Dental water jet and oral health maintenance in orthodontic patients

shutterstock_81157801-orthodontic appliance

The dental water jet or water flosser has been available since the 1960s, it produces a pulsating stream of pressurised water to remove plaque and debris from between the teeth and is used as an adjunct to toothbrushing to improve oral health. Studies have demonstrated beneficial effects of gingival health in some groups of patients with some studies suggesting advantages for maintaining oral hygiene around orthodontic appliances.

The aim of this review was to assess the effect of incorporating the dental water jet (DWJ) into the oral hygiene routines of orthodontic patients.


Searches were conducted in the Cochrane Library, PubMed, Scopus and Web of science databases. Randomised controlled trials (RCTs) in patients undergoing fixed appliance treatment that compared manual tooth brushing (MTB) against MTB with adjunctive DWJ were considered. Two reviewers independently selected studies and extracted data with study quality being assessed with the Cochrane risk of bias tool (RoB2). The main outcomes, Plaque index, Gingival index and Bleeding index were reported as mean difference (MD) with 95% confidence intervals (CI).


  • 6 RCTs (4 parallel, 1 split mouth, 1 cross-over) involving a total of 313 patients were included.
  • Only 172 patients were included in study arms 85 received MTB and 87 received MTB+DWJ.
  • 2 studies were assessed as being at low risk of bias, 2 at moderate risk and 2 at high risk.
  • 4 studies contributed to the meta-analysis finding a significant improvement in plaque index and bleeding scores in the DWJ + MTB group compared MTB alone. There was no difference between the groups for the gingival index (see table below).
  No. of studies Mean difference (95%CI)
Plaque Index 4 −0.75 (−1.29 to −0.22)
Gingival index 4 −0.02 (−0.15 to 0.10)
Bleeding score 3 −0.17 (−0.27 to −0.08)


The authors concluded: –

The use of DWJ as an adjunctive device in addition to MTB can be an effective strategy for maintaining oral hygiene in orthodontic patients with gingivitis. However, more high-quality RCTs are needed to confirm the findings.


This review was not registered so no protocol was registered. Interestingly there are currently 3  ongoing reviews of water flossers listed on the PROSPERO database one of which addresses the same topic as this review (PROSPERO 395736). The reviewers searched four major databases finally including just 6 RCTs with only 4 contributing to the meta-analysis. The studies are relatively small with only one including more than 100 patients. The authors highlight that only 172 patients in total received the comparison interventions. The follow-up periods are of short duration ranging from 0ne to six months with only one study of six months duration.  The reviewers considered that 2 studies were at low overall risk of bias although none of the included studies was at low risk in all domains considered. Only 4 of the six studies contributed the meta-analysis with the findings indicating significant improvements in plaque index and bleeding scores but not the gingival index. While a benefit to oral health is suggested from the adjunctive use of the DWJ the findings should be interpreted very cautiously because of the small number of patients included in a small number of studies none of which are at low risk of bias. Future studies should be well -conducted and reported and of appropriate size and duration using international guidelines (Equator Network).


Primary Paper  

AlMoharib HS, AlAskar MH, AlShabib AN, Almadhoon HW, AlMohareb TS. The effectiveness of dental water jet in reducing dental plaque and gingival bleeding in orthodontic patients: A systematic review and meta-analysis of randomized clinical trials. Int J Dent Hyg. 2023 Sep 11. doi: 10.1111/idh.12741. Epub ahead of print. PMID: 37694518.

Other references

Dental Elf – 7th Jun 2023

White spot lesions – treatment options

Dental Elf – 3rd May 2023

Adjunctive chlorhexidine for gingival health in orthodontic patients

Dental Elf – 17th Apr 2023

Mouthwashes, microorganisms and gingivitis in orthodontic patients

Dental Elf – 2nd Dec 2020

Powered toothbrushes and plaque control in orthodontic patients

Dental Elf – 24th Aug 2018

Orthodontic patients: Reminders improved oral hygiene and compliance


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Derek Richards

Derek Richards is a specialist in dental public health, Director of the Centre for Evidence-Based Dentistry and Specialist Advisor to the Scottish Dental Clinical Effectiveness Programme (SDCEP) Development Team. A former editor of the Evidence-Based Dentistry Journal and chief blogger for the Dental Elf website until December 2023. Derek has been involved with a wide range of evidence-based initiatives both nationally and internationally since 1994. Derek retired from the NHS in 2019 remaining as a part-time senior lecturer at Dundee Dental School until the end of 2023.

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