The effectiveness of conically shaped compared with cylindrically shaped interdental brushes - a randomized controlled clinical trial

Plaque cleaning efficacy of waist-shaped interdental brushes among individuals with open interproximal spaces: a systematic review

BACKGROUND

The shape and design of interdental brushes are crucial for appropriate adaptation to the interproximal areas, despite their excellent cleaning efficacy. The aim of this review is to assess and compare the available data on the plaque cleaning efficacy of waist-shaped interdental brushes with any other shaped-interdental brushes among patients with wide interdental spaces.

METHODS

Scopus, PubMed, Cochrane, Science Direct, EBSCO Host, Lilacs, Science Direct, Web of Science, and Google Scholar were searched from the earliest available year (2011) till May 15, 2024. PICO Strategy: P: Individuals with open interproximal spaces; I: Waist-shaped interdental brushes; C: Any other shaped interdental brushes; O: Interproximal plaque cleaning efficacy. The review only comprised randomized controlled trials. The risk of bias assessment and quality of evidence was assessed using the RoB-2 Tool and GRADE Tool respectively.

RESULTS

Three full-text publications that met the requirements for eligibility underwent additional processing for data extraction. The overall results of the review suggest that the plaque cleaning efficacy of waist-shaped interdental brushes is better than straight/cylindrical-shaped interdental brushes in patients with open interdental spaces; especially on the buccal and lingual line angles. However, the pooling of data was not possible due to the high heterogeneity between the studies.

CONCLUSION

The current review suggests that the plaque cleaning efficacy of waist-shaped interdental brushes could be better than straight or cylindrical shaped-interdental brushes in patients with open interproximal spaces, especially in buccal and lingual line angles. However, further research should focus on appropriate methodological techniques to increase overall reporting quality and limit the possibility of bias.

Efficacy of a water flosser compared to an interdental brush on gingival bleeding and gingival abrasion: A 4 week randomized controlled trial

AIM

To determine the efficacy of a water flosser (WF) compared to an interdental brush (IDB) in reducing gingival inflammation. Additionally, the products were compared on the incidence of gingival abrasion.

METHODS

Young adults with moderate gingivitis and ≥4 accessible interdental spaces by IDB in each quadrant were selected for this study. Participants were randomly assigned a WF or an IDB as an adjunct to manual toothbrushing. Clinical signs of inflammation were measured in two randomly assigned contralateral quadrants by bleeding on pocket probing (BOPP) or bleeding on marginal probing (BOMP). Gingival Abrasion Score (GAS) was assessed per quadrant. Data was recorded at the baseline, 2 weeks and 4 weeks.

RESULTS

Both groups WF (n = 40) and IDB (n = 38) showed a significant reduction (p = 0.000) in BOMP and BOPP from the baseline to 4 weeks for all sites and the interdental sites only. At 4 weeks the WF group compared to the IDB group showed significantly lower BOPP (p = 0.030) and BOMP scores (p = 0.003) for all sites. For the interdental sites WF showed compared to IDB for BOMP significant (p = 0.019) lower values but not for BOPP (p = 0.219). There were no differences between the groups for GAS at any time point.

CONCLUSION

In patients with moderate gingivitis, after 4 weeks use the WF is more effective than the IDB in obtaining marginal gingival health.

Orthodontists' instructions for oral hygiene in patients with removable and fixed orthodontic appliances

INTRODUCTION

The aim of this questionnaire-based survey was to evaluate information on frequencies, instructions and products relating to oral hygiene (OH) in orthodontic practices.

METHODS

Using a computer-generated randomization list, 1000 orthodontists were selected and sent a questionnaire. The size and number of inhabitants of the federal states of Germany were considered. The federal states with the highest return rate (Baden-Wuerttemberg [BW], Bavaria [B], Hesse [H], Lower Saxony [LS], Nordrhein-Westphalia [NRW]) were considered and differences between the 16 federal states were divided into North, South, East and Central Germany.

RESULTS

The response rate of the questionnaires was 52.4%. The majority (53.8%) worked in one practice alone. Most (59.1%) have been orthodontists for 5-25 years. For vestibular multibracket appliances (MBA) in BW, B, H and LS over 90% recommended interdental brushes (IDB). In NRW 91.4% recommend fluoride gel. In B and H more than 80% chose electric toothbrush (ETB), in BW, LS and NRW more than 80% manual toothbrush (MTB). For lingual MBA (LMBA) in BW, H, LS and NRW with approximately 50% each fluoride gel, IDB and MTB were chosen. In B fluoride gel, IDB and ETB. For removable apparatus (RA), five federal states recommended MTB (>80%) and ETB (BW, B, H > 80%; NRW > 70%; LS > 60%).

CONCLUSION

Electric toothbrushes are recommended for the use with all appliances, only with removable appliances manual toothbrushes are favoured. For vestibular MBA it is strongly advised to use IDB additionally.

New design of interdental rubber picks - does the archimedean screw design bring an improvement for experimental cleaning efficacy and force?

BACKGROUND

Up to date, interdental brushes (IDB) are the first choice for interdental cleaning because of their cleaning efficacy. Cylindrical ones must be selected individually according to the size/morphology of the interdental area (IDR), whereas conical ones cover a larger variability of IDR. However, there is a trend on the part of patients towards interdental rubber picks (IRP) which are in general conically shaped, and which seem to be linked with lower cleaning efficacy. A new IRP with an Archimedes´ screw design was developed to overcome this limitation. Therefore, the in vitro study aimed to measure the experimental cleaning efficacy (ECE) and force (ECF) during interdental use of IDBs versus the new IRP type.

METHODS

Three IRPs with different tapers (PHB angled: 0.039, PHB straight S: 0.027, Vitis straight M: 0.045; all Flexipicks, Dentaid, Cerdanyola del Vallès, Spain) were compared to one IDB (Interprox micro PHD 0.9, Dentaid, Cerdanyola del Vallès, Spain). IDR were reproduced by a 3D-printer (Form2, Formlabs Sommerville, MA, USA) according to human teeth and matched to equivalent pairs (isosceles triangle, concave, convex) in three different diameters (1.0 mm,1.1 mm,1.3 mm). Covered with simulated biofilm, pre-/ post-brushing situations of IDR (standardized, computer-aided ten cycles) were photographed and quantified by digital image subtraction to calculate ECE [%]. ECF were registered with a load cell [N]. Statistically significant differences were detected using the Mann-Whitney-U-test and the Kruskal-Wallis-test with Bonferroni correction for multiple testing.

RESULTS

Overall, the ECE (mean ± SD) was higher for IDB micro 0.9 (45.95 ± 11.34%, p < 0.001) compared to all IRPs (PHB angled: 25.37 ± 15.29%; PHB straight: 22.28 ± 16.75%; Vitis straight: 25.24 ± 12.21%; p ≤ 0.001), whereat best ECE was achieved in isosceles triangle IDR of 1.0-1.1 mm (IDB micro 0.9: 70.7 ± 7.7%; PHB angled S: 57.30 ± 4.43%; p < 0.001). The highest ECF occurred for Vitis straight M with 2.11 ± 0.46 N, while IDB micro 0.9 showed lowest ECF values (0.64 ± 0.14 N; p < 0.001).

CONCLUSIONS

IRP with an Archimedes´ screw design and a higher taper were associated with advanced ECE but also higher ECF, nevertheless, ECE didn't reach the cleaning efficacy of conventional IDBs.

Mechanical plaque removal in step-1 of care

Maintaining a regular oral hygiene routine is essential for taking care of our mouths, ensuring healthy teeth, and achieving fresh breath. Patient education on oral hygiene is an important component of their overall treatment. Firstly, patients should be informed about the direct connection between bacteria in dental plaque and oral diseases. It is important for patients to understand that these conditions can be treated, but the success of treatment greatly depends on their level of oral hygiene. This journey begins by selecting the appropriate toothbrush and mastering the correct brushing technique to effectively remove dental plaque while avoiding any potential damage to the gums. In addition to toothbrushes, there are other devices available for comprehensive dental cleaning, such as floss, interdental sticks, interdental brushes, and oral irrigators. These aids are particularly beneficial for eliminating dental plaque from hard-to-reach areas. Moreover, tongue brushing or tongue scraping can effectively reduce breath odor and tongue coating. Currently, self-care recommendations for dental implants are primarily based on existing knowledge regarding natural teeth cleaning. Evidence-based recommendations are derived from comprehensive systematic evaluation of various oral hygiene aids.

Efficacy of an interdental brush in cleaning artificial plaque on a 3D-printed model base

BACKGROUND

Among interdental cleaning aids (ICAs), interdental brushes (IDBs) are in the spotlight because they can effectively remove plaque from interdental surfaces. Guidance on the correct use of ICAs, such as IDBs, is required to prevent dental plaque accumulation. Since it is impossible to confirm the interdental proximal surface unless extracted, it is difficult to conduct quantitative experiments. This study presented an efficient way to evaluate IDBs by realizing dental structures and embrasures using a Dental computer-aided design (CAD) software and a 3D printer.

METHODS

Two different sizes of embrasure (0.7 and 1.2 mm) crown models were prepared with CAD software and a 3D printer. To evaluate the cleaning efficacy of IDBs of each size (0.6, 0.7, 0.8, 1.0, 1.2, and 1.5 mm diameters), the 9th cycle of brush move was performed where artificial plaque was spread and a digital camera was used to record the process. The pixels and percentage of cleaning from the recorded digital images were analyzed.

RESULTS

The plateau was formed after the 5th brushing cycle under all conditions-after the 5th cycle, the cleaning efficacy of the two crown models was 69.3-86.4% and 49.8-75.4%. In these results, the optimal diameters for the IDB were 1.2 and 1.5 mm for embrasure sizes of 0.7 and 1.2 mm, respectively. Moreover, the cleaning efficacy was the highest at 86.4% and 75.4% after the 9th cycle.

CONCLUSIONS

The 3D-printed model base for the human oral embrasure structure is an adequate model to test artificial plaque removal using IDB. The use of IDBs for more than five cycles does not support the conventional idea that a greater number of IDB brushing moves is more effective in a statistically substantial manner.

Mechanical plaque removal of periodontal maintenance patients: A systematic review and network meta-analysis

AIM

This systematic review synthesizes the available clinical evidence concerning efficacy of mechanical oral hygiene devices in periodontal maintenance patients.

MATERIAL AND METHODS

Three databases were searched up to October 2019 for clinical trials conducted in adult patients in periodontal maintenance which evaluated the effect of toothbrushes or an interdental device on plaque removal and parameters of periodontal diseases. Descriptive analysis and network meta-analysis (NMA) were performed.

RESULTS

Sixteen eligible publications, including 17 relevant comparisons, were retrieved. Four out of five comparisons found no clinical difference between a manual and power toothbrush. Of the interdental cleaning devices, the interdental brushes (IDBs) reduced plaque scores more effectively than a manual toothbrush alone. For the oral irrigator, two out of three comparisons indicated a positive effect on gingivitis scores, and probing pocket depth. The NMA demonstrated that for plaque removal the adjuvant use of IDBs was significantly more effective than the manual toothbrush alone. For the reduction of gingival inflammation, no product ranked higher than the manual toothbrush.

CONCLUSION

Due to the scarcity of studies that met the inclusion criteria for each of the oral hygiene devices and the low certainty of the resultant evidence, no strong "evidence-based" conclusion can be drawn concerning any specific oral hygiene device for patient self-care in periodontal maintenance.

Contemporary practices for mechanical oral hygiene to prevent periodontal disease

It is well established that dental plaque on teeth leads to gingivitis and periodontitis, and that several mechanical and chemical methods of plaque control can prevent gingivitis. The aim of the current review is to summarize and synthesize the available scientific evidence supporting practices for mechanical oral hygiene to prevent periodontal diseases. Evidence for contemporary practices of mechanical oral hygiene to prevent periodontal disease relies on studies of gingivitis patients. General recommendations concerning the ideal oral hygiene devices and procedures are still inconclusive. However, toothbrushing and interdental cleaning remain the mainstays of prevention of periodontal diseases. The primary approach requires individually tailored instruction for implementation of a systematic oral hygiene regimen.

Effect of interdental brush design on plaque during nonsurgical periodontal therapy

OBJECTIVE

The aim of this randomized controlled trial was to evaluate the interproximal cleaning efficacy of waist-shaped compared with straight soft interdental brushes in patients undergoing nonsurgical periodontal therapy.

MATERIALS AND METHODS

Ten patients diagnosed with periodontitis stage II or III were scheduled for nonsurgical periodontal therapy. Baseline plaque control record (PCR), modified approximal plaque index (API), papillary bleeding index (PBI), probing pocket depth (PPD), and bleeding on probing (BOP) were evaluated. Four interdental spaces of equal sizes were determined, and baseline plaque indices (PI) were assessed on eight surfaces of the respective adjacent teeth, resulting in 640 measuring positions. Interdental brushes with a straight or waist-shaped design were randomly allocated to the right or left side, and patients received oral hygiene instructions. Follow-up measurements including PCR, API, PBI, and site-specific PI were performed during initial nonsurgical periodontal therapy sessions and reevaluation which was undertaken 8 weeks afterwards.

RESULTS

PCR, API, and PBI decreased significantly compared with baseline at each time point (p < 0.001). PPD (waist-shaped, baseline 4 mm (range, 2-9 mm) vs. reevaluation 3 mm (range, 1-6 mm); p < 0.001; straight, baseline 4 mm (range, 2-10) vs. reevaluation 3 mm (range, 1-6) mm; p < 0.001) and BOP (p = 0.008) showed significant reduction in both groups. Sub-analysis of site-specific areas including line angles and interproximal areas revealed no significant reduction of plaque during the observation period between both brush designs. No difference between straight and waist-shaped brushes regarding PPD or BOP decrease was found.

CONCLUSION

The efficacy of both interdental brush designs concerning plaque control in patients undergoing nonsurgical periodontal therapy was similar.

CLINICAL RELEVANCE

The use of interdental brushes is essential for biofilm removal in patients during initial periodontal therapy, regardless of brush design.

CLINICAL TRIAL REGISTRATION

ISRCTNregistry (#ISRCTN24498365), http://www.isrctn.com/ISRCTN24498365.

Impact of interdental brush shape on interpapillary cleaning efficacy - a clinical trial

This study aimed to investigate whether interdental brush shape influences cleaning efficacy, by comparing a waist-shaped interdental brush (W-IDB) with a cylindrical IDB (C-IDB); both provided with the same bristle texture. Cleaning efficacy of differently shaped IDBs was measured in proximal surfaces of teeth in a split-mouth cross-over design. Twenty-eight patients abolished oral hygiene for 4 d. Line angle plaque area was scanned with an intraoral camera after use of disclosing dye in baseline and after IDB application and analyzed planimetrically. Additionally, bacterial load in the IDBs was analyzed after usage by colony forming units (cfu). A Wilcoxon signed-rank test with continuity correction was used to compare the results of the waist-shaped and the cylindrically-shaped IDBs. The waist-shaped IDBs cleaned significantly better than their cylindrically-shaped counterparts (area cleaned: 23.1% vs. 18.3%), when applied at same interdental spaces (p < 0.001). However, no significant differences were found in comparison of bacterial load on the IDBs (median cfu counts: 2.3E9 vs. 2.7E9, p = 0.93). Irrespective of bristle texture or size, IDB shape have impact on cleaning efficacy. Waist-shaped IDBs are more effective in cleaning of the line angle area than cylindrically-shaped IDBs.

Cleansing efficacy of waist-shaped inter-dental brushes. A randomized-controlled crossover study

OBJECTIVE

To compare the cleansing efficacy of waist-shaped versus cylindric inter-dental brushes in patients receiving supportive periodontal therapy.

MATERIALS AND METHODS

After sample size estimation, 20 periodontal maintenance patients diagnosed with periodontitis stage 3 were recruited. Brushing efficacy of waist-shaped and cylindric inter-dental brushes was evaluated in a randomized-controlled, examiner-blinded, two-period crossover study by assessment of the Turesky modification of Quigley-Hein plaque index (T-QHI) and the papillary bleeding index (PBI) at four sites per tooth.

RESULTS

Seventeen probands with 1,474 tooth sites finished the study. At baseline, median of overall T-QHI scores was 1.4 (interquartile range 1.38-1.92). After 1 month, T-QHI for waist-shaped inter-dental brushes was 1.24 (1.03-1.52); in 15 individuals, T-QHI 0 was the grade most often measured. T-QHI for cylindric brushes was 1.71 (1.18-2.29; p = .042), with T-QHI 0 being the grade most often measured only in seven individuals. The odds ratio for establishing plaque-free inter-dental sites with waist-shaped relative to cylindric brushes was 1.8 [95% CI 1.6-1.9] (p < .001; logistic regression analysis). There were no statistically significant differences between PBI levels of waist-shaped and cylindric brushes.

CONCLUSION

This study has demonstrated the superiority in cleansing efficacy of waist-shaped over cylindric inter-dental brushes in individuals receiving supportive periodontal treatment.

Home use of interdental cleaning devices, in addition to toothbrushing, for preventing and controlling periodontal diseases and dental caries

BACKGROUND

Dental caries (tooth decay) and periodontal diseases (gingivitis and periodontitis) affect the majority of people worldwide, and treatment costs place a significant burden on health services. Decay and gum disease can cause pain, eating and speaking difficulties, low self-esteem, and even tooth loss and the need for surgery. As dental plaque is the primary cause, self-administered daily mechanical disruption and removal of plaque is important for oral health. Toothbrushing can remove supragingival plaque on the facial and lingual/palatal surfaces, but special devices (such as floss, brushes, sticks, and irrigators) are often recommended to reach into the interdental area.

OBJECTIVES

To evaluate the effectiveness of interdental cleaning devices used at home, in addition to toothbrushing, compared with toothbrushing alone, for preventing and controlling periodontal diseases, caries, and plaque. A secondary objective was to compare different interdental cleaning devices with each other.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched: Cochrane Oral Health's Trials Register (to 16 January 2019), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2018, Issue 12), MEDLINE Ovid (1946 to 16 January 2019), Embase Ovid (1980 to 16 January 2019) and CINAHL EBSCO (1937 to 16 January 2019). The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared toothbrushing and a home-use interdental cleaning device versus toothbrushing alone or with another device (minimum duration four weeks).

DATA COLLECTION AND ANALYSIS

At least two review authors independently screened searches, selected studies, extracted data, assessed studies' risk of bias, and assessed evidence certainty as high, moderate, low or very low, according to GRADE. We extracted indices measured on interproximal surfaces, where possible. We conducted random-effects meta-analyses, using mean differences (MDs) or standardised mean differences (SMDs).

MAIN RESULTS

We included 35 RCTs (3929 randomised adult participants). Studies were at high risk of performance bias as blinding of participants was not possible. Only two studies were otherwise at low risk of bias. Many participants had a low level of baseline gingival inflammation.Studies evaluated the following devices plus toothbrushing versus toothbrushing: floss (15 trials), interdental brushes (2 trials), wooden cleaning sticks (2 trials), rubber/elastomeric cleaning sticks (2 trials), oral irrigators (5 trials). Four devices were compared with floss: interdental brushes (9 trials), wooden cleaning sticks (3 trials), rubber/elastomeric cleaning sticks (9 trials) and oral irrigators (2 trials). Another comparison was rubber/elastomeric cleaning sticks versus interdental brushes (3 trials).No trials assessed interproximal caries, and most did not assess periodontitis. Gingivitis was measured by indices (most commonly, Löe-Silness, 0 to 3 scale) and by proportion of bleeding sites. Plaque was measured by indices, most often Quigley-Hein (0 to 5).

PRIMARY OBJECTIVE

comparisons against toothbrushing aloneLow-certainty evidence suggested that flossing, in addition to toothbrushing, may reduce gingivitis (measured by gingival index (GI)) at one month (SMD -0.58, 95% confidence interval (CI) -1.12 to -0.04; 8 trials, 585 participants), three months or six months. The results for proportion of bleeding sites and plaque were inconsistent (very low-certainty evidence).Very low-certainty evidence suggested that using an interdental brush, plus toothbrushing, may reduce gingivitis (measured by GI) at one month (MD -0.53, 95% CI -0.83 to -0.23; 1 trial, 62 participants), though there was no clear difference in bleeding sites (MD -0.05, 95% CI -0.13 to 0.03; 1 trial, 31 participants). Low-certainty evidence suggested interdental brushes may reduce plaque more than toothbrushing alone (SMD -1.07, 95% CI -1.51 to -0.63; 2 trials, 93 participants).Very low-certainty evidence suggested that using wooden cleaning sticks, plus toothbrushing, may reduce bleeding sites at three months (MD -0.25, 95% CI -0.37 to -0.13; 1 trial, 24 participants), but not plaque (MD -0.03, 95% CI -0.13 to 0.07).Very low-certainty evidence suggested that using rubber/elastomeric interdental cleaning sticks, plus toothbrushing, may reduce plaque at one month (MD -0.22, 95% CI -0.41 to -0.03), but this was not found for gingivitis (GI MD -0.01, 95% CI -0.19 to 0.21; 1 trial, 12 participants; bleeding MD 0.07, 95% CI -0.15 to 0.01; 1 trial, 30 participants).Very-low certainty evidence suggested oral irrigators may reduce gingivitis measured by GI at one month (SMD -0.48, 95% CI -0.89 to -0.06; 4 trials, 380 participants), but not at three or six months. Low-certainty evidence suggested that oral irrigators did not reduce bleeding sites at one month (MD -0.00, 95% CI -0.07 to 0.06; 2 trials, 126 participants) or three months, or plaque at one month (SMD -0.16, 95% CI -0.41 to 0.10; 3 trials, 235 participants), three months or six months, more than toothbrushing alone.

SECONDARY OBJECTIVE

comparisons between devicesLow-certainty evidence suggested interdental brushes may reduce gingivitis more than floss at one and three months, but did not show a difference for periodontitis measured by probing pocket depth. Evidence for plaque was inconsistent.Low- to very low-certainty evidence suggested oral irrigation may reduce gingivitis at one month compared to flossing, but very low-certainty evidence did not suggest a difference between devices for plaque.Very low-certainty evidence for interdental brushes or flossing versus interdental cleaning sticks did not demonstrate superiority of either intervention.Adverse eventsStudies that measured adverse events found no severe events caused by devices, and no evidence of differences between study groups in minor effects such as gingival irritation.

AUTHORS' CONCLUSIONS

Using floss or interdental brushes in addition to toothbrushing may reduce gingivitis or plaque, or both, more than toothbrushing alone. Interdental brushes may be more effective than floss. Available evidence for tooth cleaning sticks and oral irrigators is limited and inconsistent. Outcomes were mostly measured in the short term and participants in most studies had a low level of baseline gingival inflammation. Overall, the evidence was low to very low-certainty, and the effect sizes observed may not be clinically important. Future trials should report participant periodontal status according to the new periodontal diseases classification, and last long enough to measure interproximal caries and periodontitis.