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 ANDERS HUGOSON 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 96 HUGOSON 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 WATER PIK AS A PLAQUE CONTROL DEVICE 97 pre-experimental period. The aim was to re-estahlish a zero baseline as a starting point for the next part of the investiga- tion. 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 periods 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 (!.2) 3.8 (0.8) 0.3 106.3 (1.1) 3.8 (0,9) 0.7 NS NS 96,6 (3.0) 11.7 (2.8) 1.3 (0.5) (1.3) 8.8 (1.3) 1.7 (0.4) NS NS NS Day 14 9.2 (2.4) 34.0 (3.2) 53.6 (3.6) 12.9 (2.8) 6.7 (1.7) 22.4 (3.6) 39.6 (4,0) 42.5 (7,1) NS 76.7 (3.2) 26.8 (2,1) 6.1 (1.7) 74.4 (3.9) 26.8 (2.7) 9.3 (1.9) NS NS NS Experimental period (Versuchsperiode, periode experimentale). 98 HUGOSON 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 data. Results 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 Score 0 1 1 0 1 2 Experimental period I Group A 99.3 (2.7) 9S (2.4) 0.5 57.0 (5.0) 44.5 C3-?)' 8.3 (1.7) Group B P 105.2 NS (1.3) 5.8 NS (1.4) 0.1 34.5 (5.4) 55.2 - (3.5) 21.6 ** (3.6) Experimental period Group C 97,7 (2.7) 11.8 (2.6) 0.1 82.1 (3.9) 25.8 (3.4) 1.7 (0.4) Group D 100.4 (2.0) 9.9 (1.9) 0.2 84.7 (3.3) 23.0 (2.6) 3.3 (Ll) 11 P NS NS - NS NS NS WATER PIK AS A PLAQUE CONTROL DEVICE 99 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 0.99 (0.11) 1.61 (0.14) Group B 1.05 (0.09) 1.92 (0.12) P N.S. N.S. Group C 1.37 (0.13) 1.41 (0.16) Group D 1.53 (0.22) 1.62 (0.22) P N.S. N.S. 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 Score 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 surfaces Proximal Buecal Lingual 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). 0 1 2 3 0 1 2 3 0 1 2 3 1.2 - 12.9 (2.1) 35.0(2.2) 5.9(1.7) 4.1 (LO) 9.7 (1.2) 9.2(1.1) 4.4 (0.9) 3.9(1.1) 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) 4.8(1.1) 8.7 (1.1) 11.7(2.0) 3.0(0.8) 9.9(1.1) 8.6 (0.8) 6.5 (1.0) - N.S. N.S. N.S. N.S. N.S. N.S. 25.7 (2.7) 23.6 (1.6) 5.5 (1.6) - - 26.1 (0.4) 1.2 (0.3) 0.2 - - - 25.0(0.7) 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 - _ _ N.S N.S N.S - N.S N.S - N.S N.S - - 100 HUGOSON 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 surfaces Experimental period [ Experimental period II Score 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.) Proximal Buccal Lingual 24.6 (3.0) 24.8(1,9) 5.5(1.4) 14.3 (1.6) 10.8 (1.2) 2.5 (0.7) 18.6(1.1) 8.9 (1,0) 0.3 (O.i) 14.4 (2.6) 26.5 (2.0) 14.6 (2.4) 8.2(1.5) 14.5(1.2) 5.1(1.1) 11.6(1,8) 14.2(1.4) 1.9 (0.5) N.S. N.S. 34.8 18.5 1.5 22.3 4.9 0.1 25.0 2.3 0,1 (2.6) (2.3) (0.4) (1.2) (1.1) - (0.6) (0.5) _ 37.2 (2.3) 15,2(1.8) 2.9(1.0) 23.2 (0.9) 4.0 (0.9) 0,4 - 23.6 (0.7) 3.9 (0.6) 0.1 - N.S N.S N.S N.S N,S - N,S N.S 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- ly)- 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 Pik. Discussion 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 WATER PIK AS A PLAQUE CONTROL DEVICE 101 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 Pik. 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 102 HUGOSON 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 1971). Acknowledgements 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. Zusammenfassung 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 beobachtet. 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. References Agerbaek, N., Melsen, B. & Ro]]a, G. (1975) App]ication of chiorhexidine by ora] irriga- tion systems. Seandinavian Journal of Den- tal Research 83, 284-287. Arnim, S. S. (1967) Dental irrigators for oral hygiene, periodontai therapy and prevention WATER PIK AS A PLAQUE CONTROL DEVICE 103 of dental disease. Journal of the Tennessee Denial Association 47, 65-93. Axelsson, P. & Lindhe, I. (1974) Tbe effeci of a preventive programme on dental plaque, gingivitis and caries in schoolchildren. Results after 1 and 2 years. Journal of Clinical Periodontology 1, 126-138. Berman, C. L. (1966) What is tbe value of Water Spray Device in maintaining adequate oral hygiene? Periodontal Abstracts 14, 151-152. Bhaskar, S. N., Cutright, D. E. & Frisch. J. (1969a) Effect of bigb pressure water jet on oral mucosa of varied density. Periodon- tics 40, 593-598. Bhaskar, S. N., Cutrigbt, D. E. & Gross, A. (1969b). Effect of water lavage on infected wounds in the rat. Journal of Periodonto- logy 40, 671-672. Bhaskar, S. N., Cutrigbt, D. E., Gross, A., Friscb, J., Beasley, J. D. & Perez, B. (1971) Water jet devices in dental practice. Journal of Periodontology 42, 658-664. Brill, N. (1959) Effect of chewing on flow of tissue fluid into human gingival pockets. Ada Odontologica Scandinavica 1.7, 277- 284. Covin, N. R., Lainson, P. A., Beiding, 3. H. & Fraleigb, C. M. (1973) The effect of stimulating the gingiva by a pulsating water device. Journal of Periodontology 44, 286-293. Egelberg, J. (1964) Gingival exudate measure- ments for evaluation of inflammatory changes of the gingivae. Odontologisk Revy 15, 381-398. Emslie, R. D. (1964) The value of oral bygiene. British Denial Journal 117, 373-383. Genco, R. I. (1973) Microbiology of periodon- tal disease. In Periodontal Therapy. Eds. H. M. Goldman & D. W. Cohen. 5th ed. pp. 178-195. Saint Louis: C. V. Mosby Company. Gupta, O. P.. O'Toole, E. T. & Hammermei- ster, R, O. (1973) Effects of a water pressure device on oral bygiene and gingival inflam- mation. Journal of Periodontology 44, 294- 298. Hoover, D. R. & Robinson, H. B, G. (1971) Tbe comparative effectiveness of a pulsating oral irrigator as an adjunct in maintaining oral beaith. Journal of Periodonlology 42, 37-39. Krajewski, J. J., Gibiin, J. & Gargiulo, A. W. (1964) Evaluation of a water pressure cleans- ing device as an a-djunct to periodontal treatment. Periodontics 2, 76~1&. Lainson, P. A,, Bergquist, J. & Fraieigh, C. M. (1970) Clinical evaluating of Pulsar. A new pulsating water pressure cleansing device. Journal of Periodontology 41, 401--405. Lindbe, J. & Nyman, S. (1975) Tbe effect of plaque control and surgical pocket elimina- tion on tbe establishment and maintenance of periodontal health. A longitudinal study of periodontal therapy in cases of ad- vanced disease. Journal of Clinical Peri- odonlology 2, 67-69. Lobene, R. R. (1969) Tbe effect of a pulsed water pressure device on oral beaitb. Jour- nal of Periodonlology 40, 667-670. Lobene, R. R., Soparkar, R. M., Hein, J. W. & Quigley, G. A. (1972) A study of the effects of antiseptic agents and a pulsating irrigating device on piaque and gingivitis. Journal of Periodontology 43, 564-572. Loe, H. & Silness, J. (1963) Periodontai dis- ease in pregnancy. I. Prevalence and sever- ity. Acta Odontologica Scandinavica 21, 533-551. Loe, H., Theilade, E. & Jensen, S. B. (1965) Experimental gingivitis in man. Journal of Periodontology 36, 177-187. Lovdal, A., Arno, A., Schei, O. & Waerbaug, L (1961) Combined effect of subgingival scaling and controlled oral hygiene on the incidence of gingivitis. Acta Odontologica Scandinavica 19, 537-555. Marshall, J. S. (1901) Principles and practice of operative dentistry. J. B. Lippincott Co., Philadelphia p. 548. Cit. from Arnim, S. S. 1967. Journal of the Tennessee Dental As- sociation 47, 65. Matsuzaki, A., Sugano, K., Tacbibana, T., Ka- tano, Y. & Nakamura, J. (1974) The effects of toothbrushing and water jetting on oral hygiene. The Japanese Journal of Conserva- tive Dentistry 17, 150-153. Siiness, J, & Loe, H. (1964) Periodontal dis- ease in pregnancy. II. Correlation between oral bygiene and periodontal condition. Acta Odontologica Scandinavica 22, 121135. Socransky, S. S. (1970) Relationsbip of bac- teria to the etiology of periodontal disease. Journal of Dental Research 49, 203-222. Theilade, E., Wright, W. H., Borglum Jensen, S. & Loe, H. (1966) Experimental gingivitis in man. II. A longitudinal clinical bacteri- ological investigation. Journal of Periodonial Research 1, 1-13. Toto, P. D., Evans, C. L. & Sawinski, V. J. 104 HUGOSON (1969) Effects of water jet rinse and tooth- Address: brushing on ora] hygiene. Journal of Peri- , , ,r , , , . , nc ->r,o Anders Bugoson odontology 40, 296-298. , ? -; D J ., i , , -, ,-,m-,. J, . . . , . . Department of Periodontology Waerhaug, J. (1971) Epidemiology of pen- -r, i . - . . . , n . j . r. . , . , .. ^ .,' _, ^ _ .-' , n . The Institute for Postgraduate Dental odonta] disease. In The Prevention of Pen- . odontal Disease. Eds. I. E. Eastoe, D. C. A. - an 1 in T Barnarpsgatan 39 Picton & A. G. Alexander, pp. 1-19. Lon- ^ - .- , . , , .. . . . . , _, , , I.. . T, , , .^oJ^ JO Jonkoping I don: Henrv Kimpton Pubhshers. c J Sweden