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Journal of Clinical Periodontology: 1978: 5: 95-104

Key words: Gingiviiis - ptaque prevention.

Accepted for publication: July 15. 1977.
Effect of the Water Pik device on
plaque accumulation
and development of gingivitis
The Department of Periodontology,
The Institute for Postgraduate Dental Education,
Jonkoping, Sweden
Abstract. The influence of the water irrigating deviee. Water Pik, on the accumulation
of plaque and development of gingivitis has been studied using the model, "experimental
gingivitis in man". The investigation was carried out on 41 patient volunteers whose teeth
were thoroughly scaled and polished during a 4-week period of intensive oral hygiene
preceding each experimental period. Gingival exudation. Plaque Index and Gingival Index
were registered at the beginning af the experimental periods. The participants were then
divided into four groups. Groups A and B abandoned all forms of active oral hygiene.
Group A, however, were given Water Pik devices as the only oral hygiene aid. Groups C
and D continued to clean their teeth using a toothbrush and Group C were given Water
Pik devices as a supplementary aid. After 14 days, gingival exudation. Plaque Index,
Gingival Index and soft tissue injuries were registered. The results showed that, while
both groups A and B demonstrated extensive plaqtie deposits and gingivitis, these were
present to a significantly lesser degree in Water Pik users. The toothbrushing groups
(C and D) failed to demonstrate any further rednction of plaque or gingivitis when
Water Pik was introduced as an additional measure. No soft tissue injuries were found.
Extensive clinical and epidemiological re- viding a pulsating stream of water under
search has clearly shown that dental plaque adjustable pressure, e.g. Water Pik. These
is an essential aetiological factor in the water irrigating devices have even been used
development of caries and periodontal dis- as a means of conveying different antiseptic
ease (Socransky 1970, Waerhaug 1971, medicaments to the oral cavity (Lobene
Genco 1973). It has also been shown that et al. 1972, Agerbaek et al. 1975).
both these diseases can be prevented or Many investigators have tried to deter-
treated by adequate plaque control (Lov- mine the value of the water irrigating device
dahl et al. 1961, Axelsson & Lindhe 1974, as an oral hygiene aid. The findings have
Lindhe & Nyman 1975). For many years, varied greatly. According to certain authors,
various water irrigating devices have been its ability to remove plaque is insignificant
advertised as supplements to the established or non-existent (Emslie 1964, Lobene 1969,
methods of mechanical plaque control. Covin et al. 1973, Matsuzaki et al. 1974),
(Marshall 1901, Amim 1967). This ap- while Covin et al. (1973) failed to demon-
plies, in particular, to those devices pro- strate a reduction in the degree of gingival
inflammation. Some investigators on the
other hand, have reported reductions in both
plaque and debris (Bhaskar et al. 1971, Gup-
ta et al. 1973, Agerbaek et al. 1975), and
gingiva! inflammation (Lobene 1969, Lain-
son et al. 1970, Gupta et al. 1973).
Loe et al. (1965) and Theilade et al.
(1966) used an experimental model to in-
vestigate the initiation and development of
gingival inflammation. From tbeir studies
it was possible to demonstrate clearly the
close relationship between bacterial plaque
accumulation and the development of gin-
givitis. The aim of this investigation was
to study the effect of the Water Pik device
on plaque accumulation and tbe develop-
ment of gingivitis using the same model.
Materials and Methods
A total of 41 individuals were selected
from a group of volunteers to participate
in the investigation. The selection process
excluded individuals with advanced gingival
recession and pathological deepening of the
gingival crevice.
Pre-experiniental Period
After a thorough oral examination, tbe par-
ticipants were motivated and instructed in
the use of the toothbrush and wooden tooth-
pick twice daily. The teeth were then scaled
and polished so that no plaque could be dis-
closed upon application of a basic fuchsin
solution. During the 4 weeks which fol-
lowed, the participants' teeth were polished
at least twice weekly. At the same time, an
effort was made to ensure that oral hygiene
measures were being carried out satisfac-
torily. By the end of the pre-expcrimenta!
period, both Plaque Index and Gingival
Index scores were extremely low.
Experimental Period 1
On day zero the patients were randomly
split into two groups (A and B). Plaque
accumulation and gingival inflammation
were registered along with the gingival
exudation from 13-^23 (Brill 1959). This
was done according to the intracrevicular
method (Egelberg 1964). Each strip (filter
paper, 1.5 mm X 10.0 mm No 3, Munktell,
Sweden), was held parallel to the tooth and
introduced into the mesiolabial part of the
gingival crevice until slight resistance was
felt. Five strips were collected from each
patient at each examination. The strips
were left in position for 3 min after which
tbey were removed and stained with a
0.2 % solution of ninhydrin. After drying,
the length of the stained segment of each
strip was measured to the nearest 0.2 mm
using a sliding caliper. The average length
of the stained area on the five strips was
taken to represent the individual exudate
value. The participants were then scored
according to tbe Plaque Index (Pll) system
(Silness & Loe 1964) and Gingival Index
(GI) system (Loe & Silness 1963). Four
surfaces and four gingival areas of each
tooth in the dentition were examined.
The individuals in group A were then
trained in the use of the Water Pik. It
was to be employed twice daily and in
accordance witb the manufacturer's instruc-
tions using the highest available pressure
and a full reservoir of water. No other
forms of oral hygiene were allowed. The
participants oi group B were asked to
abandon all forms of oral hygiene during
this period.
The trial was terminated after 14 days.
Gingivai exudation, Pll and GI were again
noted. The participants were also examined
for possible soft tissue injuries.
Intermediate Period
After this 14-day trial, the participants'
teeth were again polished and the intensive
oral hygiene program reintroduced. The
measures taken during tbis 4-week period
were identical to those characterizing the
pre-experimental period. The aim was to
re-estahlish a zero baseline as a starting
point for the next part of the investiga-
Experimental Period II
On day zero, the patients were randomly
divided into two groups (C and D). As in
the first trial, the gingival exudate, PII and
GI was noted for each individual.
The participants of group C were al-
lowed to continue active oral hygiene in
the form of toothbrushing twice daily. As
a supplementary measure, they were in-
structed in the use of the Water Pik de-
vice. The participants of group D were,
however, limited to toothbrushing twice
daily. Neither in group C nor in group D
was the use of toothpicks allowed during
this experimental period.
The trial was terminated after 14 days.
The gingival exudate, PII and GI were
again registered. The participants were also
examined for evidence of soft tissue injuries
inflicted during the test period.
All registrations and measurements of
Table 1. Oral hygiene. All tooth surfaces. Frequency distribution of tooth surfaces exhibiting
Piaque Indices of 0, 1, 2 and 3 at the baseline examination (day 0) and at the end of ihe
experimental periods (day 14). Mean values and S.E.M. are given for both experimental
Orale Hygiene. Alle Zahnoberfliichen. Frequenzverteiiung der Zahnoberflachen mit den Flaque-
indizes 0, 1, 2 und 3 wdhrend der Ausgangsuntersuchung (Tag 0) und der abschliejienden
Untersuchung (Tag 14). Fiir die beiden Versuchszeilpnnkle werden die Mittelwerte itnd der Stan-
dardfehler des Mitlcls angegeben
Hygiene bucco-dentaire. Totitcs les faces denlaires. Distribution de frequence des faces den-
laires presentant les Indices Plaque 0, 1, 2 ct 3 a I'exatnen initial (jour 0) et a la fin des
periodes experimeniales (jour 14). Les valeurs moyenties et I'erreur-type de la moyenne sont
donnees pour les deux periodes experimentales
Experimental period I
Experimental period II
Score Group A Group B Group C Group D
Day 0 105,6
Day 14 9.2
NS 76.7
Experimental period (Versuchsperiode, periode experimentale).
the stained strips were carried out by two
examiners, both of whom were unaware of
the purpose of the study.
Since Plaque and Gingival Index scoring
was carried out on an ordinal basis rather
than at interval level, nonparametric sta-
tistics (Mann-Whitney U-test) were used
far campadng the total plaque and gingival
relatianships af the corresponding groups.
However, when camparisans were made of
the number af surfaces with a certain score.
Student's t-test was utilized. This was also
used for analysing the gingival exudate
At the start of the investigation tbere were
no differences between the groups as re-
gards age, sex and number af existing teeth.
This was alsa the case concerning the num-
ber af surfaces harbauring plaque and the
gingival conditian af all sites examined
priar ta bath experimental periads (Tables
1 & 2). Following bath pre-experimeotal
and intermediate periods, law readings for
PlI and GI were obtained as a result af the
intensified orai hygiene procedures.
During the first trial (Experimental Pe-
riod I), the group using Water Pik as tbe
sale means of oral hygiene (Group A) and
the group abandoning all forms af aral
hygiene (Graup B) bath shawed an in-
crease in gingivai exudation. No statistically
significant difference between these two
groups could be found (Table 3).
Table. 2. Gingival condition. All tooth surfaces. Frequency distribution of tooth surfaces ex-
hibiting Gingival Indices of 0, 1 and 2 at the baseline examination (day 0) and at the end
of the experimental periods (day 14). Mean values and S.E.M. arc given for both experi-
mental periods
Zustand der Gingiva. Alle Zahnoberfldehen. Frequenzverteilung der Zahnoberfldehen mit den
dazu gehorenden Gingival-Indizes 0, 1, 2 und 3 wahrend der Ausgangsuntersuchung (Tag 0)
und wdhrend der Abschlu0untersuchung (Tag 14). Eiir die beiden Versuchszcitpunkte werden
die Mittelwerte und der Standardfehter des Mittels angegeben
Etat de la gencive. Toutes les faces dentaires. Distribution dr. frequence des faces dentaires
presentant les Indices Gingivatix 0,1 et 2 a I'examen initial (jour 0) et a la fin des periodes
experimentales (jour 14). Ees valeurs moyennes et I'erreur-type de la moyenne sont donnees
pour les deux periodes experimentales
Day 0
Day 14
Experimental period I
Group A
Group B P
105.2 NS
5.8 NS
55.2 -
21.6 **
Experimental period
Group C
Group D
Table 3. Gingival exudation. Mean values and S.E.M. for gingiva] exudation in each group at
the haseline examination {day 0) and at the end of the experimental periods (day 14)
Gingivale Exsudation. Mittelwerte und der Slandardfehler des Mittels fiir die gingivale Exsuda-
tion bei jeder Gruppe. Ausgangsuntersuchung (Tag 0) und Abschhifi der Versuchsperioden
(Tag 14)
Exstidation gingivale. Valeurs moyennes et erreur-lype de la moyenne pour I'exsudation gin-
givale dans ehacun des groupes a l'examen initial (jour 0) et d la fin des periodes experimen-
tales (jour 14)
Experimenta] period I
Experimenta] period II
Group A
Group B
Group C
Group D
Day 0
Day 14
Table 4. Ora] hygiene. Bueca], ]ingual, and proxima] surfaces. Frequency distribution of tooth
surfaces exhibiting Plaque Indices of 1, 2 and 3 at the end of the experimental periods (day 14).
Mean va]ues and S.E.M. are given for both experimenta] periods
Orale Hygiene. Bukkale, linguale und approximate Oberfldchen. Frequenzvertethmg der Zahn-
oberfldchen mit Plaque-Indiz.es 1, 2 und 3 bei AbscJilu^ der Versuchsperioden (Tag 14). Fiir
beide Versuchszeitpunkte werden die Mittelwerte und der Standardfehler des Mitlels angegeben
Hygiene bucco-dentaire. Faces vestibulaires, linguales et proximales. Distribution de frequence
des faces dentaires presentant les Indices Ptaque J, 2 et 3 a la fin des periodes experimenlales
(jour 14). Les valeurs moyennes et I'erreur-type de la moyenne (S.E.M.) sont donnees pour les
deux periodes experimeiitales
Experimenta] period I Experimenta] period II
Group A Group B Group C Group D
Mean (S.E.M.) Mean (S.E.M.) ^ Mean (S.E.M.) Mean (S.E.M.)
Group of
Group of surfaces (Gruppen der Zahnoberfidchcn, groupe de faces)., score (Bewertungseinheit,
score), mean {Mittelwert, moyenne), proxima] {Approximai, proximales), bucca] (Bukkal, vesti-
bulaires), lingual (Lingual, linguales).
1.2 -
12.9 (2.1)
4.1 (LO)
9.7 (1.2)
4.4 (0.9)
11.5 (0.9)
9.4 (1.0)
2.6 (0.6)
1.1 -
7.7 (2.1)
22.3 (3.4)
24.4 (4.4)
2.6 (0.8)
8.7 (1.1)
8.6 (0.8)
6.5 (1.0)
25.7 (2.7)
23.6 (1.6)
5.5 (1.6)
- -
26.1 (0.4)
1.2 (0.3)
0.2 -
- -
2.0 (0.7)
0.4 -
23.7 (3.5)
23.6 (2.4)
8.0 (1.8)
- -
26.4 (0.3)
0.8 (0.2)
0.4 -
- -
24.1 (0.5)
2.5 (0.4)
0.9 -
_ _
Table 5. Gingival condition. Buccal, lingual and proximal surfaces. Frequency distribution of
tooth surfaces exhibiting Gingival Indices of 0, 1 and 2 al tbe end of tbe experimental periods
(day 14). Mean values and S.E.M. are given for both experimental periods
Zusland der Gingiva. Bukkale, Unguale und approximate Oberfldchen. Frequenzverleilung der
Zahnoberflachen mit Gingival-Indizes von 0, 1 und 2 bei AbschlufI der Versuchsperioden (Tag
14). Fiir die beiden Versuchszeitpunkte werden Mittelwerte und der Slandardfehler des Mit-
tels angegeben
Etal de la gencive. Faces vestibulaires, Hnguales et proximales. Di.'itribution de frequence des
faces dentaires presenlant les Indices Gingivatix 0, 1 et 2 a la fin des periodes experimentales
(jour 14). Les valeurs moyennes et I'erreur-type de la moyenne sont donnees pour les deux
periodes experimentales
Group of
Experimental period [ Experimental period II
Group A Group B
Mean(S.E.M.J Mean(S.E.M.)
Group C Group D
IVlean(S.E.M.) Mean (S.E.M.)
24.6 (3.0)
14.3 (1.6)
10.8 (1.2)
2.5 (0.7)
8.9 (1,0)
0.3 (O.i)
14.4 (2.6)
26.5 (2.0)
14.6 (2.4)
1.9 (0.5)
37.2 (2.3)
23.2 (0.9)
4.0 (0.9)
0,4 -
23.6 (0.7)
3.9 (0.6)
0.1 -
During the second trial (Experimental
Period JI), the group using Water Pik as a
supplement to toothbrushing (Group C)
showed no significant difference in amount
of gingival exudate compared with the
group limited to toothbrushing alone
(Group D) (Table 3).
The PII atid GI values registered on
day 0 for groups A and B, showed a defi-
nite increase during the first trial period.
Even duritig the second trial period, both
groups C and D showed small increases in
plaque accumulation and gingival inflam-
mation (Tables ] & 4 aud 2 & 5 respective-
The number of surfaces in each group
harbouring dental plaque at the end of both
trials (day 14) is shown in Tables 1 & 4.
The difference between groups A and B in
distribution of the total scores is highly
significant (z =^ 2.52; P = 0.012). A simi-
lar difference between groups C and D
could not be found,
Tn Tables 2 & 5 the gingival condition of
ail groups at the end of both trials (day 14)
is given using the Gingival Index, The
difference between groups A and B in
distribution of the total scores is highly
significant (z 3.01; P = 0.0026). No sta-
tistically significant difference between
groups C and D could be found.
Neither in group A nor in group C could
any soft tissue injuries be found which
could be related to the use of the Water
In the model system "experimental gin-
givitis in man" (Loe et al. 1965, Theilade
et al. 1966), the effect of complete elim-
ination of active oral hygiene was studied
in regard to plaque aeeumulation and the
development of gingivitis. In the present
investigation, the frequency distribution of
the Pll and GI scores for eertain teeth and
tooth surfaces corresponded to the general
pattern reported above. Furthermore, the
increase in Pll and GI, after the partici-
pants had eeased to perform all forms of
active oral hygiene, was in accordance with
this same model. To compensate for partici-
pants who were lost after the first period,
a number of new individuals were intro-
duced for the second experimental period.
Due to this substitution of patients, the
statistical evaluation was limited to eom-
parisions between Water Pik groups (A
and C) and the corresponding control
groups (B and D) respectively. At the be-
ginning of the study, there were no signifi-
cant differences between the randomly
selected groups, concerning age, sex, num-
ber of existing teeth, degree of plaque ac-
cumulation and degree of gingivitis.
Significantly less plaque was found at
the end of the experimental period in the
group using Water Pik as the sole means
of oral hygiene compared with the group
who abandoned all forms of active oral
hygiene. TTiese results confirm the findings
of Krajewski et al. (1964), Toto et al.
(1969) and Hoover & Robinson (1971),
who reported a reduction of plaque and
calculus by comparision with control
groups. It is also apparent from this in-
vestigation that the main plaque-reducing
effect of Water Pik is in areas where plaque
accumulation is greatest, i. e. interproximal-
ly. These findings may be compared with
those claiming that Water Pik's main attri-
bute is in the removal of oral debris
(Krajewski et al. 1964, Toto et al. 1967,
Bhaskar et al. 1971).
There was an increase in gingival inflam-
mation in both groups, A and B, during the
trial. However, this increase was of lesser
degree in the group using Water Pik as
the sole means of oral hygiene (Group A).
This is at variance with the findings of
Lobene et al. (1972), Lainson et al. (1970)
and Gupta et al. (1973), who reported a
reduction in gingivitis when employing
water irrigating devices. Dissimilarities in
the nature of the experimental model and
the parameters for registration may explain
these differences. It must be emphasized,
however, that in spite of the smaller ac-
cumulation of plaque and development of
a lesser degree of gingivitis amongst Water
Pik users compared to those abandoning
all forms of oral hygiene, the Water Pik
did not completely prevent extensive plaque
accumulaion and development of gingivitis
from taking place. From these results the
Water Pik cannot be said to fulfill the
requirements of a satisfactory plaque con-
trol device. The validity of this conclusion
is strengthened when the relatively high
scores, recorded for the group using the
Water Pik alone (Group A), are compared
with the extraordinarily low scores for Pll
and GI in the toothbrushing groups C
and D.
The Water Pik was marketed as a supple-
ment to conventional mechanical methods
of tooth cleaning. This study, however, has
demonstrated that toothbrushing, properly
performed, is sufficiently effective to leave
only small amounts of plaque, and these
are resistant to removal by the Water
Several authors have reported the oc-
currence of soft tissue injuries resulting
from use of water irrigating devices (Ber-
man 1966, Bhaskar et al. 1969b). In a study
carried out by Bhaskar et al. (1969a) it was
shown, however, that no soft tissue injuries
occurred in connection with the use of pul-
sating water devices, provided the pressure
was not allowed to exceed 70 PSL In this
investigation, the device used (Water Pik)
was constructed in such a way that the
maximum pressure available at any time
was 70 PSI. No soft tissue injuries eould
be found. This observation has already
been confirmed by several other authors
(Bhaskar et al. 1969a, Hoover & Robinson
The author would like to express his deep
gratitude to Mr, Rolf Karlsson for his help
with the statistical analysis and to the den-
tal hygienists Monica Edstrom and Lilian
Grondahl for their valuable assistance.
Die Wirkung des Water Pick-Hlifsmittels
auf die Ansammlung von Plaque und die
Entwicklung der Gingivitis
Der EinfluB des Wassersplilgerates Water Pick
auf das Ansammeln dentaler P]aque und die
Entwicklung von Gingivitis ist mit dem Ver-
suchsmode]] Experimente]le Gingivitis am
Menschen untersucht worden. Die Untersu-
ehung wurde mit Hilfe von 41 freiwiiligen
Patienten durchgefuhrt, an deren Zahnen wah-
rend einer Zeitspanne von vier Woehen der
Zahnstein griindlich entfernt worden war und
die dann nach der Zahnsteinentfernung poliert
wurden. Diese Periode intensiver oraler Hygi-
ene ging jeder experimente]]en Periode voraus.
Am Anfang der Experimentperiode wurde das
gingivale Exsudat, der Plaque-Index und der
Gingiva]-Index registriert. Die Probanden wur-
den sodann in vier Gruppen elngeteilt. Die
Gruppen A und B ste]]ten jede Form aktiver
oraler Hygiene ein. Der Gruppe A wurden
jedoch Water-Pick-Hi]fsmitte] a]s einzig er-
]aubtes Hi]fsmitte] fur orale Hygiene uberlas-
sen. Die Gruppen C und D durften zur Zahn-
reinigung die Zahnburste anwenden und der
Gruppe C wurden Water-Pick-Hi]fsmittel als
zusatzliches orales Hygieneinstrument Iiber-
]assen. Nach 14 Tagen wurde wiederum das
gingiva]e Exsudat, der P]aque-Index, der Gin-
gival-Index und Verletzungen der Weich-
gewebe registriert. Die Resultate zeigten, daB
die beiden Gruppen A und B extensive Plaque-
ansammlungen und Gingivitis aufwiesen, je-
doch bei den Probanden die den Water Pick
angewendet hatten in einem signifikant ge-
ringerem Grade. Bei den Gruppen, die ihre
Zahne bursten durften (C und D) konnte je-
doeh keineriei weitere Verminderung der
Plaque und Gingivitis gesehen werden wenn
Water Piek als zusatzliche Hilfsmittel zur An-
wendung kam. WeichteHschaden wurden nieht
Effet de I'appareil Water Pik sur l'accumula-
tion de la plaque et sur le developpement de
la gingivite
L'inOuence de I'appareil a irrigation d'eau
Water Pik sur raccumnlation de !a plaque
et sur le deveioppement de la gingivite a
ete etudiee en utilisant eomme modele !a
gingivite experimentale chez ]'homme. Cette
etude a ete effectuee chez 41 patients
vo]ontaires dont ]es dents ont ete soi-
gneusement detartrees et polies pendant une
periode de quatre semaines de soins in-
tenses d'hygiene bucco-dentaire avant eha-
cune des periodes experimenta]es. Au debut
de chaque periode experimenta]e, on a en-
registre I'exsudation gingivale, ]'Indice P]aque
et ]'Indice Gingiva]. Les participants ont a]ors
ete repartis en quatre groupes. Le groupe A
et ]e groupe B ont renonce a toutc forme de
soins actifs d'hygiene bucco-dentaire. On a
cependant re>mis au groupe A des apparei]s
Water Pik, devant servlr d'unique aide pour
I'hygiene bucco-dentaire. Les groupes C et D
eontinuaient a se brosser ]es dents, et ]e
groupe C recevait de p]us des apparei]s Water
Pik eomme aide supplementaire. Au bout de
14 jours, on a enregistre l'exsudation gingivale,
I'lndice P]aque, I'lndice Gingiva] et ]es ]esions
inf]igees aux tissus mous. Les resultats ont
montre que, tandis que ]es groupes A et B
presentaient tous deux des depots de p]aque
et une gingivite considerab]es, ]e degre en
etait cependant significativement moins eleve
chez les utilisateurs du Water Pik. Les groupes
uti]isant ]es brossages de dents (C et D) ne
presentaient pas de reduction ulterieure de ]a
p]aque ou de ]a gingivite lorsque ]e Water
Pik etait uti]ise comme adjuvant. On n'a en-
registre aucune lesion infligee aux tissus mous.
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