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1Interdental oral hygiene: The evidence
Chapter 3
Interdental oral hygiene: The evidence
GA Van de Weijden1,2, DE Slot11 Department of Periodontology,
Academic Centre for Dentistry Amsterdam, University ofAmsterdam and
VU University Amsterdam, The Netherlands2 Clinic for
Periodontology, Utrecht, The Netherlands
Introduction
There is increasing public awareness of thevalue of personal
oral hygiene. People brushtheir teeth for a number of reasons: to
feel freshand confident, to have a nice smile, and toavoid bad
breath and disease. Oral cleanlinessis important for the
preservation of oral healthas it removes microbial plaque,
preventing itfrom accumulating on teeth and gingivae(Choo et al
2001). Maintenance of effectiveplaque control is the cornerstone of
anyattempt to prevent and control periodontaldisease. The benefits
of optimal home-useplaque-control measures include theopportunity
to maintain a functional dentitionthroughout life. Self-care has
been defined bythe World Health Organization as all theactivities
that the individual takes to prevent,diagnose and treat personal
ill health by self-support activities or by referral to a
healthcareprofessional for diagnosis and care (Claydon2008).
There is substantial evidence showing thattoothbrushing and
other mechanical cleansingprocedures can reliably control
plaque,provided that cleaning is sufficiently thoroughand performed
at appropriate intervals.Evidence from large cohort studies
hasdemonstrated that high standards of oralhygiene will ensure the
stability of periodontal
Multi-Disciplinary Management of Periodontal DiseaseEdited by:
PM Bartold, LJ Jin© 2012 Asian Pacific Society of
Periodontology
tissue support (Axelsson 2004, Hujoel et al2006).
Interdental plaque control is essential toevery patient’s
self-care program. Severaldental conditions result from infrequent
orineffective interdental cleaning, includingcaries and periodontal
diseases. These two, incombination, suggest a need for
effectiveinterdental cleaning. It is therefore importantthat the
effectiveness of these interdental oralhygiene products be assessed
and understood.The present review was undertaken to providethe
dental professional with the availablescientific evidence.
Interdental devices
There is confusion in the literature withrespect to the
definitions of approximal,interproximal, interdental, and proximal
sites.Commonly used indices are not suitable forassessing
interdental plaque (directly underthe contact area), and thereby
limitinterpretation of interdental plaque removal.The European
Workshop on MechanicalPlaque Control in 1999 proposed thefollowing
definitions: approximal (proximal)areas are the visible spaces
between teeth thatare not under the contact area. In health
theseareas are small, although they may increaseafter periodontal
attachment loss. The terms
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2 Chapter 3
interproximal and interdental may be usedinterchangeably and
refer to the area underand related to the contact point.
The interdental gingiva fills the embrasurebetween two teeth
apical to their contact point.This is a ‘sheltered’ area that is
difficult toaccess when teeth are in their normal positions.In
populations that use toothbrushes, theinterproximal surfaces of the
molars andpremolars are the predominant sites of residualplaque.
The removal of plaque from thesesurfaces remains a valid objective
because inpatients susceptible to periodontal disease,gingivitis
and periodontitis are usually morepronounced in this interdental
area than onoral or facial aspects (Löe 1979). Dental cariesalso
occurs more frequently in the interdentalregion than on lingual and
buccal smoothsurfaces. A fundamental principle ofprevention is that
the effect is greatest wherethe risk of disease is greatest.
Toothbrushingalone does not reach the interproximal areasof teeth,
resulting in areas of teeth that remainunclean. Good interdental
oral hygienerequires a device that can penetrate betweenadjacent
teeth.
Many different commercial products aredesigned to achieve this
goal, including floss,woodsticks, rubber-tip simulators,
interdentalbrushes, single-tufted brushes, and recentlyintroduced
electrically powered cleaning aids(i.e. oral irrigators). Flossing
is the mostadvocated method since it can be performedin nearly all
clinical situations. While pickingteeth may be one of humanity’s
oldest habits,not all interdental cleaning devices suit allpatients
or all types of dentition (Galgut 1991).Factors such as the contour
and consistencyof gingival tissues, the size and form of
theinterproximal embrasure, tooth position, andalignment and
patient ability and motivationshould be taken into consideration
whenrecommending an interdental cleaningmethod.
Dental floss
Reports of the benefits of flossing date backto the early 19th
century, when it was believedthat irritating matter between teeth
was thesource of dental disease (Hujoel et al 2006,Parmly 1819).
Over the years, it has beengenerally accepted that dental floss has
apositive effect on removing plaque (Axelsson2004, Darby &
Walsh 2003, Waerhaug 1981,Wilkins 2004). Even subgingival plaque
canbe removed, since dental floss can beintroduced 2 to 3.5 mm
below the tip of thepapilla (Waerhaug 1981) (Figure 1). The
ADAreports that up to 80% of plaque may beremoved by this method
(ADA 1984). Asdental plaque is naturally pathogenic anddental floss
disrupts and removes someinterproximal plaque, it has been thought
thatflossing should reduce gingival inflammation(Waerhaug 1981).
Flossing as the sole formof oral hygiene has been shown to be
effectivein preventing the development of gingivalinflammation and
reducing the level of plaque(Barendregt et al 2002).
Figure 1. Floss can be introduced 2 to 3.5 mmsubgingivally
relative to the tip of the interdentalpapilla.
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3Interdental oral hygiene: The evidence
Berchier and co-workers (2008) conducteda systematic review of
scientific literature toinvestigate the efficacy of dental floss as
anadjunct to toothbrushing on plaque andparameters of gingival
inflammation, in adultswith periodontal disease. Eligible
studiesprovided a test group that used dental floss asan adjunct to
toothbrushing and a controlgroup that used toothbrushing only.
TheMEDLINE and CENTRAL databases weresearched through December 2007
to identifyappropriate studies. Plaque and gingivitis wereselected
as outcome variables. Independentscreening of titles and abstracts
resulted in 11publications that met the eligibility criteria.
The majority of these studies showed thatthere was no benefit
from floss on plaque orclinical parameters of gingivitis (Table
1).From the collective data of the studies, itappeared possible to
perform a meta-analysisof plaque and gingival index scores. Table
2provides a summary of the outcomes of themeta-analysis. In both
instances, baseline
scores were not statistically different.Comparing brushing and
flossing againstbrushing only, the plaque index WMD was -0.04 (95%
CI: -0.12; 0.04, P = 0.39) and thegingival index WMD was -0.08 (95%
CI: -0.16; 0.00, P = 0.06). End scores also showedno significant
differences between groups forplaque (WMD: -0.24, 95% CI: -0.53;
0.04, P= 0.09) or gingivitis (WMD: -0.04, 95% CI: -0.08; 0.00, P =
0.06). The heterogeneityobserved at the end point for the plaque
scores(I2 = 76.4%) indicates that the WMD shouldnot be used as the
exact measure of results.Based on the individual papers in this
review,a trend that indicated a beneficial adjunctiveeffect of
floss on plaque levels was observed.However, this could only be
substantiated asa non-significant trend in the meta-analyses.The
dental professional should thereforedetermine, on an individual
patient basis,whether high-quality flossing is an achievablegoal.
If this is likely to be the case, dailyflossing may be introduced
as the oral hygiene
Table 1. Descriptive overview of the results of the dental floss
and toothbrush group compared to thetoothbrush only group.+ =
significant difference in favor of toothbrush & floss group, 0
= no significant difference, ̂ = no dataavailable, ? = unknown.
(Berchier et al 2008)
Author(s) Plaque score Gingival score Bleeding score
Finkelstein et al (1990) 0 0 0
Gjermo et al (1970) + ^ ^
Hague and Carr (2007a) ? 0 ^
Hague et al (2007b) 0 0 ^
Hill et al (1973) 0 0 ^
Jared et al (2005) + 0 0
Kiger et al (1991) + 0 ^
Schiff et al (2006) 0 0 ^
Vogel et al (1975) 0 0 ^
Walsh et al (1985) 0 ^ +
Zimmer et al (2006) 0 ^ 0
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4 Chapter 3
tool for interdental cleaning. Routinerecommendation to use
floss is not supportedby scientific evidence as established
byBerchier et al (2008) in their comprehensiveliterature search and
critical analysis.
One may critically ask why the review byBerchier et al (2008)
does not substantiallyshow dental floss as a co-operative adjunct
totoothbrushing. The advocacy of floss as aninterdental cleaning
device hinges, in largepart, on common sense. However, commonsense
arguments are the lowest level ofscientific evidence (Sackett et al
2000). Apossible explanation is that the previousnarrative reviews
have not been conductedsystematically. These reviews also lack
meta-analysis or descriptive analysis based onextracted data.
The fact that dental floss has no additionaleffect on
toothbrushing is apparent from morethan one review. Hujoel et al
(2006) foundthat flossing was only effective in reducingthe risk of
interproximal caries when appliedprofessionally. High-quality
professionalflossing performed in first-grade children onschool
days reduced the risk of caries by 40%.In contrast, self-performed
flossing failed toshow a beneficial effect. The lack of an effecton
caries and the absence of an effect on
gingivitis in the review by Berchier andcoworkers (2008) are
most likely theconsequence of plaque not being removedefficiently,
as established in the present meta-analysis. Flossing does also not
effectivelyclean wide interdental spaces, root surfacesor
concavities. Such periodontally involveddentitions are more common
with advancingage when reduced dexterity and visual acuityfurther
impede flossing.
Woodsticks
Toothpicks are one of the earliest andmost persistent “tools”
used to “pick teeth.”The toothpick may date back to the days ofthe
cave people, who probably used sticks topick food from between
their teeth. Originally,dental woodsticks were advocated by
dentalprofessionals as ‘gum massagers’ used tomassage inflamed
gingival tissue in theinterdental areas to reduce inflammation
andencourage keratinization of the gingival tissue(Galgut
1991).
Woodsticks are designed to allow themechanical removal of plaque
frominterdental surfaces. The friction of the sidesrubbing against
the interproximal toothsurfaces removes the bacterial biofilm.
They
Studies included Index WMD 95% CI Overall Test for(random)
effect heterogenicity
Jared et al (2005) Plaque index; Base -0.04 -0.12; 0.04 P=0.39
P=0.85 I2=0%Hague & Carr (2007a) Quigley & Hein End -0.24
-0.53; 0.04 P=0.09 P=0.005 I2=76.4%Hague et al (2007b) (1962)Schiff
et al (2006)
Hague & Carr (2007a) Gingival index; Base -0.08 -0.16; 0.00
P=0.06 P=0.11 I2=44.3%Hague et al (2007b) Löe & Silness End
-0.04 -0.08; 0.00 P=0.06 P=0.89 I2=0%Hill et al (1973) waxed
(1963)Hill et al (1973) unwaxedKiger et al (1991)Schiff et al
(2006)
Table 2. Meta-analyses between floss as an adjunct to
toothbrushing and toothbrushing only. Negativevalue favors floss.
(Berchier et al 2008)
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5Interdental oral hygiene: The evidence
are fabricated from soft wood to improveadaptation into the
interdental space and toprevent injury to the gingiva. They should
notbe confused with toothpicks, which are meantsimply for removing
food debris after a meal(Warren & Chater 1996). The round
toothpickis too thick and too blunt to reach the lingualhalf of the
tooth when trying to angle it, whilethe curved surface of the
toothpick providesonly point contact with the tooth surface.
Therectangular woodstick is also designedinappropriately for
interdental cleaning as thedevice is too pliable to be able to
cleanlingually (Bergenholtz et al 1974). However,a triangular
woodstick seems to have thecorrect shape to fit the interdental
space(Waerhaug 1959). Woodsticks are insertedinterdentally with the
base of the triangleresting on the gingival side. The tip
shouldpoint occlusally or incisally and the trianglesagainst the
adjacent tooth surfaces. Thetapered form makes it possible for the
patientto angle the woodstick interdentally and evenclean the
lingually localized interdentalsurfaces. Unlike floss they can be
used on the
concave surfaces of the tooth root.The tapered form of a
triangular woodstick
makes it possible for the patient to angle thedevice
interdentally and even clean thelingually localised interdental
surfaces (Morch& Waerhaug 1956). From the results ofBergenholtz
et al (1974), it may be concludedthat triangular woodsticks with
low surfacehardness and high strength values arepreferred for
interdental cleaning. Fromstudies performed in vivo and from
autopsymaterial, it was shown that a triangular pointedwoodstick
inserted interdentally can maintaina subgingival plaque-free region
of 2 to 3 mm(Morch & Waerhaug 1956). The resilience ofthe
gingival papilla allows cleaning apical tothe subgingival margins
of fillings (risksurfaces for recurrent caries). For
openinterdental spaces, common among adults,woodsticks seem most
appropriate (Lang &Karring 1994). In periodontitis patients,
thewoodstick will depress the papilla, which mayhelp in
recontouring the interdental tissues andconsequently preclude the
need forperiodontal surgery (Baer & Morris 1977).Woodsticks can
only be used effectively wheresufficient interdental space is
available.Woodsticks have the advantage of being easyto use and can
be used throughout the daywithout the need of a bathroom or
mirror(Galgut 1991).
How effective is the woodstick inmaintaining oral health? Does
it offer anyparticular advantage over flossing orinterdental
brushes? Hoenderdos andcoworkers (2008) performed a
systematicreview to evaluate and summarize theavailable evidence on
the effectiveness ofusing triangular woodsticks in combinationwith
toothbrushing to reduce both plaque andclinical inflammatory
symptoms of gingivalinflammation. The MEDLINE andCENTRAL databases
were searched throughFebruary 2008 to identify appropriate
studies.Studies were screened independently by two
Figure 2. Woodsticks are inserted interdentallywith the base of
the triangle resting on the gingivalside. The woodstick is rubbed
against theinterproximal tooth surfaces.
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6 Chapter 3
reviewers. Randomised controlled trials andcontrolled clinical
trials were selected if theywere conducted in individuals of over
18 yearsof age who were in good general health, andwhich used
plaque, bleeding or gingivitis asoutcome measures. Case reports,
letters, andnarrative or historical reviews were excludedand only
English-language papers wereconsidered. Independent screening of
the titlesand abstracts yielded seven publications witheight
clinical experiments that met theeligibility criteria.
The heterogeneity of the data preventedquantitative analysis. A
qualitative summaryis presented in Table 3 which summarizes
thedifferences between woodsticks and otherdevices. In seven
studies, the improvement ingingival health represented a
significantincremental benefit realized by the use oftriangular
woodsticks. Seven publicationsdescribing eight clinical experiments
met theinclusion criteria. The improvement ingingival health
observed in the studies
represented a significant reduction of bleedingrealised by the
use of triangular woodsticks.None of the studies that scored
plaquedemonstrated any significant advantage of theuse of
woodsticks over alternative methods ofplaque removal in people who
had gingivitis.
A series of histological investigations inpatients with
periodontitis has shown that thepapillary area with the greatest
inflammationcorresponds to the middle of the interdentaltissue. It
is difficult to clinically assess the mid-interdental area, as it
is usually not availablefor direct visualization (Walsh &
Heckman1985). When used on healthy dentition,woodsticks depress the
gingivae by up to 2mm and therefore clean part of the
subgingivalarea. Thus, woodsticks may specificallyremove
subgingivally located interdentalplaque that is not visible and
therefore notevaluated by the plaque index. This physicalaction of
woodsticks in the interdental areamay produce a clear beneficial
effect oninterdental gingival inflammation (Finkelstein
Author(s) Plaque score Bleeding score Gingival score
Comparison
Barton (1987) ^ + ^ Toothbrush onlyBassiouny & Grant (1981)
0 ^ ^ Toothbrush onlyCaton et al (1993) ^ + ^ Toothbrush
onlyFinkelstein & Grossman (1984) 0 + 0 Toothbrush onlyGjermo
& Flötra (1970) Part 1 0 ^ ^ Toothbrush only
Bergenholtz & Brithon (1980) - ^ ^ Dental FlossFinkelstein
& Grossman (1984) 0 ? 0 Dental FlossGjermo & Flötra (1970)
Part 1 0 ^ ^ Dental FlossGjermo & Flötra (1970) Part 3 0 ^ ^
Dental FlossWolffe (1976) 0 ^ ^ Dental Floss
Bassiouny & Grant (1981) ? ^ ^ Interdental BrushGjermo &
Flötra (1970) Part 3 - ^ ^ Interdental Brush
Table 3. Descriptive overview of the results for woodsticks
compared to other interventions.+ = significant difference in favor
of test group, - = significant difference in favour of the
comparison,0 = no significant difference, ^ = no data available, ?
= unknown. (Hoenderdos et al 2008)
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7Interdental oral hygiene: The evidence
1990).
Interdental brushes
Interdental brushes were introduced in the1960s as an
alternative to woodsticks. Theinterdental brush consists of soft
nylonfilaments twisted into a fine stainless steelwire. This
‘metal’ wire can proveuncomfortable for patients with sensitive
rootsurfaces. For such patients the use of plastic-coated metal
wires may be recommended. Thesupport wire is continuous or inserted
into ametal/plastic handle. Interdental brushes aremanufactured in
different sizes and forms. Themost common forms are cylindrical or
conical/tapered (like a Christmas tree). The length ofthe bristles
in cross section should be tailoredto the interdental space.
Appropriateinterdental brushes are currently available forthe
smallest to the largest interdental spacewhich ranges from 1.9 to
14 mm in diameter.Interdental brushes have the added advantageof
serving as vehicles for the local applicationof antibacterial
agents or desensitizing agentsto exposed sensitive root areas.
Interdental brushes are frequentlyrecommended by dental
professionals topatients with sufficient space between theirteeth.
Interdental brushes are small, speciallydesigned brushes for
cleaning between theteeth. They have soft nylon filaments
twistedinto a fine stainless steel wire. They can beconical or
cylindrical in shape and areavailable in different widths to match
theinterdental space. Upon examination ofextracted teeth from
individuals whohabitually used interdental brushes, Waerhaug(1976)
showed that the supragingivalproximal surfaces (the central part of
theinterdental space and the embrasures) werefree of plaque, and
that some subgingivaldeposits were removed up to a depth of 2 to2.5
mm below the gingival margin.
Slot and coworkers (2008) systematicallyreviewed the literature
to determine theeffectiveness of interdental brushes used
asadjuncts to toothbrushes in terms of plaqueand clinical
parameters of periodontalinflammation in patients with gingivitis
orperiodontitis. This situation was compared totoothbrushing alone
or toothbrushing incombination with floss or woodsticks.
TheMEDLINE–PubMed and CENTRALdatabases were searched through
November2007 to identify appropriate studies. Twoindependent
reviewers assessed studies forinclusion, aiming to identify
appropriaterandomised controlled clinical trials andcontrolled
clinical trials. Studies were selectedif they were conducted in
humans, andincluded subjects of over 18 years of age ingood general
health with sufficient interdentalspace to use an interdental
brushes. Thearticles were limited to English-languagepublications.
Case reports, letters and narrativeor historical reviews were
excluded. Clinicalparameters of periodontal inflammation suchas
plaque, gingivitis, bleeding, and pockets
Figure 3. Interdental brushes are insertedinterdentally and have
an effect of the supragingivalproximal surfaces and depths of 2 to
2.5 mm belowthe gingival margin.
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8 Chapter 3
were selected as outcome variables.Independent screening of the
titles andabstracts resulted in nine publications that metthe
eligibility criteria.
Table 4 summarizes differences betweeninterdental brushes and
various interventionstrategies. All three studies that
comparedinterdental brushes as an adjunct to brushingshowed a
significant difference in favor of theuse of interdental brushes
for plaque removal.The majority of the studies showed a
positivesignificant difference on the plaque indexwhen using
interdental brushes relative tofloss. No differences were found for
thegingival or bleeding indices. Two out of threestudies showed
that interdental brushes, whencompared to floss, had a significant
positiveeffect on pocket reduction in patients withperiodontitis.
Interdental brushes remove moredental plaque than woodsticks, as
shown byone of the two comparative studies.
From the collective data of the studies, ameta-analysis appeared
to be possible for thecomparison of interdental brushes or floss
as
adjuncts to toothbrushing. Table 5 provides asummary of the
outcome of the meta-analysis.In all instances, baseline scores were
notstatistically different. End scores only showeda significant
effect with the Silness and Löeplaque index in favor of the
interdental brushgroup relative to the floss group (WMD: -0.48,95%
CI: -0.65; -0.32, p
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9Interdental oral hygiene: The evidence
interdental brushing is the most effectivemethod to remove
plaque.
Two out of the three studies that assessedprobing pocket depth
showed that reductionwas more pronounced with interdental
brushesthan with floss (Christou et al 1998, Jacksonet al 2006).
Only Ishak & Watts (2007) couldnot support this finding. A
possible reason thatthe meta-analysis does not support
thisadvantage is the large difference between theinterdental brush
and floss groups in thesestudies at baseline. To overcome
thisimbalance, an elegant approach would be touse the difference
between baseline and endscores as a measure of effect. Only one
studyprovides this information (Christou et al1998). Jackson et al
(2006) proposed that thereduced pocket depth may have been
relatedto the reduction in swelling with concomitantrecession.
However, with a lack of effect onsigns of gingival inflammation
(Table 5), thereason for the effect on pocket depth cannotreadily
be explained by a reduction in the levelof gingival inflammation.
As an explanation
for the observed effect, the proposition byBadersten et al
(1984) seems conceivable.They suggested that a mechanical
depressionof the interdental papilla is induced byinterdental
brushes, which in turn causesrecession of the marginal gingival.
This,together with good plaque removal, could bethe origin of the
improved reduction in pocketdepth.
Oral irrigators
Additional oral hygiene aids have beendeveloped in an attempt to
augment the effectof toothbrushing on reducing interdentalplaque
(Warren & Chater 1996). The oralirrigator was introduced in
1962. This devicehas been demonstrated to be safe and
likelyprovides a particular benefit for gingival healthto a large
portion of the general public thatdoes not clean interproximal
spaces on aregular basis (Cobb et al 1988, Lobene 1969,Frascella
2000). Oral irrigation has been asource of controversy within the
field of
Studies included Index WMD 95% CI Overall Test for(random)
effect heterogenicity
Jackson et al (2006) Plaque index; Base -0.01 -0.08; 0.06 P=0.84
P=0.97 I2=0%Rösing et al (2006) Silness & Löe End -0.48 -0.65;
-0.32 P
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10 Chapter 3
periodontology. The adjunctive aid of the oralirrigator is
designed to remove plaque and softdebris through the mechanical
action of a jetstream of water. Oral irrigator devices can alsobe
used with antimicrobial agents (Lang &Räber 1981). Patients
report that the oralirrigator facilitates the removal of food
debrisin posterior areas, especially in cases of fixedbridges or
orthodontic appliances, when theproper use of interdental cleaning
devices isdifficult (Burch et al 1994).
Since its introduction, the oral irrigator hasat times been a
popular device (Newman et al1994). However, there has been
considerablecontroversy regarding the appropriate use andefficacy
of this instrument (Astwood 1975,Newman et al 1994). Studies using
an oralirrigator have reported both positive andnegative results in
terms of periodontalinflammation and plaque (Aziz-Gandour
&Newman 1986, Fine & Baumhammers 1970,Hugoson 1978, Lobene
et al 1972, Toto et al1969, Walsh et al 1989). This
inconsistencycauses confusion about the efficacy of the
oralirrigator.
Husseini and coworkers (2008) performeda systematic review to
evaluate the
effectiveness of oral water irrigation as anadjunct to
toothbrushing on plaque andclinical parameters of
periodontalinflammation relative to toothbrushing aloneor regular
oral hygiene. Papers in theMEDLINE-PubMed and CENTRALdatabases up
to January 2008 were searchedto identify appropriate studies.
Papers wereassessed for inclusion independently by tworeviewers and
only those published in theEnglish language were chosen.
Randomizedcontrolled clinical trials or controlled clinicaltrials
conducted in adults with good generalhealth were selected. Clinical
parameters ofperiodontal inflammation such as plaque,bleeding,
gingivitis and pocket depth wereselected as outcome variables.
Independentscreening of the titles and abstracts of 809PubMed and
105 Cochrane papers resulted inseven publications that met the
eligibilitycriteria.
The heterogeneity of the data preventedquantitative analysis.
Table 6 shows adescriptive analysis of the selected studies.None of
the selected studies showed asignificant difference between
toothbrushingand use of an oral irrigator and onlytoothbrushing.
When the oral irrigator wascompared to regular oral hygiene, there
weresome significant differences for the clinicalparameters of
periodontitis. With respect toplaque, no significant differences
wereobserved. All three studies that presented dataon bleeding
scores showed significantreductions in the oral irrigator group
comparedto the regular oral hygiene group (Flemmig etal 1990,
Flemmig et al 1995, Newman et al1994). When observing visual signs
ofgingival inflammation, three out of fourstudies found a
significant effect with use ofan oral irrigator as an adjunct to
regular oralhygiene (Flemmig et al 1990, Flemmig et al1995, Newman
et al 1994). Two of the fourstudies showed a significant reduction
inprobing depth as a result of using an oral
Figure 4. Tip of the oral irrigator
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11Interdental oral hygiene: The evidence
irrigator as an adjunct to regular oral hygiene(Flemmig et al
1995, Newman et al 1994).
Plaque reduction is a prerequisite for anoral hygiene device to
be considered valuable(Newman et al 1994). The selected papers
forthis review reported no statistically significantreduction in
plaque with use of an oralirrigator. Despite a lack of effect on
the plaqueindex, studies did find a significant effect onthe
bleeding index. The mechanismsunderlying these clinical changes in
theabsence of a clear effect on plaque are notunderstood. Different
hypotheses have beenput forward by the authors to explain
theresults. One of the hypotheses is that whenpatients with
gingivitis perform supragingivalirrigation on a daily basis, the
population ofkey pathogens (and their associatedpathogenic effects)
may be altered, reducinggingival inflammation (Flemmig et al
1995).There is also the possibility that H2Opulsations may alter
the specific host-microbial interaction in the
subgingivalenvironment and that inflammation is reducedindependent
of plaque removal (Chaves et al1994). Another possibility is that
the beneficialactivity of the oral irrigator is at least partlydue
to removal of food deposits and otherdebris, flushing away of
loosely adherentplaque, removal of bacterial cells, interfering
with plaque maturation and stimulatingimmune responses
(Frascella et al 2000).Other explanations include
mechanicalstimulation of the gingiva or a combinationof previously
reported factors (Flemmig et al1990, Frascella et al 2000).
Irrigation mayreduce plaque thickness, which may not beeasily
detected using 2-dimensional scoringsystems (Jolkovsky et al 1990).
This may bethe reason for an absence of an effect on plaquebut a
positive effect on gingival inflammation(Table 6).
Husseini and coworkers (2008) concludedthat the effectiveness of
an oral irrigator as anadjunct to toothbrushing does not have
abeneficial effect on reducing plaque scores.However, there is
evidence that suggests apositive tendency toward improved
gingivalhealth when using an oral irrigator as anadjunct to
toothbrushing as opposed to regularoral hygiene (that is
self-performed oralhygiene without any specific instruction).
Discussion
Clinicians have choices and makedecisions everyday as they
provide care forpatients. Some of the options may be evidencebased,
some not. This paper summarizes thehighest level of evidence that
is currently
Author(s) Plaque score Gingival score Bleeding score Pocket
depth Comparison
Frascella et al (2000) 0 0 0 ^ Toothbrush onlyHoover et al
(1968) ? ^ ? ^ Toothbrush onlyWalsh et al (1989) 0 0 0 ? Toothbrush
only
Flemmig et al (1995) 0 + + + Regular oral hygieneFlemmig et al
(1990) 0 + + 0 Regular oral hygieneMeklas et al (1972) 0 ^ 0 ^
Regular oral hygieneNewman et al (1994) 0 + + + Regular oral
hygiene
Table 6. Descriptive overview of the results of the toothbrush
and oral irrigation group relative to thetoothbrush only or regular
oral hygiene only group.+ = significant difference in favor of test
group, 0 = no significant difference, ^ = no data available, ?
=unknown. (Husseini et al 2008)
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12 Chapter 3
dentist’s clinical expertise and the patient’streatment needs
and preferences (ADA 2009).Best care for each patient rests neither
inclinician judgment nor scientific evidence butrather in the art
of combining the two throughinteraction with the patient to find
the bestoption for each individual. Consider the resultsestablished
following the systematic reviewon floss. The conclusions have
disappointedmany dental professionals and believers in theuse of
floss. The fact that floss does not appearto be effective in the
hands of the generalpublic does not preclude its use. For
instance,in interdental situations that only allow thepenetration
of a string of dental floss, thiswould be the most suitable tool.
Although flossshould not be the first tool recommended forcleaning
open interdental spaces, if the patientdoes not like any other
tool, flossing couldstill be part of oral hygiene instruction.
Thedental professional should, however, realizethat proper
instruction, sufficient motivationof the patient and a high level
of dexterity arenecessary to make the flossing
effortworthwhile.
While most patients brush at least for ashort period of time,
fewer use interdentaldevices. Adjunctive aids, including
interdentalbrushes, floss, and mechanical devices, areavailable to
remove interdental plaque. Dentalhygienists and their clients are
faced withmyriad products designed for interproximaltooth cleansing
(Asadoorian 2006). The rangeis overwhelming, from simple dental
floss ortape, through woodsticks and brushes (singleor
multi-tufted). However, what is apparentis that the choice of
interdental cleaningmethod should be tailored to the size and
shapeof each interdental and proximal space.Furthermore, in order
to gain maximumeffectiveness, the level of oral hygiene
advicedelivered to the patient must contain enoughinformation to
enable the patient to be able toidentify each site in turn, select
a device and
available. The systematic reviews includedhere attempt to
collate all empirical evidencethat fits pre-specified eligibility
criteria toanswer a specific research question. They useexplicit,
systematic methods that are selectedto minimize bias, providing
more reliablefindings from which conclusions can be drawnand
decisions can be made (Antman et al1992, Oxman & Guyatt 1993).
Systematicreviews of randomized controlled trials areseen as the
gold standard for assessing theeffectiveness of healthcare
interventions. Themethod of collecting information from asystematic
review provides a solid base forclinical decision-making (Newman et
al2003). The Cochrane Collaboration declaresin the Cochrane
Handbook for SystematicReviews that reviews are needed to
helpensure that healthcare decisions throughoutthe world can be
based on informed, high-quality, timely research evidence (Higgens
&Green 2006). Using meta-analyses, systematicreviews can
provide a quantitative distillationof apparently conflicting
clinical data oridentify a trend that might not be evident in
anarrative review. As valuable as systematicreviews can be, their
usefulness depends onthe focus and quality of the
previouslypublished studies. It is important to interpretresults of
all research in the context it wasperformed. In the case of a
systematic review,a lack of high quality, homogeneous evidencecan
result in lack of conclusive findings. Inthe presented reviews, the
high levels ofheterogeneity between study designs posesproblems in
reaching clear clinicalrecommendations.
According to the American DentalAssociation, evidenced-based
dentistry is anapproach to oral health care that requiresjudicious
integration of systematicassessments of clinically relevant
scientificevidence, relating the patient’s oral andmedical
condition and history with the
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13Interdental oral hygiene: The evidence
effectively clean the whole interdental surface(Claydon 2008).
Ongoing patient educationis also an integral part of patient
compliance.The patient’s ability to remove plaque fromall areas,
including interproximal areas, is anessential part of every
patient’s selfcareprogram.
Research shows that few individuals flosscorrectly (Lang et al
1995). The inability tofloss correctly may cause a lack of
motivation(Tedesco et al 1991). Historically, compliancewith
regular flossing has been far less thanideal and only a minority of
patients arecompliant flossers (Ciancio 2003). The routineuse of
dental floss has consistently been shownto be dramatically low
(e.g. approximately 7%of the Dutch population flosses on a
regularbasis). The reasons for this lack of complianceapparently
encompass two issues: a lack ofpatient ability and a lack of
motivation(Christou et al 1998, Van der Weijden et al2005). Studies
are inconsistent in their abilityto demonstrate that educational
attempts toinfluence floss frequency can be successful(Asadoorian
2006). However, it has also beenshown that flossing is like any
other skill inthat it can be taught, and those who are
givenappropriate instruction will increase theirflossing frequency
(Asadoorian 2006,Segelnick 2004, Stewart & Wolfe
1989).Sniehotta et al (2007) provided evidence forthe effects of a
concise intervention on oralself-care behavior. Other studies have
shownthat educational attempts to modify clientbehavior were not
successful in improvingflossing frequency (Asadoorian 2006, Lewiset
al 2004). The difficulty in flossing likelymakes application of
this technique less thanuniversal.
Patient acceptance is a major issue to beconsidered when it
comes to the long-term useof interdental cleaning devices (Warren
&Chater 1996). Patient preferences wereevaluated in three
studies (Christou et al 1998,
Ishak & Watts 2007, Kiger et al 1991).Comparing interdental
brushes and dentalfloss, patients preferred the interdentalbrushes.
The interdental brushes wereconsidered to be simpler to use,
despite theirtendency to bend, buckle and distort whichmade the
procedure somewhat complicated attimes (Ishak & Watts 2007).
Interdentalbrushes were considered to be less time-consuming and
more efficacious than floss forinterdental plaque removal, which
isconsistent with previous reports (Bergenholtz& Brithon 1980,
Christou et al 1998).
Patients need interdental brushes of varioussizes. Schmage et al
(1999) assessed therelationship between the interdental space
andthe position of teeth. Most interproximalspaces in anterior
teeth were small and suitablefor the use of floss. Premolars and
molars havelarger interproximal spaces and are accessibleby
interdental brushes. Most studies do notdiscuss the different
interdental brush sizes,nor do they indicate if the interdental
brusheswere used in all available approximal sites.This need to
account for different sizes ofinterdental spaces makes a ‘true’
randomassignment of interdental brushes in clinicaltrials
difficult.
The available studies from the Hoenderdosand coworkers (2008)
review show thatchanges in gingival inflammation, as assessedby the
gingival index, are not as apparent asbleeding as an indicator of
disease. Numerousstudies have shown that sulcular bleeding is avery
sensitive indicator of early gingivalinflammation. Bleeding
following the use ofwoodsticks can also be used to increase
patientmotivation and awareness of their gingivalhealth. Several
studies have shown the clinicaleffectiveness of gingival
self-assessment(Kallio et al 1990, Kallio et al 1997, Walsh etal
1985). The presence of bleeding providesimmediate feedback on the
level of gingivalhealth. The dental professional can also
easily
-
14 Chapter 3
Collins, CO, USA), facilitates subgingivalpenetration of
irrigants to 90% of 6 mm pocketdepths when placed 1 mm
subgingivally(Braun & Ciancio 1992). Supragingivalirrigation
applies considerable force to thegingival tissues. Irrigation was
shown to havethe potential to induce bacteremia relative
tobrushing, flossing, scaling and root planing,and chewing (Carrol
& Sebor 1980, Cobe1954, Felix et al 1971, Sconyers et al
1973,Silver et al 1979, Wampole 1978). Given thecollective
evidence, it appears that irrigationis safe for healthy
patients.
Conclusion
Based on the available literature withrespect to interdental
cleaning, the bestavailable data suggest the use of
interdentalbrushes. These brushes should therefore be thefirst
choice in patients with open interdentalspaces. Meta-analysis
showed a superiority ofthe interdental brush to floss with respect
toplaque removal.
Acknowledgements
The illustrations are used with permissionfrom the Clinic for
Periodontology in Utrechtand taken from the patient instruction
brochure"Uw Schone Gebit".
This paper is an edited version of "Van DerWeijden F, Slot DE.
Oral hygiene in theprevention of periodontal diseases:
TheEvidence". Periodontol 2000 2011;1:104-123".
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