|Year : 2017 | Volume
| Issue : 4 | Page : 296-302
Effect of supragingival oral irrigation as an adjunct to toothbrushing on plaque accumulation in chronic generalized gingivitis patients
Manish Khatri1, Aamir Shams Malik1, Mansi Bansal1, Komal Puri1, Geeti Gupta2, Ashish Kumar1
1 Department of Periodontology, Institute of Dental Studies and Technologies, Modinagar, Uttar Pradesh, India
2 Al Thuraya Dental and Implant Centre, Abu Dhabi, UAE
|Date of Submission||07-Nov-2015|
|Date of Acceptance||31-Oct-2017|
|Date of Web Publication||29-Jan-2018|
Dr. Mansi Bansal
B-66 Friends Colony (West), New Delhi
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aim: The aim of this study was to evaluate the efficacy of supragingival oral irrigation either with water or different concentrations of chlorhexidine (CHX) digluconate as an adjunct to toothbrushing on plaque accumulation in chronic generalized gingivitis patients. Materials and Methods: Fifty patients were randomly allocated into five groups. Group 1: toothbrushing alone, Group 2: toothbrushing with mouthwash, Group 3: toothbrushing with water irrigation, Group 4: toothbrushing with 0.0075% CHX digluconate (36 mg) supragingival irrigation, and Group 5: toothbrushing with 0.02% CHX digluconate (96 mg) supragingival irrigation. The collected data were subjected to statistical analysis. Statistical Analysis: Descriptive data were obtained for all outcome variables and reported as mean ± standard deviation. The Student's t-test, Chi-square test, and one-way analysis of variance (ANOVA) were applied for the statistical evaluation of means and comparisons of proportions, and post hoc Bonferroni test was used for multiple comparisons after the application of the ANOVA test for comparison within the groups. Results: When intergroup difference of the mean differences was compared for individuals using toothbrushing along with 0.0075% CHX digluconate irrigation and those using toothbrushing along with 0.02% CHX digluconate irrigation from BL-14, BL-28, and between 14 and 28 days, it was found to be statistically nonsignificant. Conclusions: In our study, the CHX digluconate concentration for mouthwash and oral irrigation in addition with toothbrushing was found to be same, i.e., <50 mg for improving the gingival health by reducing gingival inflammation.
Keywords: Chlorhexidine, dental plaque, gingivitis therapeutic irrigation, toothbrushing
|How to cite this article:|
Khatri M, Malik AS, Bansal M, Puri K, Gupta G, Kumar A. Effect of supragingival oral irrigation as an adjunct to toothbrushing on plaque accumulation in chronic generalized gingivitis patients. J Indian Soc Periodontol 2017;21:296-302
|How to cite this URL:|
Khatri M, Malik AS, Bansal M, Puri K, Gupta G, Kumar A. Effect of supragingival oral irrigation as an adjunct to toothbrushing on plaque accumulation in chronic generalized gingivitis patients. J Indian Soc Periodontol [serial online] 2017 [cited 2022 May 25];21:296-302. Available from: https://www.jisponline.com/text.asp?2017/21/4/296/223970
| Introduction|| |
Scientific knowledge has expanded the professional understanding of dental plaque. Treatment and prevention are now focused on removal of biofilm. Biofilms consist of microcolonies of bacteria embedded in slimy matrix that can survive in hostile surroundings. Removal of plaque by appropriate mechanical and chemical methods reduces and controls gingivitis as recommended by Loe et al. using the experimental gingivitis model.
The most common means of actively removing plaque is toothbrushing. The toothbrush, however, does not reach the interproximal surfaces of the teeth as efficiently as it reaches the facial, lingual, and occlusal surfaces. The removal of plaque from interproximal surfaces is significant because gingivitis and periodontitis are usually distinct in the interdental areas where bacteria can accumulate, multiply, and remain uninterrupted. However, the limitation with all interdental cleaning aids is patient dexterity and motivation. Efficacy of various interdental products, for example, floss/tape, water jets, and interdental brushes are based on its effectiveness in reducing bleeding, gingival inflammation, quality, and quantity of biofilm accumulations. The chemical approach of plaque control suffers from the constraint that the most effective antimicrobial agents do not penetrate the biofilm.
Oral irrigator (OI) introduced in 1962 is a device that has been demonstrated to be an adequate system for delivering the antibacterial agent for both supragingival and subgingival treatment. OIs assist the removal of food debris in posterior areas, especially in cases of fixed bridges or orthodontic appliances, where the proper use of interdental cleaning devices is complex.
The research on the Waterpik ® Dental Water Jet (OI Device) spans over 45 years and demonstrates significant reductions in inflammation and infection. In 2001, the American Academy of Periodontology stated, “Among individuals who do not perform excellent oral hygiene, supragingival irrigation with or without medicaments is capable of decreasing gingival inflammation beyond that normally achieved by toothbrushing alone. This effect is likely due to the cleansing of subgingival bacteria.” Chlorhexidine (CHX) has been evaluated frequently in dental water jet studies. Furthermore, diluting CHX is acceptable for use in a dental water jet. Dilutions of 0.04% and 0.06% (based on a 0.12% concentration) have been shown to be effective through randomized clinical trials.,
The aim of the present study was to evaluate the efficacy of supragingival oral irrigation either with water or different concentrations of CHX digluconate as an adjunct to toothbrushing on plaque accumulation in chronic generalized gingivitis patients.
| Materials and Methods|| |
A total of seventy BDS student volunteers and dental auxiliary staff aged between 19 and 30 years with no sex predilection were selected from the Outpatient Department of Periodontology. The patients were selected by the following criteria.
- Both sexes diagnosed with chronic generalized gingivitis, with presence of ≥20 teeth with clinical signs of inflammation confined to gingiva only
- Bleeding on probing ≥30% teeth
- Gingival index (GI) ≥1.
- Systemic disease or medications influencing gingival tissues
- Pregnant or lactating woman
- Patients who have undergone any periodontal therapy in the last 6 months.
Ethical committee of the institution approved the study design. Screening of the individuals according to the inclusion and exclusion criteria and preassessment full mouth indices (plaque index [PI], GI, gingival bleeding index [BI]) was done. A total of seventy BDS student volunteers were selected for the study. However, ten individuals did not fulfill the inclusion criteria, and ten individuals were noncompliant with the instruction and the appointment date. Hence, fifty patients were included in the study. The treatment protocol was explained to all the patients, and a written informed consent was taken from each individual.
Full mouth PI, GI, and bleeding on probing index at 4 sites per tooth were recorded in a tabulated pro forma at baseline (day 0) by a single examiner blinded to treatment. After baseline examination, thorough scaling and polishing of teeth was done to render the mouth plaque free and oral hygiene instructions were given to all the individuals who were then given the same manual toothbrush (Oral B/Soft) and toothpaste (Oral B/Pro Health) and were instructed to brush twice daily using modified bass method, which was demonstrated to them. The individuals were recalled depending on the respective group and their treatment.
The selected patients were randomly allocated into one of the following five groups:
- Group 1: Toothbrushing alone twice daily for 2 min
- Group 2: Toothbrushing twice daily for 2 min followed by CHX mouthwash (Aster-X™) 15 ml of undiluted 0.12% (18 mg) twice daily for 1 min
- Group 3: Toothbrushing twice daily for 2 min plus professional supragingival oral irrigation with 480 ml of water once daily using the supragingival irrigation tip of Oral Irrigation Device (Waterpik ® Dental Water Jet, Waterpik, Inc, Fort Collins, CO)
- Group 4: Toothbrushing twice daily for 2 min plus professional supragingival oral irrigation with 480 ml of 0.0075% CHX digluconate (36 mg) once daily using Waterpik ®. 30 ml of 0.12% CHX solution (Aster-x ™) was diluted with 450 ml of water (in the ratio of 1:15) to achieve the specific volume and required concentration of CHX digluconate
- Group 5: Toothbrushing twice daily for 2 min plus professional supragingival oral irrigation with 480 ml of 0.02% CHX digluconate (96 mg) (Aster-X ™) once daily using Waterpik ®. 80 ml of 0.12% CHX solution was diluted with 400 ml of water in the ratio of 1:5 to achieve the specific volume and required concentration of CHX digluconate.
PI [Figure 1], gingival BI [Figure 2], and GI [Figure 3] were recorded again at 14th and 28th day from baseline. The collected data were subjected to statistical analysis.
|Figure 2: Gingival bleeding index at (a) baseline, (b) 14, and (c) 28 days|
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Descriptive data were obtained for all outcome variables and reported as mean ± Standard deviation. The Student's t-test, Chi-square test, and one-way analysis of variance were applied for the statistical evaluation of means and comparisons of proportions, and post hoc Bonferroni test was used for multiple comparisons.
| Results|| |
The individuals included were 36 males (72%) and 14 females (28%), with age range of 19–30 years (mean age of 22.56 ± 2.00 years) [Graph 1] and [Graph 2]. The mean PI, GI, and BI scores for all groups and intragroup comparison at different time intervals are shown in [Table 1], [Table 2], [Table 3], respectively. The intergroup difference of the mean differences when compared at different time intervals is shown in [Table 4], [Table 5], and [Table 6] and [Graph 3],[Graph 4],[Graph 5], respectively.
|Table 1: Mean plaque index for all groups and intragroup comparison at different time intervals|
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|Table 2: Mean gingival index for all groups and intragroup comparison at different time intervals|
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|Table 4: Intergroup comparison of differences in plaque index at different time intervals|
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|Table 5: Intergroup comparison of differences in gingival index at different time intervals|
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|Table 6: Intergroup comparison of differences in bleeding index at different time intervals|
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| Discussion|| |
CHX mouthwash is used in concentrations of 0.12% solution (30 mg–40 mg) to deliver the required minimal dosage of <50 mg of CHX digluconate to exert the desirable antibacterial effect. It is interesting to note that oral irrigation without chemical agents has also demonstrated the ability to reduce gingivitis without significantly reducing the dental plaque. Therefore, in the present study, different concentrations of CHX were used to analyze if lower concentration with increased volume can be used to compensate for the decreased concentration of the drug and therefore leading to less staining effect of CHX digluconate.
The oral environment is dark and moist, and the bacteria producing dental plaque thrive in such environment. It takes 12 h for the bacteria to repopulate and cause the destruction of the oral cavity; therefore, to minimize such effect, brushing twice daily is recommended. Brushing time of 2–3 min is standardized so as to avoid variation in the plaque-removing efficacy, which may vary between the individuals. To remove bias in any of the irrigation groups, 480 ml of supragingival oral irrigation is kept constant in Group 3, Group 4, and Group 5.
In the present study, the clinical parameters in individuals using toothbrushing alone significantly reduced from baseline to 14 and 28 days. These results are in accordance with the study of Singh et al. and Lang et al. who found that toothbrushing could significantly reduce plaque score with reduction in gingival inflammation.
When pre- and post-treatment plaque scores, gingival scores, and bleeding on probing were compared in Group 2 individuals, then it was found that the measurements significantly decreased from baseline to 14 days and then to 28 days and from 14 to 28 days. When intergroup comparison was done between Group 1 and Group 2 individuals, it was found to be nonsignificant. This suggests that mouthrinse has no effect when combined with toothbrushing. These results are in accordance with the study of Löe and Schiott, Binney et al., Finkelstein et al., and Van Strydonck et al. who found that complete inhibition of plaque and prevention of gingivitis may be achieved by daily application of CHX, provided the agent is administered in such a way that it reaches all tooth surfaces.
The mean PI, gingival, and bleeding scores in Group 3 individuals significantly reduced at 14 days, which further reduced at 28 days. The results of our study were found to be similar to the results of Walsh et al., Newman et al., Barnes et al., and Rosema et al. who found that adjunctive supragingival irrigation with water could provide meaningful clinical outcomes. However, the nonsignificant result between 14 and 28 days in plaque scores was in accordance with the study of Chaves et al. who also had minimal or no effect on clinical plaque levels. Therefore, it was suggested that benefits of irrigation are not the result of reduction in supragingival plaque. When intergroup comparison between Group 1 and Group 3 was done from BL-14 and 28 days, it was found to be statistically nonsignificant. Hugoson  also suggested that Waterpik failed to demonstrate reduction of gingivitis when used as an additional measure. The results of the present study are in contrast to that of Cutler et al. who concluded that oral irrigation with water for 14 days had an improved therapeutic benefit for adult periodontitis over that of routine oral hygiene alone. When intergroup difference of the mean differences was compared at BL-14 and 28 days and from 14 to 28 days in Group 2 and Group 3, it was found to be statistically nonsignificant which is similar to Brownstein et al.'s  study who found nonsignificant result when CHX rinse is compared to a placebo rinse after 2 months.
In the present study, in Group 4 individuals, the plaque gingival and bleeding scores reduced at 14 days which was further reduced at 28 days. These results found in accordance with the results of Cumming and Löe  who found that if larger volumes are used in much lower concentrations of CHX, plaque inhibition in the posterior portion of the oral cavity is better with an irrigator than with normal rinsing and that staining is less with large volumes of dilute concentrations than with small volumes of stronger concentrations. When intergroup difference of the mean differences was compared at BL-14 days and 28 days, it was found to be statistically significant in Group 1 and Group 4 individuals. However, the results were not significant for PI for all the time intervals. These results are in accordance with the study of Chaves et al. who suggested that gingivitis reduced because of specific host-microbiota alterations and not because of plaque reduction. These results are in accordance with the study of Walsh et al. who compared toothbrushing with and without adjunctive oral irrigation for controlling plaque and gingivitis and reported that all the treatment regimens were effective in reducing gingival inflammation from BL-3 months and 6 months. Above results suggest that the benefit of OI is that it delivers CHX digluconate in larger volume and helps in the distribution of CHX in various regions of dentition resulting in the reduction of gingival scores.
In the present study, the benefits of irrigation on plaque scores were only minimally reduced but GI and BI scores significantly reduced in Group 2 and Group 4 individuals. The results of the present study obtained are in accordance with results of Hugoson  and Emslie  who suggested that Waterpik could not be said to fulfill the requirements of a satisfactory plaque control device. Furthermore, it was suggested that plaque-removing potency of irrigating systems is poor and they seem to be effective against the food debris rather than against dental plaque. However, the results of the present study are not in accordance with the study by Al-Mubarak et al. who reported that scaling and root planing along with adjunctive use of water irrigation had statistically significant reduction in PI. The difference in the result may be justified in our study that professional supragingival irrigation was done once daily whereas in Al-Mubarak et al.'s study, subgingival irrigation was done twice daily which might have resulted in improvement in plaque scores. Furthermore, study by the Sanders et al., who concluded that supragingival pulsated jet irrigation, has limited effects on the composition of subgingival plaque which further supports the results of our study. However, the results were insignificant from 14 to 28 days. Bleeding scores were significantly reduced when toothbrushing along with 0.02% CHX digluconate irrigation was used whereas gingival scores remain unaffected.
When intergroup difference of the mean differences was compared from BL-14 and from BL-28 and between 14 and 28 days, it was found statistically nonsignifi cant for GI and PI scores when Group 3 was compared with Group 4 or Group 5. However, BI scores at all time intervals and GI compared from 14 to 28 days were found to be statistically significant. These results are also found in accordance with the results of Chaves et al. and Flemmig et al. who reported that there is enhanced effect of CHX on gingivitis when used with the OI as a treatment regimen, whereas irrigation with water had less effect then CHX irrigation in their study.
The plaque score in individuals using toothbrushing along with 0.02% (96 mg) CHX digluconate irrigation reduced at 14 days, which remained constant at 28 days. The PI measurements at 14 and 28 days were significantly lower than baseline. However, the difference in PI measurements at 14 and 28 days failed to reach the level of statistical significance. The gingival and bleeding scores however reduced from 14 to 28 days significantly. These results are in accordance with the study of Lang and Ramseier-Grossmann  who evaluated the role of CHX digluconate in different concentrations using a fractioned jet OI and reported that once daily irrigator application of 400 ml of a 0.02% CHX solution was the optimal and lowest concentration and dose to be used for complete inhibition of dental plaque and reduction in gingival inflammation and bleeding. While the plaque measurements were not found to be statistically significant between 14 and 28 days in the present study, this may be correlated with the study of Lang and Räber  who found similar results in their 29th day study.
However, when mean differences of Group 3 was compared to Group 4 and Group 5, at 14days -28 days, the BI results were found to be statistically nonsignificant. This suggested that patient consistently maintained the oral hygiene from 14 to 28 days. Furthermore, as suggested by Ciancio et al. in their 6-week study, nonsignificant reduction of bleeding score was noted for the antimicrobial group compared to control group.
When intergroup difference of the mean differences was compared from BL-14 and from BL-28 and between 14 and 28 days, it was found to be statistically nonsignificant in Group 4 and Group 5 individuals. These results are in accordance with the study of Cumming and Löe  who reported that for plaque inhibition, the preferred method of delivering CHX digluconate solutions is with an OI and that the minimum effective dosage or optimal dosage would be 400 ml of a 0.25% to 0.5% (100–200 mg) concentration. However, in our study, 480 ml of 0.0075% (36 mg) along with toothbrushing and 480 ml of 0.02% (96 mg) concentration of CHX digluconate along with toothbrushing is used. Hence, this difference in concentration of CHX may be a reason for nonsignificant results in both the irrigation groups.
| Conclusions|| |
In this study, we used different concentration of CHX as an irrigant and it was observed that 0.0075% (36 mg) was better than 0.02% (96 mg). Increasing the concentration of CHX did not have any additive effect on reduction of gingival inflammation. Furthermore, oral irrigation with 0.0075% CHX was found to be better in reducing gingival inflammation as compared to 0.12% CHX mouthwash. In our study, the CHX concentration for mouthwash and oral irrigation in addition with toothbrushing was found to be same, i.e., <50 mg for improving the gingival health by reducing gingival inflammation.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]