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Why clinicians must always consider the needs of individual patients and supporting research when selecting a protocol.
“Gotta love him,” Cher mumbled to herself as she made preparations to seat a stubborn but intensely loyal male patient. Jim was in his early 70s, and he admitted recently that he’s been getting out of bed in the middle of the night and eating cookies. Not only does he have root caries on the facial surfaces of his mandibular anterior teeth, but Cher also struggles to manage his periodontitis. Jim thinks he’s cleaning his teeth adequately, but the plaque/biofilm and cookie residue are residing happily on the tooth roots.
Jim thinks he’s doing a great job with his powered toothbrush, interdental brushes and 5000 ppm sodium fluoride toothpaste, but nothing could be further from the truth. Cher sits back, crosses her arms for about 20 seconds, and then decides to change Jim’s self-care regimen. (Jim is one of those compliant patients with the exception of eliminating middle-of-the-night munchies.) Cher decides to introduce oral irrigation and she’s going to pair it with an inexpensive antiseptic called ioRinse that Jim will place in his irrigator.
Oral irrigation for older adults
I’m a big fan of oral irrigation for older adults, and my opinion is based on anecdotal, personal and clinical experience as well as expertise as a prevention specialist. For older adults with gingivitis or periodontitis, I’m an even bigger proponent of adding an appropriate antiseptic to the water bath.
Oral irrigation has been available since 1962 when Aqua Tec Corporation, the company that eventually became WaterPik, Inc., was founded. We didn’t know a lot about plaque biofilm back then and oral irrigators were first designed to be used supragingivally. Oral irrigators use water pressure to disrupt plaque/biofilm. Later, various tips were designed to be used subgingivally.1
Scientific evidence to support oral irrigation in older adults, with and without antiseptics, is confusing because there are no clinical guidelines to support oral irrigation as an alternative to other means of biofilm disruption. American healthcare providers are known for overusing, underusing and misusing healthcare interventions and medications, so we must remain cautious and apply best research evidence when available. If research evidence isn’t available, we often rely on clinician and patient preferences and, in doing so, monitoring outcomes such as a reduction in bleeding on probing is key. Although there are many research studies showing oral irrigators with water remove biofilm from tooth surfaces and bacteria from periodontal pockets, practitioner and other evidence-based policy maker recommendations are inconsistent, and there’s only one systematic review2 and no clinical guidelines to assist us in recommending oral irrigation to specific patients.
A 2008 systematic review on the efficacy of oral irrigation in addition to toothbrushing on plaque and periodontal inflammation concluded the oral irrigator doesn’t have a beneficial effect in reducing visible plaque; however, the authors also reported a positive trend in favor of oral irrigation in improving gingival health over toothbrushing alone.2
If you review the literature on oral irrigation, you’ll find a ton of studies suggesting that oral irrigation removes plaque/biofilm from tooth surfaces and microorganisms from periodontal pockets when compared to string flossing and toothbrushing in various combinations. Systematic reviews of the literature are more reliable than single studies (most of the time) because of study biases and other errors, so a clinician has to rely on patient outcomes over time in recommending one self-care protocol over another when there’s a scarcity of quality research.
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Adding an antiseptic to an oral irrigator
The addition of an antiseptic to an oral irrigator for a select number of adult patients can confuse a practitioner further because the literature doesn’t offer much guidance. For periodontal patients, antiseptics have a long history of use in periodontal therapy.3
In the 1970s, chlorhexidine (CHX) as an adjunct to nonsurgical periodontal therapy was widely adopted by dentists and hygienists as a “gold standard” oral chemotherapeutic agent, and many practices still send patients home with a script or bottle of CHX to use post-periodontal therapy for four weeks or longer. There’s high-quality evidence that the use of mouth rinses containing CHX in addition to usual toothbrushing and cleaning for four to six weeks leads to a large reduction in the buildup of plaque/biofilm.3 Adverse effects of mouth rinses containing CHX include tenacious brown-black staining of teeth, increased formation of calculus and altered taste sensation.3 CHX is expensive and not designed to be diluted in an oral irrigator. Generally speaking, it’s not designed for long-term usage.
An inexpensive antiseptic that can be added to an irrigator is household bleach (sodium hypochlorite). Several pilot (small-scale) studies have shown safety and efficacy of diluted sodium hypochlorite as an oral irrigant in reducing supragingival plaque biofilm and bleeding on probing.4, 5-7 For a good tutorial with instructions on diluted sodium hypochlorite rinsing, including use in an oral irrigator, visit https://pdmillerswebtextbook.com. PD Miller is a periodontist.
Another relatively inexpensive antiseptic that’s compatible with an oral irrigator is ioRinse, or molecular iodine. It’s different from povidone iodine (common brand, Betadine). The company claims that molecular iodine rapidly destroys a broad spectrum of pathogenic microbes, similar to povidone iodine and chlorohexidine gluconate, and it also claims broad spectrum against viruses, bacteria and fungi. ioRinse doesn’t stain and it has a pleasant taste and many applications, including twice-a-day use in an oral irrigator or as an oral rinse. It can also be used with a periodontal subgingival tip once a day in an oral irrigator. Prospective, randomized clinical trials aren’t yet available to support some biofilm-guided care decisions such as oral irrigation with antimicrobial agents, so personal experience is sometimes used to guide clinicians. ioRinse is an antimicrobial agent, like sodium hypochlorite, that periodontists are recommending for use in an oral irrigator.
Clinicians must always consider the needs of individual patients and supporting research in selecting a protocol that the patient will comply with and one that will improve outcomes. Make sure your recommendations are based on ample scientific evidence whenever possible-and keep those cookie monsters at bay.
1. Johnson TM, Worthington HV, Clarkson JE, Poklepovic Pericic T, Sambunjak D, Imai P. Mechanical interdental cleaning for preventing and controlling periodontal diseases and dental caries. Cochrane Database of Systematic Reviews 2015, Issue 12. Art. No.: CD012018. DOI: 10.1002/14651858.CD012018.
2. 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 periodon- tal inflammation: a systematic review. Int J Dent Hyg. 2008; 6: 304-14.
3. James P, Worthington HV, Parnell C, et al. Chlorhexidine mouthrinse as an adjunctive treatment for gingival health. Cochrane Database Syst Rev. 2017;3(3):CD008676. Published 2017 Mar 31. doi:10.1002/14651858.CD008676.pub2
4. Rich, SK, Slots J. Sodium hypochlorite (diluted chlorine bleach) oral rinse in patient self-care. Periodontal Abstracts. J of Western Society of Periodontol. 2015; 63(4): 99-103.
5. Galvin M et al. Periodontal effects of 0.25% sodium hypochlorite twice-weekly oral rinse. J Periodont Res 2014: 49: 696–702.
6. DeNardo R et al. Effects of 0.05% sodium hypochlorite oral rinse on supragingival biofilm and gingival inflammation. Inter Dent J 2012; 62: 208–212.
7. Shah P et al. Clinical evaluation of 0.10% sodium hypochlorite as an oral rinse in chronic generalized periodontitis patients. Adv Hum Biol. 2016: 6(1): 51-56.
8. Snyder RJ et al. Wound biofilm: current perspectives and strategies on biofilm disruption and treatments. Wounds. 2017 Jun;29(6):S1-S17.
Conflict of interest disclosure
Author Lynne Slim has no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or nonfinancial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.