Oral irrigators (irrigators, mouthwashers, water jet devices) are valuable aids for oral hygiene. They are not only a useful addition to daily dental care with toothbrush, dental floss and/or interdental brushes (interdental brushes), but in combination with the toothbrush are the means of choice for patients with fixed orthodontic appliances, for implant carriers and patients who are reluctant to more elaborate interdental care. The use of an oral irrigator is not only suitable for patients who already have periodontal disease (inflammation of the tooth bed). Rather, a water jet device can be used prophylactically (preventively) by anyone who shies away from daily interdental space hygiene with dental floss, toothpicks and interdental space brushes. This not inconsiderable number of patients can – in combination with toothbrushing – keep their teeth and gums healthy with the help of an oral irrigator and avoid the development of periodontal disease. Research even suggests that the combination of toothbrush and oral irrigator is more effective than toothbrushing in conjunction with conventional flossing. Plaque or biofilm is the term used to describe the microbial plaque that forms on surfaces and in interdental spaces (synonyms: approximal spaces, interdental spaces) when dental care is inadequate. Due to an overabundance of carbohydrates for too long, plaque matures into a well-organized ecosystem firmly adhering to the teeth, leading to an increased risk of caries. In addition, however, the biofilm is the essential factor in the development and progression of gingivitis (inflammation of the gums). This is because the increase in plaque over a longer period of time and the resulting impeded oxygen supply in the deeper biofilm layers cause anaerobic (living without oxygen) germs to thrive there, which inevitably lead to gingivitis in the uncleaned areas within a few days. If other unfavorable factors are added, inflammatory damage to the periodontium in the form of periodontitis (inflammation of the periodontium) can be the result. In the long term, periodontitis results in bone loss of the alveolus (the bony compartment of the tooth) and eventually tooth loss. In addition, effects on general health have been scientifically proven: Periodontitis increases the risk of apoplexy (stroke), myocardial infarction (heart attack) or premature birth. The therapeutic approach is therefore aimed at regularly disrupting the formation of the biofilm by appropriate oral hygiene techniques and thus reducing the periodontopathogenic germs (those that damage the periodontium) contained therein. Scanning electron microscopy studies show that a plaque-colonized tooth surface is practically free of biofilm after a treatment period of 3 seconds with the oral irrigator. If this has already matured for 48 hours, it can still be reduced by 85% after 5 seconds by the waterjet device. Bacterial cell walls are destroyed by the jet. Despite the effective action of water jets, recommendations do not go so far as to use oral irrigators as the sole hygiene tool, as they alone cannot completely prevent the development of inflammation. To keep the gingival margin and pockets permanently free of inflammation, several therapeutic measures must go hand in hand:
- Oral hygiene counseling – The patient is taught proper brushing techniques using a toothbrush, in addition to interdental space hygiene techniques (techniques designed for the interdental spaces that are difficult to clean). This includes, especially for patients who have difficulty in the proper use of dental floss and / or interdental brush, the daily use of an oral irrigator.
- Regular professional dental cleaning (PZR).
- Control of the success of practice – The successful implementation of the newly learned methods is monitored by the dental office.
- If necessary, periodontal treatment – following the gripping hygiene measures.
- Close recalls – preventive appointments with the dentist help prevent the development or flare-up of periodontitis.
If water jet devices germ-reducing rinsing solutions (eg chlorhexidine 0.06%) are added,they show better effect in the subgingival (pocket) area than pure mouth rinsing measures with higher percentage solutions (eg chlorhexidine 0.2%).Since chlorhexidine also increasingly shows side effects such as tooth and tongue discoloration and taste irritation with increasing concentration, the patient thus experiences a clear benefit from the application of the active ingredient by means of the oral irrigator.
Indications (areas of application)
The use of water jet devices is useful – as a supplement to toothbrushing:
- For uncomplicated cleaning of the interdental spaces (interdental spaces) or under pontics.
- As a means of choice for patients with fixed orthodontic appliances.
- For effective reduction of the established biofilm.
- For the removal of food residues
- To effectively reduce the signs of inflammation of the gingiva (gums).
- In the context of a UPT (Supportive Periodontal Therapy) – for the application of germ-reducing rinsing solutions (eg chlorhexidine 0.06%) by means of special nozzles (eg Waterpik Pik Pocket) in gingival pockets.
- For the prevention (prophylaxis) of peri-implantitis (implant bed inflammation) – e.g. Waterpik Pik Pocket subgingival nozzle for the daily application of 0.06% chlorhexidine
- For periodontitis prevention in diabetes mellitus (diabetes).
- For massage and stimulation of the gingiva (the gums).
- For prevention against gingivitis or periodontitis.
- For oxygen enrichment of the bacterial pocket environment
- To reduce halitosis (bad breath).
- To clean teeth in intermaxillary lacing (wiring upper and lower teeth together to immobilize the lower jaw in fractures (breaks)).
Contraindications
- Oral irrigators are not suitable as the sole tool for cleaning teeth, as this method does not completely prevent the development of gingivitis (inflammation of the gums).
- If the application of the water jet is done improperly with too high pressure into the inflammatory changed gum pocket, this can lead to injury to the already edematous (swollen) and loosened by the inflammatory processes pocket tissue. The germs that thus enter the bloodstream lead to increased bacteremia (washing of bacteria into the bloodstream), which should be avoided in patients at risk of endocarditis (inflammation of the inner lining of the heart) or at risk of developing rheumatic fever. However, bacteremia is also detectable after cleaning with a toothbrush and flossing.
The procedures
Oral irrigators usually offer the ability to adjust pressure on the handle and allow antimicrobial additives such as CHX (chlorhexidine digluconate). For pocket rinses, the pressure regulator must be set to the lowest pressure. Oral irrigators are available with one or more jets, with the option of changing the water jet and with a rotating jet. In this case, the focused jet is used to remove biofilm and loose food debris, while the multi-jet setting can be assumed to have a massaging effect on the gingiva (gums). Pulsating water jets with a frequency of 800 to 3,000 oscillations per minute improve the cleaning effect. Newly developed models (e.g. Oral-B OxyJet) filter the air and enrich the water jet with millions of micro air bubbles with the aim of reducing anaerobic (living without oxygen) germs in the pocket environment and plaque (dental plaque). The water jet does not penetrate completely into the depths of the gingival pockets, especially since the pressure must be minimized during pocket rinsing to prevent injury to the inflammatory changed pocket tissue with subsequent bacteremia (washing of bacteria into the bloodstream). Special nozzles (e.g. Waterpik Pik Pocket) improve the application of the irrigation fluid to about 50% of the pocket depth. A special feature is represented by so-called mouth baths, with which various antimicrobial additives – usually solutions containing tartaric acid or carbon dioxide (0.3 %) and neutralizing sodium hydrogen carbonate solutions (0.3 %) – can be applied alternately via a programmable sequence in the dental practice. The following application instructions should be considered:
- The oral irrigator is used before or after brushing teeth, both in the morning and in the evening.
- To prevent injury, the lower pressure range should be set at the beginning until you are used to handling. The same applies to inflammation of the gums.With healthy gums and after acclimatization can be increased to the medium pressure range.
- First, the water jet must be directed at right angles to the tooth axis or away from the gum towards the tooth crown to remove loose plaque.
- After that, the angle of the water jet can be slightly directed towards the gingival pockets to remove any remaining plaque there and, if necessary, enrich the pocket environment with oxygen. This deprives the anaerobic – living without oxygen – bacteria of the basis for life.
- Initial inflammation-related bleeding gums recede after the first few weeks with proper use.
Possible complications
- Injury to gingival pockets if used improperly under excessive pressure setting.
- Bacteremia (washing of bacteria into the bloodstream).
- Germination of the water-bearing pathways if the device is not properly maintained.
