The Internohonol Journal Ot Perjodonhcs £ Restorative Denlisi 289

288

The InternoHonol Journal ot PerJodonhcs £ Restorative DenlisI 289

Effect of Calculus and Abstract The role of supragingivol irrigotion in Irrigator Tip Design on the treatment of gingivitis is clear'"^; Depth of Subgingival This study oddressed three foctors however, the ability of subgingivol ir- Irrigation thot moy affect the penetratian af rigation ta improve the periadontal medicaments inta periadontol pock- stotus of patients with periodontitis re- ets: calculus, ejection site pressure, mains cantroversial.^"* Theoretically, ond irrigatar tip design. Ejection site delivery of antimicrobial solutions to pressure far the Mox-i-Probe, the suppress putotive periodontal path- Ytadent ond Water-Pik tips were de- ogens could represent a supplemen- termined with a variant of Bernoullis' tal procedure to enhance mechoni- equation. Depth of irrigont penetra- cal instrumentation. However, the fol- tion was determined by delivering lowing principles must be considered disclosing salutian supragingivotly before irTigction theropy is integrated ond subgingivolly. Following irriga- into treotment regimens: ¡1) drugs tion, assessed teeth were extracted must be delivered to the site of dis- and the percentage af packet pen- ease activity, ¡2} ontibocterial solu- Jeffrey R. Larner, DDS, MS' etratian by the dye was calculated. tions must be used ot bactericidal Gary Greenstein, DDS, M5' The Max-I-Probe and Viodent tips concentrotions, ond ¡31 medicaments had significantly greoter penetration than did the Water-File tip. Further- must be present long enough to more, calculus deposits reduced irri- work.' The latter two foctors can be gation penetration in deep pockets regulated by adjusting drug concen- (7 ta W mm¡. Ejection site pressures trations, selecting substantive medi- af the three tips ronged fram 0.10 to caments, ond odministering irrigotion 4.80 psi. The ejection site pressure of therapy frequently. the Mox-I-Frabe side-port delivery The ability of clinicians and po- system was lawer thon that af the tients to deliver drugs ta the base of other two systems. Results indicated pockets hos been evaluated. Inves- thot subgingivol calculus, Irrigator tip tigators reported that supragingivol design, and plocement of the tip af- irrigation achieves secondary subgin- fect the depth to which drugs con be givol penetration of pockets to ap- delivered subgingivolly. proiiimotely ane holf the probing (Int J Periodont Rest Dent 1993; depth.^''^ In contrast, subgingival ir- } 3:289-297.) rigation viflfh o syringe, Pik Pocket (Teledyne), or o connula attached to a jet irrigotor results in penetrotion of irrigonts ta about 80% of deep probing depths.'"'^ Although insertion of irrigating devices into pockets en- hances penetratian of irrigonts, these devices still fail to deliver fluids con- sistently to the bose of deep pockets, where loss of attachment occurs. ' Private Practice 226B East Main Street Therefore, odditional information is PO Box 365 needed regarding factors thot influ- Snellville, Géorgie 30278 ence the extent to which drugs are • Private Proctice 900 W. Main Street projected subgingivolly. Freehold, New Jersey 07728

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To clarify possible determinants of Ejection site pressure drug penetration, this study was un- dertaken to ascertain if imgator tip The mean discharge rate (mL/s) for design, ejection site pressure, or cal- the three tips was determined by colculus influence the effectiveness of lecting dischorged water for eoch tip subgingival irrigation. Supragingival for 30 seconds in a groduated cyl- and subgingival devices were eval- inder. The volume was divided by the uated, because both result in subgin- discharge time, A technique devised gival penetration of medicaments, by Lugassy et aP was used to ascertain the average ejection velocity for each tip. Irrigating tips were held Methad and materials at 45 degrees during the evaluation, Two related siudies were conducted. which permitted the maximum dis- Ejection site pressures were deter- tonce that a stream could travel. This mined in vitro for three irrigotor tips, information was used to calculate and the depth of dye penetration into ejection site pressure with a variant of pockets was assessed histometrical- Bernoulli's equation:''' ly. The fallawing imgator tips were evaluoted: o 24-gouge Mox-I-Prabe 10 I imgationI cannuias: |A| WF,- [MIP) side-port cannula (Smith & 11 MIP; |C| VIA Nephew), o Water-Pik (WP) irrigation = p. + ^Y^ + Q (G) [H,] tip [Teledynel with an internal dia- meter of 0,955 mm (both were con- where G = gravitational constant; fV, nected to o Water-Pik pumpi, and a = height of the tank; /-^ = height of 23-gauge Viadent (VIA) end-port the ejection tip; P, = pressure at ejec- cannula (Viadent) attached to the tion point; P.J — pressure within the gually, A reference notch was cut Viadent pump (Fig 1|, Settings 2 system; Vj = velocity within the sys- using a YA round bur ot the gingival through 10 for the Woter-Pik unit and tem; VJ = velocity at the ejection margin, where probing measure- 1 through 5 for the Viadent unit were point; and Q — density of water. ments were performed. used to determine clinical and me- Erythrosin solution was used to chanical charocteristics of the irtiga- stoin the roots, (Red Cote, John O, Subgingival irrigotion tion tips. These settings correlated to Butler.) It was diluted with woter at a less thon 20 psi, as indicated by the Five patients requiring extraction of 29 dye-water ratio of 1:4 ond delivered monufocturer. perlodontolly hopeless teeth were into pockets with the three tips The selected for this study. Selected teeth Water-Pik unit was allowed to dis- ¡]l were periodontally hopeless; (2} charge at setting 4 and the Viadent exhibited hypermobility that allowed pump at setting 3, because these set- simple forcep extraction; and ¡3} had tings delivered equivalent amounts of received no scaling or root planing solution (MIP ond VIA delivered 0,26 in the lost 6 months. mL/s and WP delivered 2.6 mL/s), After administration of local on- Both devices provided on irrigotion force of less than 20 psi. esthetic, a Michigan O tip was used wifh gentle manual probing force to measure probing depths at six sites on each tooth: mesially, distally, and at midroot, both buccally and lin-

The Iriterrotionol Joumol ol PenodonticE S Reslorative Dentislry 291

Pig 2 Ptocement oí MIP into gingivai pocket with reference notch on imgotion cannula ¡3 mm irom ejection tip} at the gingival margin.

Fig 3 Surface landmarks on extracted teeth: (A) reference notch ¡gingival mor- ginj; (B) reference groove (apical extent af dye penetratian/; (C] coronal limit ai cannective tissue ottochment

13, Number 3, 1993 292

Teeth were randomly irrigated with one of the three tips. The WP was placed at the gingival morgin at ap- proximately 45 degrees to the tooth and each site wos irrigated for 1 second, while MIP and VIA were placed 3 mm into the sulcus and each of fhe sites was irrigated for 1 0 seconds (Fig 2¡ Precise subgingival placement was facilifoted by placement of a notch an the cannula 3 mm from the ejection site orifice. During extroction, forcep beoks were placed at the cementoenomel junction, avoiding the stain on root surfoces. Teeth were rinsed in cold water to remave blood and debris, ond o reference groove correspond- ing to the apical extent of dye penetration was cut circumferential ly Fig 4 Extracted tooth previausly irrigoted Fig 5 Extracted tooth previously irrigated oround the tooth with o '/i round bur. with WP irrigation cannula: (A) enamel with MIP cannuia. (A) reference groove; Extracted teeth were immersed in a projections; (B) reference groove fapicot (B| coronal limit of connective tissue at- extent of dye penetration/; (C) coronal tachment; {C] calculus; (D) pocket 4% oqueous toluidine blue solution limit of connective tissue attachment; depths, 4 to 6 mm, with no catcuius pres- to stain the connective tissue and [D] calculus. ent; (E) pocket depths, 4 to 6 mm with calculus present were fixed in a 2% glutaraldehyde. Dye penetration was determined at six surfaces per tooth (midbuccal ond midlingual surfaces and the line angles of the mesiobuccol, mesio- lingual, distobuccal, and distolinguol surfaces). The following measurements were recorded with a dial cal- iper: from reference notch (gingival margin) to reference groove (opical extent of dye penetration) and from reference notch to the coronal limit of connective tissue attachment (Fig 3). The meon percentage of dye penetration was calculated for each root. Vertical measurements taken at six separóte sites around each tooth were converted into percentages. Subsequently, a mean percentage of Fig 6 Extracted tooth previously irrigated penetration was calculated for all with VIA cannula. (A) reference groove; (B) coronol limit of connective tissue at- teeth within each group. tachment; (C) pocket depths, 7 to 10 mm with calculus present; (D) pocket depths, 4 to 6 mm with colculus present

The International Journal ot Periodonlicä S ReslorolK/e Dentistiv 293

To facilitate o comparison of the Table 1 Discharge rate and averoge velocity ability of different tips to deliver medicaments into moderate and deep Mean rate Mean averoge velocity pockets associated with periodontitis, Machine Setting [mL/s) (ft/s)- probing depth measurements were divided into two groups: 4 to 6 mm Water-Pik 2 2.33 and 7 to 10 mm. These groups were 4 2,60 further subdivided into colculus and 4.13 23.26 noncolculus groups for all three irri- 6 gator tips. Roots were ossessed vis- 8 5.60 ually to determine if calculus was 10 7.33 present on the root surfaces. If o root Max-I-Probe 2 0.20 surface hod visibly detectable cal- 4 0,26 culus, it was ploced in the calculus 6 0.40 4.41 group [Figs 4 to 6). Roots with no 8 0.56 calculus were placed m the noncal- 10 0.73 culus group. Viadent 1 0,20 A one-way analysis of vanonce 2 0.23 wos used with o Scheffe's test to 3 0.2Ó 12.34 compare characteristics of irrigotor 4 0.30 tips, because it ollowed for compor- 5 0.3Ó isan of efficiency of penetration within and among all subgroups. • There is a stotisticolly significont difference {P < .01 ) omong the meon averoge velocity recorded for all three tips.

Results

Irrigator tip characteristics The average discharge rotes of water released by WP, MIP, and VIA tips Clínico i findings etration (Table 3). This finding was were calculated [Table 1), The WP consistent for all three in-igotor tips. In discharged 10.00 times the omount Depth of dye penetrotion was as- 7 to 10-mm-deep pockets, when cal- of woter per second dischorged by sessed ot 174 sites [29 teeth¡ from culus was present use of MIP resulted MIP. The mean velocity of WP was five potients; of these sites 56, 46, in significontly more (P < .01) dye 5.27 times greater than thot of MIP, and 51 surfoces were assigned to the penetration than did either WP or and the mean velocity of VIA was MIP, VIA. and WP groups, respec- VIA 2.80 times greater thon that of MIP. tively. When dye penetration in deep At shallower sites [pockets 4 to 6 There were significant differences pockets (7 to 10 mm) with and with- mm deep), the presence of calculus (P < .01] among the average ve- out calculus (groups III and IV¡ were did not impede dye penetration for locity of oil three groups. compared, sites with calculus had ony of the tips [groups I ond II). The mean ejection site pressure of significantly less {P < .01) dye pen- WP was 28.46 times greater than that of MIP and the pressure of VIA was 8.00 times greater than that of MIP (Toble 2). Ejection site pressure was significantly different {P < .01) among all three groups.

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Table 2 Ejection site pressure

Mean pressure Tatal mean Machine Setting ¡psil ± SD (psi)*

Water-Pik 2 2.54 4 2.92 6 3.76 3,70 ± 0.97 8 4.47 10 4.80

Max-I-Probe 2 0,10 4 0,11 6 0.14 0,13 + 0,02 8 0,15 10 0,17

Viadent 1 0,70 2 0.93 3 1.06 1.04 + 0.25 4 1.12 5 1.38

There is o stotisticoily significant difference [P < .01 ] omong the meon pressure recorded for o I i three tips

Table 3 Dye penetration into pockets (%)

Group 1 Group II Group III Group IV

Irrigator Mean ± SD Meon ± SD Mean ± SD Meon ± SD

WP 39+8 42 ± 9 29 + 6 39 ±4 (n-4) In = 20) In = 15)

MIP* 80 ± 6 80 + 4 55 + 5*' 76 ± 6 (n = 6) In = 81 (n=281

VIA* 67 + 7 72 ± 6 42 ± 5*1 60 ± 6 (n - 26) |n = 4)

Group I = Poci(ets 4 to 6 mm deep with colculus on roots. Group II = Pockets 4 to ó mm deep with no coiculus on roots. Group III = Pockets 7 to 10 mm deep witii calculus on roots. Group IV = Pockets 7 to 1 0 mm deep with no colculus on roots. * Statisticolly significant difference (P < 011 between groups iil and IV ' Stotisticdlly significant difference (P < .011 between MIP group ill ond VIA group III. ' StaHsticaliy significant difference {P < .01 ) between all MIP and WP groups ond oil VIA and WP groups.

Inlernational Joijrral of Penodontics & Restoratire Dentistry 295

Discussion Tfie data indicated that apical pro- gingival irrigotion with WP does not gression of the dye was impeded by result in increased bacteremias.'^ This study confirmed that supragin- calculus in deep pockets, and this un- Results of the present study indi- gival irrigation with WP resulted in derscores the need for potients to cated that supragingival irrigotors will secondary subgingivol in-igation and undergo root planing prior to irriga- only be effective in the treatment of that irrigation cannuias placed tion therapy. Root planing could en- gingivitis or as an adjunct to main- subgingivally were capable of deliv- hance drug penetration and may tenance therapy for patients with ering drugs deeply into pockets. even preclude the need for subgin- shallow probing depths, because However, it appeored that the pres- gival lavage. In shallower pockets, these devices cannot project medi- ence af calculus and the inigator tip calculus did not impede dye pene- caments to the apical border of design offected depth of penetration. tration, becouse the irrigator tip, when ploque in deep pockets. If deep The finding that irrigating connulas placed 3 mm subgingivally, probably probing depths ore present, it is ad- (MIP, VIA) placed 3 mm into the sul- bypassed deposits. visable to employ a cannulated tip cus delivered a solution more deeply Ejection site pressure did not seem (irrigation needle) attached to a than did WP corroborated results of to influence the extent of dye pene- syringe or a jet irrigator to maximize previous studies,°-"'^ trafion. The WP tip had the greotest subgingival penetration of drugs. It When calculus was present in 7 to election site pressure; however, it re- appears that a critical factor regord- 10-mm pockets (group III), MIP dem- sulted in the least dye penetration ing depth of drug delivery is place- onstrated significantly greater pene- into pockets. Poor penetration wos ment of the irrigation device into the tration than did VIP, Failure of VIA in attributed to the supragingival place- pocket so thot fluids ore confined by this circumstance to demonstrate ment of the irrigotor tip. Furthermore, the soft tissue woll ond consequently penetratian equivalent to that of MIP although greater ejection pressure directed opicolly. was surprising, because it demon- was demonstrated by VIA, it resulted Severol new irrigoting devices hove strated similar dye penetration in in less penetration than MIP in group recently become commerciolly avoil- groups I, II, and IV and had greater III ond equivalent penetration in able: Perioselect (Sultan Chemists), ejectian site pressure than did MIP. groups I, II, and IV. Therefore, im- Perio Pik with subgingival irrigating This result could not be attributed to gator tip design and plocement handpiece (Teledyne), and Cavimed increased discharge volume, be- seemed to hove more influence on (Dentsply), All three devices employ cause both tips delivered equivalent efficacy than did ejection site pres- o cannulated irrigating tip similiar to amounts of solution. Furthermore, sure. tfie ones tested in this study ond operture position would seem to fo- Some investigators have cautioned should be capable of delivering varVIA, because it projected solution apically rather than laterally. Al- that high irrigation pressure may pro- drugs into deep pockets. The Peri- though the data indicated that MIP pel organisms into tissues, thereby oselecf features o central dispensing achieved greoter dye penetration promoting disease octivity,'^'* Ac- unit that contoins six different medi- than did VIA in group III, it cannot cordingly, it was recommended that caments, which can be delivered se- be concluded that a side-port can- low flushing forces be used subgin- quentially. Nevertheless, there are no nula is more efficient than an end- givally." Data in the present study dato to suggest thot multiple agents port delivery tip, because penetration indicated thot WP had greater dis- used in concert provide any benefit was equivalent in groups I, II, and 111, charge rate, average velocity, and beyond thot of o single medicament. ejection site pressure than did either The Perio Pik consists of a cannula MP or VIA. However, this should not inserted into an autoclavable hond- be interpreted ta indicate that WP has piece, and irrigonts are projected a deleterious effect on the periodon- subgingivolly by gentle oir pressure tium, because it is used suprogingi- derived from the dental unit. The vally, and the other devices are used handpiece provides a quiet, precise subgingivally. Furthermore, it has flow that is vibration free. The Cav- been reported that the use of supra- imed unit has two handpieces, one

Voljme 13, Number 3, 1993 296

for ultrasonic debridement and the In contrast, a few studies have in- patients moy prove to be on integrol other for subgingival irrigation. Al- dicated that irrigotion and root plon- part of maintenance progroms. though ultrasonics reportedly deliver ing ore synergisfic.^""^^ Southard et irrigonts to the base of pockets," al^^ provided the best support for Summary there are limited data to suggest that combined therapy (root planing and additionol lavoge provides any ben- irrigotion). However, patients were ir- Many aspects of irrigotion therapy efit beyond thot of ultrasonic de- rigoted 4 weeks in o row with a 2% warront further investigotion. In the fu- bridement.^ " solution of chlorhexidine (20 times ture, subgingival irrigotion moy prove These devices ond the ones eval- stronger than Peridex (Procter 8. to be of even greater benefit, if uated in this study focilitote drug de- Gamble]), and monitored microbes sironger drug concentrations ore em- livery within pockets, but the question (Porphyromonas gingivalis} still re- ployed, techniques to prolong drug remoins as to whether irrigotion bounded to boseline within 15 retention are developed, and meth- should be performed by clinicions, by weeks.^^ Other investigators have re- ods of predictable drug deliver/ to patients, or at all. Several investiga- ported that, in the presence of bload, the base of deep pockets are en- tors hove reported thot irrigotion by it takes a 0.5% solution of chlorhex- hanced. idine (five times stronger than Peridex) clinicians does not enhance the ben- This study provided odditional in- 10 minutes to eliminate P gingivalis.^^ efits of root planing.''"" They noted formation regarding factors that of- When these dato are interpreted in that subgingival irrigation with o vo- fect the ability of irrigating devices to light af the fact that gingival crevicular riety of drugs |ie, chlorhexidine, tetra- deliver drugs subgingivolly, Irrigoting fluid eliminotes 50% of irrigants v^thin cycline, and stonnous fluoride) does devices have the potential to deliver 12.5 minutes,^'' it is not surprising that not provide ony further reduction of medicaments into deep pockets. Fur- results of combined therapy are little microbes or extend the time neces- thermore, the reduced ejection site different from those of root planing sary for organisms to repopulate pressure ossodated with cannulas alone. At present, the literature does pockets.^'-" was odequate, because subgingivol not support the contention that a sin- plocement facilitated penetration of gle episode of subgingival irrigation imgants into deep pockets. Finally, it enhonces the efficacy of root plon- appeared thot o major impediment ing. Therefore, there are insufficient to dye penetration in deep pockets doto to justify use of irrigation therapy was colculus. Therefore, irrigation as a routine, supplemental, in-office therapy should be preceded by root procedure. planing. On the other hand, subgingival irrigation ot home allows patients to frequently engoge in self-therapy ot problem sites. Previously, individual efforts were limited to supragingival brushing and interdental cleaning. Now pofients have a meons to par- ticipate in mointaining bacterial reduction affained after root planing. Many patients do not hove the dex- terity to irrigóte with a subgingival cannulo, ond compliance can present another problem. However, use of jet irrigators with special tips (eg Pik Pocket, Gingival Sulcus Tip) by

The Inlernolional Joumol of Periodor)tic3 S Reîlorotiue DenHätry 297

References

t. Jotkovsky DL, et ot. Clinicot ond micro- 15. Romons AR, App GR. Bacteremia. o 28. Southard S, et al. The effects of 2% biologicoi effects of subgingivol ond result from oral irrigotion in subjects vjith chlorheüidine digluconote irrigation on gingivot morginat irrigation with chlor- gingivitis. J Periadontol 1971;42:757- the levels of bocteraides gingivoiis in hexidine gluconate. J Periadantol 766. pen od on to I pockets J Periadontol 1990;61 663-669. !6. Felix JE, Rosen S, App GR. Detection )989;60:302-309. 2. Flemmig TF, et al. Suprogingival irri- of bacteremia after ttie use ot on orai 29 Gusberti F, et at. Mlcrobioi effects of gation with 0.06% chlorfiexidine m nat- irrigation device in subjects with peri- chlorhexidine digiuconote irrigation on urolty occurng gingivitis, t 6 manth odontitis. J Periodontot 1971;42:785- the subgingivot microfioio in patients clinicot observations. J Periodontal 787. with advonced periodontitis [obstract 1990;61:112-117. 17. Bhoskar SN, Cutright DE, Gross A, et 1668). J Dent Res 1985,64.360. 3. Newman MG, et oi. Inigation with ai. Water ¡et devices in dentat practice 30. Rosling BG, Stats T, Webber RL, Chris- 0.06% chiorhexidine m naturatiy oc- J Perodontol t971,42:658-064. tersson LA, Genco RJ. Micrabiotogical curing gingivitis, it. 6 months micro- t8. Loftous J, Wat< M, Joikavsky D, et ot. and ciinicol eftects of topicot subgin- biologicoi obsenrations. J Periadantol Bocteremio fotlowing subgingival im- givoi ond antimicrobiol treatment on gotian and seating ond raot ptaning. human perodantal disease. J Ciin Peri- Greenstein G. Subqingival irrigation — J Periadontol 199t;62 602-607. odantal 1983;10487-514. an adjunct to periodontoi ttieropy. Cur- 19. Nosal G, Sctieidt M, O'Neat R, Van 31. Khoo JGL, Newman HN. Subgingivat rent status ond future direction. J Dent Dyke T The penetrotion of iovoge so- plaque control by simplified oral hy- Hyg i990;64:389-^97. tution into the peiiadontol pocket dur- giene regime plus locat chlorhexidine Greenïtein G. The abiiily of subgingi- ing ultrosonlc instrumentation J Peri- or metronidoïoie J Periodont Res vol irrigotion to enhance periodontoi odontol i99i;62:554-557. 1983;18.607^619. tiealth. Compend Contin Educ Dent 20 Reynoid M, et ai. Simuttaneous ultra- 32. Woiff LF, et al. The effect ol profes- 1988;9327-337. sonic scaling and subgingivat irrigation sional ond home subgmgivot irrigation Greenstein G. Eftects of subgingivci ir- [abstract 1832]. J Dent Res 1989, with antimicrobial agents an gingivitis rigation on periodontot stotus. J Peri- Ó8 410. ond eorty periodontitis. J Dent IHyg 1989;63:222-225. odontot 1987;58-827-836. 21. Wennstrom J, et ol. Periodic subgin- Gaadson JM. Controlted drug detiv- giual antimicrobiai imgotion of pockets. 33 Oosterwaal PJ, et ot. Boctericidoi con- ery; A new means of treatment of den- it. Microbiologie and radiographie ob- centrations of chtorhexidine diglucon- tal diseoses. Compend Contin Educ servotion. J Gin Periodontol 1987; ate, omine fluoride gel and stannous Dent 1985;6:27-36. 14 573-580. fluoride get tor subgingival bocteria Eakle WS, Boyd RL, Robertson PB tested in senjm at short contoct times. 22. MacAlpine R, Mognusson I, Kiger R, et J Periodont Res 1989;24 155. Penetration of periodontal pockets with al. Antimicrobial irrigation of deep irrigotion by O newty designed tip [ob- pockets to suppiement oroi tiygiene in- 34. Oosterwaal PJ, Mikx FHM, Renggii stroct 2295J. J Dent Res 1988;6J27. struction ond root debridement. i. Bi- tHi-i. Clearance af a topicotly applied Hotiander BN, Boyd RL, Eokle WS weeidy irrigation J Ctin Periodontoi fluorescein gel from periodontoi pock- Comparson of cannuia versus stand- 1985;12i568-577. ets. J Gin Perodantoi 1990;17:613- 616. ard tip far arat irrigation (abstroct 23. Braatz L, Garret S, Claffey N, Egetberg 1829J. J Dent Res 1989^68:410. J. Antimicrobial irrigotion of deep pack- Larner JR, Robinson PJ, Lautenschioger ets to suppiement non-surgical peri- E. Penetrability of periodontal paci

Votume 13, Number 3, 1993