Interdental oral hygiene: The evidence

1Interdental oral hygiene: The evidence

Chapter 3

Interdental oral hygiene: The evidence

GA Van de Weijden1,2, DE Slot1

1 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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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.


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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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)


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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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)


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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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 <0.00001).Comparisons using the other indices (Quigleyand Hein plaque index, bleeding on probingand pocket depth) were not statisticallysignificant. The heterogeneity observed withthe Silness and Löe index (P = 0.001, I2 =85.4%) reflects the different behaviors of thestudy populations to the study product,differences in study designs and other factorsthat may influence outcome. Again, the readershould therefore exercise caution when usingthis WMD as an exact measure of outcomes.Within the limitations of the search andselection strategy of the review, Slot andcoworkers (2008) showed that Interdentalbrushes are a useful device to complementtoothbrushing. The evidence suggests that

Author(s) Plaque score Gingival score Bleeding score Pocket depth Comparison

Bassiouny & Grant (1981) ? ^ ^ ^ Toothbrush onlyJared et al (2005) + + 0 ^ Toothbrush onlyKiger et al (1991) + 0 ^ ^ Toothbrush only

Christou et al (1998) + ^ 0 + Dental FlossGjermo & Flötra (1970) + ^ ^ ^ Dental FlossIshak & Watts (2007) 0 ^ 0 0 Dental FlossJackson et al (2006) + ^ 0 + Dental FlossJared et al (2005) 0 0 0 ^ Dental FlossKiger et al (1991) + 0 ^ ^ Dental FlossRösing et al (2006) + ^ ^ ^ Dental FlossYost et al (2006) 0 0 0 ^ Dental Floss

Bassiouny & Grant (1981) ? ^ ^ ^ WoodstickGjermo & Flötra (1970) + ^ ^ ^ Woodstick

Table 4. Descriptive overview of the results for interdental brushes and other interventions. + = significant difference in favor of test group, 0 = no significant difference, ^ = no data available, ? =unknown. (Slot et al 2008)


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<0.00001 P=0.001 I2=85.4%

(1964)

Christou et al (1998) Plaque index; Base -0.01 -0.28; 0.26 P=0.94 P=1.0 I2=0%Jared et al (2005) Quigley & Hein End -0.25 -0.57; 0.06 P=0.12 P=0.74 I2=0%

(1962)

Christou et al (1998) Bleeding on Base 0.01 -0.04; 0.06 P=0.62 P=0.86 I2=0%Ishak & Watts (2007) probing End -0.04 -0.10; 0.02 P=0.17 P=0.74 I2=0%Jackson et al (2006)

Christou et al (1998) Pocket Base 0.14 -0.19; 0.47 P=0.39 P=0.28 I2=22.0%Ishak & Watts (2007) depth End -0.04 -0.28; 0.21 P=0.77 P=0.77 I2=0%Jackson et al (2006)

Table 5. Meta-analyses between interdental brushes and floss. Negative value favors interdental brushes.(Slot et al 2008)

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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


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 H

2O

pulsations 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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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


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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Plaque accumulation is greater betweenmolars and premolars than anterior teeth. Thewider the interdental space, the more protectedthe bacterial biofilm will be. Molars andpremolars provide the perfect interdental spacefor bacterial biofilm formation and maturation,without disruption by chewing ortoothbrushing. Research has shown poweredtoothbrushing to have improved efficacy inapproximal plaque removal compared withmanual toothbrushing (Van der Weijden et al1993, 1994). The findings are based onrelatively young study subject andextrapolation to a general population shouldbe undertaken with caution.

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Interdental oral hygiene: The evidence