Cleansing efficacy of an oral irrigator with microburst technology in adolescent orthodontic patients. A randomized-controlled crossover study

Cleansing efficacy of an oral irrigator with microburst technology in adolescent orthodontic patients. 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A randomized-controlled crossover study hanna gänzer, Manuel Kasslatter, Vera Wiesmüller, Lena Denk, Anna-Maria Sigwart, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3781500/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objectives Simplifying interdental space cleaning is a constantly discussed topic. The present study aimed to compare the cleansing efficacy of an oral irrigator with that of dental flossing in adolescent patients with fixed braces after four weeks of home-use. Materials and methods The study design is a randomized, single-blinded cross-over study. Following a twenty-eight-day period of product utilization in a home setting, a comparative analysis was conducted on hygiene indices, specifically the Rustogi Modified Navy Plaque Index (RMNPI) and the Gingival Bleeding Index (GBI), between the test group (oral irrigator) and the control group (dental floss). Results Seventeen adolescent individuals finalized the study. After 28 days of cleaning with the oral irrigator, RMNPI was 58.81% (55.31 – 66.47) compared to 59.46% (52.68 - 68.67) with dental floss ( p = 0.070). Subgroup analyses did not classify either of the two methods as superior. GBI after the test phase with the oral irrigator was 28.93% (23.21 – 33.97) and insignificant higher compared to 26.40% (21.01 – 31.41) with dental floss ( p = 0.1585). Conclusion s None of the two products proved significantly superior in terms of cleaning efficiency. Therefore, no recommendation can be made in favor of one over the other. It is evident that through special attention to home oral hygiene, improved index values were achieved, leading to the conclusion that paying careful attention to daily dental cleaning is of highly importance. Clinical relevance It´s less about the tool but more about oral hygiene instruction and motivation provided by the orthodontist or the responsible guardians at home. Oral irrigator Adolescent Orthodontic Oral hygiene Plaque index Gingival Bleeding Index Fixed orthodontic treatment Figures Figure 1 Figure 2 Introduction The most important measure to prevent tooth decay is good oral hygiene. If the adherent bacterial film is regularly removed, further accumulation of germs and their sugar metabolism can be prevented ( 1 ). Individuals who integrate interdental cleaning devices in their daily oral hygiene schedules experience fewer instances of dental caries, less periodontal diseases and have less missing teeth compared to those who exclusively employ electric or manual toothbrushes for oral hygiene ( 2 ). Interdental brushes appear to offer superior effectiveness compared to dental floss ( 3 ). As outlined in the consensus report compiled by the European Federation of Periodontology in 2015, the application of dental floss should be restricted to areas with gingival and periodontal health, where interdental brushes might pose a risk of causing traumatic injuries ( 2 , 4 ). The willingness to incorporate dental floss into the daily oral hygiene routine is quite limited. Additionally, the proper use of dental floss proves to be a significant challenge ( 5 ). A noteworthy issue in the field of orthodontics is that in patients with fixed braces, the accumulation of biofilm is promoted both above and below the gumline, compromising effective oral hygiene and consequently resulting in alterations in the oral microbiome, enamel decalcification, and the development of gingivitis ( 6 – 8 ). Furthermore, several systematic reviews have consistently demonstrated the worsening of clinical parameters linked to periodontal diseases, including indicators such as the plaque index, bleeding on probing (BOP), attachment loss, and the development of pockets or gingival recessions. This deterioration has been associated with both the duration and the type of orthodontic treatment. ( 7 , 9 ) Water flossers represent a recent innovation in interdental tools designed for regular use at home which seems to be relatively easy to use. Operating on the principles of pulsation and pressure, the water flosser effectively disrupts plaque and removes loosely lodged debris. The primary use of water flossers is to assist individuals with reduced manual skills, but it may also be useful for patients undergoing orthodontic treatment. ( 10 , 11 ) The available data regarding the use of oral irrigators in orthodontic patients is currently quite limited, and the results obtained from existing studies exhibit significant variations in terms of effectiveness ( 12 ). There has been no study specifically designed to evaluate the performance of an oral irrigator featuring microburst technology in adolescent orthodontic patients. The aim of this current randomized, single-blinded cross-over study was to assess and compare the cleaning effectiveness of microburst technology and dental flossing in adolescent individuals with fixed braces undergoing orthodontic treatment, following a 4-week period of at-home use. The null hypothesis postulates that there is no distinction between the two methods. Material and Methods This study was approved by the Ethics committee of the Medical University of Innsbruck, Austria (ID AN 5123). The study was conducted in accordance with the 1964 Helsinki declaration and its later amendments. Prior to inclusion all subjects signed an informed written consent. Study subjects Twenty minor subjects of the University Hospital of Orthodontic Dentistry, Innsbruck, Austria, were recruited in the period from October 2021 to March 2023. Inclusion criteria were fixed braces attached buccally at a minimum of four teeth per quadrant and existing contact points between all teeth. Exclusion criteria were pregnancy, oral or systemic diseases other than gingivitis, and the need for frequent drug consumption. Due to time constraints, it was not possible to start with all 20 study participants simultaneously. As a result, the children were enrolled in the study in staggered groups. Clinical intervention The cleansing efficacy of the microburst technology ( Airfloss ® , Philips, Hamburg, Germany) versus interdental cleaning with dental floss ( Superfloss ® , Oral-B, Boston, USA) was evaluated in a randomized-controlled, examiner-blinded, crossover study. The study design consisted of four appointments for each subject at intervals of one month. During appointment one, the probands received an explanation of the study procedure. The adolescents were assessed for study inclusion and exclusion criteria using the Case-Report-Forms (CRF) and an informed consent form was signed. Documentation of plaque-covered areas was evaluated using the Modified Navy Plaque Index according to Rustogi (RMNPI) (13) after plaque disclosing ( 2Tone , Young, Earth City, Mo, USA) and the Gingival Bleeding Index after Ainamo & Bay (GBI) (14) was used for evaluation of the baseline hygiene indices. The Rustogi Modified Navy Plaque Index (RMNPI) subdivides each buccal and lingual tooth surface into nine distinct segments (designated as A – I), which are subject to evaluation regarding the presence or absence of dental plaque. This particular index facilitates the differentiation of marginal regions of the dentition (A – C), interdental spaces (D, F), as well as the overall tooth surface areas (A – I). The RMNPI is computed as the proportion of biofilm-adhering sites relative to the total number of assessed sites. In the context of the assessment of the Gingival Bleeding Index (GBI), a periodontal probe (PCP 12, Hu Friedy, Chicago, USA) was inserted into the gingival sulcus. This instrument is utilized to dichotomously determine, at six distinct sites per tooth (mesiobuccal – buccal – distobuccal – mesiolingual – lingual – distolingual), whether bleeding is elicited or not. The percentage of bleeding sites in relation to the total number of measured sites was calculated. It is noteworthy that teeth that weren’t integrated into the fixed orthodontic treatment were excluded from the analysis. Moreover, all examinations were conducted by a single trained examiner. Prior to commencing the investigation, randomization of the test products was carried out using a computer-generated method within Microsoft ® Office Excel. This randomization process was executed by study assistants, who also provided comprehensive hands-on training to the study participants to ensure that the examiner remained unaware of which specific product was being used. The approach enabled the collection of data in a blinded manner. Following the manufacturer’s recommended protocol for the oral irrigator with microburst technology ( Airfloss ® , Philips, Hamburg, Germany), the device was filled with water and activated once per interdental space, utilizing the default setting of three sprays per activation. For the control products ( Superfloss ® , Oral-B, Boston, USA) participants were instructed to thread it from the buccal side below the orthodontic wire and position it around the tooth in a c-shaped manner to facilitate cleaning in the apico-coronal direction. In relation to toothbrushing, participants were directed to maintain their customary oral hygiene routine and use their preferred products. Following comprehensive instruction regarding the initial randomly assigned test product, professional tooth cleaning was carried out using an air-polishing device ( Airflow ® prophylaxis master and Airflow ® Plus powder; both EMS, Nyon, CH), supplemented using sonic scalers and rubber cups with polishing paste ( Cleanic ® , Kerr, Bioggo, CH) as needed. After an initial period of twenty-eight days employing the first test product, study participants attended their second visit. At this juncture, hygiene indices and inclusion/exclusion criteria were reevaluated (see Table 1). Subsequently, there was a washout phase lasting twenty-eight days during which the subjects reverted to their usual oral hygiene procedures. Following this period, they returned for the third visit. Once again, plaque disclosure was performed, and subjects were given detailed instructions for the utilization of the second product, followed by another professional dental cleaning. In a manner consistent with the first test phase, participants utilized the second product for twenty-eight days, then presented for an examination of the plaque- and gingival index during the fourth and final appointment of the study. Statistical analysis The calculation of the sample size was based on the mean values and standard deviations of overall plaque scores, as provided by Heiß-Kisielewsky et al. in their study, where they compared the cleansing effectiveness of microburst technology (Airfloss â , Philips, Hamburg, Germany) with dental flossing. (15) The sample size calculation for dependent samples, with a power of 80% and a = 0.05, resulted in a sample size of 16. Accounting for an assumed drop-out rate of 25%, the final sample size was n = 20. At the individual level, RMNPI values were determined by dividing the total number of areas with plaque present by the total number of assessed sites. These values were then compared between the two tooth-brushing techniques using the Wilcoxon signed-rank test. The gingival bleeding index was computed in a similar way. Unless indicated otherwise, median and interquartile range statistics are provided. The significance level was established at p < 0.05. Results Twenty individuals were recruited. Seventeen participants (seven females and ten males) finished the study with a mean age of 14.76 ± 1.15 (range 14–18) years. The drop-out rate was 15%. Three of them could not continue due to systemic antibiotic therapy, illness, and non-compliance, and were therefore excluded from the statistics. Plaque scores At baseline, the median of overall RMNPI was 73.43% (69.84–79.56). After 28 days of interdental cleaning with microburst technology, the median of overall RMNPI was 60.71% (55.31–66.47) and insignificantly higher than after 28 days of interdental cleaning with the control procedure dental flossing (median of overall RMNPI 59.72%; range 52.68–68.67) ( p = 0.070) (see Fig. 1 ). A statistically significant improvement was observed between the plaque index measured at the initial assessment, before any instruction, and the second baseline value after the four-week washout phase at the third assessment. While initially an average of 73.93% of tooth surfaces exhibited plaque, this was reduced to 63.04% at the third assessment. The medians differed, with 73.43% (69.84–79.56) at the first assessment and 67.86% (56.06–75.99) at the third assessment. The p -value was 0.0009. Subgroup analysis revealed no statistically significant differences in higher cleansing efficacy. Gingival Bleeding Index At baseline, the median of GBI was 35.26% (range 29.76–40.74). After 28 days of interdental cleaning with the oral irrigator GBI was 29.17% (23.21–33.97) and insignificantly higher compared to 25.60% (21.01–31.41) after interdental cleaning with dental floss ( p = 0.1585) (see Fig. 2 ). A noticeable improvement was observed in the Gingival Bleeding Index, with an initial median value of 37.16% (29.76–40.74) reducing to 31.76% (25.00–42.95) at the third assessment, although without statistically significance. The p -value was 0.1362. Subgroup analysis revealed no statistically significant differences in gingival bleeding. Table 1 Plaque and bleeding levels after one month of home use. The Rustogi modified plaque-index splits every buccal and lingual tooth surface into nine sections (A – I) and was calculated as percentage of biofilm adhering sites to measured sites. Gingival bleeding was calculated dichotomously at 6 sites per tooth as percentage of bleeding sites to measured sites. Data was presented using median and interquartile ranges. Microburst technology Dental flossing p-value Full mouth RMNPI (%) 60.71% (55.31–66.47) 59.72% (52.68–68.67) 0.070 Gingival bleeding index (%) 29.17% (23.21–33.97) 25.60% (21.01–31.41) 0.1585 Approximal sites RMNPI (%) 85.71% (83.93–94.32) 86.36% (78.85–93.75) 0.704 Gingival bleeding index (%) 26.14% (20.37–31.00) 23.21% (17.86–30.56) 0.529 Approximal buccal sites RMNPI (%) 94.64% (87.50–97.83) 94.64% (85.19–97.92) 0.905 Gingival bleeding index (%) 18.18% (9.62–28.00) 19.64% (13.64–30.36) 0.912 Approximal lingual / palatal sites RMNPI (%) 82.69% (71.43–94.64) 82.14% (75.00–91.07) 0.624 Gingival bleeding index (%) 27.27% (22.22–44.23) 25.00% (19.64–32.69) 0.271 Anterior Teeth RMNPI (%) 62.04% (54.63–70.37) 60.32% (49.54–73.15) 0.596 Gingival bleeding index (%) 26.39% (24.24–33.33) 22.92% (20.83–30.56) 0.453 Posterior Teeth RMNPI (%) 57.64% (48.99–64.93) 57.29% (50.17–63.10) 0.337 Gingival bleeding index (%) 29.73% (23.21–33.97) 25.44% (19.23–32.29) 0.168 RMNPI, Rustogi Modified Navy Plaque Index; %, percent; *, p -value < 0.05 Discussion It is the daily challenge of interdental tooth cleaning for patients undergoing orthodontic treatment, which must be combated using simplified cleaning methods. In addition to dental floss, other oral hygiene aids such as interdental brushes or water floss are available. However, especially in young people, the spaces between the teeth are often too narrow for the use of interdental brushes and the orthodontic wires makes it difficult to use dental floss. The result is gingivitis and white spot lesions as a common side effect of fixed orthodontic treatment. ( 7 , 8 , 13 ) The existing research regarding the effectiveness of dental floss and water flossers is quiet varied. Some studies have indicated that water flossers offer superior cleaning results, along with a reduction in inflammation, especially among individuals with orthodontic treatment. ( 16 , 17 ) On the other hand, studies have concluded that both methods are equally effective. Notably, a previous similarly designed trial conducted as part of this study, which also concentrated on patients with fixed orthodontic appliances, found that Superfloss dental floss provided more efficient cleaning results, a finding in contrast to most other studies ( 18 ). However, in this current study no statistically significant differences were observed between Superfloss and Airfloss in terms of cleaning efficacy across various areas of tooth surfaces. Therefore, the results obtained from the prior study involving adults could not be directly applied to teenagers. Only when comparing the average values, there was a statistically significant preference for Superfloss, suggesting a potential inclination towards better cleaning with dental floss, though this result is not conclusive and might be influenced by chance. Finally, the nearly one-minute extension of brushing duration and the observed enhancements in motivation hold significant clinical relevance, as compliance stands as a primary impediment to the achievement of effective oral hygiene. ( 20 ) In this study we used the Rustogi Modified Navy Plaque Index ( 19 ) for evaluating plaque presence or absence in nine areas on buccal or lingual tooth surfaces. This dichotomous index allows us to measure plaque levels on a full-mouth level, but also subgroup analyses including smooth surfaces, interdental and gingival margin areas. Following a four-week period of dental flossing (using Superfloss), the mean plaque index showed a score of 59.46% whereas Airfloss scored 58.81%. Correspondingly, the median plaque index values for Superfloss and Airfloss were 59.72% (52.68–68.67) and 60.71% (55.31–66.47), respectively. In contrast, the gingival index exhibited an average of 26.40% (with a median of 25.60%) following to the use of Superfloss, a result which stood in contrast to the 28.93% mean (with a median of 29.17%) recorded following the use of Airfloss. It is noteworthy, however, that both inequalities failed to attain statistical significance, as indicated by their respective p -values of 0.070 and 0.1585. A limiting factor of the significance of this study undoubtedly resides in the small number of participants. The selection process posed challenges due to the inclusion criteria specifying an age of over 14 years, which naturally, constrained the pool of eligible patients. Many younger patients receiving treatment at the University Clinic of Orthodontics were thereby excluded from the study. Furthermore, the age-related aspects of the participants also contributed to the diminished motivation and interest in maintaining oral hygiene. Coupled with the fact that many adolescents do not receive instructions or monitoring from their parents in this regard, it was challenging to ascertain the accuracy with which the products were used. Another study design´s limitations may include the potential decrease in gingival bleeding index due to professional cleaning, which could diminish the comparability with the baseline gingival bleeding index. In order to achieve a consistent baseline value before the first and second test phase, a washout period of 28 days was chosen, during which participant maintained their original oral hygiene routine. In conclusion and as mentioned before, none of the two products proved significantly superior in terms of cleaning efficiency. Therefore, no recommendation can be made in favor of one over the other. However, it is evident that through instruction and special attention to home oral hygiene, improved index values were achieved, leading to the conclusion that paying careful attention to and eagerly carrying out daily dental cleaning is of highly importance and has the most significant effect on preserving oral health. Declarations Conflict of Interest and Source of Funding Statement The authors declare that there are no conflicts of interest. The authors do not have any financial interests, either directly or indirectly, in the products tested in this study. Ethical approval The present study was carried out in accordance with the 1964 Declaration of Helsinki and its later amendments, and ethical approval was obtained by the Ethics committee of the Medical University of Innsbruck, Austria (study ID AN 5123). Informed consent All subjects signed an informed written consent prior to the study enrolment. Competing interests The authors declare that there are no conflicts of interest in this study. Authors’ contribution All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Manuel Kasslatter, Lena Denk und Anna­-Maria Sigwart. The first draft of the manuscript was written by Hanna Gänzer and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Funding This study received no fundings. Availability of data and materials Not Applicable Conflict of Interest Not Applicable References Sälzer S, Slot DE, Van Der Weijden FA, Dörfer CE. Efficacy of inter‐dental mechanical plaque control in managing gingivitis – a meta‐review. J Clinic Periodontology [Internet]. 2015 Apr [cited 2023 Nov 8];42(S16). Available from: https://onlinelibrary.wiley.com/doi/10.1111/jcpe.12363 Marchesan JT, Morelli T, Moss K, Preisser JS, Zandona AF, Offenbacher S, et al. 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Müller LK, Jungbauer G, Jungbauer R, Wolf M, Deschner J. Biofilm and Orthodontic Therapy. In: Eick S, editor. Monographs in Oral Science [Internet]. S. Karger AG; 2021 [cited 2023 Nov 8]. p. 201–13. Available from: https://www.karger.com/Article/FullText/510193 Lucchese A, Bondemark L, Marcolina M, Manuelli M. Changes in oral microbiota due to orthodontic appliances: a systematic review. Journal of Oral Microbiology. 2018 Jan 1;10(1):1476645. Contaldo M, Lucchese A, Lajolo C, Rupe C, Di Stasio D, Romano A, et al. The Oral Microbiota Changes in Orthodontic Patients and Effects on Oral Health: An Overview. JCM. 2021 Feb 16;10(4):780. Giugliano D, d’Apuzzo F, Majorana A, Campus G, Nucci F, Flores-Mir C, et al. Influence of occlusal characteristics, food intake and oral hygiene habits on dental caries in adolescents: a cross-sectional study. European Journal of Paediatric Dentistry. 2018;(2):95–100. Sharma NC, Lyle DM, Qaqish JG, Schuller R. 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Erbe C, Klees V, Braunbeck F, Ferrari-Peron P, Ccahuana-Vasquez RA, Timm H, et al. Comparative assessment of plaque removal and motivation between a manual toothbrush and an interactive power toothbrush in adolescents with fixed orthodontic appliances: A single-center, examiner-blind randomized controlled trial. American Journal of Orthodontics and Dentofacial Orthopedics. 2019 Apr;155(4):462–72. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3781500","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":265200734,"identity":"8f217205-cca3-4fd7-869b-42c142d6ab3a","order_by":0,"name":"hanna gänzer","email":"","orcid":"","institution":"Medical University of Innsbruck","correspondingAuthor":false,"prefix":"","firstName":"hanna","middleName":"","lastName":"gänzer","suffix":""},{"id":265200735,"identity":"25804591-c965-4fea-b775-81aee0546cf6","order_by":1,"name":"Manuel Kasslatter","email":"","orcid":"","institution":"Medical University of 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Crismani","email":"data:image/png;base64,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","orcid":"","institution":"Medical University of Innsbruck","correspondingAuthor":true,"prefix":"","firstName":"Adriano","middleName":"","lastName":"Crismani","suffix":""}],"badges":[],"createdAt":"2023-12-20 11:14:48","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3781500/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3781500/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":49242387,"identity":"fbafa5e3-9b12-429e-a74d-e85b4b9abaff","added_by":"auto","created_at":"2024-01-05 18:29:50","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":21699,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eRustogi Modified Navy Plaque Index (RMNPI) after 28-days of home-use of dental floss in comparison to an oral irrigator.\u003c/strong\u003e Rustogi modified plaque-index splits every buccal and lingual tooth surface into nine sections (A – I) and was calculated as percentage of biofilm adhering sites to measured sites of \u003cstrong\u003eA)\u003c/strong\u003e all tooth surfaces (A – I), and \u003cstrong\u003eB)\u003c/strong\u003e approximal surfaces (D, F) \u003cstrong\u003eC)\u003c/strong\u003e compares the two baseline values\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-3781500/v1/07d1d320adb49b20087c285f.png"},{"id":49242386,"identity":"7767b525-f75e-45bd-9266-0aff79d19d36","added_by":"auto","created_at":"2024-01-05 18:29:50","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":26119,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eGingival Bleeding Index after 28-days of home-use of a dental floss in comparison to an oral irrigator.\u003c/strong\u003e Gingival bleeding Index was calculated dichotomously as percentage of bleeding sites to measured sites of \u003cstrong\u003eA)\u003c/strong\u003e all tooth surfaces, \u003cstrong\u003eB)\u003c/strong\u003e approximal surfaces, and \u003cstrong\u003eC)\u003c/strong\u003e compares the two baseline values\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-3781500/v1/e4e9f465f45f684b101ad896.png"},{"id":49510022,"identity":"74c3ac65-6043-4e57-849e-8b51b6c48bec","added_by":"auto","created_at":"2024-01-12 05:52:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":409734,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3781500/v1/303c36e5-b3a4-425d-a05f-309ed5788e60.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Cleansing efficacy of an oral irrigator with microburst technology in adolescent orthodontic patients. A randomized-controlled crossover study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe most important measure to prevent tooth decay is good oral hygiene. If the adherent bacterial film is regularly removed, further accumulation of germs and their sugar metabolism can be prevented (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Individuals who integrate interdental cleaning devices in their daily oral hygiene schedules experience fewer instances of dental caries, less periodontal diseases and have less missing teeth compared to those who exclusively employ electric or manual toothbrushes for oral hygiene (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Interdental brushes appear to offer superior effectiveness compared to dental floss (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). As outlined in the consensus report compiled by the European Federation of Periodontology in 2015, the application of dental floss should be restricted to areas with gingival and periodontal health, where interdental brushes might pose a risk of causing traumatic injuries (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). The willingness to incorporate dental floss into the daily oral hygiene routine is quite limited. Additionally, the proper use of dental floss proves to be a significant challenge (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). A noteworthy issue in the field of orthodontics is that in patients with fixed braces, the accumulation of biofilm is promoted both above and below the gumline, compromising effective oral hygiene and consequently resulting in alterations in the oral microbiome, enamel decalcification, and the development of gingivitis (\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Furthermore, several systematic reviews have consistently demonstrated the worsening of clinical parameters linked to periodontal diseases, including indicators such as the plaque index, bleeding on probing (BOP), attachment loss, and the development of pockets or gingival recessions. This deterioration has been associated with both the duration and the type of orthodontic treatment. (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) Water flossers represent a recent innovation in interdental tools designed for regular use at home which seems to be relatively easy to use. Operating on the principles of pulsation and pressure, the water flosser effectively disrupts plaque and removes loosely lodged debris. The primary use of water flossers is to assist individuals with reduced manual skills, but it may also be useful for patients undergoing orthodontic treatment. (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) The available data regarding the use of oral irrigators in orthodontic patients is currently quite limited, and the results obtained from existing studies exhibit significant variations in terms of effectiveness (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). There has been no study specifically designed to evaluate the performance of an oral irrigator featuring microburst technology in adolescent orthodontic patients. The aim of this current randomized, single-blinded cross-over study was to assess and compare the cleaning effectiveness of microburst technology and dental flossing in adolescent individuals with fixed braces undergoing orthodontic treatment, following a 4-week period of at-home use. The null hypothesis postulates that there is no distinction between the two methods.\u003c/p\u003e"},{"header":"Material and Methods","content":"\u003cp\u003eThis study was approved by the Ethics committee of the Medical University of Innsbruck, Austria (ID AN 5123). The study was conducted in accordance with the 1964 Helsinki declaration and its later amendments. Prior to inclusion all subjects signed an informed written consent.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStudy subjects\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTwenty minor subjects of the University Hospital of Orthodontic Dentistry, Innsbruck, Austria, were recruited\u0026nbsp;in the period from October 2021 to March 2023.\u0026nbsp;Inclusion criteria were fixed braces attached buccally at a minimum of four teeth per quadrant and existing contact points between all teeth.\u0026nbsp;Exclusion criteria were pregnancy, oral or systemic diseases other than gingivitis, and the need for frequent drug consumption.\u003c/p\u003e\n\u003cp\u003eDue to time constraints, it was not possible to start with all 20 study participants simultaneously. As a result, the children were enrolled in the study in staggered groups.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eClinical intervention\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe cleansing efficacy of the microburst technology (\u003cem\u003eAirfloss\u003c/em\u003e\u003csup\u003e®\u003c/sup\u003e, Philips, Hamburg, Germany) versus interdental cleaning with dental floss (\u003cem\u003eSuperfloss\u003c/em\u003e\u003csup\u003e®\u003c/sup\u003e\u003csup\u003e,\u003c/sup\u003e Oral-B, Boston, USA) was evaluated in a randomized-controlled, examiner-blinded, crossover study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe study design consisted of four appointments for each subject at intervals of one month. During appointment one, the probands received an explanation of the study procedure. The adolescents were assessed for study inclusion and exclusion criteria using the Case-Report-Forms (CRF) and an informed consent form was signed. Documentation of plaque-covered areas was evaluated using the Modified Navy Plaque Index according to Rustogi (RMNPI)\u0026nbsp;(13)\u0026nbsp;after plaque disclosing (\u003cem\u003e2Tone\u003c/em\u003e, Young, Earth City, Mo, USA) and the Gingival Bleeding Index after Ainamo \u0026amp; Bay (GBI)\u0026nbsp;(14)\u0026nbsp;was used for evaluation of the baseline hygiene indices.\u003c/p\u003e\n\u003cp\u003eThe Rustogi Modified Navy Plaque Index (RMNPI) subdivides each buccal and lingual tooth surface into nine distinct segments (designated as A – I), which are subject to evaluation regarding the presence or absence of dental plaque. This particular index facilitates the differentiation of marginal regions of the dentition (A – C), interdental spaces (D, F), as well as the overall tooth surface areas (A – I). The RMNPI is computed as the proportion of biofilm-adhering sites relative to the total number of assessed sites. In the context of the assessment of the Gingival Bleeding Index (GBI), a periodontal probe (PCP 12, Hu Friedy, Chicago, USA) was inserted into the gingival sulcus. This instrument is utilized to dichotomously determine, at six distinct sites per tooth (mesiobuccal – buccal – distobuccal – mesiolingual – lingual – distolingual), whether bleeding is elicited or not. The percentage of bleeding sites in relation to the total number of measured sites was calculated. It is noteworthy that teeth that weren’t integrated into the fixed orthodontic treatment were excluded from the analysis. Moreover, all examinations were conducted by a single trained examiner.\u003c/p\u003e\n\u003cp\u003ePrior to commencing the investigation, randomization of the test products was carried out using a computer-generated method within\u0026nbsp;\u003cem\u003eMicrosoft\u003c/em\u003e\u003csup\u003e®\u003c/sup\u003e Office Excel. This randomization process was executed by study assistants, who also provided comprehensive hands-on training to the study participants to ensure that the examiner remained unaware of which specific product was being used. The approach enabled the collection of data in a blinded manner. Following the\u0026nbsp;manufacturer’s recommended protocol for the oral irrigator with microburst technology (\u003cem\u003eAirfloss\u003c/em\u003e\u003csup\u003e®\u003c/sup\u003e, Philips, Hamburg, Germany), the device was filled with water and activated once per interdental space, utilizing the default setting of three sprays per activation. For the control products\u0026nbsp;(\u003cem\u003eSuperfloss\u003c/em\u003e\u003csup\u003e®\u003c/sup\u003e, Oral-B, Boston, USA) participants were instructed to thread it from the buccal side below the orthodontic wire and position it around the tooth in a c-shaped manner to facilitate cleaning in the apico-coronal direction. In relation to toothbrushing, participants were directed to maintain their customary oral hygiene routine and use their preferred products. Following comprehensive instruction regarding the initial randomly assigned test product, professional tooth cleaning was carried out using an air-polishing device (\u003cem\u003eAirflow\u003c/em\u003e\u003csup\u003e®\u003c/sup\u003e prophylaxis master and \u003cem\u003eAirflow\u003c/em\u003e\u003csup\u003e®\u003c/sup\u003e Plus powder; both EMS, Nyon, CH), supplemented using sonic scalers and rubber cups with polishing paste (\u003cem\u003eCleanic\u003c/em\u003e\u003csup\u003e®\u003c/sup\u003e, Kerr, Bioggo, CH) as needed.\u003c/p\u003e\n\u003cp\u003eAfter an initial period of twenty-eight days employing the first test product, study participants attended their second visit. At this juncture, hygiene indices and inclusion/exclusion criteria were reevaluated (see Table 1). Subsequently, there was a washout phase lasting twenty-eight days during which the subjects reverted to their usual oral hygiene procedures. Following this period, they returned for the third visit. Once again, plaque disclosure was performed, and subjects were given detailed instructions for the utilization of the second product, followed by another professional dental cleaning. In a manner consistent with the first test phase, participants utilized the second product for twenty-eight days, then presented for an examination of the plaque- and gingival index during the fourth and final appointment of the study.\u003c/p\u003e\n\u003ch3\u003eStatistical analysis\u003c/h3\u003e\n\u003cp\u003eThe calculation of the sample size was based on the mean values and standard deviations of overall plaque scores, as provided by Heiß-Kisielewsky et al. in their study, where they compared the cleansing effectiveness of microburst technology (Airfloss\u003csup\u003eâ\u003c/sup\u003e, Philips, Hamburg, Germany) with dental flossing. (15) The sample size calculation for dependent samples, with a power of 80% and a = 0.05, resulted in a sample size of 16. Accounting for an assumed drop-out rate of 25%, the final sample size was \u003cem\u003en\u003c/em\u003e = 20. At the individual level, RMNPI values were determined by dividing the total number of areas with plaque present by the total number of assessed sites. These values were then compared between the two tooth-brushing techniques using the Wilcoxon signed-rank test. The gingival bleeding index was computed in a similar way. Unless indicated otherwise, median and interquartile range statistics are provided. The significance level was established at \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eTwenty individuals were recruited. Seventeen participants (seven females and ten males) finished the study with a mean age of 14.76 \u0026plusmn; 1.15 (range 14\u0026ndash;18) years. The drop-out rate was 15%. Three of them could not continue due to systemic antibiotic therapy, illness, and non-compliance, and were therefore excluded from the statistics.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003ePlaque scores\u003c/h2\u003e \u003cp\u003eAt baseline, the median of overall RMNPI was 73.43% (69.84\u0026ndash;79.56). After 28 days of interdental cleaning with microburst technology, the median of overall RMNPI was 60.71% (55.31\u0026ndash;66.47) and insignificantly higher than after 28 days of interdental cleaning with the control procedure dental flossing (median of overall RMNPI 59.72%; range 52.68\u0026ndash;68.67) (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.070) (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA statistically significant improvement was observed between the plaque index measured at the initial assessment, before any instruction, and the second baseline value after the four-week washout phase at the third assessment. While initially an average of 73.93% of tooth surfaces exhibited plaque, this was reduced to 63.04% at the third assessment.\u003c/p\u003e \u003cp\u003eThe medians differed, with 73.43% (69.84\u0026ndash;79.56) at the first assessment and 67.86% (56.06\u0026ndash;75.99) at the third assessment. The \u003cem\u003ep\u003c/em\u003e-value was 0.0009.\u003c/p\u003e \u003cp\u003eSubgroup analysis revealed no statistically significant differences in higher cleansing efficacy.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eGingival Bleeding Index\u003c/h2\u003e \u003cp\u003eAt baseline, the median of GBI was 35.26% (range 29.76\u0026ndash;40.74). After 28 days of interdental cleaning with the oral irrigator GBI was 29.17% (23.21\u0026ndash;33.97) and insignificantly higher compared to 25.60% (21.01\u0026ndash;31.41) after interdental cleaning with dental floss (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.1585) (see Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA noticeable improvement was observed in the Gingival Bleeding Index, with an initial median value of 37.16% (29.76\u0026ndash;40.74) reducing to 31.76% (25.00\u0026ndash;42.95) at the third assessment, although without statistically significance. The \u003cem\u003ep\u003c/em\u003e-value was 0.1362.\u003c/p\u003e \u003cp\u003eSubgroup analysis revealed no statistically significant differences in gingival bleeding.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003ePlaque and bleeding levels after one month of home use.\u003c/b\u003e The Rustogi modified plaque-index splits every buccal and lingual tooth surface into nine sections (A \u0026ndash; I) and was calculated as percentage of biofilm adhering sites to measured sites. Gingival bleeding was calculated dichotomously at 6 sites per tooth as percentage of bleeding sites to measured sites. Data was presented using median and interquartile ranges.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMicroburst technology\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDental flossing\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFull mouth\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRMNPI (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e60.71% (55.31\u0026ndash;66.47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e59.72% (52.68\u0026ndash;68.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.070\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGingival bleeding index (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29.17% (23.21\u0026ndash;33.97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25.60% (21.01\u0026ndash;31.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.1585\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eApproximal sites\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRMNPI (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e85.71% (83.93\u0026ndash;94.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e86.36% (78.85\u0026ndash;93.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.704\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGingival bleeding index (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26.14% (20.37\u0026ndash;31.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23.21% (17.86\u0026ndash;30.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.529\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eApproximal buccal sites\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRMNPI (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e94.64% (87.50\u0026ndash;97.83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e94.64% (85.19\u0026ndash;97.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.905\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGingival bleeding index (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18.18% (9.62\u0026ndash;28.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19.64% (13.64\u0026ndash;30.36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.912\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eApproximal lingual / palatal sites\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRMNPI (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e82.69% (71.43\u0026ndash;94.64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e82.14% (75.00\u0026ndash;91.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.624\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGingival bleeding index (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27.27% (22.22\u0026ndash;44.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25.00% (19.64\u0026ndash;32.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.271\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAnterior Teeth\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRMNPI (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e62.04% (54.63\u0026ndash;70.37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e60.32% (49.54\u0026ndash;73.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.596\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGingival bleeding index (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26.39% (24.24\u0026ndash;33.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22.92% (20.83\u0026ndash;30.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.453\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePosterior Teeth\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRMNPI (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e57.64% (48.99\u0026ndash;64.93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e57.29% (50.17\u0026ndash;63.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.337\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGingival bleeding index (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29.73% (23.21\u0026ndash;33.97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25.44% (19.23\u0026ndash;32.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.168\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRMNPI, Rustogi Modified Navy Plaque Index; %, percent; *, \u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIt is the daily challenge of interdental tooth cleaning for patients undergoing orthodontic treatment, which must be combated using simplified cleaning methods.\u003c/p\u003e \u003cp\u003eIn addition to dental floss, other oral hygiene aids such as interdental brushes or water floss are available. However, especially in young people, the spaces between the teeth are often too narrow for the use of interdental brushes and the orthodontic wires makes it difficult to use dental floss. The result is gingivitis and white spot lesions as a common side effect of fixed orthodontic treatment. (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) The existing research regarding the effectiveness of dental floss and water flossers is quiet varied. Some studies have indicated that water flossers offer superior cleaning results, along with a reduction in inflammation, especially among individuals with orthodontic treatment. (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eOn the other hand, studies have concluded that both methods are equally effective. Notably, a previous similarly designed trial conducted as part of this study, which also concentrated on patients with fixed orthodontic appliances, found that Superfloss dental floss provided more efficient cleaning results, a finding in contrast to most other studies (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). However, in this current study no statistically significant differences were observed between Superfloss and Airfloss in terms of cleaning efficacy across various areas of tooth surfaces. Therefore, the results obtained from the prior study involving adults could not be directly applied to teenagers. Only when comparing the average values, there was a statistically significant preference for Superfloss, suggesting a potential inclination towards better cleaning with dental floss, though this result is not conclusive and might be influenced by chance. Finally, the nearly one-minute extension of brushing duration and the observed enhancements in motivation hold significant clinical relevance, as compliance stands as a primary impediment to the achievement of effective oral hygiene. (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eIn this study we used the Rustogi Modified Navy Plaque Index (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) for evaluating plaque presence or absence in nine areas on buccal or lingual tooth surfaces. This dichotomous index allows us to measure plaque levels on a full-mouth level, but also subgroup analyses including smooth surfaces, interdental and gingival margin areas.\u003c/p\u003e \u003cp\u003eFollowing a four-week period of dental flossing (using Superfloss), the mean plaque index showed a score of 59.46% whereas Airfloss scored 58.81%. Correspondingly, the median plaque index values for Superfloss and Airfloss were 59.72% (52.68\u0026ndash;68.67) and 60.71% (55.31\u0026ndash;66.47), respectively.\u003c/p\u003e \u003cp\u003eIn contrast, the gingival index exhibited an average of 26.40% (with a median of 25.60%) following to the use of Superfloss, a result which stood in contrast to the 28.93% mean (with a median of 29.17%) recorded following the use of Airfloss. It is noteworthy, however, that both inequalities failed to attain statistical significance, as indicated by their respective \u003cem\u003ep\u003c/em\u003e-values of 0.070 and 0.1585.\u003c/p\u003e \u003cp\u003eA limiting factor of the significance of this study undoubtedly resides in the small number of participants. The selection process posed challenges due to the inclusion criteria specifying an age of over 14 years, which naturally, constrained the pool of eligible patients. Many younger patients receiving treatment at the University Clinic of Orthodontics were thereby excluded from the study. Furthermore, the age-related aspects of the participants also contributed to the diminished motivation and interest in maintaining oral hygiene. Coupled with the fact that many adolescents do not receive instructions or monitoring from their parents in this regard, it was challenging to ascertain the accuracy with which the products were used.\u003c/p\u003e \u003cp\u003eAnother study design\u0026acute;s limitations may include the potential decrease in gingival bleeding index due to professional cleaning, which could diminish the comparability with the baseline gingival bleeding index. In order to achieve a consistent baseline value before the first and second test phase, a washout period of 28 days was chosen, during which participant maintained their original oral hygiene routine.\u003c/p\u003e \u003cp\u003eIn conclusion and as mentioned before, none of the two products proved significantly superior in terms of cleaning efficiency. Therefore, no recommendation can be made in favor of one over the other. However, it is evident that through instruction and special attention to home oral hygiene, improved index values were achieved, leading to the conclusion that paying careful attention to and eagerly carrying out daily dental cleaning is of highly importance and has the most significant effect on preserving oral health.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of Interest and Source of Funding Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that there are no conflicts of interest. The authors do not have any financial interests, either directly or indirectly, in the products tested in this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe present study was carried out in accordance with the 1964 Declaration of Helsinki and its later amendments, and ethical approval was obtained by the\u0026nbsp;Ethics committee of the Medical University of Innsbruck, Austria (study ID AN 5123).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll subjects signed an informed written consent prior to the study enrolment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that there are no conflicts of interest in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Manuel Kasslatter, Lena Denk und\u0026nbsp;Anna­-Maria\u0026nbsp;Sigwart. The first draft of the manuscript was written by Hanna Gänzer and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received no fundings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eS\u0026auml;lzer S, Slot DE, Van Der Weijden FA, D\u0026ouml;rfer CE. Efficacy of inter‐dental mechanical plaque control in managing gingivitis \u0026ndash; a meta‐review. J Clinic Periodontology [Internet]. 2015 Apr [cited 2023 Nov 8];42(S16). Available from: https://onlinelibrary.wiley.com/doi/10.1111/jcpe.12363\u003c/li\u003e\n\u003cli\u003eMarchesan JT, Morelli T, Moss K, Preisser JS, Zandona AF, Offenbacher S, et al. Interdental Cleaning Is Associated with Decreased Oral Disease Prevalence. J Dent Res. 2018 Jul;97(7):773\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eWorthington HV, MacDonald L, Poklepovic Pericic T, Sambunjak D, Johnson TM, Imai P, et al. Home use of interdental cleaning devices, in addition to toothbrushing, for preventing and controlling periodontal diseases and dental caries. Cochrane Oral Health Group, editor. Cochrane Database of Systematic Reviews [Internet]. 2019 Apr 10 [cited 2023 Nov 8];2020(4). Available from: http://doi.wiley.com/10.1002/14651858.CD012018.pub2\u003c/li\u003e\n\u003cli\u003eChapple ILC, Van Der Weijden F, Doerfer C, Herrera D, Shapira L, Polak D, et al. Primary prevention of periodontitis: managing gingivitis. J Clinic Periodontology [Internet]. 2015 Apr [cited 2023 Nov 8];42(S16). Available from: https://onlinelibrary.wiley.com/doi/10.1111/jcpe.12366\u003c/li\u003e\n\u003cli\u003eAshkenazi M, Bidoosi M, Levin L. Factors associated with reduced compliance of children to dental preventive measures. Odontology. 2012 Jul;100(2):241\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eM\u0026uuml;ller LK, Jungbauer G, Jungbauer R, Wolf M, Deschner J. Biofilm and Orthodontic Therapy. In: Eick S, editor. Monographs in Oral Science [Internet]. S. Karger AG; 2021 [cited 2023 Nov 8]. p. 201\u0026ndash;13. Available from: https://www.karger.com/Article/FullText/510193\u003c/li\u003e\n\u003cli\u003eLucchese A, Bondemark L, Marcolina M, Manuelli M. Changes in oral microbiota due to orthodontic appliances: a systematic review. Journal of Oral Microbiology. 2018 Jan 1;10(1):1476645.\u003c/li\u003e\n\u003cli\u003eContaldo M, Lucchese A, Lajolo C, Rupe C, Di Stasio D, Romano A, et al. The Oral Microbiota Changes in Orthodontic Patients and Effects on Oral Health: An Overview. JCM. 2021 Feb 16;10(4):780.\u003c/li\u003e\n\u003cli\u003eGiugliano D, d\u0026rsquo;Apuzzo F, Majorana A, Campus G, Nucci F, Flores-Mir C, et al. Influence of occlusal characteristics, food intake and oral hygiene habits on dental caries in adolescents: a cross-sectional study. European Journal of Paediatric Dentistry. 2018;(2):95\u0026ndash;100.\u003c/li\u003e\n\u003cli\u003eSharma NC, Lyle DM, Qaqish JG, Schuller R. Comparison of two power interdental cleaning devices on plaque removal. J Clin Dent. 2012;23(1):17\u0026ndash;21.\u003c/li\u003e\n\u003cli\u003eLyle DM. Relevance of the water flosser: 50 years of data. Compend Contin Educ Dent. 2012 Apr;33(4):278\u0026ndash;80, 282.\u003c/li\u003e\n\u003cli\u003eMazzoleni S, De Stefani A, Bordin C, Balasso P, Bruno G, Gracco A. Dental water jet efficacy in the plaque control of orthodontic patients wearing fixed appliance: A randomized controlled trial. J Clin Exp Dent. 2019;0\u0026ndash;0.\u003c/li\u003e\n\u003cli\u003eManuelli M, Marcolina M, Nardi N, Bertossi D, De Santis D, Ricciardi G, et al. Oral mucosal complications in orthodontic treatment. Minerva Stomatol [Internet]. 2019 Mar [cited 2023 Oct 20];68(2). Available from: https://www.minervamedica.it/index2.php?show=R18Y2019N02A0084\u003c/li\u003e\n\u003cli\u003eAinamo J, Bay I. Problems and proposals for recording gingivitis and plaque. Int Dent J. 1975 Dec;25(4):229\u0026ndash;35. \u003c/li\u003e\n\u003cli\u003eHei\u0026szlig;-Kisielewsky I, Sandbichler L, Kapferer-Seebacher I. Plaquereduktion mit der Sonicare AirFloss im Vergleich zur Zahnseide. Ergebnisse einer randomisiert kontrollierten Cross-over-Studie. Parodontologie. 2015 Jan 1;26:41.\u003c/li\u003e\n\u003cli\u003eHusseini A, Slot D, Van Der Weijden G. The efficacy of oral irrigation in addition to a toothbrush on plaque and the clinical parameters of periodontal inflammation: a systematic review. Int J Dental Hygiene. 2008 Nov;6(4):304\u0026ndash;14.\u003c/li\u003e\n\u003cli\u003eLyle DM, Goyal CR, Qaqish JG, Schuller R. Comparison of Water Flosser and Interdental Brush on Plaque Removal: A Single-Use Pilot Study. J Clin Dent. 2016 Mar;27(1):23\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003eWiesm\u0026uuml;ller V, Kasslatter M, Zengin B, Zotz D, Offermanns V, Steiner R, et al. Cleansing efficacy of an oral irrigator with microburst technology in orthodontic patients\u0026mdash;a randomized-controlled crossover study. Clin Oral Invest. 2023 Apr 6;27(5):2089\u0026ndash;95.\u003c/li\u003e\n\u003cli\u003eRustogi KN, Curtis JP, Volpe AR, Kemp JH, McCool JJ, Korn LR. Refinement of the Modified Navy Plaque Index to increase plaque scoring efficiency in gumline and interproximal tooth areas. J Clin Dent. 1992;3(Suppl C):C9-12.\u003c/li\u003e\n\u003cli\u003eErbe C, Klees V, Braunbeck F, Ferrari-Peron P, Ccahuana-Vasquez RA, Timm H, et al. Comparative assessment of plaque removal and motivation between a manual toothbrush and an interactive power toothbrush in adolescents with fixed orthodontic appliances: A single-center, examiner-blind randomized controlled trial. American Journal of Orthodontics and Dentofacial Orthopedics. 2019 Apr;155(4):462\u0026ndash;72. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Oral irrigator, Adolescent, Orthodontic, Oral hygiene, Plaque index, Gingival Bleeding Index, Fixed orthodontic treatment","lastPublishedDoi":"10.21203/rs.3.rs-3781500/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3781500/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eObjectives\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSimplifying interdental space cleaning is a constantly discussed topic. The present study aimed to compare the cleansing efficacy of an oral irrigator with that of dental flossing in adolescent patients with fixed braces after four weeks of home-use.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eMaterials and methods\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe study design is a randomized, single-blinded cross-over study. Following a twenty-eight-day period of product utilization in a home setting, a comparative analysis was conducted on hygiene indices, specifically the Rustogi Modified Navy Plaque Index (RMNPI) and the Gingival Bleeding Index (GBI), between the test group (oral irrigator) and the control group (dental floss).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSeventeen adolescent individuals finalized the study. After 28 days of cleaning with the oral irrigator, RMNPI was 58.81% (55.31 – 66.47) compared to 59.46% (52.68 - 68.67) with dental floss (\u003cem\u003ep\u003c/em\u003e = 0.070). Subgroup analyses did not classify either of the two methods as superior. GBI after the test phase with the oral irrigator was 28.93% (23.21 – 33.97) and insignificant higher compared to 26.40% (21.01 – 31.41) with dental floss (\u003cem\u003ep\u003c/em\u003e = 0.1585).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003es\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone of the two products proved significantly superior in terms of cleaning efficiency. Therefore, no recommendation can be made in favor of one over the other. It is evident that through special attention to home oral hygiene, improved index values were achieved, leading to the conclusion that paying careful attention to daily dental cleaning is of highly importance.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eClinical relevance\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIt´s less about the tool but more about oral hygiene instruction and motivation provided by the orthodontist or the responsible guardians at home.\u003c/p\u003e","manuscriptTitle":"Cleansing efficacy of an oral irrigator with microburst technology in adolescent orthodontic patients. A randomized-controlled crossover study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-05 18:29:46","doi":"10.21203/rs.3.rs-3781500/v1","editorialEvents":[{"type":"communityComments","content":1}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bace5244-99b6-494b-8c6d-776564972a71","owner":[],"postedDate":"January 5th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-01-12T05:44:16+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-05 18:29:46","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3781500","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3781500","identity":"rs-3781500","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}