Having just shy of a year of
experience in the clinic, it has become apparent that most of my patients do
not enjoy flossing, nor do they floss as often as they should. They all seem to
understand the importance of flossing daily, however, it seems rare that they actually
do so. On one occasion, a patient asked me--somewhat cynically--why there
hasn't been a better invention than a "piece of string" to clean between
teeth. I mentioned that there actually are
more high-tech devices than floss, known as oral irrigators and manufactured by
Waterpik. My patient seemed intrigued and wanted to know if they worked better
than floss. While I remember briefly learning about these devices in class, I
didn't remember specifically if they performed any better than floss. Because
of this patient's inquiry, I wanted to learn more about how oral irrigators
compare to floss in plaque control and in the management of gingivitis.
In order to fully address this
question, it is important to first consider whether or not flossing is
effective as an adjunct to toothbrushing. Flossing has received a lot of
attention in the discussion of maintaining the health of the interproximal
areas because a toothbrush cannot access and clean these areas sufficiently. In
addition, these areas often show an increased amount of inflammation and dental
caries.1 In a systematic review from 2008 about flossing as an
adjunct to brushing, the authors stated, "dental flossing provides no
benefit above and beyond toothbrushing on removing plaque and reducing
gingivitis. Based on the individual papers in this review, a trend was observed
that indicated a beneficial adjunctive effect of floss on plaque levels;
however, this could only be substantiated as a non-significant trend in the
meta-analyses."2 At first this finding surprised me, as I have
always been taught that flossing is a very necessary adjunct to brushing.
However, the authors commented about patient compliance--saying that many
people do not floss properly, which could skew results and portray flossing in
a bad light.
In another systematic review, researchers found that there is some
evidence that flossing as an adjunct to brushing reduces gingivitis (because it
reduced gingival bleeding). They noted, however, that the evidence is weak
because the trials were poor in quality and are unreliable.1 Based
on these two systematic reviews, the consensus seems to be that flossing does
not have a significant effect in plaque reduction and reducing gingivitis. The
authors in these studies referenced other systematic reviews that had similar
findings.3
Another interesting point that
Berchier et al noted was that in a 21-day non-brushing study, it was found that
flossing alone was able to reduce bleeding scores by about 40%. This shows that
flossing isn't necessarily useless, especially if done with proper technique.
However, as stated earlier, flossing as an adjunct to brushing may not provide
much added benefit. Given these findings, it is no surprise that many other
types of interdental cleansing devices have been developed to aid patients in
their homecare.
With the previously stated
findings as a baseline, a comparison can be made between floss and oral
irrigators. Interestingly enough, a systematic review (done by a similar group
of authors mentioned previously) found that oral irrigators do in fact show a
positive trend in favor of improving gingival health compared with
toothbrushing alone. These findings were based on plaque scores, gingival
indices, and bleeding.4 One limitation in this study, however, was
that they could not carry out a meta-analysis due to insufficient data. While
this systematic review still provides important insights, it may not be
complete. In another 4-week study from 2011 in favor of oral irrigation,
evidence suggests that oral irrigators have a significant advantage over
flossing in improving gingival health. The authors of this study claim,
"When combined with manual toothbrushing the use of an oral irrigator...is
significantly more effective in reducing gingival bleeding scores as compared
to the use of dental floss."5 One important consideration within
this study, however, was the involvement of Waterpik in its completion;
therefore there could be some potential of bias although they claim that they
have no conflict of interest.
I must admit that the results
I found in the systematic reviews surprised me a little bit. I was somewhat
skeptical about the oral irrigators because I thought they might just be
marketing tools. At the same time, the data didn't show any overwhelming
evidence that oral irrigators were highly superior to flossing. However, one
thing that kept sticking out to me while thinking about the studies was that
there may be a deficiency in the way in which we educate patients how to floss
(and perhaps use the irrigators). This leads me to my first main take away: the
importance of persistent and consistent oral hygiene instructions (OHI) for
patients. Not only is it important to demonstrate the appropriate techniques to
patients, but also for them to demonstrate back what they understand.
Additionally, each patient will need individualized OHI and oral hygiene
adjuncts to toothbrushing that cater to his or her specific needs and
limitations (e.g., manual dexterity, time, and other intraoral factors of the
individual). For some, flossing may be the best; for others an irrigator may be
more effective.
Furthermore, I will share more
with patients about oral irrigators than I have before, especially to those who
abhor flossing. Because the evidence
shows the advantage that oral irrigators have over floss, I feel that this may
give patients a better chance at achieving periodontal health.
References
1. Sambunjak
D, Nickerson JW, Poklepovic T, et al. Flossing for the management of
periodontal diseases and dental caries in adults. Cochrane Database of
Systematic Reviews 2011, Issue 12. Art. No.: CD008829. DOI:
10.1002/14651858.CD008829.pub2.
2. Berchier
C, Slot D, Haps S, Van der Weijden G. The efficacy of dental floss in addition
to a toothbrush on plaque and parameters of gingival inflammation: A systematic
review. Int J Dental Hygiene 2008;6(4):265-279.
3. Hujoel
PP, Cunha-Cruz J, Banting DW, Loesche WJ. Dental flossing and interproximal
caries: A systematic review. J Dent
Res 2006;85:298-305.
4. Husseini
A, Slot D, Van der Weijden G. (2008), The efficacy of oral irrigation in
addition to a toothbrush on plaque and the clinical parameters of periodontal
inflammation: A systematic review. Int J Dental Hygiene 2008;6(4):304-314.
5. Rosema NA, 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.