflammation and bleeding have been studied assiduously.1-6
Reductions in bleeding, gingivitis and plaque accumulations
have been the key dependent variables for oral irrigation clinical trials. Repeatedly, in studies that have compared the adjunctive use of dental flossing or irrigation with toothbrushing,

22 FEB 2012

oral irrigation has shown significantly greater reductions in

bleeding and gingivitis levels. The following three studies compared the Water Flosser to string floss when each was used as
an adjunct to toothbrushing.4-6 All studies demonstrated that
the Water Flosser provided superior results over string floss
for reducing gingival bleeding. Barnes et al.4 found that the
combined use of a Water Flosser with toothbrushing was as
effective in removing plaque and significantly better at reducing bleeding and gingivitis when compared to flossing and
toothbrushing. With orthodontic patients, Sharma et al.5 found
that when comparing the use of manual toothbrushing and a
dental water jet using an orthodontic tip to manual toothbrushing with flossing or floss threaders, or to just brushing alone, the Water Flosser was more effective in reducing
plaque and bleeding scores. Rosema et al.6 compared three
study groups, two of which used a manual toothbrush and a
Water Flosser with two different tips and a third group that
used flossing with manual toothbrushing. Both water flossing
groups experienced a significantly greater reduction in gingival
bleeding scores when compared to the flossing group.

Plaque Removal
Although two dated reports, one involving a case study and another that comp5 Professional
pared toothbrushing to a Water Flosser
Responsibilities
alone, questioned the plaque removal capa- and Considerations
bilities of water flossing, subsequent studies refute those results.4-9 In recent studies where the Water
Flosser was used alone or as an adjunct to toothbrushing, superior or equivalent reductions in plaque accumulations were
found.4-6 Another study found that the Water Flosser with the
Classic Jet Tip removed 99.9 percent of plaque biofilm.7

Host Response
Another body of research examines the
effects of oral irrigation on plaque disruption,
p3 Introduction
bacterial virulence and host response indicators.
Drisko et al.10 and Chaves et al.,11 respectively, found subgingival disruption of bacteria and a reduction of pathogens
when an oral irrigator was used. Drisko noted that spirochetes
were disrupted in pockets of up to 6 millimeters, while Chaves
found a reduction of pathogens when the irrigator was used
with either chlorhexidine 0.04 percent or water. Rinsing with
chlorhexidine 0.12 percent or toothbrushing alone did not reduce pathogens. Cobb and colleagues also noted a qualitative
difference in the bacteria up to 6 mm when water irrigation
was used.12 Cytokine profiles have been studied to determine
how oral irrigation impacts the host inflammatory response.
While reducing the traditional clinical measures of plaque biofilm, bleeding and gingivitis, the oral irrigation also increased
anti-inflammatory mediators while simultaneously deceasing
pro-inflammatory cytokines.13 Only in the irrigation group did
reductions in bleeding on probing correlate with reductions in
IL-1. Another randomized controlled trial (RCT) measured
the serum cytokine profile of diabetic subjects. Following
scaling and root planing, subjects performed routine hygiene
either alone or with oral irrigation twice daily. The results
similarly showed that Water Flosser users had greater reductions in bleeding, gingivitis and plaque biofilm plus significant

access

reductions in IL-1 and PGE2.14 Given the

symbiotic relationship between diabetes
and periodontal
disease, oral self-care
p4 Definition of Dental
measures that curb
Hygiene Practice
the inflammatory
p7 Standard 1. III. d.
process are critical to
a diabetic patients
oral and systemic well-being. Research
suggests that water flossing may decrease
the toxic products generated by plaque
biofilm and that a change in the host response could be the mechanism by which
the Water Flosser achieves improvements
in gingival health.11-15

Comparing Power Interdental

Cleaners

Mechanism of Action
The Water Flossers mechanisms of
action are central to its effectiveness. The
two main physical features of water flossing action include pulsation and pressure.
Pulsation essentially regulates pressure.
A combination of these two actions allows
for disruption of bacterial activity, the
expulsion of subgingival bacteria and the
removal of loosely lodged debris and food
particles. Research has determined the
appropriate levels of pressure that should
be applied during usage. Clinical effectiveness has been demonstrated in the 5090
psi (pounds of pressure per square inch)
range. These levels reflect what both
healthy and inflamed
p5 Professional
tissues can comfortResponsibilities
ably handle without
and Considerations
tissue damage.22,23

A recent randomized controlled trial

compared the effectiveness of two power
interdental devices, the Water Flosser
and the Air Floss, when used as adjuncts
Versatility/Benefits
to manual toothbrushing. Both groups
showed significant reductions in gingiviThose with diminished dexterity can
tis, bleeding on probing, and plaque from
easily use the Water Flosser. It requires the
baseline for all regions and time points
user to simply hold the handle at a 90-demeasured (p<0.001). Between groups, the
gree angle to the tooth and irrigate the
Water Flosser group showed significantly
tissues at an appropriate pressure setting.
higher plaque reductions for whole-mouth,
With shifting demographics and a growmarginal, approximal, facial and lingual
ing elderly population, concerns related
areas. For bleeding on probing, the Water
to dexterity and other physical limitations
Flosser group was numerically better than
will grow. The elderly who suffer from
The Waterpik Ultra Water Flosser is clinically
proven up to twice as effective as string floss to
the Air Floss group for all areas and time
arthritis or other conditions that comproreduce bleeding and improve gingival health.
points, with statistically significant findmise the use of their hands may find the
ings for whole-mouth and facial areas, at
Water Flosser easy to manage and control.
week 2 and for the facial area at week 4.
Manufacturers instructions clearly state the
The Water Flosser group was significantly more effective at reducdesired power settings, and instructions are printed in readable type
ing plaque and gingivitis at weeks 2 and 4 for all areas measured
with accompanying graphics.
(p<0.001).16
The versatility of the Water Flosser also merits attention. In addition to subgingival lavage with water, the Water Flosser can hold,
deliver and direct antimicrobial solutions into the sulcus and interSystematic and Literature Reviews
proximal regions. Thus, when patients are advised to use antimicrobial
agents for home care, the Water Flosser is an appropriate choice.
Two comprehensive literature reviews and one systematic review
Six different water-flossing tips can attach to the unit. These inserts
conducted between 2005 to 2008 address the Water Flosser.17-19
are designed to address patient needs specific to general and tongue
In its published report, the American Academy of Periodontology
cleansing, orthodontic appliances, fixed restorative appliances, deeper
emphasizes the value of the oral irrigation for use in periodontal
periodontal pocket areas and toothbrushing.
maintenance and for the treatment of gingivitis. A key advantage
The Water Flosser also is a safe and effective
p7 Standard 1. II. d. 8.
cited was the Water Flossers ability to attenuate bacterial reductions
approach for cleansing between implants.24
obtained during scaling and root planing. The Water
Orthodontic patients, in particular, can benFlosser was recommended for patients who display
efit from water lavage.5 Food debris and plaque cling to orthodontic
p6 Standard 1. I. a.
inadequate interdental cleansing skills.17 Husseini
wires, brackets and plastic orthodontic appliances. Although people
et al. found that in the majority of studies cited in
of all ages may require orthodontic care, the majority of orthodontic
their systematic review, the addition of oral irrigation to toothbrushpatients typically are adolescents and young adults who tend to be
ing significantly reduced bleeding and gingivitis levels when compared
less amenable to the time commitment and labor intensity of flossing.
to toothbrushing alone. No differences in plaque accumulations were
Further, younger orthodontic patients may not have the dexterity to
found.18 The Canadian Dental Hygienists Associations 2006 position
be skillful and effective when flossing. The Water Flosser is ideal for
paper on flossing recommends the home irrigator (Water Flosser)
thorough cleansing of orthodontic fixtures.
as a viable alternative to finger flossing.18 The paper cites the fact
that patients often have difficulty removing interproximal plaque with
traditional string dental floss.19 Although dental floss is routinely sugConclusion
gested as the option of choice for interdental cleansing, low compliance with flossing has been reported.20,21 Therefore,
The Water Flosser offers convenience and ease of usage to a broad
other evidence-based options must be prescribed to p9 Standard 5. III.
consumer group. With todays technology and a world of quick and
patients who have been unable to achieve effectiveeasy, a large segment of the market is attracted to power-driven deness with dental flossing and/or are noncompliant
vices and oral hygiene practices that require minimal time and energy.
with its usage.
The Water Flosser is adaptable, easy to use, versatile and suitable for

access

FEB 2012 23

diverse populations. Research studies demonstrating its effectiveness, patient acceptance and provider p10 Key Terms
validation place it among the evidence-based choices
for effective interdental cleansing. When dental hygienists make
recommendations to their patients, they should include the Water
Flosser, a well-researched, effective and reliable approach to interdental cleansing,

References
1. Lobene R. The effect of a pulsed water pressure cleansing device on oral
health. J Periodontol. 1969; 40: 51-4.
2. Hoover DR, Robinson HBG. The comparative effectiveness of a pulsating
oral irrigator as an adjunct in maintaining oral health. J Periodontol. 1971;
42: 37-39.
3. Lainson PA, Bergquist JJ, Fraleigh CM. A longitudinal study of pulsating
water pressure cleansing devices. J Periodontol. 1972; 43: 444-6.
4. Barnes CM, Russell CM, Reinhardt RA, et al. Comparison of irrigation to
floss as an adjunct to tooth brushing: Effect on bleeding, gingivitis, and
supragingival plaque. J Clin Dent. 2005; 16(3): 71-7.
5. Sharma NC, Lyle DM, Qaqish JG, et al. The 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: 56571.
6. Rosema NAM, Hennequin-Hoenderdos NL, Berchier CE, et al. The effect
of different interdental cleaning devices on gingival bleeding. J Int Acad
Periodontol. 2011; 13(1): 2-10.
7. Gorur A, Lyle DM , Schaudinn C, Costerton JW. Biofilm removal with a dental water jet. Compend Contin Educ Dent. 2009; 30 (Suppl 1): 1-6.
8. Hugoson A. Effect of the Water Pik device on plaque accumulation and the
development of gingivitis. J Clin Periodontol. 1978; 5: 95-104.
9. Winter A. Rapid destruction caused by a water-irrigating device. Periodontal
Case Rep. 1981; 3: 11-4.
10. Drisko C, White CL, Killoy WJ, Mayberry WE. Comparison of dark-field
microscopy and a flagella stain for monitoring the effect of a Water Pik on
bacterial motility. J Periodontol. 1987; 58: 381-6.
11. Chaves ES, Kornman KS, Manwell MA, et al. Mechanism of irrigation effects
on gingivitis. J Periodontol. 1994; 65: 1016-21.
12. Cobb CM, Rodgers RL, Killoy WJ. Ultrastructural examination of human
periodontal pockets following the use of an oral irrigation device in vivo. J
Periodontol. 1988; 59(3): 155-63.
13. Flemmig TF, Newman MG, Doherty FM, et al. Supragingival irrigation with
0.06% chlorhexidine in naturally occurring gingivitis. I. 6 month clinical
observations. J Periodontol. 1990; 61: 112-7.
14. Cutler CW, Stanford TW, Abraham 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: 134-43.

15. Al-Mubarak S et al. Comparative evaluation of adjunctive oral irrigation in

diabetes. J Clin Periodontol 2002; 29:295-300.
16. Sharma NC, Lyle DM, Qaqish JG, Schuller R. Comparison of two power
interdental cleaning devices on the reduction of gingivitis. J Clin Dent.
2012; 23: (in press).
17. Greenstein G. Research, Science, and Therapy Committee of the American
Academy of Periodontology. Position paper: the role of supra- and subgingival irrigation in the treatment of periodontal diseases. J Periodontol. 2005;
76: 2015-27.
18. Husseini A, Slot DE, Van der Weijden GA. 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 Hyg. 2008; 6: 304-14.
19. Assadorian J. Canadian Dental Hygienists Association Position Statement:
Flossing. Can J Dent Hyg. 2006; 40: 1-10.
20. Warren PR, Chater BV. An overview of established interdental cleaning
methods. J Clin Dent. 1996; 7: 65-9.
21. Just the facts. flossing survey center, ADA News, Nov 2007.
22. Bhaskar SN, Cutright DE, Gross A, et al. Water jet devices in dental practice. J Periodontol. 1971; 42(10): 658-64.
23. Selting WJ, Bhaskar SN, Mueller RP. Water jet direction and periodontal
pocket debridement. J Periodontol. 1972; 43(9): 569-72.
24. Felo A, Shibly O, Ciancio SG, et al. Effects of subgingival chlorhexidine
irrigation on peri-implant maintenance. Am J Dent 1997; 10: 107-110.
Jacquelyn L. Fried, RDH, MS, received her
Bachelor of Arts in political science and her
Certificate in Dental Hygiene from Ohio State
University. She also holds a Master of Science
in Dental Hygiene from Old Dominion University. She is associate professor and director of
the Dental Hygiene Program in the Department
of Health Promotion and Policy at the University of Maryland Dental School. She has been
in dental hygiene education for over 30 years.
She has been involved with clinical, research,
didactic and community activities related to
tobacco. She has served as principal investigator for tobacco training grants funded by the
State of Maryland. An active member of the American Dental Hygienists Association, Fried is widely published and has authored numerous
manuscripts and book chapters. She teaches both didactically and clinically and has received student awards for her teaching abilities.

This column was made possible by an educational grant sponsored by

WaterPik.

n Your Feedback Is Welcome!

In 2008, the ADHA Board of Trustees approved the current Standards for Clinical Dental Hygiene Practice. In her annual report, then President Jean Connor, RDH, wrote, These standards reflect the dental
hygiene process of care and will be instrumental in assisting clinicians in their daily delivery of patient care
and educating the public, other care providers and policy makers on dental hygiene practice. Links to the
standards document appear throughout this article on professional tooth whitening and are expanded on the
opposite page.
The Standards are intentionally general so that they apply to all aspects of clinical dental hygiene care. If
you have comments about or additions to the links made in this article, please write and let us know. ADHA
intends for the Standards to be a living document, and we welcome your participation in the process. Send
comments and comments to
American Dental Hygienists Association
Access Standards in Practice
444 N Michigan Avenue
Suite 3400
Chicago, IL 60611
[email protected]
312-440-8916

24 FEB 2012

access

How this article reflects the

The Water Flosser was recommended for patients who display inadequate interdental cleansing skills.

Interdental cleansing is necessary for the attainment of optimal oral health.

Other evidence-based options must be prescribed to patients

who have been unable to achieve effectiveness with dental
flossing and/or are noncompliant with its usage. p9 Standard
5. III.

Standards for Clinical

Dental Hygiene Practice

The Definition of Dental Hygiene Practice (p4) includes removal of biofilm

plaque and calculus from teeth. Interdental cleansing is integral to this aspect
of dental hygiene care.

Dental hygienists can assist by offering recommendations

that are individualized and based on patients needs and
abilities.
The Standards Dental Hygiene Process of Care section (p6) states that the
purpose of the dental hygiene process of care is to provide a framework
where the individualized needs of the patient can be met; and to identify the
causative or influencing factors of a condition that can be reduced, eliminated,
or prevented by the dental hygienist.

Although two dated reports, one involving a case study and

another that compared toothbrushing to a Water Flosser
alone, questioned the plaque removal capabilities of water
flossing, subsequent studies refute those results.
The Standards Professional Responsibilities and Considerations (p5) require
the dental hygienist to access and utilize current, valid, and reliable evidence in
clinical decision making through analyzing and interpreting the literature and
other resources; and to commit to lifelong learning to maintain competence in
an evolving health care system. As illustrated here, new research can change
the best evidence on which to base clinical decisions.

Research examines the effects of oral irrigation on plaque

disruption, bacterial virulence and host response indicators.
The Introduction to the Standards (p3) states that the purpose of medical and
dental science is to enhance the health of individuals as well as populations.
The dental hygienist is educated to observe host response to dental hygiene
services as part of individualized, patient-centered care that includes
interdental cleansing.

Given the symbiotic relationship between diabetes and

periodontal disease, oral self-care measures that curb the
inflammatory process are critical to a diabetic patients oral
and systemic well-being.
The Definition of Dental Hygiene
Practice (p4) requires that the dental
hygienist discuss the progress being
made toward isolating evidence that
notes the potential association between
systemic and oral health and disease.
Engaging the patient with diabetes
in discussion of the oral-systemic link
helps enforce compliance with self-care
behaviors such as selection and use of
the right interdental cleansing regimen.
Standard 1. III. d. (p7) specifically cites
systemic diseases including diabetes
as factors to be evaluated as part of
risk assessment prior to dental hygiene
treatment planning.

access

Standard 1. I. a. (p 6) requires the dental hygienist to record as part of

patient history personal information including knowledge, skills and attitude.
This aspect of patient assessment will help ensure that patients do not go
unidentified who may benefit from selection of and education about aides for
interdental cleansing.

Standard 5. III. (p9) states that, throughout the process of care, the dental
hygienist evaluates and documents the outcomes of care and is required to
collaborate to determine the need for additional care based on treatment
outcomes and self-care behaviors. The dental hygienist can identify a patient
who cannot or will not successfully use dental floss for interdental cleansing
and can intervene by suggesting alternatives such as oral irrigation.

[Appropriate levels of pressure for water flossing] reflect

what both healthy and inflamed tissues can comfortably
handle without tissue damage.
Professional Responsibilities and Considerations (p5) require that the dental
hygienist take action to prevent situations where patient safety and well-being
could potentially be compromised. Knowing and informing the patient of the
manufacturers recommended settings for use of aides such as the Water
Flosser help ensure patient safety as part of the dental hygiene process of care.

The Water Flosser also is a safe and effective approach for

cleansing between implants.
Standard 1. II. d. 8. (p7) identifies fixed and removable prostheses among
the factors the dental hygienist must include in the clinical phase of patient
assessment. Noting the presence of (an) implant(s) in the chart will help
ensure that the dental hygienist will have it in mind when recommending the
best interdental cleansing regimen for this patient.

Research studies demonstrating its effectiveness, patient

acceptance and provider validation place [the Water Flosser]
among the evidence-based choices for effective interdental
cleansing.
Key Terms (p 10) define Evidence-Based Care as the integration of best
research evidence with clinical expertise and patient values. Being current with
ongoing research, using clinical judgment to evaluate assessment data and
treatment outcomes, and bearing in mind the patients abilities and willingness
to comply with an interdental cleansing home care regimen,
the dental hygienist will be able to assist the patient in
achieving and maintaining optimal oral health.

FEB 2012 25

The Evolution of Floss

Easy & Even More Effective!

New clinical research confirms the Waterpik Water Flosser
is significantly more effective than both String Floss
and Sonicare Air Floss for reducing gingivitis. And all
Water Pik clinical research is conducted by independent
universities and research facilities, and is published in
peer reviewed journals.
Join the evolution and recommend the Waterpik Water
Flosser for all of your patients who dont like to floss.
Plaque
Removal:

99.9%
From Treated
Areas1

Gingivitis
Reduction:

Gingivitis
Reduction:

50%

More Effective vs.

String Floss2

More Effective
vs. Sonicare
Air Floss3

1. Gorur A et al. Compend Contin Ed Dent. 2009; 30 (Suppl 1): 1 - 6.

2. Barnes CM et al. Journal of Clinical Dentistry, 2005; 16(3): 71 - 77.
3. Sharma NC et al. Journal of Clinical Dentistry, 2012; 23: In Press.
For research abstracts go to Waterpik.com
2012 Water Pik, Inc.

Sonicare is not a trademark of Water Pik, Inc.

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