Comparison of the Impact of Two Interdental Cleaning Devices on the Reduction of Bleeding Around Implants (2024)

ABSTRACT

Objective:

Purpose: To evaluate the efficacy of water flossing to traditional flossing in lowering the bleeding on probing (BOP) index around dental implants.

Methods and Materials:

This single-center, examiner-masked research enrolled patients with implants and randomly allocated them to one of two groups. The research analyzed the effectiveness of manual toothbrushes when used with either string floss or a water flosser.

Results:

After 30 days, the main result was a decrease in BOP occurrence. At the outset, neither group had noticeably higher rates of bleeding than the other. While only six of 20 implants in the floss group demonstrated a decrease in BOP after 30 days, 18 of 20 implants in the water flosser group did.

Conclusions:

These results demonstrate that the use of water flossers was associated with much less bleeding than that of string floss. The researchers think that water flossing might be a useful addition to the maintenance of dental implants.

KEYWORDS: Bleeding on probing, dental implants, interdental cleaning devices, water flossing

INTRODUCTION

A mucosal inflammatory lesion known as peri-implant mucositis may develop around an implant. Like gingivitis, it has similar origins and symptoms.[1] Lack of bone surrounding the implant (peri-implantitis) is a risk factor for implant failure. While peri-implantitis and periodontitis have comparable clinical features, they have distinct histological hallmarks.[2] Peri-implant mucositis affects over 80% of implant recipients, or roughly 50% of implant sites, whereas peri-implantitis affects 28–56% of implant recipients, or between 12% and 40% of implant sites.[3]

Anaerobic bacteria, predominated by Gram-negative organisms, make up the bulk of the subgingival microbiota, which is comparable to that seen in persistent periodontal diseases.[4] A common indicator of mucositis is bleeding during the examination. In most cases, a stable peri-implant region may be inferred when there is no sign of bleeding.[5,6]

Peri-implant illnesses may develop and spread if plaque is not well-controlled.[7] Proper dental care with implants may prevent biofilm buildup and infection. Home care instructions often include brushing, flossing, and rinsing, much as they do for dentate people. According to a recent systematic analysis, there is no solid proof of an intervention that effectively treats peri-implant illness.[8] Daily washing surrounding implants and prosthetic replacements is essential; hence, research comparing the efficacy and safety of various approaches and technologies is warranted. This study aimed to compare traditional string floss with a water flosser in its ability to reduce the bleeding on probing (BOP) index around dental implants.

METHODS AND MATERIALS

Subjects

Volunteers were adults ranging in age from 22 to 62. The criteria for both inclusion and exclusion were analyzed. Two of six potential bleeding sites on at least one implant must be present for a candidate to be considered positive. Up to two implants per participant were included if they had more than one that met the study’s criteria.

If a participant had more than two eligible implants, a computer-generated randomization procedure decided which two would be included in the trial.

Study design

This study compared the efficiency of a manual toothbrush with either regular string floss or a water flosser. The researchers conducted the study at a single location using a double-arm, parallel-group design. There were a total of four months invested in the research, consisting of three months of participant recruiting and one month of analysis. Using a computer-generated randomization procedure, the individuals were assigned to one of two groups. Totaling 40 implants, the study’s participants were split evenly between two groups. The distribution was uniformly fair. At the time a subject was being recruited, the research coordinator (but not the examiners) had access to a spreadsheet containing the randomization scheme devised by the statistician. A study coordinator also recruited and randomly assigned volunteers. The subjects’ treatment group was concealed from the evaluators.

The patients’ medical histories and personal information were recorded. Each participant had their mouth, teeth, gums, and surrounding tissues thoroughly examined. Participants used the American dental association (ADA)-recommended manual toothbrush (Procter and Gamble’s Oral-B® Soft Compact 35, available at www.pg.com) and dentifrice (Crest® Cavity Protection Gel Toothpaste, also made by Procter and Gamble).

Each participant was randomly allocated to either group 1 (string floss [SF]) or group 2 (water floss [WF]) and given either unflavored waxed string floss or a water flosser with a specific tip. The examiner was kept at a safe distance when test items were dispersed. The Bass method for cleaning teeth was shown to the participants. While those in the SF group were given generic instructions, those in the WF group followed the recommendations of the floss maker. Before being sent home with their goods, participants used them under the supervision of the study’s coordinator and were given written instructions and a record to keep note of how often they brushed, flossed, or used water floss. Both groups were given sand timers and told to use them to clock their twice-daily brushing routines. The SF group’s subjects brushed their teeth in the morning and then flossed before bed. The WF group’s subjects brushed their teeth with a water flosser and a particular tip in the evening before bed, using 500 ml of lukewarm water and a pressure level of 6 (medium). During the course of the trial, all participants abstained from using any other kind of oral hygiene product.

Screening/baseline, day 14, and day 30 BOP were recorded by a qualified examiner using a plastic probe at six locations per implant (i.e., mesio-facial, facial, disto-facial, mesio-lingual, lingual, and disto-lingual).

Discontinuation criteria were evaluated at visits 2 (day 14) and 3 (day 30). The bleeding index was measured at six places per implant during a thorough oral examination. At this appointment, the toothbrushing record was reviewed to confirm that the subject was following the protocol.

Study products

The Waterpik® Ultra Water Flosser is a pulsing device that uses water or another solution to clean between teeth and under the gums (Water Pik, Inc., www.waterpik.com). The solution is stored in a reservoir, the pressure may be adjusted, and the tip is positioned using a handle. The subjects utilized a Plaque Seeker® Tip from Water Pik, Inc., which has an aperture for delivering the irrigant and three separate tufts of soft nylon bristles. From the lingual and buccal sides of the mouth, the tip is aimed toward the implant prosthesis’ gingival margin and interdental areas.

In the SF group, waxed string dental floss (Reach®, Johnson and Johnson Oral Care Company, www.jnj.com) was provided to the participants. Subjects were instructed to clean the proximal surfaces of the implants by making a “C” with the floss on the mesial and distal surfaces of the prosthesis and then moving the floss multiple times up and down the surface.

Statistical analysis

Prevention of BOP at 30 days was the main endpoint of the trial. By 30 days, at least 50% of those assigned to water floss would have seen no bleeding from more than one site/implant, but only 10% of those assigned to string floss would have done so. A sample size of 20 individuals per group using an exact test of two proportions with alpha set at 0.05 would have 80% power to differentiate between a 50% decrease in BOP in the Waterpik group and a 10% reduction in the control group.

All enrolled patients were included in the analysis. A two-sample t-test was used to compare the two groups’ mean ages at baseline. A statistically significant result was defined as a P -value less than 0.05.

RESULTS

Forty potential participants made the cut. They participated in the randomization process and provided 44 implants altogether. Therefore, 40 implants were included in this final study, with 40 individuals’ total.

The average age of participants using water flossers was 45 years, whereas that of the 13 using string floss was 46 years. The statistical significance of this difference was not found (P = 0.7).

The primary outcome measure was the percentage reduction in BOP after 30 days. BOP was defined as bleeding in at least two of the six locations. At baseline, 100% of the individuals were affected by BOP. Both groups had a similar percentage of bleeding locations. The average percentage of bleeding sites was 45.0% in the WF group and 55% in the SF group. P = 0.3 indicates that this difference is not significant. At 30 days, 18 of 20 implants in the WF group had a decrease in BOP, whereas only six of 20 implants in the SF group did. Subjects in the WF group showed a substantial threefold difference in BOP, with a P -value of 0.001 indicating statistical significance. There were no documented safety concerns throughout the study’s duration [Table 1].

Table 1.

Reduction in BOP at baseline, 14 days and 30 days

BOP	Water flosser (n=20)		Floss (n=20)		P

	n	%	n	%
Baseline	20	100.0	20	100.0
Day 14	15	77.3	16	50.0	0.08
Day 30	18	81.8	6	33.3	0.001

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DISCUSSION

The purpose of this research was to assess whether or not implant-related bleeding may be reduced by the use of water irrigation equipped with a specific tip. The results showed that less bleeding occurred while using a water flosser with medium pressure and tap water to clean around implants as opposed to string floss. This study’s findings are consistent with those of others that examined the effectiveness of water flossing and traditional string floss for cleaning natural teeth. Barnes et al.[9] found that utilizing a water flosser on medium pressure with just water once a day resulted in a 40–93% decrease in bleeding and a 51–53% reduction in gingivitis compared to string floss used once a day. Comparing the water flosser to regular string floss (13% vs. 26%) and specialist string floss (13% vs. 20%), the water flosser was shown to be much more effective in preventing bleeding by Rosema et al.[10] After four weeks, there was still a significant reduction in bleeding (from 15% to 17%) in the water flosser groups. The flossing group reverted to pre-intervention levels. The third research evaluated the effectiveness of string floss and a water flosser with an orthodontic tip on reducing gum bleeding in adolescents (aged 11–17) with fixed orthodontic equipment and found that the water flosser group was 26% more effective.[11]

As dentists and experts become more confident in the long-term viability of dental implants, they are more likely to use them.[12,13] The patient should be informed about the potential for treatment failure due to factors such as smoking, previous radiation therapy, and the amount and quality of bone in the patient’s immediate area. Poor oral hygiene, the use of a noncleansable prosthesis, or the use of ineffective implant care guidelines may all lead to peri-implant illness. Therefore, following a proper care routine is crucial to the long-term health of an implant.

There is no evidence to support the need for special care while cleaning around implants or replacing prosthetics. Five papers assessing the effectiveness of an implant maintenance program were included in a systematic review.[8] Neither a powered toothbrush nor a sonic toothbrush demonstrated statistically significant improvement over manual brushing in the two studies that tested them. Plaque, bleeding, and gingival index all improved in one trial when participants rinsed with an antiseptic for 30 seconds twice a day rather than a placebo. Differences in probing depth or degree of connection did not emerge.

After three months of usage, irrigating with a subgingival delivery tip was more effective than washing with chlorhexidine in reducing plaque, gingivitis, and the stain index.[14]

To combat BOP around implants, this research presents clinical data on the effectiveness of a water flosser. Research on natural teeth has shown comparable benefits, including less gum disease,[9,10] checking the depth of a pocket,[15] below the gum line microbes,[16,17,18] serum levels of inflammatory markers, and gingival crevicular fluid levels of proinflammatory mediators.[15,19] Having access to[20,21] harmful microorganisms from cracks as little as 6 mm[16,17,18] pocket depths between 3 mm and 5 mm provides the greatest clinical outcomes for implant-supported prostheses. People who wear orthodontics have also been subjected to water flossing studies,[11,22] diabetes,[19] and the people who care for your gums and teeth.[23,24]

Water flossing was tested for its efficacy on single implants after crown repair. Dentures, bridges, and other prosthetic devices that are supported by implants need to be studied more thoroughly to determine their efficacy.

CONCLUSION

Researchers showed that compared to string floss, using a water flosser with a manual toothbrush decreased bleeding around implants by a factor of 2.45 (145%) throughout the course of a 30-day randomized clinical intervention.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

REFERENCES

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