Is Water Flossing an Alternative to String Flossing?

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Growing up as a kid I always saw my grandmother flossing with some “weird device” that spat water through her teeth. I never really knew what it was until I entered the Dental field. This method is called water flossing.

To this day, water flossing is controversial in the dental field. Even though water flossers have been evaluated more than 50 times since they were introduced in 1962, not all dental hygienists are complete believers in the product. More than 20 clinical trials have found that water flossing reduced bleeding and gingivitis. A study at the University of Nebraska found that the water flosser with the Classic Jet Tip was up to 93% more effective when it came to reducing bleeding and up to 52% more effective, reducing gingivitis, than string floss. The study also showed it was more effective at removing plaque than string floss. Another study at the University of Amsterdam compared water flossing with the Classic Jet Tip and the Plaque Seeker® Tip to string floss, and found the water flosser to be twice as effective at reducing bleeding as string floss.

People with Diabetes tend to be at greater risk for periodontal disease and often have more severe gingival inflammation. Those with Diabetes, who used the water flosser for three months, had a 44% reduction in bleeding and a 41% reduction in gingivitis, over those who did not use the water flosser. Another study, conducted in Canada on adolescents with fixed orthodontic appliances, found the water flosser with the orthodontic tip to be significantly more effective at removing plaque and reducing bleeding, than normal brushing and flossing.

Water flossing is safe and gentle to use around orthodontic appliances and implants. Keeping things like braces clean is tedious and challenging. Water flossing makes it easier, but according to some dental hygienists, you still need to use string floss. Adolescents age 11 through 17, who used a water flosser with the orthodontic tip every day, for four weeks, had three times the reduction in plaque vs. those who used a manual brush and floss. They also had five times the reduction than those who only brushed. The water flosser reduced bleeding by 84.5% from baseline, which was 26% better than brushing and flossing, and 53% better than tooth brushing alone. Maintenance of implants is critical to their long-term survival. Using a water flosser does the trick of gently cleaning the entire mouth.

According to studies, not only does it reduce bleeding and gingivitis, but it removes plaque and gets deeper into the pockets compared to string floss. A study at the University of Southern California Center for Biofilms found that a three-second application of water flossing with the classic jet tip, at medium pressure, removed 99.9% of plaque biofilm from the treated area. Findings indicate that using the water flosser with the classic jet tip results in penetration of approximately 50% of the depth of the pocket. An evaluation of the Pik Pocket™ Tip found it delivers the solution to 90% of the depth of a pocket and to 64% of the depth of a pocket. In contrast, floss reaches about 3 mm due to technique and/or anatomical constraints. On the flip side, some dental hygienists say the only way for plaque to be removed is by flossing with string floss because if used incorrectly water flossers are unable to get the pockets clean.

Water flossing has been proven to reduce inflammation. An analysis of water flossing on cytokine production and its relationship to clinical outcomes found that both the water flosser and tooth brushing removed plaque, but only the water flosser reduced the inflammatory cytokine Interleukin-1β. Importantly, the reduction in bleeding was correlated to the reduction in IL-1β, not plaque, providing new evidence as to why the water flosser is so effective at reducing inflammation.

Water flossing is also known to reduce periodontal infection. One of the primary benefits of the water flosser is that the pulsating action creates a compression/decompression phase that expels subgingival bacteria from the pocket. Teeth with no instrumentation for six months or more, that were treated with the water flosser, had reductions in bacteria up to 6 mm. When the water flosser was compared to both tooth brushing and mouth rinsing with 0.12% chlorhexidine (CHX), only water flossing reduced subgingival bacteria. A paper by the American Academy of Periodontology notes that one of the greatest advantages of water flossing is that it “permits patients to participate in maintaining the bacterial reduction that was attained during root planing.” The American Academy of Periodontology also notes in its review that the greatest benefit from water flossing “is seen in patients who perform inadequate inter-proximal cleansing.”

Although studies show that water flossing is a better alternative to string flossing, some dental hygienists, who deal with teeth all day long, disagree over how effective water flossing can be.  They say in order to floss properly; the only way is to use string floss. If you do not properly use water flossers they can cause a negative effect. If not properly used water flossers can push plaque further into your gums, cause irritated gums and excessive bleeding. It is also a bacteria feeding ground if not cleaned properly. Speak with your hygienist and dentist next time you go in for a cleaning to learn their position on water flossing.

 

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