It’s Tuesday morning. Jeff, your 10 a.m. patient, takes his seat and begins sharing about his summer family trip to Rome. Like many of your patients, Jeff predictably presents every 3 months for his periodontal maintenance appointment.
Through years of various non-surgical attempts, you and Jeff have found good success in a consistent recare schedule and a detailed home care routine. Today, however, Jeff’s periodontal assessments show changes. Somewhere between hearing about the Colosseum and the Trevi Fountain, you note a generalized increase in periodontal probe depths and a marked increase in bleeding tendency.
Just as Jeff dips into his back pocket to bring out his phone (get ready for some family photos), you ask, “Jeff, your gums are bleeding more significantly today—what has changed?” Jeff admits that throughout his travels, he forgot to bring his trusted water flosser on his Italian adventure.
The Good…
Water flossing has been used as an adjunctive oral hygiene method for decades, with Waterpik introducing the first commercial device with a built-in water reservoir in 1962. These devices use a pulsating stream of water directed along the gingival margin and into interdental areas, providing patients with an alternative to conventional interdental cleaning methods.
As a result, dedicated users like Jeff have benefitted from consistent results when it comes to plaque and inflammation control. The results are oftentimes so predictable that dental hygienists can almost immediately identify when water flossing compliance has changed, for example, when a wine tasting tour across Italy means your trusty water flosser doesn’t make it into the checked-bag.
Importantly, water flossing has also been evaluated in clinical research with studies evaluating water-flossing devices reporting improvements in several measures of oral hygiene and gingival health.
In one study, water flossing demonstrated greater plaque-removal efficacy than string floss after a single use.1 Other clinical investigations found it is twice as effective as string floss for reducing gingival bleeding2 and is over 50% more effective than string floss for reducing gingivitis3 when water flossing was used as an adjunct to toothbrushing.
These findings show water flossing can be a key component of individualized home-care recommendations, particularly when patient needs, preferences and likelihood of adherence are considered.
Addressing Safety Concerns
Despite a long-standing, sound body of evidence from clinical studies, a layer of skepticism from some dental professionals has arisen. They have continued to spread incorrect and de-bunked statements about the pressure from water flossing.
One concern involves the potential impact of pulsating water on gingival tissues. Specifically, clinicians have questioned whether pressure from a water flosser could disrupt the clinical attachment apparatus and contribute to attachment loss. A related concern is increased pressure from pulsating water translocates bacteria deeper into the periodontal pocket, potentially aggravating an existing periodontal condition.
Clinical research evaluating water flossing at different pressure settings has helped address these questions. In a study of more than 100 participants, investigators found no evidence that water flossing caused destruction of the tissue attachment or migration of bacteria deeper into periodontal pockets. Rather, it was discovered that patients who effectively and efficiently used the water flosser, even at the highest pressure setting had better improvements in probing depth and clinical attachments when compared with brushing and flossing or brushing alone.4
These finding debunk the myth that water flossing is associated with trauma to the gingival tissue or epithelial attachment.
Laboratory research has also examined the ability of water flossing to disrupt plaque biofilm. Using scanning electron microscopy, investigators in one study reported removal of 99.9% of plaque biofilm from treated areas following a 3-second application of a dental water jet.5
From Efficacy to Optimization
As evidence supporting water flossing has accumulated, an important question has emerged: How can clinicians help patients use these devices most effectively?
Pressure is one consideration. Many water flossers offer multiple pressure settings, and patients are commonly encouraged to begin at a comfortable lower setting before gradually increasing pressure as tolerated. This approach can help patients become accustomed to the sensation of water flossing while developing proper technique.
In a study of the newest model from Waterpik, the Promax, subjects were either assigned level 3 or level 9 setting. For control, another group used a manual toothbrush only. Examiners measured reduction in plaque, gingivitis, and bleeding on probing over 6-weeks of usage.
The results demonstrated that the best clinical outcomes were at setting 9. Not only did those using the device at level 9 have the best bleeding reduction at over 85%, but 80% of the users reduced their level of bleeding to less than 10%,6 which the American Academy of Periodontology defines as clinically healthy gingiva.
In comparison, those at setting 3 had a 70.5% bleeding reduction and those using a manual brush only had marginal results. Importantly none of the study participants using a manual brush or the water flosser at setting 3 users were able to reduce bleeding of less than 10%.
Adherence Matters
One of the greatest barriers to adopting any home-care device is not efficacy—it is adherence.
The best interdental cleaning method for a particular patient is ultimately one that is both clinically appropriate and likely to be used consistently. For many patients water flossing is simply easier to incorporate into their daily routines. Patients with orthodontic appliances, implants, bridges, dexterity limitations or difficulty using conventional floss may find water flossing particularly useful.
For dental professionals, the goal should be to understand the available evidence and match appropriate home-care strategies to individual patient needs.
Jeff’s experience provides a simple reminder. His oral health routine had been working—until part of that routine disappeared for several weeks. Although no single home-care behavior can explain every change in periodontal status, asking what has changed between visits can reveal important information about adherence and help guide patient education.
The Next Evolution in Water Flossing
One of the greatest barriers to adopting any new home-care device isn’t entirely efficacy, it’s confidence. The next evolution in water flossing is not about reinventing what already works, it’s about removing the barriers that stand between proven science and everyday patient success. With the growing body of evidence supporting the efficacy and safety of the technology, those barriers are shrinking.
As water-flossing devices continue to evolve, features that improve pressure control, ease of use, access to posterior areas, and patient adherence make the technology practical for a wider range of patients. But technology alone is not the goal.
The goal is better daily biofilm management.
When evidence-based recommendations are paired with individualized instruction, water flossing becomes a way to empower more patients to experience healthier gums, greater confidence and better oral health-one effortless routine at a time.
References
1. Goyal CR, Lyle DM, Qaqish JG, Schuller R. Evaluation of the plaque removal efficacy of a water flosser compared to string floss in adults after a single use. J Clin Dent. 2013;24(2):37-42.
2. Rosema NAM, Hennequin-Hoenderdos NL, Berchier CE, Slot DE, Lyle DM, van der Weijden GA. The effect of different interdental cleaning devices on gingival bleeding. J Int Acad Periodontol. 2011;13(1):2-10.
3. Barnes CM, Russell CM, Reinhardt RA, Payne JB, Lyle DM. Comparison of irrigation to floss as an adjunct to tooth brushing: effect on bleeding, gingivitis, and supragingival plaque. J Clin Dent. 2005;16(3):71-77.
4. Goyal CR, Qaqish JG, Schuller R, Lyle DM. Evaluation of the safety of a water flosser on gingival and epithelial tissue at different pressure settings. Compend Contin Educ Dent. 2018;39(suppl 2):8-13.
5. Gorur A, Lyle DM, Schaudinn C, Costerton JW. Biofilm removal with a dental water jet. Compend Contin Educ Dent. 2009;30(suppl 1):1-6.
6. Waterpik. Waterpik Promax water flosser reduces bleeding and helps restore gum health within 6 weeks. Accessed September 9, 2026. https://www.waterpik.com/pro/clinical-research/promax-gingival-bleeding-6-week-clinical-study/
Figures and Images
Katrina M. Sanders, RDH, BSDH, MEd
