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WaterpikTM Water Flosser: Removes > 90% Of Biofilm On Titanium Implant Surface Disc; Better Than CHX, Titanium Brushes And Nylon Brushes

Effect of implant cleaning on surface alterations and titanium dissolution

Kotsakis G, Black R, Kum J et al. J Periodotol 2020; 1-12. DOI: 10.1002/JPER.20-0186. https://doi.org/10.1002/JPER.20-0186. Conducted at University of Washington, Seattle, USA.


To determine the effects that mechanical peri-implantitis treatments have on titanium implant surfaces, and whether surface changes are associated with increases in titanium dissolution and loss of cytocompatibility.


This study utilized two hundred acid etched micro-rough Titanium (Ti) discs as the substrate and multi species of human dental biofilm. A biofilm sample was obtain from a 56-year-old non-smoker male diagnosed with severe peri-implantitis. The biofilm sample was grown anaerobically on the 10 mm diameter Ti discs for 48 hrs. Sterile saline was used as negative control and 0.12% Chlorhexidine (CHX) was used as positive control. The mechanical treatments were a nylon brush (NB) and titanium brush (TB) with a surgical implant motor function at 300 rpms or a WaterpikTM water flosser (WF) on low setting or high setting for 30s.

The discs were assessed for biofilm removal using colony forming units (CFU), surface alterations using scanning electron microscopy (SEM), atomic force microscopy (AFM) and stereomicroscopic imaging, and corrosion resistance and titanium dissolution rates using electrochemical cell model (over 30 days). Cell viability relationship to Ti surface changes was assessed using a re-osseointegration model to evaluate the ability of osteoblasts to attach and proliferate following the different interventions.


Biofilm removal: The WF groups showed >90% biofilm removal compared to saline solution (p<0.01). The CHX group was the least effective. The TB and NB showed partial biofilm removal.

Surface alterations: The WF and NB groups were similar to control demonstrating little to no change of the Ti surface. The Ti brush showed the most variation with larger peaks and valleys consistent with surface abrasion.

Corrosion resistance and dissolution rates: WF groups were the most stable resisting corrosion and dissolution of the Ti.

Cytocompatibility: WF groups and nylon brush group did not differ from control in number of live cell counts for increased compatibility. Ti brush and CHX had the least live cells.


The WaterpikTM water flosser was more effective in removing biofilm compared to CHX, nylon brush, and Ti brush.

Antimicrobial Effect Assays Images: Biofilm Removal After 30-Second Treatment

Green stain is live bacteria, and red stain is dead bacteria still on the disc. The black area shows where the bacteria was removed.

Image courtesy of Georgios A. Kotsaks, DDS, MS