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Penetration of Fluids into Peridontal Pockets
Using a Powered Toothebrush/Irrigator Device
Abstract
This study was a single-blind, randomized, controlled clinical trial. The researchers evaluated a powered
brush/irrigating device (HydraBrush Oral Health System™; OHS) for its safety and ability to deliver a solution
to the bottom of 5-6 mm pockets, compared to rinsing alone with a solution following brushing with a powered
toothbrush (Sonicare Elite™ 7800; SE). An evaluation technique to measure the quantity and quality of solution
able to enter the pocket was also introduced in this project.
Methods: Subjects were randomized in one of two-groups: brush plus simultaneous irrigation (OHS) versus
brush plus rinsing (SE). Subjects used their devices at home for two weeks. At the measurement visit, subjects
used the OHS to irrigate and brush simultaneously for 1 minute (30 seconds per each side of the mouth) with
a 0.01% erythrosine disclosing solution in 10 oz of distilled water. Control subjects brushed for 2 minutes
with a SE followed by a 1 minute rinse with an identical disclosing solution. A blinded evaluator collected six
samples of approximately of 1 µL of sucular fluid from six 5-6 mm evaluation sites. This was accomplished by
inserting a microcapillary tip with a 20 µL micropipette in the sulcus. Two-group repeated measures ANOVA
was used to examine differences in two measures of the disclosing solution between OHS and SE subjects; the
spectrometer reading of the disclosing solutions, and by visual inspection of the samples (positive/negative) to
determine the presence or absence of solution in the samples. Subjects’ diaries were collected. Bleeding and
discomfort during the evaluation period was reported.
© Seer Publishing
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Results: Visually, OHS had a significantly greater proportion of solution taken from the base of 5-6 mm sites
than the SE (p=0.0001). However, there was no statistical difference between the two groups (p=.1359) in the
spectrophotometer readings.
Conclusion: The experimental device is more efficient in delivering a solution to the base of 5-6 mm pockets
than rinsing following use of a control powered toothbrush. Both devices have demonstrated they are safe and
well accepted by patients. The technique developed provides a useful method for quantitative and qualitative
studies of solutions from the base of periodontal pockets.
Keywords: Powered toothbrush, periodontal irrigation, oral rinsing, and plaque removal.
Citation: Brackett MG, Drisko CL, Thompson AL, Waller JL, Marshall DL, Schuster GS. Penetration of
Fluids into Periodontal Pockets Using a Powered Toothbrush/Irrigator Device. J Contemp Dent Pract 2006
July:(7)3:030-039.
Introduction
Periodontal therapy patients with 5-6 mm pockets
could possibly be maintained if they are able
to clean to the base of the periodontal pockets.
The use of chemotherapeutic liquids should offer
promise in managing these conditions; however,
their use has been limited due to the lack of a
home care armamentarium to predictably deliver
these agents to the depths of the periodontal
pockets.1 Studies have shown sulcus penetration
of fluids by mouth rinsing alone is less than
2mm.1-3
Oral irrigators may have the potential to deliver
liquids more efficiently than rinsing. Yet, studies
conducted on oral irrigators concluded pockets
greater than 4 mm in depth are difficult to
irrigate,1-5 and effective irrigation depends on
ejection site pressure, irrigator tip design and
presence of subgingival calculus.6 Several
investigators have examined the relationship
of the placement of the irrigation cannula and
liquid penetration into the sulcus. One study
showed when the tip of a supragingival irrigator
was positioned at either a 45° or 90° degree to
the long axis of the tooth, irrigation solutions
penetrated to an average of one-half the depth
of the pockets.7 Larner and Greenstein6 found
irrigators positioned subgingivally were more
efficient than those positioned supragingivally
at delivering liquids to the depth of periodontal
pockets. An investigation by Hardy et al.8
determined irrigation to the base of both
shallow and deep pockets only occurred when
the irrigating cannula was placed 3.0 mm
subgingivally. Given this data, the question still
remains as to whether patients are capable of
applying such irrigation techniques in a home
care regimen.
In order to find an easier and more efficient
home care method for dental patients, some
studies have suggested a combination of cleaning
modalities. These studies have suggested
incorporating a water pressure device with
toothbrushing, interdental stimulation, and
professional prophylaxis may help reduce
plaque and improve solution penetration into the
periodontal pocket.1,11 Wunderlich et al.1 studied
the relationship between the probed sulcus
depth and the degree of subgingival penetration
of a solution using an irrigation technique and
a rinsing technique. They reported the mean
percentage of penetration for 2-4 mm pockets
was greater after a prophylaxis was performed.
In addition, other researchers6 have found both
supragingival and subgingival irrigators achieved
superior irrigation into 7-10 mm pockets after
calculus had been removed from the roots of
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teeth. Thus, it is possible there is a relationship
between plaque and calculus removal and the
successful irrigation of periodontal pockets.
While powered toothbrushes have proven to
be efficient in removing dental plaque12-15, their
use in conjunction with oral irrigation has not
been tested as a method of improving sulcus
penetration.
adaptability of the patients to these devices and,
3) to introduce a new technique designed for
efficient collection of samples from the base of
the sulcus.
The first goal was to evaluate a powered
brush/irrigating device (HydraBrush Oral Health
System™ Oralbotics, Inc. Escondido, CA) for its
ability to deliver a solution to the bottom of 5-6
mm pockets, compared to rinsing with a solution
following brushing with a powered toothbrush
(Sonicare Elite™ 7800 Philips Oral Healthcare,
Inc. Snoqualmie, WA). The hypothesis in the
present study was using an experimental device,
the bristles of the unit may deflect the gingival
tissue, allowing simultaneous improved irrigation
of a solution into the periodontal pockets. The
control protocol for this study was selected
because the Sonicare Elite has been shown
in laboratory studies to remove plaque up to 3
mm beyond its bristle tips12,13 and up to 1 mm
subgingivally in a clinical study.14 Therefore, the
investigators are of the opinion the effectiveness
of this toothbrush at removing subgingival plaque
may allow a deeper penetration of a rinsing
solution.
Various protocols have been established to
evaluate the effectiveness of sulcular irrigation
techniques. Published techniques include
application of irrigation solutions containing
disclosing dyes applied prior to tooth extraction,
then measuring the stained tooth surfaces extraorally.2, 3, 6-8 Wunderlich1 applied a fluorescent
irrigating solution and then used photographs to
measure the penetration of the solution into the
pocket. While these techniques allow for accurate
measure of sulcular penetration, none measure
the volume and quality of the solution penetrating
into the periodontal pocket.
The current study had three goals: 1) to compare
a powered brush/irrigating device to rinsing with
a solution following brushing with a powered
toothbrush, 2) to evaluate the safety and
Table 1. Inclusions and exclusion criteria.
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Secondly, the safety of the devices was evaluated
by giving the subjects a diary in which to document
any bleeding and discomfort, during the two weeks
of this study. Finally, a new technique designed
for efficient collection of samples from the base
of the sulcus was introduced. The quantity and
quality of penetration of the dye solution into
periodontal pockets was evaluated by extracting
the applied solution with the tip of a micropipette,
and analyzing its color concentration.
Methods and Materials
After receiving Institutional Review Board
approval, subjects were recruited from patients
who came to the Department of Dental Hygiene
and Periodontology for routine oral examinations.
Potential subjects were invited to participate, and
asked to sign an informed consent. Calibrated
examiners conducted medical history, all
oral tissue examinations, and probing depth
measurements. Probing depth (measured from
the gingival margin to the apical extent of the
probable sulcus/pocket) was determined to the
nearest millimeter using a manual Hu-Friedy
PQOW periodontal probe with Williams’ markings
using normal probing force (20-30gms). Each
evaluated tooth was assessed on six surfaces
(mesiolingual, lingual, distolingual, distofacial,
facial, and mesiofacial). Those who satisfied the
inclusion/exclusion criteria were recruited into the
study (Table 1).
Figure 1. Control powered
toothbrush. Sonicare Elite 7800.
Thirty subjects (17 females, 13 males, between
the ages of 30 to 71, mean age 48.8) who met
the above criteria were enrolled into the study.
These subjects were assigned randomly to an
experimental or control group.
Figure 2. Experimental device: Hydrabrush
Oral Health System
At the first appointment, following randomization,
the subjects were given their oral care device and
received instructions on the brushing technique,
according to the manufacturer’s directions. The
control group received a Sonicare Elite™ 7800
(SE) (Figure 1) and the experimental group
received the HydraBrush Oral Health System™
(OHS). (Figure 2)
Figure 3. Oral Health System placed on
one side of the mouth. Upper and lower
quadrants are being brushed and irrigated
simultaneously.
In the experimental group, subjects were advised
to brush and irrigate their teeth simultaneously for
30 seconds on each side of the mouth, (each side
has two quadrants) for a total of 1 minute using a
timer (Figure 3).
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In order to reduce potential soft tissue damage,
two types of brush heads were used in this
group, an extra soft and a soft. During the first or
introductory week of the study, the subjects used
a brush head with extra soft bristles for one minute;
they changed to the soft brush head in the second
week.
only the dentifrice provided (Crest® Regular,
Procter & Gamble, Cincinnati, OH).
In order to evaluate subjects’ tolerance to their
power toothbrushes, the subjects received a
diary, and they were asked to record ‘Yes’ or ‘No’,
if they experienced any bleeding, or discomfort
while brushing with their powered devices. They
were also asked to record the times and dates
of brush usage in their diary (Table 2). They
were asked to refrain from using any other oral
hygiene products during the study, for example,
dental floss, interdental stimulators, toothpicks,
other toothpastes, other toothbrushes, antiplaque mouthrinse, anti-plaque chewing gum, oral
cosmetic preparations (tooth whitening products),
or water irrigation devices (such as Water PIK™).
There were no restrictions with regard to smoking
or dietary habits. Subjects were informed the
diaries had to be returned at the end of the
examination.
The control group was instructed to brush their
teeth for a total of two minutes, as directed by the
manufacturer, 30 seconds per quadrant, using
the timer apparatus in the control toothbrush. The
Sonicare Elite™ 7800 has a dual speed control
(low and high). In order for the subjects to get used
to the toothbrush, they brushed their teeth on low
speed for the first week and on high speed during
the second week.
Subjects were advised to use their assigned oral
care devices twice daily, in the morning and before
bedtime, in accordance with the manufacturers’
directions. The subjects were requested to utilize
Table 2. Sample of subjects’ brushing diary for the first three days of the
14 day total.
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done so the examiner would have no knowledge
of the patients’ routine at the time the samples
were taken.
Control subjects were asked to brush their teeth
with the powered toothbrush for two minutes.
After the subjects finished brushing, they were
asked to rinse for one minute with .01% disclosing
solution (20 drops). After the subjects finished
rinsing, the examiner, who was blind to the study
treatment, collected samples of approximately
1 microliter of sucular fluid from each of the
evaluation sites. The examiner gently inserted a
microcapillary tip in a 20 µL micropipette into the
bottom of the periodontal pocket (Figure 4). In
order to avoid collecting more superficial solution
around gingival margin, a positive pressure was
maintained on the tip until it reached the bottom
of the pocket. Once the sample was collected,
the tip of the micropipette was placed against a
white paper filter as background and evaluated
as negative or positive for dye. If the sample was
positive (reddish colored solution in the apex of
the micropipette), the sample was placed in a
multiwell plate containing five microliters of water
in each well (Figure 5).
Figure 4. Micro capillary tip
penetrating into the depth of the
5-6 mm pocket.
Up to six samples were collected from each
subject. The solutions in the plate were then
placed into a plate reader for measuring of the
concentration of disclosing solution retrieved from
the base of the pocket, based upon color.
Figure 5. Sample placed in a 384 multiwell plate containing five microliters of
water in each well.
With subjects using the experimental device,
.01% of disclosing solution (40 drops) and 10
ounces of distilled water were added to the
irrigator receptacle. The subjects in this group
were asked to brush their teeth and activate the
water jets of the experimental device for one
minute, 30 seconds per each side of the mouth.
After they had finished brushing and irrigating,
the samples from the base of the pockets of the
designated sites were taken in the same manner
as in the controls.
After two weeks, all subjects returned to the
clinical facility with their toothbrush. At that time,
an examiner, blinded to case control status,
performed clinical examination with mouth mirror
and digital palpation. The lips, tongue, hard
and soft palate, oro-pharynx, uvula, gingiva,
mucobuccal folds, buccal mucosa, sublingual
space, floor of the mouth, and teeth were
assessed and reported by the examiner as
normal or abnormal. Any reports of irritation,
as well as any tissue changes observed during
these examinations were recorded. Diaries were
collected.
Laboratory Procedure
The optical densities of the samples were read
at 530 nm using a spectrophotometer (FL600
Micro plate Fluorescence Reader KC 4. BioTek Instruments, Inc. Vinooski, VA), capable of
reading individual wells on a 384 well plate.
After the completion of the soft tissue
examination, the examiner left the room while the
subject brushed his/her teeth. This procedure was
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Statistical Analyses
For any sample visually evaluated as having no
solution, the sample was not pipetted into the
wells for spectrophotometer readings and, thus,
no spectrophotometer data was determined
for those negative samples (24% of the
experimental samples, and 54% of the control
samples).
to the base of the 5-6 mm pockets was found
76% of time (65 out of 86 periodontal pockets) in
the experimental group, and 46% of time (41 out
of 89) in the control group. Thus, the experimental
device had a significantly greater proportion of
positive sites than the control (p=0.0001). The
spectrophotometer was used to evaluate the
intensity of the disclosing solution in the pocket.
There was no statistical difference in intensity of
the solution between the two groups among those
for which the visual test was positive. (p=0.14)
(Table. 3)
Two-group repeated measures analysis of
variance (ANOVA) was used to examine
differences in two different measures of the
disclosing solution between subjects using
the Hydrabrush Oral Health System™ and
subjects using the Sonicare™ toothbrush:
the spectrometer reading of the disclosing
solution, and an investigator’s visual evaluation
(positive/negative) as to whether the disclosing
solution was present in the sample. Performing
a repeated measures ANOVA is similar to
performing a GEE model with repeated
measures when the outcome is a dichotomous
variable.20-21 For each outcome measured,
the subject was nested within the brush type
and considered a random effect in the model.
Brush type was included in the model and was
considered a fixed effect. The F-test for brush
type used the error term for subject nested
within brush type as the denominator in the Fstatistic. Statistical significance was assessed at
an alpha level of 0.05 using SAS 8.2.
At the recall appointment, no severe adverse
reactions were reported by any of the examiners
for either of the devices.
Table 4 describes the differences in their initial
probing depths. There were no statistically
significant differences in initial probing depths
between the two groups (p= 0.65). Table 4 also
describes differences in the type of adverse
reaction (bleeding, discomfort) across time
and between the two brush types the subjects
recorded in their diary while brushing.
Differences in bleeding and discomfort were
observed between the two groups. In relation to
bleeding, a significant interaction between time
and brush type was observed. This indicated
the effect of brush type across time on bleeding
was different. The experimental group had
significantly lower rates of bleeding at follow-up
than at baseline (p=0.002, post-hoc analysis),
while rates of bleeding in the control group
remained similar (p=1.00, post-hoc analysis).
Within the time period, the experimental group
had significantly higher rates of bleeding at
baseline (p<0.0001, post-hoc analysis). Rates of
bleeding at follow-up were not different between
the experimental and control groups (p=0.26,
post-hoc analysis).
Examination of differences in periodontal
disease, between the brush type groups,
measured by initial pocket depth, was performed
using repeated measures ANOVA. Bleeding and
discomfort were evaluated at baseline and at
follow-up during the two weeks of the evaluation.
The assessment of complications reported by
the patients was either positive (Yes) or negative
(No) as to whether or not they experienced
some type of adverse effect while brushing.
A two-group repeated measures analysis of
variance test was used to examine changes in
bleeding, and discomfort across time between
the two brush types. Statistical significance was
assessed at an alpha level of 0.05. A Bonferroni
correction to the alpha level was used to perform
post hoc multiple comparisons.
For discomfort, a significant interaction between
brush type and time was not detected. Neither
the experimental nor control groups had
significantly lower rates of discomfort at followup than at baseline. Within the time period, the
experimental group had significantly higher rates
of discomfort than the control group at baseline
(p=0.0087 post-hoc analysis) but not at follow-up
(p=0.27, post-hoc analysis).
Results
All patients completed and complied with the
study protocol. Penetration of disclosing solution
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Table 3. Two-group repeated measures ANOVA results for mean spectrometer reading and
visibility of the presence or absence of disclosing solution between brush types.
Discussion
A pilot study was initiated to verify some clinical
aspects of the evaluation of the toothbrushes
used, and to see whether or not it would be
feasible to visualize and read the samples
of erythrosine extracted from the periodontal
pockets in the spectrophotometer.
The amount of disclosing solution (10 ounces by
40 drops of 0.01% of erythrosine) was selected
because the reservoir of the experimental device
holds 10 ounces. It is also takes 1 minute to
deliver all the water into the mouth. Control
subjects used only half of that amount. Subjects
were asked to rinse with 5 ounces of the same
solution during one minute.
In this study, the researchers introduced a
new intracrevicular method designed to collect
representative samples from the base of the
periodontal pocket. The advantage of the method
used to collect subgingival samples in this study
was using a positive pressure maintained on
the tip until it is at the sample-collection depth,
false positives, for example, superficial samples
acquired while passing the sampling device
through the solution around the gingival margin
are avoided. Using a micropipette to extract
the disclosing solution from the base of the
pocket was a delicate technique. Problems with
the micropipette collection technique and data
Initially, probing depth and plaque index were
going to be tested on the evaluation day. Probing
depth was excluded from the study because the
probe may tear the sulcular epithelium and may
contaminate the samples with blood. Plaque
index was also deleted because the disclosing
solution used to evaluate the plaque index may
contaminate the pocket sample.
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Table 4. Two-group repeated measures ANOVA results. This measured mean pocket depth,
presence of bleeding, and discomfort reported by the subjects.
Mean indicates the mean pocket depth or the mean rate of outcome measure (under outcome
in the table). For bleeding, discomfort, and any complication, this is the proportion of individuals
indicating they had bleeding, discomfort, or any complication.
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analysis included: contamination of the sample
with blood or plaque and the absence of any
visible sample in the micropipette. When there was
contamination of blood or plaque in the sample,
the sample was discharged, and a different site
was selected and sampled. Other studies have
reported similar difficulties using this technique,
and have excluded the contaminated samples from
their analyses.17-19 In addition, another problem
encountered was an absence of any visible
sample in the micropipette, such samples were
not evaluated in the spectrophotometer. This was
a limitation in the technique used in the study, as
it was impossible to obtain fluid samples from the
base of some pockets. However, when fluid was
able to be extracted using this technique, similar
concentration of fluid was found regardless of the
delivery method.
sulcular epithelium have been reasons for lack
of total penetration when using supra gingival
irrigation. In addition, another study11 suggested
the use of brushing and interdental stimulation
in conjunction with an oral irrigator was superior
in reducing periodontal index as well as the
amount of plaque and calculus accumulation
than brushing and interdental stimulation alone.
Therefore, the use of oral irrigation may be
considered optimal when no calculus is present
and plaque control has been achieved.
Researchers also have found irrigator tip design
and placement of the tip affect the depth to which
drugs can be delivered subgingivally.6 When
the tip of the irrigator is placed 3 mm below
the gingival margin, fluid penetration occurs in
95% of the times regardless of pocket depth.8
However, subgingival irrigation may not be easy
for most patients to use at home. The results
in this study show it is possible to deliver an
irrigant subgingivally with the experimental device
at a similar level of pocket penetration as can
achieved by an oral irrigator device.
Since powered toothbrushes have proven to be
efficient in removing dental plaque,12-15 it was
thought brushing before rinsing or brushing
and irrigating simultaneously would allow better
penetration of a solution into the periodontal
pocket,11 This assumption seems correct as each
of the powered devices demonstrated improved
pocket penetration when compared to previous
studies. The control/rinsing protocol allowed
penetration of the disclosing solution to the base
of 46% of the pockets, while the experimental
protocol did it to 76%.
During the two weeks of the study, the
experimental group reported significantly higher
rates of bleeding and discomfort than the control
group at both baseline (Table 4) and at followup. However, at the end of the two weeks,
no adverse events were reported other than
those observed with regular brushing in either
group. Both experimental and control groups
showed significantly less self report bleeding and
discomfort by the end of the second week, this
results may reflect the reduction of inflammation
and the adaptability of the subjects to use the
powered devices.
Using only those samples for which spectrometric
data was available, no statistically significant
differences were found in the mean spectrometer
readings between the experimental and control
toothbrush systems (p =0.1359) (Table 3).
Therefore, it appears regardless of the brush used,
similar intensities (concentrations) of solution were
able to reach the depth of the pocket.
The experimental unit’s treatment regimen
demands less time when compared to other oral
care systems. The six-headed device may allow
patients to clean more efficiently than any singleheaded brush. The one minute therapy time is
more compatible with the brushing behavior of the
general population, and it may be an additional
advantage of the experimental device.16
The increase in effectiveness of the experimental
unit may be explained by its six-head brush design
and the simultaneous brushing and flushing action.
These features may physically remove plaque
more effectively, allowing for better penetration of
the irrigating solution.15 These assumptions are
in agreement with other supragingival irrigation
studies.1,6,11
The researchers suggest the experimental
device is safe to use and effective 76% of the
time at delivering an irrigation solution to the
base of 5-6 mm periodontal pockets. Because it
Pitcher et al2 found the presence of subgingival
calculus on the surface of the root and a tight
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requires patients to use the system for only one
minute, it may be recommended for convenient
maintenance of a healthy periodontium and
prevention of periodontal disease. The design of
the experimental device opens the door for further
studies to be done to access the effectiveness of
this system for physically and mentally challenged
patients as well as for children.
1. The experimental device is more efficient in
delivering a solution to the base of 5-6 mm
pockets than a mouth rinse following the use
of the control powered toothbrush.
2. Both powered devices have proven to be safe,
well accepted devices.
3. The technique developed provides a useful
method for studies of quantitative and
qualitative solutions at the base of periodontal
pockets.
Conclusion
Based on the findings of this study, the following
conclusions may be drawn:
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subjects. Quintessence Int. 2001; 32(2):147-54
15. Khocht A, Spindel L, Person P. A Comparative Clinical Study of the Safety and Efficacy of Three
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J Dent Res 1969; 48:159
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19. Slonen JI, Paunio KU: An intracrevicular washing method for collection of crevicular contents. Scand
J Dent Res 1991;99:406-12
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About the Authors
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The Journal of Contemporary Dental Practice, Volume 7, No. 3, July 1, 2006
Acknowledgment
The researches would like to thank Ms. Tanya Shores for her valuable help and dedication in localizing
patients for the study.
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The Journal of Contemporary Dental Practice, Volume 7, No. 3, July 1, 2006
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