Title Water Flossers Are More Effective in Reducing Gingival Bleeding Around Implants Than Conventional String Floss
Clinical Question For a patient with peri-implant mucositis, are water flossers more effective in reducing gingival bleeding around implants than conventional string floss?
Clinical Bottom Line For patients with peri-implant mucositis, there is sufficient evidence to support the use of water flossers as adjunct therapy in implant maintenance regimen.
Best Evidence  
PubMed ID Author / Year Patient Group Study type
(level of evidence)
24568169Magnuson et al / 201344 implants in 30 patientsRandomized Controlled Trial
Key resultsMagnuson et al. observed a significant reduction in bleeding on probing around implants in patients with peri-implant mucositis following the use of water flossers (WF) when compared to the use of conventional floss (F). The authors reported that “At 30 days, 18 of the 22 (81.8%) implants in the water flosser group showed a reduction in BOP compared to 6 of the 18 (33.3%) in the floss group (P=0.0018)."
31159354Ng & Lim / 2019105 articles published from 1974-2018Review
Key resultsNg et al. reviewed 105 articles discussing adjuncts to tooth brushing in performing oral hygiene and assessed different interdental cleaning aids. Systematic reviews, meta-analyses, and clinical trials were included in this review. High-quality flossing is effective in plaque reduction; however, it is difficult to achieve. Interdental brushes are more effective than brushing alone and are efficient in cleaning teeth with widened embrasures. Rubber picks are as effective as interdental brushes, while wooden interdental aids are not. Oral irrigators reduce gingival inflammation but are not effective in plaque removal. Moreover, when cleaning dental implants, oral irrigators and interdental brushes are superior to conventional floss.
Evidence Search ("water"[MeSH Terms] OR "water"[All Fields] OR "drinking water"[MeSH Terms] OR ("drinking"[All Fields] AND "water"[All Fields]) OR "drinking water"[All Fields]) AND flosser[All Fields] AND ("dental implants"[MeSH Terms] OR ("dental"[All Fields] AND "implants"[All Fields]) OR "dental implants"[All Fields])
Comments on
The Evidence
Validity: The Magnuson et al. 2013 study was an examiner blinded, parallel-group, randomized controlled study. Each subject was recruited to have at least 2/6 sites of bleeding on probing around an implant. Subjects were divided into two groups by a computer-generated randomization scale. One group was instructed how to floss while the other group was instructed how to use a WaterPik (water flosser). Both groups were taught the Bass tooth brushing technique and were evaluated at 14 days and 30 days. The study controlled for medical and social history of each patient; however, the author did not discuss any exclusion criteria such as active periodontal disease or history of tobacco use. The Ng/2019 review included 105 articles between 1974 and 2018 discussing different interdental cleaning aids and their effectiveness. The review assessed evidence from systematic reviews, meta-analyses, and clinical trials. With respect to water flossers specifically, 5 randomized controlled trials and 1 systematic review compared the effectiveness of water flossers versus conventional floss in reducing bleeding on probing. Perspective: Although Magnuson et al. does not discuss smoking, details of medical history, or periodontal disease, the author reports no significant difference between groups with regards to age, dental implant placement, medical history, and local factors. Moreover, the Magnuson/2013 study has low risk of bias when reviewed using the Cochrane Risk of Bias tool. The Ng/2019 review provides consistent and concrete evidence from higher-levels of evidence such as systematic reviews, meta-analyses, and randomized controlled trials. Based on these papers, water flossers are more effective in reducing bleeding on probing around dental implants.
Applicability Clinicians, particularly general dentists and periodontists, can apply this information when treating patients with an implant, regardless of whether the patient has existing peri-implant mucositis. Ultimately, water flossers can improve implant maintenance, thus increasing the implant success rate. It is important to note that the subjects in the Magnuson study used a specialized tip (Plaque Seeker® Tip, Water Pik, Inc.) “to deliver the irrigant surrounded by three individual tufts of soft nylon bristles.”
Specialty (General Dentistry) (Periodontics)
Keywords water floss, implant maintenance, bleeding on probing, peri-implant mucositis
ID# 3430
Date of submission 04/30/2020
E-mail saqr@livemail.uthscsa.edu
Author Aziz Saqr
Co-author(s) Dr. John Rugh
Co-author(s) e-mail rugh@uthscsa.edu
Faculty mentor Dr. Archie Jones
Faculty mentor e-mail jonesa@uthscsa.edu
Basic Science Rationale
(Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?)
None available
Comments and Evidence-Based Updates on the CAT
None available