Clinical Oral Investigations (2024) 28:524

https://doi.org/10.1007/s00784-024-05842-9

RESEARCH

Cleansing efficacy of an oral irrigator with microburst technology in

adolescent orthodontic patients. A randomized-controlled crossover
study
Hanna Gänzer1 · Manuel Kasslatter3 · Vera Wiesmüller2 · Lena Denk2 · Anna-Maria Sigwart2 · Adriano Crismani1

Received: 22 February 2024 / Accepted: 18 July 2024 / Published online: 13 September 2024
© The Author(s) 2024

Abstract
Objectives Simplifying interdental space cleaning is a constantly discussed topic. The present study aimed to compare the
cleansing efficacy of an oral irrigator with that of dental flossing in adolescent patients with fixed braces after four weeks of
home-use.
Materials and methods The study design is a randomized, single-blinded cross-over study. Following a twenty-eight-day
period of product utilization in a home setting, a comparative analysis was conducted on hygiene indices, the Rustogi Modi-
fied Navy Plaque Index (RMNPI) and the Gingival Bleeding Index (GBI), between the test group (oral irrigator) and the
control group (dental floss).
Results Seventeen adolescent individuals completed the study. After 28 days of cleaning with the oral irrigator, RMNPI was
58.81% (55.31–66.47) compared to 59.46% (52.68–68.67) with dental floss (p = 0.070). Subgroup analyses did not indicate
the superiority of either method. GBI after the test phase with the oral irrigator was 28.93% (23.21–33.97) and insignificantly
higher compared to 26.40% (21.01–31.41) achieved with dental floss (p = 0.1585).
Conclusions Neither of the two products demonstrated statistically significant superiority in terms of cleaning efficacy.
Therefore, no recommendation can be made in favor of one over the other. It was found that the high initial hygiene indices
for fixed orthodontic appliances could be improved through increased awareness and precise instruction.
Clinical relevance For adolescent patients who struggle to use interdental brushes an oral irrigator may be suggested as a
simple alternative in hard-to-reach areas, such as those around a fixed dental appliance.

Keywords Oral irrigator · Adolescent · Orthodontic · Oral hygiene · Plaque index · Gingival bleeding index · Fixed
orthodontic treatment

Introduction metabolism can be prevented [1]. Individuals who inte-

grate interdental cleaning devices in their daily oral hygiene
The most important measure to prevent tooth decay is good schedules experience fewer instances of dental caries, less
oral hygiene. If the adherent bacterial film is regularly periodontal diseases and have less missing teeth compared
removed, further accumulation of germs and their sugar to those who exclusively employ electric or manual tooth-
brushes for oral hygiene [2]. Interdental brushes appear to
offer superior effectiveness compared to dental floss [3]. As
outlined in the consensus report compiled by the European
Adriano Crismani
Adriano.crismani@i-med.ac.at Federation of Periodontology in 2015, the application of
dental floss should be restricted to areas with gingival and
1
University Hospital of Orthodontics, Medical University of periodontal health, where interdental brushes might pose a
Innsbruck, Anichstr. 35, Innsbruck 6020, Austria risk of causing traumatic injuries (2, [4]. The willingness
2
Department of Conservative Dentistry and Periodontology, to incorporate dental floss into the daily oral hygiene rou-
Medical University of Innsbruck, Anichstr. 35, tine is quite limited. Additionally, the proper use of dental
Innsbruck 6020, Austria
floss proves to be a significant challenge [5]. A noteworthy
3
Südtirol Dental Clinic, Latsch, Italy

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issue in the field of orthodontics is that in patients with teeth. Exclusion criteria were pregnancy, oral or systemic
fixed braces the accumulation of biofilm is promoted both diseases other than gingivitis, and the need for frequent drug
above and below the gumline, compromising effective oral consumption.
hygiene and consequently resulting in alterations in the oral Due to time constraints, it was not possible to start with
microbiome, enamel decalcification, and the development all 20 study participants simultaneously. As a result, the
of gingivitis [6–8]. Furthermore, several systematic reviews children were enrolled in the study in staggered groups.
have consistently shown a decline of clinical parameters Data collection was performed from October 2021 to March
linked to periodontal diseases, including indicators such as 2023.
the plaque index, bleeding on probing (BOP), attachment
loss, and the development of pockets or gingival recessions
[9, 10]. This deterioration has been associated with both Clinical intervention
the duration and the type of orthodontic treatment. [7, 11]
Water flossers represent a recent innovation in interdental The cleansing efficacy of the microburst technology (Air-
tools designed for regular use at home with the advantage floss®, Philips, Hamburg, Germany) versus interdental
of very easy application. Operating on the principles of pul- cleaning with dental floss (Superfloss®, Oral-B, Boston,
sation and pressure, the water flosser disrupts plaque and USA) was evaluated in a randomized-controlled, examiner-
removes loosely lodged debris. The primary use of water blinded, crossover study.
flossers is to assist individuals with reduced manual skills, The study design consisted of four appointments for each
but it may also be useful for patients undergoing orthodontic subject at intervals of one month. During the first appoint-
treatment. [12, 13] The available data regarding the use of ment, the probands received an explanation of the study pro-
oral irrigators in orthodontic patients is currently quite lim- cedure. The adolescents were assessed for study inclusion
ited, and the results obtained from existing studies exhibit and exclusion criteria using the Case-Report-Forms (CRF)
significant variations in terms of efficacy [14]. Most oral and an informed consent form was signed. Documentation
irrigators use water only, however there is the possibility to of plaque-covered areas was evaluated using the Modified
use a mixture of air and water, called microburst technology, Navy Plaque Index developed by Rustogi (RMNPI) [15]
to mechanically remove plaque. There has been no study subsequent to plaque disclosure (2Tone, Young, Earth City,
specifically designed to evaluate the performance of an oral Mo, USA) and the Gingival Bleeding Index after Ainamo
irrigator featuring microburst technology in adolescent orth- & Bay (GBI) [16] was used for evaluation of the baseline
odontic patients. The aim of this current randomized, sin- hygiene indices.
gle-blinded cross-over study was to assess and compare the The Rustogi Modified Navy Plaque Index (RMNPI)
cleaning effectiveness of microburst technology and dental subdivides each buccal and lingual tooth surface into nine
flossing in adolescent individuals with fixed braces under- distinct segments (designated as A – I), which are subject
going orthodontic treatment, following a 4-week period of to evaluation regarding the presence or absence of dental
at-home use. The null hypothesis postulates that there is no plaque. This particular index facilitates the differentiation of
distinction between the two methods. marginal regions of the dentition (A – C), interdental spaces
(D, F), as well as the overall tooth surface areas (A – I). The
RMNPI is computed as the proportion of biofilm-adhering
Materials and methods sites relative to the total number of assessed sites. In the
context of the assessment of the Gingival Bleeding Index
This study was approved by the Ethics committee of the (GBI), a periodontal probe (PCP 12, Hu Friedy, Chicago,
Medical University of Innsbruck, Austria (ID AN 5123). USA) was inserted into the gingival sulcus. This instrument
The study was conducted in accordance with the 1964 Hel- is utilized to dichotomously determine, at six distinct sites
sinki declaration and its later amendments. Prior to inclu- per tooth (mesiobuccal – buccal – distobuccal – mesiolin-
sion all subjects signed an informed written consent. gual – lingual – distolingual), whether bleeding is elicited or
not. The percentage of bleeding sites in relation to the total
Study subjects number of measured sites was calculated. It is noteworthy
that teeth that weren’t integrated into the fixed orthodontic
Twenty minor subjects of the University Hospital of Orth- treatment were excluded from the analysis. Moreover, all
odontic Dentistry, Innsbruck, Austria, were recruited in the examinations were conducted by a single trained examiner.
period from October 2021 to March 2023. Inclusion criteria Prior to commencing the investigation, randomization of
were fixed braces attached buccally at a minimum of four the test products was carried out using a computer-generated
teeth per quadrant and existing contact points between all method within Microsoft® Office Excel. The randomization

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process was carried out by study assistants, who also provided median and interquartile range were provided. The signifi-
thorough hands-on training to the study participants to ensure cance level was established at p < 0.05.
that the examiner was blinded. Following the manufacturer’s
recommended protocol for the oral irrigator with microburst
technology (Airfloss®, Philips, Hamburg, Germany), the Results
device was filled with water and activated once per interden-
tal space, utilizing the default setting of three sprays per acti- Twenty individuals were recruited. Seventeen participants
vation. For the control products (Superfloss®, Oral-B, Boston, (seven females and ten males) finished the study with a mean
USA) participants were instructed to thread it from the buc- age of 14.76 ± 1.15 (minimum 14 to maximum 18) years.
cal side below the orthodontic wire and position it around The drop-out rate was 15%. Three participants could not
the tooth in a c-shaped manner to facilitate cleaning in the continue due to systemic antibiotic therapy, illness, and non-
apico-coronal direction. In relation to toothbrushing, partici- compliance, and were therefore excluded from the study.
pants were directed to maintain their customary oral hygiene
routine and use their preferred products. After comprehensive Plaque scores
instruction regarding the initial randomly assigned test prod-
uct, professional tooth cleaning was carried out using an air- After 28 days of interdental cleaning with microburst tech-
polishing device (Airflow® prophylaxis master and Airflow® nology, the median of overall RMNPI was reduced from
Plus powder; both EMS, Nyon, CH), supplemented by using baseline 69.56% (56.06–76.59) to 60.71% (55.31–66.47)
sonic scalers and rubber cups with polishing paste (Cleanic®, (p = 0.037). Dental flossing for 28 days after a median base-
Kerr, Bioggo, CH) as needed. line value of 71.79% (69.44–78.53) resulted in a RMNPI of
After a test period of twenty-eight days employing the 59.72% (52.68–68.67). There was no statistically significant
first test product, study participants attended their second difference found between the plaque scores of the test prod-
visit to reassess hygiene indices and inclusion/exclusion ucts (p = 0.250) and the initial values (p = 0.070) (see Fig. 1).
criteria. Subsequently, there was a washout phase lasting Subgroup analysis, differentiating between approximal
twenty-eight days during which the subjects reverted to surfaces, marginal surfaces, anterior, or posterior teeth, did
their usual oral hygiene procedures. Following this period, not reveal any statistically significant differences in plaque
they returned for the third visit. Once again, plaque dis- scores (p > 0.05) (see Table 1). As shown in Fig. 1 there was
closure was performed, and subjects were given detailed no difference in plaque index after 28 days of dental floss-
instructions for the utilization of the second product, fol- ing compared to microburst technology on approximal areas
lowed by another professional dental cleaning. In a manner (median 86.36% and 85.71%, respectively; p = 0.704). (see
consistent with the first test phase, participants utilized the Fig. 1)
second product for twenty-eight days, then presented for an RMNPI, Rustogi Modified Navy Plaque Index; %, per-
examination of the plaque- and gingival index during the cent; *, p value < 0.05.
fourth and final appointment of the study.
Gingival bleeding index
Statistical analysis
The median full mouth GBI after 28 days of interdental
The sample size calculation relied on the average values and cleaning with the oral irrigator did not show a statistically
standard deviations of overall plaque scores analyzed in a significant change from baseline, with values of 29.33%
study conducted by Heiß-Kisielewsky et al., which aimed to (25.00–40.74) and 29.17% (23.21–33.97) respectively
compare the efficacy of microburst technology (Airfloss®, (p = 0.509). Dental flossing for 28 days after a median
Philips, Hamburg, Germany) with dental flossing. [17] baseline value of 35.26% (28.85–42.49) resulted in a GBI
The sample size calculation for dependent samples, with a of 25.60% (21.01–31.41) (p = 0.001). The bleeding scores
power of 80% and α = 0.05, resulted in a sample size of 16. of the test products did not show a statistically significant
Accounting for an assumed drop-out rate of 25%, the final difference (p = 0.230). Similarly, there was no statistically
sample size was n = 20. significant difference found between the bleeding scores of
At the individual level, RMNPI values were determined the initial bleeding scores before intervention (p = 0.158)
by dividing the total number of areas with plaque present by (see Fig. 2). Subgroup analysis revealed that the gingival
the total number of assessed sites. These values were then bleeding index was not statistically significantly different on
compared between the two tooth-cleaning techniques using approximal sites after 28 days of interdental cleaning with
the Wilcoxon signed-rank test. The gingival bleeding index floss compared to microburst technology (median 23.21%
was computed in a similar way. Unless indicated otherwise, and 26.14%, respectively; p = 0.529) (see Fig. 1).

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Fig. 1 Rustogi Modified Navy Plaque Index (RMNPI) after 28-days into nine sections (A – I) and was calculated as percentage of biofilm
of home-use of dental floss in comparison to an oral irrigator. Rustogi adhering sites to measured sites of (A) all tooth surfaces (A – I), and
modified plaque-index splits every buccal and lingual tooth surface (B) approximal surfaces (D, F)

Table 1 Plaque and bleeding levels after one month of home use. The Rustogi modified plaque-index splits every buccal and lingual tooth surface
into nine sections (A – I) and was calculated as percentage of biofilm adhering sites to measured sites. Gingival bleeding was calculated dichoto-
mously at 6 sites per tooth as percentage of bleeding sites to measured sites. Data was presented using median and interquartile ranges
Microburst technology Dental flossing p-value
Full mouth
RMNPI (%) 60.71% (55.31–66.47) 59.72% (52.68–68.67) 0.070
Gingival bleeding index (%) 29.17% (23.21–33.97) 25.60% (21.01–31.41) 0.158
Approximal sites
RMNPI (%) 85.71% (83.93–94.32) 86.36% (78.85–93.75) 0.704
Gingival bleeding index (%) 26.14% (20.37–31.00) 23.21% (17.86–30.56) 0.529
Approximal buccal sites
RMNPI (%) 94.64% (87.50–97.83) 94.64% (85.19–97.92) 0.905
Gingival bleeding index (%) 18.18% (9.62–28.00) 19.64% (13.64–30.36) 0.912
Approximal lingual / palatal sites
RMNPI (%) 82.69% (71.43–94.64) 82.14% (75.00–91.07) 0.624
Gingival bleeding index (%) 27.27% (22.22–44.23) 25.00% (19.64–32.69) 0.271
Anterior Teeth
RMNPI (%) 62.04% (54.63–70.37) 60.32% (49.54–73.15) 0.596
Gingival bleeding index (%) 26.39% (24.24–33.33) 22.92% (20.83–30.56) 0.453
Posterior Teeth
RMNPI (%) 57.64% (48.99–64.93) 57.29% (50.17–63.10) 0.337
Gingival bleeding index (%) 29.73% (23.21–33.97) 25.44% (19.23–32.29) 0.168
RMNPI, Rustogi Modified Navy Plaque Index; %, percent

There were no statistically significant differences in GBI In addition to dental floss, other oral hygiene aids such as
when analyzing only the proximal surfaces, anterior or pos- interdental brushes or water flossers are available. However,
terior teeth (p > 0.05) (see Table 1). especially in young people, the spaces between the teeth are
often too narrow for the use of interdental brushes and the
orthodontic wires makes it difficult to use dental floss. The
Discussion result is gingivitis and white spot lesions as a common side
effect of fixed orthodontic treatment. [7, 8, 15]
It is the daily challenge of interdental tooth cleaning for The existing research regarding the efficacy of dental
patients undergoing orthodontic treatment, which must be floss and water flossers is quite varied. Several industry-
combated using simplified cleaning methods. funded studies have suggested that water flossers provide

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Fig. 2 Gingival Bleeding Index after 28-days of home-use of a dental floss in comparison to an oral irrigator. Gingival bleeding Index was calcu-
lated dichotomously as percentage of bleeding sites to measured sites of (A) all tooth surfaces, (B) approximal surfaces

better cleaning results and more reduction of inflammation A limiting factor of the significance of this study undoubt-
than flossing or interdental brushes [18, 19], while Worthing- edly resides in the small number of participants. The selection
ton et al. expressed uncertainty about the effectiveness of process posed challenges due to the inclusion criteria speci-
oral irrigators in reducing gingival inflammation [3]. Data fying an age of over 14 years, which naturally, constrained
on oral irrigators in orthodontic patients is limited. On one the pool of eligible patients. Many younger patients receiv-
hand, the superiority of an oral irrigator with an orthodontc ing treatment at the University Clinic of Orthodontics were
tip over dental floss could be demonstrated in reducing gin- thereby excluded from the study. Additionally, the age of the
gival bleeding (p < 0,001) [20]. On the other hand a previ- participants played a role in their decreased motivation and
ous similarly designed trial, which concentrated on adult interest in maintaining oral hygiene. Furthermore, many ado-
patients with fixed orthodontic appliances, found that den- lescents do not receive proper instructions or monitoring from
tal floss provided more efficient cleaning results, especially their parents regarding oral hygiene. This made it difficult to
with regard to reducing gingival bleeding [21]. However, in motivate the study participants to accurately use the products.
this current study no statistically significant differences were Another study design´s limitations may include the poten-
observed between microburst technology and dental flossing tial decrease in gingival bleeding index due to professional
neither in terms of plaque reduction (60.71% (55.31–66.47), cleaning, which could diminish the comparability with the
respectively 59.72% (52.68–68.67); p = 0.070) nor in regard baseline gingival bleeding index. In order to achieve a con-
of gingival bleeding (29.17% (23.21–33.97), respectively sistent baseline value before the first and second test phase,
25.60% (21.01–31.41); p = 0.158). a washout period of 28 days was chosen, during which par-
In this study we used the Rustogi Modified Navy Plaque ticipant maintained their original oral hygiene routine.
Index [22] for evaluating plaque presence or absence in In conclusion and as mentioned before, none of the two
nine areas on buccal or lingual tooth surfaces. The authors products proved significantly superior in terms of cleaning
decided to use a dichotomous index due to better analyz- efficacy and reduction of gingival bleeding. Neither of the
ability from a statistical point of view. The RMNPI allows two products demonstrated statistically significant superior-
to measure plaque levels on a full-mouth level, but also ity in terms of cleaning efficacy. Therefore, no recommen-
subgroup analyses including smooth surfaces, interdental dation can be made in favor of one over the other. It was
and gingival margin areas. Based on the lack of statistically found that the high initial hygiene indices for fixed orth-
significant difference found in any subgroup (p > 0.05) (see odontic appliances could be improved through increased
Table 1), the use of an oral irrigator in adolescents with nar- awareness and precise instruction. For adolescent patients
row interdental spaces can be recommended because of its who struggle to use interdental brushes an oral irrigator may
easy-to-use application. be suggested as a simple alternative in hard-to-reach areas,
such as those around a fixed dental appliance.

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524 Page 6 of 7 Clinical Oral Investigations (2024) 28:524

Author contributions All authors contributed to the study conception 4. Van Der Chapple ILC, Doerfer C, Herrera D, Shapira L, Polak
and design. Material preparation, data collection, and analysis were D et al Primary prevention of periodontitis: managing gingivi-
performed by M.K, D.L. and A.M.S. The first draft of the manuscript tis. J Clinic Periodontology [Internet]. 2015 Apr [cited 2023
was written by H.G. and V.W. and all authors commented on previous Nov 8];42(S16). https://onlinelibrary.wiley.com/doi/https://doi.
versions of the manuscript. All authors read and approved the final org/10.1111/jcpe.12366
manuscript. 5. Ashkenazi M, Bidoosi M, Levin L (2012) Factors associated with
reduced compliance of children to dental preventive measures.
Funding This study received no fundings. Odontology 100(2):241–248
Open access funding provided by University of Innsbruck and Medical 6. Müller LK, Jungbauer G, Jungbauer R, Wolf M, Deschner J. Bio-
University of Innsbruck. film and Orthodontic Therapy. In: Eick S,Monographs in Oral
Science [Internet]., Karger S (2021) AG; [cited 2023 Nov 8]. pp.
201–13. https://www.karger.com/Article/FullText/510193
Data availability No datasets were generated or analysed during the
7. Lucchese A, Bondemark L, Marcolina M, Manuelli M (2018)
current study.
Changes in oral microbiota due to orthodontic appliances: a sys-
tematic review. J Oral Microbiol 10(1):1476645
Declarations 8. Contaldo M, Lucchese A, Lajolo C, Rupe C, Di Stasio D, Romano
A et al (2021) The oral microbiota changes in Orthodontic patients
Ethical approval The present study was carried out in accordance with and effects on oral health: an overview. JCM 10(4):780
the 1964 Declaration of Helsinki and its later amendments, and ethical 9. Onisor F, Mester A, Mancini L, Voina-Tonea A (2022) Effec-
approval was obtained by the Ethics committee of the Medical Univer- tiveness and clinical performance of Erythritol Air-Polishing in
sity of Innsbruck, Austria (study ID AN 5123). Non-surgical Periodontal Therapy: a systematic review of Ran-
domized clinical trials. Medicina 58(7):866
Informed consent All subjects signed an informed written consent 10. Da Silva-Junior PGB, Abreu LG, Costa FO, Cota LOM, Esteves-
prior to the study enrolment. Lima RP (2023) The effect of antimicrobial photodynamic ther-
apy adjunct to non-surgical periodontal therapy on the treatment
of periodontitis in individuals with type 2 diabetes mellitus: a
Conflict of interest The authors declare that there are no conflicts of
systematic review and meta-analysis. Photodiagn Photodyn Ther
interest. The authors do not have any financial interests, either directly
42:103573
or indirectly, in the products tested in this study.
11. Giugliano D, d’Apuzzo F, Majorana A, Campus G, Nucci F,
Flores-Mir C et al (2018) Influence of occlusal characteristics,
Competing interests The authors declare no competing interests. food intake and oral hygiene habits on dental caries in adoles-
cents: a cross-sectional study. Eur J Pediatr Dentistry. ;(2):95–100
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use is not permitted by statutory regulation or exceeds the permitted 15. Manuelli M, Marcolina M, Nardi N, Bertossi D, De Santis D,
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holder. To view a copy of this licence, visit http://creativecommons. odontic treatment. Minerva Stomatol [Internet]. 2019 Mar [cited
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