Comparison of different approaches of interdental oral hygiene: interdental brushes versus dental floss

Evaluation of the efficacy of inter-dental brush and dental floss for peri-implant mucositis: A crossover randomized clinical trial

OBJECTIVES

To evaluate the most effective method for mechanical inter-dental plaque removal between inter-dental brushes (IDB) and dental floss (DF), in addition to toothbrushing in patients affected by peri-implant mucositis (PIM); to identify possible factors related to the patient or to the single implant-supported element that could influence plaque accumulation and inflammation of peri-implant tissues.

METHODS

Forty patients with PIM were recruited. They were randomly assigned to two different groups depending on inter-dental device used (IDB or DF). At baseline (T0), interproximal area (IA), interproximal emergence angle of the implant crown (A°) and manual dexterity (evaluated with Purdue Pegboard) have been recorded. At 14 days (T1), the inter-dental cleaning devices have been inverted between groups. After 14 days (T2), the Plaque Index (PI) and Gingival Index (GI) have been recorded. A questionnaire has been submitted to a patient for the analysis of preferences at T0, T1 and T2.

RESULTS

Both inter-dental cleaning devices were effective in reducing PI and GI in the inter-dental area after 14 days of use. GI reduction was influenced by manual dexterity of the dominant hand. No significant differences were found for PI and GI at the variation of IA and A°.

CONCLUSION

IDB was the most effective method for inter-dental plaque removal in all subjects regardless of their manual dexterity. DF seems to be more effective than IDB only in subjects with good dexterity.

The effectiveness of water jet flossing and interdental flossing for oral hygiene in orthodontic patients with fixed appliances: a randomized clinical trial

BACKGROUND

Orthodontic treatment presents challenges with plaque accumulation around brackets, archwires, and elastics, leading to retained plaque and gingival inflammation. Conventional toothbrushing may not be enough, requiring additional oral hygiene aids like interproximal brushes, dental flosses, and water flossers. Limited research exists on comparing water flossing and interdental flossing in orthodontic patients. Therefore, this study aims to assess their effectiveness in maintaining oral hygiene during active orthodontic treatment.

METHODS

A single-blind, randomized, parallel clinical study recruited orthodontic patients with full-mouth brackets and archwires. Thirty participants were randomly assigned to either water jet flossing or interdental flossing groups. All participants were instructed to brush twice daily with a provided toothbrush and toothpaste and use the assigned intervention once daily at night. Clinical measures, including the Gingival Bleeding Index (BI), Plaque Index (PI), and Gingival Index (GI), were recorded at baseline and day 14. Descriptive statistics and statistical tests were performed using SPSS software.

RESULTS

The water jet flossing group demonstrated a slightly higher, albeit non-significant, benefit in plaque removal (median difference of 6.79%%, P = 0.279) and bleeding reduction (median difference of 5.21%%, P = 0.172) compared to the interdental flossing group after two weeks. Both groups showed significant reductions in gingival bleeding index and plaque index from baseline to the 2-week follow-up. The interdental flossing group had median mean percentage differences of 16.13%% (plaque index) and 23.57% (gingival bleeding index), while the water jet flossing group had median percentage differences of 21.87% (plaque index) and 32.29% (gingival bleeding index). No significant changes in gingival index grades were observed in either group.

CONCLUSION

Both water jet flossing and interdental flossing were effective in reducing plaque accumulation and gingival bleeding among orthodontic patients. While no significant differences were found between the two methods, water jet flossing showed a potential advantage. Further research is needed to validate its effectiveness, assess long-term impact, and understand its benefits for orthodontic patients.

Ibero-Panamerican Federation of Periodontology Delphi study on the trends of periodontology and periodontics by the year 2030. A Latin American consensus

BACKGROUND AND OBJECTIVE

As elsewhere in the world, the prevalence of periodontitis in stages I-II is high in the Latin American population, this scenario emphasizes the need for identification of urgent needs for allocating adequate resources to provide diagnosis, prevention, and treatment of these diseases. The aim of this Delphi study was to predict the trends in periodontology/periodontics in the Latin American region by the year 2030.

METHODS

A steering committee and an advisory group of experts in periodontology/periodontics were selected from 16 countries. An open questionnaire of 60 questions was validated and used following the Delphi methodology.

RESULTS

Two hundred and twenty-five experts from Latin America answered the two rounds of the questionnaire. Moderate to strong consensus was reached on 45 questions (75%). The prediction was that the prevalence of gingivitis and periodontitis in stages I and II will be maintained, the importance of the link with systemic diseases will increase, and the impact of prevention and periodontal treatment will also increase, mainly in the private sector. There was a strong consensus that plastic and regenerative surgical procedures will increase, as well as the demand for training in the specialty of periodontology.

CONCLUSIONS

The present study has provided relevant and useful information on predictions in periodontology/periodontics in Latin America, with important level of consensus among experts. It has been predicted that periodontitis will still be a highly prevalent disease, and its links with other medical conditions should demand more attention by health authorities to develop adequate prevention and management policies and strategies.

Comparative Evaluation of Cleaning Efficacy of Interdental Brush and Interdental Floss in Orthodontics Patients From Vidarbha Region: An Interventional Study

Background Plaque and dental caries are the primary agents causing gingival and periodontal diseases, eventually progressing into tooth loss. If oral hygiene practice is poor, plaque easily accumulates on the tooth surface, especially in interproximal areas. To maintain a good oral environment, it is mandatory to remove or at least reduce the percentage of plaque formation from the oral cavity. To achieve this, interdental aids should be used along with toothbrushes, as cleansing the teeth only with a toothbrush is not effective. Various interdental aids, like interdental brushes, floss, toothpicks, etc., are now available on the market. The objective of the current survey was to rate knowledge as well as make a comparison between the cleaning effectiveness of interdental brushes and interdental floss to determine which was better at reducing plaque accumulation and, subsequently, dental caries. The survey was accessed by measuring individual plaque and gingival index before and after using interdental cleaning aids. Methodology The objective of the survey was to evaluate and analyze the efficiency of interdental brushes and interdental floss in maintaining oral hygiene among orthodontic patients residing in the Vidarbha region. After receiving approval from the Ethical Committee DMIHER(DU)/IEC/2023/721, a study was conducted over a 30-day period, focusing on a group of 100 individuals aged between 15 and 30 years, and their assessments were analyzed. The patient was briefed about the study and asked to make use of an interdental brush and interdental floss. The gingival index and plaque index were calculated on the same patients before and after the use of the interdental brush and interdental floss to determine which was better at reducing plaque accumulation on the surface of teeth. Descriptive analysis, unpaired for intergroup comparison, and paired T-tests for intragroup comparison were used. The software used was SPSS 24.0 (IBM Corp., Armonk, NY) and GraphPad Prism 7.0 (GraphPad Software, Inc., La Jolla, CA). Result Everyone's tooth surfaces naturally develop a thin layer of plaque biofilm, but the presence of heavy plaque deposits on teeth indicates poor dental hygiene, which can lead to various oral health issues. Failure to improve dental hygiene status can result in problems such as halitosis, gingival issues, periodontal disease, and eventually tooth loss. Dentists play a crucial role in raising awareness about these concerns among their patients and providing education on effective oral care practices, including the use of interdental aids in conjunction with toothbrushes. When comparing the effectiveness of interdental brushes and dental floss in removing plaque, interdental brushes have been found to be more efficient. They not only excel in plaque removal but also contribute to a reduction in gingival problems. The statistical analysis supports this, with a significant p-value of less than 0.01 for both the plaque index and gingival index when using interdental brushes, indicating their superior performance in maintaining oral health. Conclusion The study will help every individual improve their oral hygiene status with the help of an interdental aid and a toothbrush. This will reduce the chances of having gingival and periodontal diseases and eventually reduce the risk of tooth loss.

Comparison of the Efficacy of Different Oral Hygiene Aids in Maintaining Periodontal Health in Patients With Gingivitis

Background Gingivitis is a common oral health condition characterized by inflammation of the gingiva, which, if left untreated, can progress to more severe forms of periodontal disease. Effective oral hygiene practices play a crucial role in managing gingivitis, but the comparative efficacy of different oral hygiene aids remains unclear. This study aimed to evaluate and compare the efficacy of various oral hygiene aids in maintaining periodontal health in patients with gingivitis, considering gender and the degree of gingivitis as potential influencing factors. Methods A total of 120 participants with gingivitis were enrolled in this study. The participants were randomly assigned to one of four groups, each utilizing a different oral hygiene aid: Group A (toothbrush), Group B (electric toothbrush), Group C (brushing along with the use of an interdental brush), and Group D (brushing along with the use of a water flosser). All participants received toothpaste for use with their respective oral hygiene aids. Periodontal health parameters, including plaque index (PI), gingival index (GI), and bleeding on probing (BOP) score, were assessed at baseline and after a specified duration of oral hygiene intervention. Also, the microbial count for Streptococcus, Actinomyces, Porphyromonas, Fusobacterium, and Veillonella species was evaluated. Results No significant differences in periodontal health outcomes were observed between males and females in any of the oral hygiene aid groups. Similarly, no significant differences were found among the mild, moderate, and severe gingivitis groups within each oral hygiene aid group. The microbial count also has no statistical significance except for streptococcus species. These findings indicate that the efficacy of the tested oral hygiene aids was comparable across genders and different degrees of gingivitis. Conclusion The findings of this study suggest that the tested oral hygiene aids were effective in maintaining periodontal health in patients with gingivitis, irrespective of gender and the degree of gingivitis. These results have implications for oral healthcare professionals in their recommendations to patients regarding oral hygiene practices. However, it is important to consider the limitations of this study, including the relatively small sample size and the specific oral hygiene aids tested.

Furcation-involved molar teeth - part 2: management and prognosis

Furcation-involved molars are a common presentation in general dental practice. Teeth with increasing degrees of furcation involvement are at a higher risk of requiring extraction. This second article reviews management and prognosis of furcation-involved molar teeth. An improved understanding of how to appropriately manage these teeth can result in improved outcomes for patients.

Multicenter Randomized Controlled Trial Comparing the Contribution of Proxabrushes with Regular Toothbrushes and Only Regular Toothbrushes to the Oral Health of Thai Elderly

Objective

The aim of this two-group experimental study was to explore the effects of proxabrush on Thai elderly oral health. Design and Setting. Multicenter randomized controlled trial, parallel grouped, open label, blocked randomization was used at each province to allocate treatment. The study was conducted at public hospitals in 16 provinces in Thailand between November 2019 and January 2020.

Methods

Participants in the test group used proxabrushes and regular toothbrushes, and participants in the control group used only regular toothbrushes for 6 weeks. Plaque accumulation, gingival status, and oral healthcare data were collected at baseline and at 6-week follow-up. Clinical oral health examiner was blinded to group assignment. Randomization was computer-generated, with allocation concealment by opaque sequentially number sealed envelopes. Data analysis compared plaque and gingival indices between the test and control groups.

Results

A total of 510 elderly with at least 20 natural teeth and interdental spaces were randomized (test n = 255; control n = 255), and 35 were excluded from analysis because of early drop out leaving 239 in the test group and 236 in the control group. A sample of 475 aged between 60 and 91 years participated in the study; 158 (33.3%) were males and 317 (66.7%) were females. The results revealed that, compared to baseline knowledge, attitude and practice were improved at follow-up for both the test and control groups (p < 0.05). At follow-up, the independent-samples t-test compares the test group plaque index mean of 0.49 (SD 0.44) to the control group mean of 0.60 (SD 0.56); a mean difference of 0.11 (95% CI 0.02 to 0.20) obtained demonstrated statistical significance (p = 0.014), and comparing the test group gingival index mean of 0.52 (SD 0.50) to the control group mean of 0.65 (SD 0.60), a mean difference of 0.13 (95% CI 0.03 to 0.23) obtained demonstrated statistical significance (p = 012). At follow-up, the test group had lower plaque accumulation and better gingival status than the control group. Gender, medical problems, educational level, occupation, and age were not different between the test and control groups. A combination of daily proxabrush and regular toothbrush use yielded significant benefits over regular tooth-brushing alone.

Conclusions

In conclusion, proxabrush has been found to be an effective interdental cleaning aid among Thai elderly. This trial is registered with TCTR20220127004.

Interdental plaque reduction after use of different devices in patients with periodontitis and interdental recession: A randomized clinical trial

OBJECTIVES

To determine the efficacy of four different oral hygiene protocols involving adjunctive interdental devices in terms of plaque and bleeding scores in periodontitis-affected patients.

MATERIAL AND METHODS

This was a randomized clinical trial with a 5-week follow-up, including previously treated periodontitis-patients not undergoing any supportive care. Patients were randomly allocated to 4 groups: manual toothbrush (group TB); toothbrush plus dental floss (group TB/F); toothbrush plus interdental brushes (group TB/IDB); toothbrush plus rubber interdental picks (group TB/RIDB). Oral hygiene instructions (OHI) were provided at baseline (T-7) and at T0 (1-week) then bi-weekly (T14/T28). At T0 (supragingival professional cleaning was delivered. Plaque and bleeding indexes were taken at all time-points by a single calibrated examiner, blind to group allocation.

RESULTS

At T-7 patients were comparable for age, body mass index (BMI), and all clinical parameters, exceptions for the Interdental Angulated Bleeding Index. At T28, significant reductions of plaque and gingival inflammation were noted in all groups (p<0.001) and within the expected ranges. Intergroup comparisons identified that group TB/IDB and group TB/RIDB achieved lower levels of plaque and inflammation than group TB (p<0.05). Group TB/IDB and group TB/RIDB showed lower levels of plaque and lower inflammation as measured by angulated bleeding index than group TB/RIDB (p<0.05).

CONCLUSION

Interdental brushes and rubber interdental picks were more efficient than toothbrushing alone and toothbrushing and floss in reducing plaque and gingival inflammation measured in a periodontitis-affected population.

Effectiveness of Standard Oral Care Plan During Hospital Stay in Individuals With Brain Injury

Objective: To investigate the effectiveness of an existing standard oral care program (SOCP) and factors associated with it during hospitalization in individuals with acquired brain injury (ABI).

Material and Methods: A total of 61 individuals underwent a SOCP for 4 weeks in a longitudinal observational study. Rapidly noticeable changes in oral health were evaluated by performing plaque, calculus, bleeding on probing (BOP) and bedside oral examination (BOE) at weeks 1 and 5. Individuals' brushing habits, eating difficulties, and the onset of pneumonia were retrieved from their medical records. Association between oral-health outcomes to systemic variables were investigated through multilevel regression models.

Results: Dental plaque (P = 0.01) and total BOE score (P &lt; 0.05) decreased over time but not the proportion of dental calculus (P = 0.30), BOP (P = 0.06), and tooth brushing frequency (P = 0.06). Reduction in plaque and BOE over time were negatively associated with higher periodontitis scores at baseline (coef. −6.8; −1.0), respectively, which in turn were associated with an increased proportion of BOP (coef. ≈ 15.0). An increased proportion of calculus was associated with eating difficulties (coef. 2.3) and the onset of pneumonia (coef. 6.2).

Conclusions: Nursing care has been fundamental in improving oral health, especially reducing dental plaque and BOE scores. However, our findings indicate a need for improving the existing SOCP through academic-clinical partnerships.

Clinical Relevance: Early introduction of oral care program to brain-injured individuals is beneficial in reducing plaque accumulation and improving oral health.

Bacterial colonisation during regular daily use of a power-driven water flosser and risk for cross-contamination. Can it be prevented?

Objective

To assess whether bacterial colonisation in a power-driven water flosser can be prevented.

Materials and methods

Twenty-four patients undergoing supportive periodontal treatment used 2 power-driven water flossers [Sonicare AirFloss (SAF), AirFloss Ultra (SAFU)] for 12 weeks each as follows: (a) with bottled water (BW); (b) with BW and cleaning the device extra-orally twice per week with chlorhexidine gluconate or (c) essential-oil-based (EO) mouth-rinse; (d) with EO only. Water-jet samples were taken after 6 and 12 weeks with the used nozzle and after exchanging to a brand-new nozzle. After 12 weeks, all devices underwent an intensive cleaning procedure. Samples were analysed by PCR-based method for cariogenic and periodontal pathogens and culture for staphylococci, aerobe gram-negative bacteria, and Candida sp.

Results

Contamination of SAF/SAFU with Streptococcus mutans was found in > 95% of the samples; periodontal pathogens and aerobe gram-negative bacteria were detected in 19–56% of the samples, while Staphylococcus aureus and Candida sp. were identified only in few samples. Contamination rate was basically unaffected by time-point, device, or way of use. Further, exchanging the nozzle did not prevent transmission of a contaminated water-jet, but the intensive cleaning reduced most of the pathogens significantly, except of S. mutans.

Conclusion

Neither a specific way of use nor exchanging the nozzle prevented bacterial colonisation and transmission of biofilm components via the water-jet of SAF/SAFU.

Clinical relevance

Bacterial colonisation in a power-driven water flosser seems impossible to prevent; to restrict the risk of cross-contamination within a household, one device per person should be recommended.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00784-021-04167-1.

Does flossing before or after brushing influence the reduction in the plaque index? A systematic review and meta-analysis

OBJECTIVES

The purpose of this systematic review was to assess whether flossing before or after influences plaque index reduction.

METHODS

This systematic review was conducted according to the guidelines of the preferred reporting items for systematic reviews and meta-analyses and registered with the International prospective register of systematic reviews under number CRD42019126239. The PICO question was, 'does flossing before or after brushing have any effect on reducing dental plaque?'. An electronic search was performed until April 2020 in the following databases: PubMed/MEDLINE, Scopus Web of Science and Cochrane Library. The initial database search resulted in 9679 references, and after detailed analysis of the titles and abstracts of the selected studies, the inclusion/exclusion criteria were applied, and 06 complete articles were downloaded and selected for further analysis. After the complete 02 articles were selected, 60 patients with a mean age of 23.1 years were studied and compared dental flossing before or after dental brushing.

RESULTS

The results showed that there was no statistical difference between brush-floss and floss-brush in reducing plaque index (p = 0.91, RR: 0.01, 95% CI: -0.16, 0.18).

CONCLUSIONS

Flossing before or after brushing has no significant effect on reducing dental plaque index. However, more clinical studies should be conducted.

Comparative evaluation of efficacy and patient-reported outcome measures of oral hygiene instruction methods for calibrated interdental brush

OBJECTIVES

To compare the efficacy and patient-reported outcome measures of oral hygiene instruction methods for calibrated interdental brush.

MATERIALS AND METHODS

A total of 60 participants, with 30 each in control and test group, participated in the study. Clinical examination included gingival index, full mouth bleeding scores and approximal plaque index. Supragingival scaling was performed. Interdental access probe was used to assess the size of interdental brush and corresponding interdental brush were given to the participants. For the control group, oral hygiene instructions were given through demonstration with model and video. For the test group, oral hygiene instructions were given through 'Touch-to-Teach' method. At 4-week follow-up, oral hygiene instructions were repeated to respective groups. After 3 months, clinical examination was done and exit survey on patient-reported outcome measures was administered. Statistical analysis was done.

RESULTS

Intergroup comparison of gingival index, full mouth bleeding index and approximal plaque index showed statistically significant difference between test and control group. 'Touch-to-Teach' method of oral hygiene instruction was found to be 'Good'. Acceptance of interdental brush was regarded to be 'Good'.

CONCLUSION

Within limitations of the study, Touch-to-Teach method of oral hygiene instruction method was found to be effective and more acceptable and participants used the interdental brush regularly.

Patients' opinion on the use of 2 generations of power-driven water flossers and their impact on gingival inflammation

Objectives

To assess patients' opinion on the use of 2 generations of power‐driven water flossers and their impact on gingival inflammation.

Material & Methods

In the present prospective cohort study 24 periodontitis patients under regular supportive periodontal therapy used daily 2 generations of a power‐driven water flosser (Sonicare AirFloss [SAF] and Sonicare AirFloss Ultra [SAFU]) for 12 weeks each. Patients were instructed to position the nozzle interproximally from the buccal aspect at each interproximal space. Patients' opinion was assessed by a questionnaire and interproximal bleeding on probing (BoP) was recorded.

Results

Overall satisfaction with SAF/SAFU was rated high, by about 80% of the patients. About 66% of the patients preferred SAF/SAFU compared to their previous interdental cleaning device and indicated that they would continue using SAF/SAFU after the study; none of the patients reported any discomfort or pain. Compared to only tooth brushing, daily use of SAF/SAFU caused a significant reduction of interproximal BoP values, which were well maintained over 6 months; that is, BoP at interproximal buccal and oral sites (pooled), as well as at interproximal buccal and oral sites separately, was proportionately reduced by 29.1%, 41.2%, and 24.8%, respectively (pooled: p = 0.027; buccal sites: p = 0.030; oral sites: p = 0.030).

Conclusion

Patients were very fond of the power‐driven water flossers tested herein, and daily use of the devices for 6 months (i.e., each device was used for 3 months) resulted in a significant reduction of gingival inflammation interproximally.

Bacterial colonization of a power-driven water flosser during regular use. A proof-of-principle study

Objectives

The present proof‐of‐principle study assessed whether daily use of a power‐driven water flosser (Sonicare AirFloss; SAF) leads to bacterial colonization in the nozzle and/or the device, resulting in contaminated water‐jet.

Material and Methods

In five participants, saliva samples at baseline and water‐jet samples of devices used daily with bottled water for 3 weeks (test) were collected. Additionally, water‐jet samples from devices used daily with bottled water extra‐orally for 3 weeks (positive control) and from brand new devices (negative control), as well as samples from newly opened and 1‐ and 3‐week opened water bottles were collected. Colony forming units (CFU) were recorded after 48 h culturing and 20 oral pathogens were assessed by polymerase chain reaction‐based analysis.

Results

Distinct inter‐individual differences regarding the number of detected bacteria were observed; water‐jet samples of test devices included both aerobic and anaerobic bacterial species, with some similarities to the saliva sample of the user. Water‐jet samples from positive control devices showed limited number of aerobic and anaerobic bacterial species, while the samples from negative control devices did not show any bacterial species. Very few aerobic bacteria were detected only in the 3‐week‐old bottled water samples, while samples of newly and 1‐week opened water bottles did not show any bacterial growth.

Conclusions

The present proof‐of‐principle study showed that daily use of a power‐driven water flosser for 3 weeks resulted in bacterial colonization in the nozzle and/or device with both aerobic and anaerobic, not only oral, species, that are transmitted via the water‐jet.

In vitro comparison of cleaning efficacy and force of cylindric interdental brush versus an interdental rubber pick

BACKGROUND

Interdental brushes (IDB) are according to the actual evidence the first choice for cleaning interdental areas (IDR). Their size should be chosen individually according to the IDR morphology. However, interdental rubber picks (IRP) are appreciated better by the patients and are hence becoming more and more popular but the evidence regarding their efficacy is still limited. The aim of this in vitro study was to measure the experimental cleaning efficacy (ECE) and force (ECF) during the use of interdental brushes versus newer wireless types with rubber filaments (IRP), both fitted and non-fitted for different IDR.

METHODS

The medium size of a conical IRP (regular, ISO 2) with elastomeric fingers versus four sizes (ISO 1, 2, 3, 4) of cylindric IDB with nylon filaments (all Sunstar Suisse SA, Etoy, Switzerland) were tested. Interdental tooth surfaces were reproduced by a 3D-printer (Form 2, Formlabs Sommerville, MA, USA) according to human teeth and matched to morphologically equivalent pairs (isosceles triangle, concave, convex) fitting to three different gap sizes (1.0 mm, 1.1 mm, 1.3 mm). The pre-/post brushing situations at IDR (standardized, computer aided ten cycles) were photographically recorded and quantified by digital image subtraction to calculate ECE [%]. ECF were registered with a load cell [N].

RESULTS

Overall, a higher ECE was recorded for IDB compared to IRP (58.3 ± 14.9% versus 18.4 ± 10.1%; p < 0.001). ECE significantly depended on the fitting of the IDB. ECE was significant higher in isosceles triangle compared to concave and convex IDR for both IDB and IRP (p ≤ 0.001). ECF was lower for IDB (0.6 ± 0.4N) compared to IRP (0.8 ± 0.5N; p ≤ 0.001). ECE in relation to ECF increases with smaller IDB. For IRP highest values of ECF were found in the smallest IDR.

CONCLUSIONS

Within the limitations of an in vitro study, size fitted IDB cleaned more effectively at lower forces compared to conical IRP.

Comparison between water flosser and regular floss in the efficacy of plaque removal in patients after single use

Objective

The objective was to compare water flosser and regular floss in the efficacy of plaque removal in patients after single use.

Materials and Methods

A randomized controlled clinical trial was conducted to compare the plaque removal efficacy of water flosser and regular floss. Eighty three subjects who met the inclusion criteria were recruited from dental clinic. Silness and Löe plaque index was measured for all the subjects prior to and after the intervention by an examiner who was blind to the type of aid used. The type of floss used was randomly assigned to each side of the oral cavity; unflavored waxed regular floss (oral B) used on one side, while a water flosser (Waterpik® Cordless Plus Water Flosser) was used on the other side. A trained investigator used either unflavored waxed regular floss or water flosser as assigned. Paired t-test was used to compare between the two groups.

Results

The mean plaque scores at baseline were 1.10(±0.38) and 0.94(±0.38) respectively for regular floss and water flosser. The mean plaque scores were 0.12(±0.13) and 0.12(±0.15) respectively for regular floss and water flosser. There was no statistically significant difference in the plaque scores (p = 0.58) between the groups after the use of respective interdental aids. There was a statistically significant difference in the plaque scores before and after use of interdental aids for both the groups (p < 0.001). Reduction in plaque scores for regular floss and water flosser groups was 89.09% and 87.23% respectively.

Conclusion

The results showed that water flosser was as efficient as regular floss in removing interdental plaque on single use. Water flosser could be recommended for subjects lacking manual dexterity, by care takers for better plaque control and subjects with fixed prostheses or undergoing orthodontic treatment.

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.

The efficacy of a rubber bristles interdental cleaner on parameters of oral soft tissue health-a systematic review

Aim

This study aimed to establish the efficacy of a rubber bristles interdental cleaner (RBIC) as an adjunct to toothbrushing (TB) compared to that of the adjuvant use of other interdental cleaning devices and TB alone on plaque and gingivitis parameters. Additionally, the safety aspects and panellists’ appreciation were evaluated.

Materials and Methods

Databases were searched for randomized controlled clinical trials (RCTs) evaluating plaque (PI), bleeding (BS), and gingival index (GI) scores, safety assessments, and participants’ appreciation. Extracted data were summarized in a descriptive and, if possible, a meta‐analysis.

Results

The search retrieved 142 unique papers; six studies with 10 comparisons were included in a descriptive analysis. Five RCTs compared RBICs with interdental brushes (IDBs), four with dental floss (DF) and one with manual TB only. No comparisons to wood sticks were retrieved. Using an RBIC resulted in no difference in plaque scores compared to DF and IDBs. For overall bleeding scores, no difference was found. Two studies analysing the accessible sites separately found RBICs to be more favourable than DF and IDBs. Conversely, one study evaluating the efficacy of RBICs compared to IDBs, according to the GI scores, showed that IDBs achieved significantly greater reduction. Moreover, RBICs caused fewer gingival abrasions and were preferred by the study participants.

Conclusion

Based on a descriptive and a meta‐analysis of the available literature, it is synthesized that in gingivitis patients, a weak to very weak certainty exists that a RBIC is indicated for gingivitis and plaque reduction. The evidence supports user safety and participants’ preferences.

Development of a European consensus from dentists, dental hygienists and physicians on a standard for oral health care in care-dependent older people: An e-Delphi study

OBJECTIVES

This study aimed to obtain a consensus on oral health policy, access to dental care, oral hygiene measures and training levels.

BACKGROUND

Poor oral health is widespread in care-dependent older people, but no consensus for a minimum standard of oral health care exists yet.

METHODS

The e-Delphi approach was applied to a selected panel of interdisciplinary experts. Data analysis was based on three measurements: (a) ≥70% of experts' opinion fall into category "agree or strongly agree," (b) median score on the 5-point Likert scale ≥4, (c) interquartile range ≤1.

RESULTS

A total of 31 experts from 17 European countries participated in this survey. Agreement was achieved for a compulsory dental examination when an elder is admitted to a long-term care (LTC) facility. Older people should brush their teeth twice/day and regularly clean interproximal spaces and oral mucosa. Dentures should be rinsed after meals and cleaned twice/day. The use of denture cleansing tablets was considered necessary. Dentures should be removed before sleeping and stored dry. A 5000 ppm fluoride toothpaste should be applied daily in elder with high caries risk. A short report on the oral health status of the elder should be included in the geriatric assessment. All experts concluded that the knowledge and the training in oral health care for caregivers and family members of care-dependent older people were imperative.

CONCLUSIONS

Using the e-Delphi method, multidisciplinary healthcare professionals from different countries agreed on certain cardinal recommendations for a standard oral health care for care-dependent older people.

Adjunct use of mouth rinses with a sonic toothbrush accelerates the detachment of a Streptococcus mutans biofilm: an in vitro study

BACKGROUND

The aim of this in vitro study was to examine the possible enhancement of the biofilm peeling effect of a sonic toothbrush following the use of an antimicrobial mouth rinse.

METHODS

The biofilm at a noncontact site in the interdental area was treated by sound wave convection with the test solution or by immersion in the solution. The biofilm peeling effect was evaluated by determining the bacterial counts and performing morphological observations. A Streptococcus mutans biofilm was allowed to develop on composite resin discs by cultivation with stirring at 50 rpm for 72 h. The specimens were then placed in recesses located between plastic teeth and divided into an immersion group and a combination group. The immersion group was treated with phosphate buffer, chlorhexidine digluconate Peridex™ (CHX) mouth rinse or Listerine® Fresh Mint (EO) mouth rinse. The combination group was treated with CHX or EO and a sonic toothbrush.

RESULTS

The biofilm thickness was reduced by approximately one-half compared with the control group. The combination treatment produced a 1 log reduction in the number of bacteria compared to the EO immersion treatment. No significant difference was observed in the biofilm peeling effect of the immersion group compared to the control group.

CONCLUSIONS

The combined use of a sonic toothbrush and a mouth rinse enhanced the peeling of the biofilm that proliferates in places that are difficult to reach using mechanical stress.

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.

New experimental setup for the measurement of cleaning efficacy and force of interdental aids in 3D-reproduced interdental areas

BACKGROUND

Interdental rubber picks (IRP) have become a frequent and convenient alternative for interdental cleaning. However, only little evidence exists supporting the effectiveness of newer designs available on the market. Therefore, a new in vitro model was evaluated to measure the experimental cleaning efficacy (ECE), as well as the force needed for insertion and during the use of IRP, with high reproducibility.

METHODS

Five different sizes of commercially marketed IRP with elastomeric fingers (IRP-F) (GUM SOFT-PICKS® Advanced, Sunstar Deutschland GmbH, Schönau, Germany) or slats (IRP-S) (TePe EasyPick™, TePe D-A-CH GmbH, Hamburg, Germany) were tested. Interdental tooth surfaces were reproduced by a 3D-printer (Form 2, Formlabs Sommerville, MA, USA) according to human teeth and matched to morphologically equivalent pairs (isosceles triangle, concave, convex) fitting to different gap sizes (1.0 mm, 1.1 mm, 1.3 mm). The pre-/post brushing situations at interdental areas (standardized cleaning, computer aided ten cycles) were photographically recorded and quantified by digital image subtraction to calculate ECE [%]. Forces were registered with a load cell [N].

RESULTS

IRP-F have to be inserted with significant higher forces of 3.2 ± 1.8 N compared to IRP-S (2.0 ± 1.6 N; p < 0.001) independent of the size and type of artificial interdental area. During cleaning process IRP-S showed significantly lower values for pushing/pulling (1.0 ± 0.8 N/0.5 ± 0.4 N) compared to IRP-F (1.6 ± 0.8 N/0.7 ± 0.3 N; p < 0.001) concomitant to significantly lower ECE (19.1 ± 9.8 vs. 21.7 ± 10.0%, p = 0.002). Highest ECE was measured with largest size of IRP-F/IRP-S independent the morphology of interdental area.

CONCLUSIONS

New interdental cleaning aids can be tested by the new experimental setup supported by 3D printing technology. Within the limitations of an in vitro study, IRP-F cleaned more effectively at higher forces compared to IRP-S.

Plaque-removing Effects of Interdental Instruments in Molar Region

Many types of interdental instrument, such as dental floss and interdental brushes, can be purchased easily and sell in large numbers. Many studies have compared the effects of such instruments. Few studies have investigated their relationship with regions of residual plaque, however. The purpose of this study was to compare rates of plaque removal from the mesial and distal surfaces of the bilateral maxillary and mandibular premolars and molars among 3 types of interdental instrument: finger-winding-dental floss, holder-type dental floss, and an interdental brush. Prior to the experiment, the artificial teeth in a jaw model were removed for application of artificial plaque. The teeth were then replaced and the model attached to a phantom. An operator brushed the teeth in a posture close to that adopted in actual tooth brushing with each type of instrument, after which the plaque removal rate was compared among them. The rate of plaque removal using finger-winding floss was the highest, although this type of instrument is less easy to hold than the others. The rate with a handle-equipped interdental instrument showed a decrease in some regions, although it is easy to hold. The results of this study suggest that the type of interdental instrument used should differ depending on the region to be cleaned.

A network meta-analysis of interproximal oral hygiene methods in the reduction of clinical indices of inflammation

BACKGROUND

A wide selection of Interdental Oral Hygiene (IOH) aids is available to consumers. Recommendations for selection are, however, limited by the lack of direct comparisons in available studies. We aimed to assess the comparative efficacy of IOH aids using Bayesian Network Meta-Analysis (BNMA).

METHODS

Two independent reviewers performed a systematic literature review of randomized clinical trials assessing IOH aids, based on a focused question. Gingival inflammation (Gingival Index (GI), Bleeding-on-probing (BOP)) was the primary outcome and plaque and probing depth were secondary outcomes A random-effects arm-based BNMA model was run for each outcome; posterior medians and 95% credible-intervals (CIs) summarized marginal distributions of parameters.

RESULTS

A two-phase selection process identified 22 trials assessing 10 IOH aids as brushing adjuncts. Interdental brushes (IB) yielded the largest reduction in GI (0.23 [95% CI: 0.09, 0.37]) as toothbrushing adjuncts, followed by water-jet (WJ) (0.19 [95% CI: 0.14, 0.24]). Rankings based on posterior probabilities revealed that IB and WJ had the highest probability of being "best" (64.7% and 27.4%, respectively) for GI reduction, whereas the probability for toothpick and floss being the "best" IOH aids was near zero. Notably, except for toothpicks, all IOH aids were better at reducing GI as compared with control.

CONCLUSIONS

BNMA enabled us to quantitatively evaluate IOH aids and provide a global ranking of their efficacy. Interdental brushes and water-jets ranked high for reducing gingival bleeding, whereas toothpicks and floss ranked last. The patient-perceived benefit of IOH aids is not clear because gingival inflammation measures are physical indicators of periodontal health.

Knowledge, attitudes and behaviours of patients regarding interdental deplaquing devices: A mixed-methods study

OBJECTIVES

This mixed-methods study assessed patients' oral health literacy, motivation level and barriers regarding interdental plaque control.

METHODS

Participants (n = 49) from a study comparing the use of Glide® Pro-Health Floss Original (F) or GUM® Curved Soft-Picks® Advance (SP) completed daily diaries and questionnaires regarding motivation, tiredness, confidence and satisfaction for their deplaquing method. The Mantel-Haenszel chi-square test was utilized. Data were also collected from 19 participants who attended focus group discussions regarding their oral health habits, knowledge, motivators and barriers with interdental plaque control. Discussions were digitally recorded, transcribed and imported into ATLAS.ti 7.5.15 to identify themes.

RESULTS

There were no statistically significant differences between the two groups in relation to age, sex or ethnicity. F users reported statistically significant higher agreement about ability to remove food/debris (P = 0.01), cleaning thoroughly (P = 0.02) and clean feeling of the mouth (P = 0.01). SP users reported higher ease/efficiency of use (P = 0.01), convenience (P = 0.003), easy to hold (P = 0.0001) and easy use away from home (P = 0.008). Daily diaries revealed higher motivation and compliance/ease of use (SP). During the focus groups, some reported that they did not feel clean unless they deplaqued interdentally; however, most reported that they lacked motivation due to constraints on time, no desire due to lack of immediate or tangible rewards, and lack of knowledge on proper use of interdental devices or the benefits of using them.

CONCLUSION

This study showed that the lack of compliance may be due to poor literacy and lack of motivation in patients due to gaps in patient education.

An Overview of Different Interdental Cleaning Aids and Their Effectiveness

Optimisation of plaque control is essential for the success of non-surgical and surgical periodontal therapy. This cannot be achieved with brushing alone; hence, there is a need for adjunctive interdental cleaning aids. The aim of this paper is to provide an overview of different interdental cleaning aids and review the literature for consensus on their effectiveness. A literature search of articles in English, up to December 2018, was conducted in Pubmed. High-quality flossing is difficult to achieve, and ineffective routine use of floss may not confer significant benefits over brushing alone. Interdental brushes are more effective than brushing as a monotherapy. They are at least as good if not superior to floss in reducing plaque and gingivitis. Although they are effective for patients regardless of their periodontal status (healthy or active), they are especially indicated in periodontal patients where widened embrasures are common. Added benefits include ease of use, patient acceptance, and recontouring of interdental tissues. Rubberpiks do not demonstrate inferiority to conventional interdental brushes. Wooden interdental aids appear to offer no significant advantage over brushing with respect to plaque removal; they may, however, reduce gingival bleeding. Oral irrigators are a promising tool for reducing gingival inflammation, despite minimal changes to plaque levels. For cleaning around dental implants, oral irrigators and interdental brushes are preferred over floss.

WITHDRAWN: Interdental brushing for the prevention and control of periodontal diseases and dental caries in adults

BACKGROUND

Effective oral hygiene is a crucial factor in maintaining good oral health, which is associated with overall health and health-related quality of life. Dental floss has been used for many years in conjunction with toothbrushing for removing dental plaque in between teeth, however, interdental brushes have been developed which many people find easier to use than floss, providing there is sufficient space between the teeth.

OBJECTIVES

To evaluate the effects of interdental brushing in addition to toothbrushing, as compared with toothbrushing alone or toothbrushing and flossing for the prevention and control of periodontal diseases, dental plaque and dental caries.

SEARCH METHODS

We searched the following electronic databases: the Cochrane Oral Health Group's Trials Register (to 7 March 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 2), MEDLINE via OVID (1946 to 7 March 2013), EMBASE via OVID (1980 to 7 March 2013), CINAHL via EBSCO (1980 to 7 March 2013), LILACS via BIREME (1982 to 7 March 2013), ZETOC Conference Proceedings (1980 to 7 March 2013) and Web of Science Conference Proceedings (1990 to 7 March 2013). We searched the US National Institutes of Health Trials Register (http://clinicaltrials.gov) and the metaRegister of Controlled Trials (http://www.controlled-trials.com/mrct/) for ongoing trials to 7 March 2013. No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

We included randomised controlled trials (including split-mouth design, cross-over and cluster-randomised trials) of dentate adult patients. The interventions were a combination of toothbrushing and any interdental brushing procedure compared with toothbrushing only or toothbrushing and flossing.

DATA COLLECTION AND ANALYSIS

At least two review authors assessed each of the included studies to confirm eligibility, assessed risk of bias and extracted data using a piloted data extraction form. We calculated standardised mean difference (SMD) and 95% confidence interval (CI) for continuous outcomes where different scales were used to assess an outcome. We attempted to extract data on adverse effects of interventions. Where data were missing or unclear we attempted to contact study authors to obtain further information.

MAIN RESULTS

There were seven studies (total 354 participants analysed) included in this review. We assessed one study as being low, three studies as being high and three studies as being at unclear risk of bias. Studies only reported the clinical outcome gingivitis and plaque data, with no studies providing data on many of the outcomes: periodontitis, caries, halitosis and quality of life. Three studies reported that no adverse events were observed or reported during the study. Two other studies provided some data on adverse events but we were unable to pool the data due to lack of detail. Two studies did not report whether adverse events occurred.Interdental brushing in addition to toothbrushing, as compared with toothbrushing aloneOnly one high risk of bias study (62 participants in analysis) looked at this comparison and there was very low-quality evidence for a reduction in gingivitis (0 to 4 scale, mean in control): mean difference (MD) 0.53 (95% CI 0.23 to 0.83) and plaque (0 to 5 scale): MD 0.95 (95% CI 0.56 to 1.34) at one month, favouring of use of interdental brushes. This represents a 34% reduction in gingivitis and a 32% reduction in plaque.Interdental brushing in addition to toothbrushing, as compared with toothbrushing and flossingSeven studies provided data showing a reduction in gingivitis in favour of interdental brushing at one month: SMD -0.53 (95% CI -0.81 to -0.24, seven studies, 326 participants, low-quality evidence). This translates to a 52% reduction in gingivitis (Eastman Bleeding Index). Although a high effect size in the same direction was observed at three months (SMD -1.98, 95% CI -5.42 to 1.47, two studies, 107 participants, very low quality), the confidence interval was wide and did not exclude the possibility of no difference. There was insufficient evidence to claim a benefit for either interdental brushing or flossing for reducing plaque (SMD at one month 0.10, 95% CI -0.13 to 0.33, seven studies, 326 participants, low-quality evidence) and insufficient evidence at three months (SMD -2.14, 95% CI -5.25 to 0.97, two studies, 107 participants very low-quality evidence).

AUTHORS' CONCLUSIONS

Only one study looked at whether toothbrushing with interdental brushing was better than toothbrushing alone, and there was very low-quality evidence for a reduction in gingivitis and plaque at one month. There is also low-quality evidence from seven studies that interdental brushing reduces gingivitis when compared with flossing, but these results were only found at one month. There was insufficient evidence to determine whether interdental brushing reduced or increased levels of plaque when compared to flossing.

WITHDRAWN: Flossing for the management of periodontal diseases and dental caries in adults

BACKGROUND

Good oral hygiene is thought to be important for oral health. This review is to determine the effectiveness of flossing in addition to toothbrushing for preventing gum disease and dental caries in adults.

OBJECTIVES

To assess the effects of flossing in addition to toothbrushing, as compared with toothbrushing alone, in the management of periodontal diseases and dental caries in adults.

SEARCH METHODS

We searched the following electronic databases: the Cochrane Oral Health Group Trials Register (to 17 October 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 4), MEDLINE via OVID (1950 to 17 October 2011), EMBASE via OVID (1980 to 17 October 2011), CINAHL via EBSCO (1980 to 17 October 2011), LILACS via BIREME (1982 to 17 October 2011), ZETOC Conference Proceedings (1980 to 17 October 2011), Web of Science Conference Proceedings (1990 to 17 October 2011), Clinicaltrials.gov (to 17 October 2011) and the metaRegister of Controlled Clinical Trials (to 17 October 2011). We imposed no restrictions regarding language or date of publication. We contacted manufacturers of dental floss to identify trials.

SELECTION CRITERIA

We included randomised controlled trials conducted comparing toothbrushing and flossing with only toothbrushing, in adults.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed risk of bias for the included studies and extracted data. We contacted trial authors for further details where these were unclear. The effect measure for each meta-analysis was the standardised mean difference (SMD) with 95% confidence intervals (CI) using random-effects models. We examined potential sources of heterogeneity, along with sensitivity analyses omitting trials at high risk of bias.

MAIN RESULTS

Twelve trials were included in this review, with a total of 582 participants in flossing plus toothbrushing (intervention) groups and 501 participants in toothbrushing (control) groups. All included trials reported the outcomes of plaque and gingivitis. Seven of the included trials were assessed as at unclear risk of bias and five were at high risk of bias.Flossing plus toothbrushing showed a statistically significant benefit compared to toothbrushing in reducing gingivitis at the three time points studied, the SMD being -0.36 (95% CI -0.66 to -0.05) at 1 month, SMD -0.41 (95% CI -0.68 to -0.14) at 3 months and SMD -0.72 (95% CI -1.09 to -0.35) at 6 months. The 1-month estimate translates to a 0.13 point reduction on a 0 to 3 point scale for Loe-Silness gingivitis index, and the 3 and 6 month results translate to 0.20 and 0.09 reductions on the same scale.Overall there is weak, very unreliable evidence which suggests that flossing plus toothbrushing may be associated with a small reduction in plaque at 1 or 3 months.None of the included trials reported data for the outcomes of caries, calculus, clinical attachment loss, or quality of life. There was some inconsistent reporting of adverse effects.

AUTHORS' CONCLUSIONS

There is some evidence from twelve studies that flossing in addition to toothbrushing reduces gingivitis compared to toothbrushing alone. There is weak, very unreliable evidence from 10 studies that flossing plus toothbrushing may be associated with a small reduction in plaque at 1 and 3 months. No studies reported the effectiveness of flossing plus toothbrushing for preventing dental caries.

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.

Effectiveness of Different Bristle Designs of Toothbrushes and Periodontal Status among Fixed Orthodontic Patients: A Double-blind Crossover Design

AIM

The aim of the present study was to evaluate the effectiveness of different bristle designs of toothbrushes and the periodontal status among patients undergoing fixed orthodontic treatment.

MATERIALS AND METHODS

This randomized controlled trial (RCT) consisted of 45 adolescents (comprising 20 males and 25 females) undergoing fixed orthodontic treatment. The study participants were randomly allocated to three groups, each group being assigned a locally available toothbrush with a particular design of toothbrush bristle. In the first test phase, group I study participants were allocated to toothbrush with flat bristles, group II study subjects were allocated to toothbrush with zigzag bristles, and group III study participants were allocated to toothbrush with crisscross bristles. The study participants were recalled after 4 weeks to check the effectiveness of the allocated toothbrushes. A washout period of 1 week was maintained to ensure that there was no carryover effect of the different bristle designs. In the second test phase, each patient used the opposite toothbrush bristle design (group I: toothbrush with zigzag bristles, group II: toothbrush with crisscross bristles, and group III: toothbrush with flat bristles). Plaque scores were measured using Turesky-Gilmore-Glickman modification of Quigley-Hein plaque index (PI).

RESULTS

In both phase 1 and 2 of this RCT, toothbrush with crisscross bristles exhibited maximum plaque reduction among the three different bristle design toothbrushes following 30 days (p = 0.312 ± 0.102 and 0.280 ± 0.110, respectively), which was statistically significant.

CONCLUSION

It was concluded that all the three designs of toothbrushes were effective in removing plaque in patients with fixed orthodontic appliances. But among the three different toothbrushes, toothbrush with crisscross bristles showed the highest mean plaque reduction.

CLINICAL SIGNIFICANCE

Plaque accumulation around the orthodontic brackets and gingival margins is quite common among the fixed orthodontic patients, who encounter difficulty in maintaining good oral hygiene. Specially designed toothbrushes are very essential for effective plaque removal among the patients undergoing fixed orthodontic treatment.

Interdental plaque reduction after use of different devices in young subjects with intact papilla: A randomized clinical trial

OBJECTIVES

To determine the efficacy of 4 different oral hygiene regimens involving adjunctive interdental cleaning devices in unsupervised young subjects with intact interdental papilla.

MATERIAL AND METHODS

Sixty periodontally healthy subjects were randomly allocated to 4 groups following different oral hygiene regimens (T-7): use of manual toothbrush alone; manual toothbrush plus dental floss; manual toothbrush plus interdental brushes; and manual toothbrush plus rubber interdental picks. Oral hygiene instructions (OHI) were given. One week after (T0), professional supragingival scaling and polishing was performed, and subjects were then reseen every 2 weeks (T14 and T28). At T-7, T0, T14 and T28, full-mouth plaque score (FMPS), full-mouth bleeding score (FMBS) and angulated bleeding index (AngBI) were taken.

RESULTS

During the first week (T-7/T0 unclean phase), FMPS decreased significantly in all groups except the group using dental floss. At T28, a significant decrease in FMPS (P < .001, all groups) and FMBS (P < .05, all groups except the group using flossing P < .001) was noted. Interdental FMPS showed significantly lower values in subjects treated with interdental brushes or rubber interdental picks vs toothbrushing alone (P < .05). The use of interdental picks was associated with reduced interdental FMBS when compared to flossing (P < .05).

CONCLUSION

In young subjects, with no interdental attachment loss, toothbrushing or toothbrushing and adjunctive interdental cleaning devices such as dental floss, interdental brushes or interdental rubber picks can significantly reduce both plaque and gingival inflammation. Use of interdental brushes or rubber picks reduces more interdental plaque in comparison with toothbrushing alone.

Efficacy of a rubber bristles interdental cleaner compared to an interdental brush on dental plaque, gingival bleeding and gingival abrasion: A randomized clinical trial

AIM

To determine the efficacy of a rubber bristles interdental cleaner (RBIC) compared to an interdental brush (IDB) in reducing gingivitis and additionally to evaluate participants' attitudes and possible side effects.

MATERIAL AND METHODS

The study was a 2-treatment, parallel, split-mouth, examiner-blind RCT, evaluating the reversal of experimental gingivitis. In total, 42 systemically healthy volunteers were recruited that were currently non-users of interdental cleaning devices. After familiarization and prophylaxis, participants refrained from brushing mandibular teeth for 21 days, followed by 4-week product use of the assigned interdental cleaning device as adjunct to manual toothbrushing. Bleeding on marginal probing (BOMP), dental plaque index score (PI) and gingival abrasion score (GAs) were assessed in the lower jaw.

RESULTS

Overall, no statistically significant differences between the RBIC and IDB in reducing BOMP and PI were obtained. Analysing the sites that were accessible for the RBIC/IDB only showed that the sites treated with the RBIC had significantly less BOMP after 4 weeks (P = .009). The RBIC also caused less GAs (P => .016) and was considered more pleasurable to use by the participants (P = .0001).

CONCLUSIONS

In accessible sites, the RBIC, in conjunction with manual toothbrushing, was found to be more effective in reducing gingival inflammation after 4 weeks. The RBIC caused less abrasion of the gingiva and was appreciated more by the participants.

The Bleeding on Brushing Index: a novel index in preventive dentistry

BACKGROUND

The aim of this study was to evaluate the suitability of a dichotomous index, based on a special interdental brushing tool, to detect initial pathological processes in interproximal areas. Furthermore, different techniques of interdental hygiene were compared.

METHODS

Participants (n = 108) were instructed to clean their teeth using the Bass technique and were randomly assigned to three groups according to the type of interdental cleaning used: group A, use of interdental brushes; group B, no interdental hygiene (the control group); and group C, use of dental floss. Approximal Plaque Index (API), Plaque Index (PI), modified Sulcus Bleeding Index (mSBI) and the Bleeding on Brushing Index (BOB) were measured at baseline, and after 2 (t1) and 4 (t2) weeks. Statistical analysis was performed using the Wilcoxon test and the Mann-Whitney U-test.

RESULTS

One-hundred and six participants completed the study. The BOB decreased significantly in all groups (P < 0.001) with the most pronounced reduction being recorded for group A (baseline: 49.3 ± 23.0%; 4 weeks: 5.1 ± 6.9%). Also, the mSBI (P < 0.001) decreased significantly in all groups during the study. The API appeared to be less affected by the oral hygiene than other indices. The highest correlation was observed between BOB and mSBI (r = 0.785, P < 0.001).

CONCLUSION

The BOB is a valuable complement for the existing array of indices in preventive dentistry, and is able to detect potential pathological processes in interproximal spaces. Additionally, this study suggests that interdental hygiene with individually selected brushes is superior to flossing.

CLINICAL RELEVANCE

With the BOB, gingival inflammation can be demonstrated to patients, which could increase compliance.

Efficacy of various side-to-side toothbrushes and impact of brushing parameters on noncontact biofilm removal in an interdental space model

OBJECTIVES

The objective of this study was to evaluate the efficacy of four different side-to-side toothbrushes and the impact of various brushing parameters on noncontact biofilm removal in an adjustable interdental space model.

MATERIALS AND METHODS

A three-species biofilm, consisting of Porphyromonas gingivalis, Fusobacterium nucleatum, and Streptococcus sanguinis, was formed in vitro on protein-coated titanium disks using a flow chamber combined with a static biofilm growth model. Subsequently, the biofilm-coated disks were exposed to four different powered toothbrushes (A, B, C, D). The parameters distance (0 and 1 mm), brushing time (2, 4, and 6 s), interdental space width (1, 2, and 3 mm), and toothbrush angulation (45° and 90°) were tested. The biofilm volumes were determined using volumetric analyses with confocal laser scanning microscope (Zeiss LSM700) images and Imaris version 7.7.2 software.

RESULTS

The median percentages of simulated interdental biofilm reduction by the tested toothbrushes ranged from 7 to 64 %. The abilities of the analyzed toothbrushes to reduce the in vitro biofilm differed significantly (p < 0.05). Three of the tested toothbrushes (A, B, C) were able to significantly reduce a simulated interdental biofilm by noncontact brushing (p ≤ 0.005). The brushing parameters and their combinations tested in the experiments revealed only minor effects on in vitro interdental biofilm reduction (p > 0.05).

CONCLUSIONS

A three-species in vitro biofilm could be altered by noncontact brushing with toothbrushes A, B, and C in an artificial interdental space model.

CLINICAL RELEVANCE

Certain side-to-side toothbrushes demonstrate in vitro a high efficacy in interdental biofilm removal without bristle-to-biofilm contact.

Efficacy of interdental calibrated brushes on bleeding reduction in adults: a 3-month randomized controlled clinical trial

This study investigated the effect of interdental brushes on the reduction of interproximal bleeding in adults without periodontal disease. Forty-six adults were enrolled in a 3-month, observer-blinded, parallel-group randomized control trial. The test group used a standard manual toothbrush twice daily and an interdental brush daily. The control group used a standard manual toothbrush. At each visit, a calibrated colorimetric probe was used in all interdental spaces to determine the appropriate size of the interdental brush required, the brush of the corresponding size was introduced into the interproximal space, and the presence of bleeding was recorded. The outcome was the frequency of bleeding after application of the appropriate interdental brush. All participants were evaluated 1 wk, 1 month, and 3 months after the baseline visit. The overall preventive fraction with respect to bleeding frequency was 46% at 1 wk and 72% at 3 months. More bleeding reduction was observed in anterior sites than in posterior sites (80% vs. 69%, respectively). Participants with low baseline bleeding frequency presented with less bleeding (OR = 2.3). This study shows that daily use of calibrated interdental brushes reduces interdental bleeding. These findings may support interdental cleaning as an effective means to help individuals maintain and/or achieve optimal oral health.

Evaluating awareness regarding oral hygiene practices and exploring gender differences among patients attending for oral prophylaxis

BACKGROUND

Oral hygiene is intimated in health of all parts of the body including oral cavity. The understanding of actual practices in keeping the oral heath at standard based on patient's perceptions of oral health care is vital. Understanding the effect of gender on oral health would facilitate the development of successful attitude and behavior modification approach towards sustainable oral health.

PURPOSE OF STUDY

To evaluate awareness regarding oral hygiene practices and exploring gender differences among patients attending for oral prophylaxis.

MATERIALS AND METHODS

A survey was conducted among 250 patients attending the department of periodontology, Maulana Azad institute of dental sciences for oral prophylaxis. A structured questionnaire was used to collect information regarding practices and perception about oral hygiene.

RESULTS

Majority of the patients (60.4%) felt that oral hygiene is mandatory for overall health of the body. The use of toothpaste and toothbrush (83.6%) was the most preferred cleaning aid among the study population in the present study. The major constraint for avoiding dental examination was no felt need (41.2%) followed by cost of dental treatment (26.8%) and time constraints (24.0%).

CONCLUSIONS

Professional plaque removal and regular follow-up combined with oral hygiene instructions to the patients can minimize the level of gingival inflammation and swelling. The poor resources for dental care, common malpractices and nonavailability of professional care are the main barriers in seeking optimum oral hygiene.

The effect of periodontal therapy on glycaemic control in a Hispanic population with type 2 diabetes: a randomized controlled trial

OBJECTIVE

In the Mexican-American population, the prevalence of Type 2 diabetes mellitus (T2DM) is as high as 50% of the population. This randomized controlled clinical trial was designed to elucidate how treatment of periodontal disease affects HbA1c values in this population.

MATERIALS AND METHODS

One hundred and fifty-four T2DM patients with periodontal disease were enrolled in the study. The test group was treated with scaling and root planing (SRP); the control group received oral hygiene instructions. At baseline and 4-6 weeks after therapy, a complete periodontal examination was performed. Blood was collected at baseline and 4 months later for HbA1c levels.

RESULTS

One hundred and twenty-six individuals completed the study. Baseline mean ± SD HbA1c for the test and control groups were 9.0 ± 2.3% and 8.4 ± 2.0% respectively. Non-significant difference in HbA1c reductions (0.6 ± 2.1% and 0.3 ± 1.7%) was found between test and control groups at 4 months. Comparisons of the periodontal clinical parameters between the test and control groups found significant differences with improved results in the test subjects.

CONCLUSIONS

No statistically significant differences were found in the changes of HbA1c levels between test and control groups. Non-surgical periodontal therapy improved the magnitude of change in periodontal parameters as compared to the control subjects. ClinicalTrials.gov Identifier: NCT01128374.

Clinical efficacy and patients' acceptance of a rubber interdental bristle. A randomized controlled trial

OBJECTIVES

Interdental cleaning is an essential component of home plaque control to prevent periodontitis and caries. There is limited data on the efficacy of commonly used metal-core interdental brushes in comparison to metal-free interdental brushes. The aim of this study was to compare a new rubber interdental bristle (Fuchs®) with a standard metal-core interdental brush (TePe®) for their impact upon gingival bleeding, plaque removal, and patient experience.

MATERIALS AND METHODS

A single-blind, prospective, randomized, and controlled clinical trial with a crossover design was used to measure plaque index (Turesky-Modified Quigley & Hein Index), bleeding index (Eastman Interdental Bleeding Index by Caton & Polson), and patient satisfaction by means of questionnaires in 39 patients. Each patient was randomly assigned with regard to the sequence of interdental product used and recalled.

RESULTS

Both groups showed statistically significant decreases of plaque after a single usage, respectively. Bleeding was statistically significantly reduced after 4 weeks, with no statistically significant differences concerning between the two tested interdental brushes. Rubber interdental bristles reached significantly higher scores with regard to patient acceptance in overall assessment and in sub-items for less pain during usage, comfort of brushing, and willingness to buy the product.

CONCLUSION

Rubber interdental bristles were similarly effective compared to the interdental brushes. In addition, rubber interdental bristles were significantly more comfortable for participants than metal-core brushes.

CLINICAL RELEVANCE

Rubber interdental bristles can be used as an alternative interdental cleaning product which may be more accepted by patients.

Interdental brushing for the prevention and control of periodontal diseases and dental caries in adults

BACKGROUND

Effective oral hygiene is a crucial factor in maintaining good oral health, which is associated with overall health and health-related quality of life. Dental floss has been used for many years in conjunction with toothbrushing for removing dental plaque in between teeth, however, interdental brushes have been developed which many people find easier to use than floss, providing there is sufficient space between the teeth.

OBJECTIVES

To evaluate the effects of interdental brushing in addition to toothbrushing, as compared with toothbrushing alone or toothbrushing and flossing for the prevention and control of periodontal diseases, dental plaque and dental caries.

SEARCH METHODS

We searched the following electronic databases: the Cochrane Oral Health Group's Trials Register (to 7 March 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 2), MEDLINE via OVID (1946 to 7 March 2013), EMBASE via OVID (1980 to 7 March 2013), CINAHL via EBSCO (1980 to 7 March 2013), LILACS via BIREME (1982 to 7 March 2013), ZETOC Conference Proceedings (1980 to 7 March 2013) and Web of Science Conference Proceedings (1990 to 7 March 2013). We searched the US National Institutes of Health Trials Register (http://clinicaltrials.gov) and the metaRegister of Controlled Trials (http://www.controlled-trials.com/mrct/) for ongoing trials to 7 March 2013. No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

We included randomised controlled trials (including split-mouth design, cross-over and cluster-randomised trials) of dentate adult patients. The interventions were a combination of toothbrushing and any interdental brushing procedure compared with toothbrushing only or toothbrushing and flossing.

DATA COLLECTION AND ANALYSIS

At least two review authors assessed each of the included studies to confirm eligibility, assessed risk of bias and extracted data using a piloted data extraction form. We calculated standardised mean difference (SMD) and 95% confidence interval (CI) for continuous outcomes where different scales were used to assess an outcome. We attempted to extract data on adverse effects of interventions. Where data were missing or unclear we attempted to contact study authors to obtain further information.

MAIN RESULTS

There were seven studies (total 354 participants analysed) included in this review. We assessed one study as being low, three studies as being high and three studies as being at unclear risk of bias. Studies only reported the clinical outcome gingivitis and plaque data, with no studies providing data on many of the outcomes: periodontitis, caries, halitosis and quality of life. Three studies reported that no adverse events were observed or reported during the study. Two other studies provided some data on adverse events but we were unable to pool the data due to lack of detail. Two studies did not report whether adverse events occurred. Interdental brushing in addition to toothbrushing, as compared with toothbrushing alone Only one high risk of bias study (62 participants in analysis) looked at this comparison and there was very low-quality evidence for a reduction in gingivitis (0 to 4 scale, mean in control): mean difference (MD) 0.53 (95% CI 0.23 to 0.83) and plaque (0 to 5 scale): MD 0.95 (95% CI 0.56 to 1.34) at one month, favouring of use of interdental brushes. This represents a 34% reduction in gingivitis and a 32% reduction in plaque. Interdental brushing in addition to toothbrushing, as compared with toothbrushing and flossing Seven studies provided data showing a reduction in gingivitis in favour of interdental brushing at one month: SMD -0.53 (95% CI -0.81 to -0.24, seven studies, 326 participants, low-quality evidence). This translates to a 52% reduction in gingivitis (Eastman Bleeding Index). Although a high effect size in the same direction was observed at three months (SMD -1.98, 95% CI -5.42 to 1.47, two studies, 107 participants, very low quality), the confidence interval was wide and did not exclude the possibility of no difference. There was insufficient evidence to claim a benefit for either interdental brushing or flossing for reducing plaque (SMD at one month 0.10, 95% CI -0.13 to 0.33, seven studies, 326 participants, low-quality evidence) and insufficient evidence at three months (SMD -2.14, 95% CI -5.25 to 0.97, two studies, 107 participants very low-quality evidence).

AUTHORS' CONCLUSIONS

Only one study looked at whether toothbrushing with interdental brushing was better than toothbrushing alone, and there was very low-quality evidence for a reduction in gingivitis and plaque at one month. There is also low-quality evidence from seven studies that interdental brushing reduces gingivitis when compared with flossing, but these results were only found at one month. There was insufficient evidence to determine whether interdental brushing reduced or increased levels of plaque when compared to flossing.

Flossing for the management of periodontal diseases and dental caries in adults

BACKGROUND

Good oral hygiene is thought to be important for oral health. This review is to determine the effectiveness of flossing in addition to toothbrushing for preventing gum disease and dental caries in adults.

OBJECTIVES

To assess the effects of flossing in addition to toothbrushing, as compared with toothbrushing alone, in the management of periodontal diseases and dental caries in adults.

SEARCH METHODS

We searched the following electronic databases: the Cochrane Oral Health Group Trials Register (to 17 October 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 4), MEDLINE via OVID (1950 to 17 October 2011), EMBASE via OVID (1980 to 17 October 2011), CINAHL via EBSCO (1980 to 17 October 2011), LILACS via BIREME (1982 to 17 October 2011), ZETOC Conference Proceedings (1980 to 17 October 2011), Web of Science Conference Proceedings (1990 to 17 October 2011), Clinicaltrials.gov (to 17 October 2011) and the metaRegister of Controlled Clinical Trials (to 17 October 2011). We imposed no restrictions regarding language or date of publication. We contacted manufacturers of dental floss to identify trials.

SELECTION CRITERIA

We included randomised controlled trials conducted comparing toothbrushing and flossing with only toothbrushing, in adults.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed risk of bias for the included studies and extracted data. We contacted trial authors for further details where these were unclear. The effect measure for each meta-analysis was the standardised mean difference (SMD) with 95% confidence intervals (CI) using random-effects models. We examined potential sources of heterogeneity, along with sensitivity analyses omitting trials at high risk of bias.

MAIN RESULTS

Twelve trials were included in this review, with a total of 582 participants in flossing plus toothbrushing (intervention) groups and 501 participants in toothbrushing (control) groups. All included trials reported the outcomes of plaque and gingivitis. Seven of the included trials were assessed as at unclear risk of bias and five were at high risk of bias.Flossing plus toothbrushing showed a statistically significant benefit compared to toothbrushing in reducing gingivitis at the three time points studied, the SMD being -0.36 (95% CI -0.66 to -0.05) at 1 month, SMD -0.41 (95% CI -0.68 to -0.14) at 3 months and SMD -0.72 (95% CI -1.09 to -0.35) at 6 months. The 1-month estimate translates to a 0.13 point reduction on a 0 to 3 point scale for Loe-Silness gingivitis index, and the 3 and 6 month results translate to 0.20 and 0.09 reductions on the same scale.Overall there is weak, very unreliable evidence which suggests that flossing plus toothbrushing may be associated with a small reduction in plaque at 1 or 3 months.None of the included trials reported data for the outcomes of caries, calculus, clinical attachment loss, or quality of life. There was some inconsistent reporting of adverse effects.

AUTHORS' CONCLUSIONS

There is some evidence from twelve studies that flossing in addition to toothbrushing reduces gingivitis compared to toothbrushing alone. There is weak, very unreliable evidence from 10 studies that flossing plus toothbrushing may be associated with a small reduction in plaque at 1 and 3 months. No studies reported the effectiveness of flossing plus toothbrushing for preventing dental caries.

Effectiveness of different interdental brushes on cleaning the interproximal surfaces of teeth and implants: a randomized controlled, double-blind cross-over study

OBJECTIVES

To compare the interproximal cleansing efficacy of the novel, waist-shaped Circum brush (Topcaredent, Switzerland; CB) with that of a straight soft interdental brush (IB) (TePe, Sweden; SB) on posterior surfaces.

MATERIAL & METHODS

Eight patients after completion of initial periodontal therapy abolished oral hygiene for 3 days. Baseline plaque scores (PlI, Silness & Löe ) were assessed on eight surfaces of all premolars and molars. Subsequently, an instructed nurse applied at random one of the two IB, three times per interdental space . Following this, registration of the PlI was repeated by the same blinded examiner. After a 2-week recovery, patients abolished oral hygiene practices for another 3 days. Again, pre-and post-brushing PlI were recorded by the same examiner. The second IB was now applied.

RESULTS

Patient mean PlI and site PlI were evaluated before and after application of the SB or CB respectively. Paired t-tests were performed to yield statistically significant differences. The reduction of biofilm from before to after the use of the IB on a subject basis was highly significant (P < 0.0001). The mean PlI after the use of the CB was significantly lower than after the use of the SB (P < 0.0001). Comparing the PlI of the line angles (MB, ML, DB, DL), significantly more biofilm had been removed by applying CB compared with SB (P < 0.0001). Moreover, comparing the PlI of the buccal (MB, DB) or the lingual line angles (DL, ML) yielded a significantly higher reduction of biofilm in favour of the CB (P < 0.0001). The reduction of the PlI in the mid-interproximal portion, both mesially and distally did not differ significantly between CB and ST. No biofilm reduction was seen on the buccal sites with either IB.

CONCLUSION

The application of the waist-shaped Circum IB resulted in significantly lower PlI scores than the use of a straight IB. This was predominantly due to the higher cleansing effect of the waist-shaped CB on the buccal and lingual line angles.

The use of interdental brushes along with toothbrushing removes most plaque

DATA SOURCES

The National Library of Medicine (Washington DC; to access Medline-PubMed) and the Cochrane Central Register of Controlled Trials were searched for articles dated from 1965 up to November 2007.

STUDY SELECTION

Two independent reviewers assessed studies for inclusion, aiming to identify appropriate randomised controlled clinical trials and controlled clinical trials. Studies were selected if they were conducted in humans, and included subjects of over 18 years of age in good general health with sufficient interdental space to use an interdental brushes. The articles were limited to English-language publications. Case reports, letters and narrative or historical reviews were excluded.

DATA EXTRACTION AND SYNTHESIS

As there was considerable heterogeneity in the design of the studies, a meta-analysis was only conducted for the comparison of the interdental brush with floss, with weighted mean differences (WMD) calculated using a random effects model. Descriptive comparisons were presented for brushing alone, brushing and flossing or brushing and woodsticks where appropriate.

RESULTS

After searching the literature, 234 titles and abstracts required screening, resulting in 18 full-text articles. Based on the full texts, another five articles were excluded and finally nine studies were identified as eligible. Two were of crossover design, three of a split-mouth design and four were parallel design. The longest study duration was 12 weeks.

CONCLUSIONS

The evidence showed that interdental brush use as an adjunct to toothbrushing removes more dental plaque than brushing alone, being even more effective than dental floss or woodsticks in removing dental plaque. The evidence available for the effect on gingival inflammation is less conclusive. The reduction of pocket depth after the use of the interdental brush is more pronounced than with floss.