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Irrigating Pockets

It’s a bit insidious how, without any obvious symptoms, a little inattention over time can allow the development of gum pockets.  A gum pocket is where the gum still lies alongside the tooth, but some of the gum cells that were supposed to be attached to the tooth’s root have become detached.  (See the discussion of plaque and gum pockets.)  The gum pocket develops its own micro-environment, sealed off from the larger environment of the mouth.  Over time a pocket can get deeper and deeper.

A deep pocket interacts with a tooth somewhat like the space between a rubber doormat interacts with a concrete porch floor.  The mat is not attached to the floor, but the area in between is effectively sealed off from the outside.  Even when the rest of the porch has become clean and dry, it can retain dirt and remain wet enough for mildew to grow.  On a porch you can just pick up the doormat frequently and scrub the area underneath as often as dirt accumulates.  In the mouth this is not an option.

Even so, one of the least well-known but effective ways of working with this situation is by gum irrigation-if done correctly.  This doesn’t mean that irrigation is a substitute for regular brushing and flossing.  You don’t allow dirt to accumulate over the entire porch just because you’re going to clean under the doormat.

Correct irrigation also means using the technique that’s right for the desired outcome.  There are two kinds of gum irrigation, according to where the irrigating fluid is discharged and what the intent is.  If liquid is dispersed from above the gum margin (supragingival irrigation), then it flushes away bacteria from the top of the gum margin.  It’s like squirting a garden hose  from beyond the outside edge of the doormat; you can keep dirt from accumulating around the doormat so that it won’t work its way underneath (which can be quite valuable), but the spray won’t penetrate very far underneath, even with the hose pressure on high.  The second technique disperses liquid inside the gum pocket (subgingival irrigation), which reduces the detritus that’s already accumulated inside.  It’s like slipping the garden hose between the mat and the porch floor; it will penetrate and flush out dirt even at fairly low pressures.

Most home irrigators on the market perform supragingival irrigation.  These irrigators plug into a wall outlet and put out a pulsating stream, where the pressure pulse loosens contaminants and the decompression pulse allows them to escape.  One of the founders of Good Gums uses one of these electrically powered irrigators daily, and dissolves a bit of the blended natural substances in with the irrigant water.

Not so prevalent, but still possible to find, are subgingival irrigators for home use, both manual and plug-in.  A manual irrigator is typically a squeeze bottle that feeds a thin metal cannula (Latin for little hollow reed).  A counter-top, plug-in irrigator pumps the fluid through the cannula.  Dentists typically don’t trust their patients to irrigate inside their own gum pockets, doubting either the patients’ dexterity or willingness to do it properly, even though the technique is easy to do.  Instead dentists themselves often perform the subgingival irrigation on their patients.  But the effects of subgingival irrigation may not last even a week, while months may pass before people go back to their dentist.  Some dentists try to compensate for this by irrigating with chemicals of varying potency. These include CHX (chlorohexidine), TCN (tetracycline), PVP-I (Povidone iodine), Betadine, Stannous fluoride, and Metronidazole.  So far, even the most powerful chemical has been unable to make infrequent subgingival irrigation last between typical dentist appointments.

Frequent (e.g., once or twice a day) subgingival irrigation done at home is another story.  The frequent flush of contaminants out of the pocket can help keep the level low enough for healing to occur.  The irrigation is done by placing the irrigator’s thin metal cannula along the length of a tooth and gently sliding it into the gum pocket.  It doesn’t have to go all the way to the bottom; only as deep as is comfortable.  Then you squirt liquid into the pocket.  Low pressure is best; it seems to disperse the liquid into a pocket just as well as high pressure, but without forcing bacteria into the tissues.  A cannula with a side port (sideways opening near a rounded tip) is just as effective as one with an end port (opening at the end).  If the pocket is quite deep, there may not be much sideways dispersion, so it’s best to repeat with the cannula in several places around the tooth.

What liquid should we use as a subgingival irrigant?  It needs to be a liquid that contains no solids at all, as even minute particles might clog up the tiny port hole in the cannula.  Historically plain water, salt water, and hydrogen peroxide (3% in 97% water) have been used extensively for subgignigval irrigation at home.  All three liquids will have the same beneficial mechanical action for flushing out the pockets.  The salt water can be soothing in a mild solution (about half a teaspoon per cup of water).  And the hydrogen peroxide has additional antiseptic properties that are useful against plaque bacteria.  You’ll probably wish to spit out the debris and bacteria from irrigation.  It’s particularly important not to swallow if you use hydrogen peroxide as an irrigant, because large amounts of it may cause irritation to the digestive tract.  The hydrogen peroxide that’s disposed in the sink will break down harmlessly into water and oxygen.

Because subgingival irrigation necessarily means squirting liquid into a gum pocket and down toward the tooth’s root, you might feel an uncomfortable temperature sensitivity unless you warm the liquid irrigant first.  You have to make sure that the liquid is only warm, and not hot; before putting the liquid in the irrigator, it should just feel warm on the outer lip.  Another of the founders of Good Gums warms a small amount of hydrogen peroxide in a glass creamer for five seconds in a microwave oven before pouring it into a squeeze-bottle irrigator.

In order to determine which teeth have deep pockets, ask the dentist or dental hygienist to write down the measurements of your pocket depths for you when you go in to the dentist for an oral exam or cleaning.  By comparing the depths of the pockets in successive visits, you’ll be able to monitor your pockets and any progress you make in their reduction.

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