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. 2019 Apr 10;4(4):CD012018.
doi: 10.1002/14651858.CD012018.pub2.

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

Helen V Worthington  1 , Laura MacDonald, Tina Poklepovic Pericic, Dario Sambunjak, Trevor M Johnson, Pauline Imai, Janet E Clarkson
Affiliations

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

Helen V Worthington et al. Cochrane Database Syst Rev. .

Abstract

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.

PubMed Disclaimer

Conflict of interest statement

Helen Worthington: none known. Co‐ordinating Editor of Cochrane Oral Health. Author on one included study (assessed by other review authors) Laura MacDonald: none known. Managing Editor with Cochrane Oral Health Tina Poklepovic Pericic: none known Dario Sambunjak: none known Trevor Johnson: none known. Editor with Cochrane Oral Health Pauline Imai: none known. Author on one included study (assessed by other review authors) Jan Clarkson: none known. Co‐ordinating Editor of Cochrane Oral Health

Figures

1
1
Study flow diagram
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study
1.1
1.1. Analysis
Comparison 1 Toothbrushing plus floss vs toothbrushing alone, Outcome 1 Gingival index at 1 month (lower better).
1.2
1.2. Analysis
Comparison 1 Toothbrushing plus floss vs toothbrushing alone, Outcome 2 Gingival index 3 months (lower better).
1.3
1.3. Analysis
Comparison 1 Toothbrushing plus floss vs toothbrushing alone, Outcome 3 Gingival index at 6 months (lower better).
1.4
1.4. Analysis
Comparison 1 Toothbrushing plus floss vs toothbrushing alone, Outcome 4 Bleeding at 1 month (lower better).
1.5
1.5. Analysis
Comparison 1 Toothbrushing plus floss vs toothbrushing alone, Outcome 5 Bleeding at 3 months (lower better).
1.6
1.6. Analysis
Comparison 1 Toothbrushing plus floss vs toothbrushing alone, Outcome 6 Bleeding at 6 months (lower better).
1.7
1.7. Analysis
Comparison 1 Toothbrushing plus floss vs toothbrushing alone, Outcome 7 Plaque at 1 month (lower better).
1.8
1.8. Analysis
Comparison 1 Toothbrushing plus floss vs toothbrushing alone, Outcome 8 Plaque at 3 months (lower better).
1.9
1.9. Analysis
Comparison 1 Toothbrushing plus floss vs toothbrushing alone, Outcome 9 Plaque at 6 months (lower better).
2.1
2.1. Analysis
Comparison 2 Toothbrushing plus interdental brush versus toothbrushing alone, Outcome 1 Gingival index at 1 month.
2.2
2.2. Analysis
Comparison 2 Toothbrushing plus interdental brush versus toothbrushing alone, Outcome 2 Bleeding at 1 month.
2.3
2.3. Analysis
Comparison 2 Toothbrushing plus interdental brush versus toothbrushing alone, Outcome 3 Plaque index at 1 month.
3.1
3.1. Analysis
Comparison 3 Toothbrushing plus wooden tooth cleaning stick versus toothbrushing alone, Outcome 1 Bleeding at 3 months.
3.2
3.2. Analysis
Comparison 3 Toothbrushing plus wooden tooth cleaning stick versus toothbrushing alone, Outcome 2 Plaque Index at 3 months.
4.1
4.1. Analysis
Comparison 4 Toothbrushing plus rubber/elastomeric tooth cleaning stick versus toothbrushing alone, Outcome 1 Gingival Index at 1 month.
4.2
4.2. Analysis
Comparison 4 Toothbrushing plus rubber/elastomeric tooth cleaning stick versus toothbrushing alone, Outcome 2 Bleeding at 1 month.
4.3
4.3. Analysis
Comparison 4 Toothbrushing plus rubber/elastomeric tooth cleaning stick versus toothbrushing alone, Outcome 3 Plaque Index at 1 month.
5.1
5.1. Analysis
Comparison 5 Toothbrushing plus oral irrigation versus toothbrushing alone, Outcome 1 Gingivitis at 1 month (lower better).
5.2
5.2. Analysis
Comparison 5 Toothbrushing plus oral irrigation versus toothbrushing alone, Outcome 2 Gingivitis at 3 months (lower better).
5.3
5.3. Analysis
Comparison 5 Toothbrushing plus oral irrigation versus toothbrushing alone, Outcome 3 Gingivitis at 6 months (lower better).
5.4
5.4. Analysis
Comparison 5 Toothbrushing plus oral irrigation versus toothbrushing alone, Outcome 4 Bleeding at 1 month (lower better).
5.5
5.5. Analysis
Comparison 5 Toothbrushing plus oral irrigation versus toothbrushing alone, Outcome 5 Bleeding at 3 months (lower better).
5.6
5.6. Analysis
Comparison 5 Toothbrushing plus oral irrigation versus toothbrushing alone, Outcome 6 Plaque at 1 month (lower better).
5.7
5.7. Analysis
Comparison 5 Toothbrushing plus oral irrigation versus toothbrushing alone, Outcome 7 Plaque at 3 months (lower better).
5.8
5.8. Analysis
Comparison 5 Toothbrushing plus oral irrigation versus toothbrushing alone, Outcome 8 Plaque at 6 months (lower better).
6.1
6.1. Analysis
Comparison 6 Interdental brush versus floss, Outcome 1 Gingival Index at 1 month (lower better).
6.2
6.2. Analysis
Comparison 6 Interdental brush versus floss, Outcome 2 Bleeding at 4/6 weeks.
6.3
6.3. Analysis
Comparison 6 Interdental brush versus floss, Outcome 3 Bleeding at 3 months.
6.4
6.4. Analysis
Comparison 6 Interdental brush versus floss, Outcome 4 Probing pocket depth at 4 to 6 weeks.
6.5
6.5. Analysis
Comparison 6 Interdental brush versus floss, Outcome 5 Probing pocket depth at 12 weeks.
6.6
6.6. Analysis
Comparison 6 Interdental brush versus floss, Outcome 6 Plaque at 1 month (lower better) (parallel group studies).
6.7
6.7. Analysis
Comparison 6 Interdental brush versus floss, Outcome 7 Plaque at 1 month (split‐mouth studies).
6.8
6.8. Analysis
Comparison 6 Interdental brush versus floss, Outcome 8 Plaque at 3 months.
7.1
7.1. Analysis
Comparison 7 Wooden interdental cleaning stick versus floss, Outcome 1 Bleeding at 3 months.
7.2
7.2. Analysis
Comparison 7 Wooden interdental cleaning stick versus floss, Outcome 2 Plaque index at 3 months.
8.1
8.1. Analysis
Comparison 8 Rubber/elastomeric interdental cleaning stick versus floss, Outcome 1 Gingival index at 1 month/6 weeks.
8.2
8.2. Analysis
Comparison 8 Rubber/elastomeric interdental cleaning stick versus floss, Outcome 2 Gingival index at 3 months.
8.3
8.3. Analysis
Comparison 8 Rubber/elastomeric interdental cleaning stick versus floss, Outcome 3 Bleeding at 1 month/6 weeks (lower better).
8.4
8.4. Analysis
Comparison 8 Rubber/elastomeric interdental cleaning stick versus floss, Outcome 4 Bleeding at 3 months.
8.5
8.5. Analysis
Comparison 8 Rubber/elastomeric interdental cleaning stick versus floss, Outcome 5 Plaque index at 1 month/6 weeks.
9.1
9.1. Analysis
Comparison 9 Oral irrigation versus floss, Outcome 1 Gingival Index at 1 month (lower better).
9.2
9.2. Analysis
Comparison 9 Oral irrigation versus floss, Outcome 2 Bleeding at 1 month (lower better).
9.3
9.3. Analysis
Comparison 9 Oral irrigation versus floss, Outcome 3 Plaque Index at 1 month (lower better).
10.1
10.1. Analysis
Comparison 10 Interdental cleaning stick versus interdental brush, Outcome 1 Gingival index at 1 month/6 weeks.
10.2
10.2. Analysis
Comparison 10 Interdental cleaning stick versus interdental brush, Outcome 2 Bleeding at 1 month/6 weeks.
10.3
10.3. Analysis
Comparison 10 Interdental cleaning stick versus interdental brush, Outcome 3 Plaque index at 1 month/6 weeks.
See this image and copyright information in PMC

Comment in

References

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Gupta 1973 {published data only}
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Hill 1973 {published data only}
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Larsen 2017 {published data only}
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NCT01307358 {published data only}
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Newbrun 1980 {published data only}
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Rich 1989 {published data only}
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Sharma 2012 {published data only}
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References to studies awaiting assessment

NCT02836223 {published data only}
    1. NCT02836223. Evaluation of the addition of an interdental cleaning device to manual brushing on gingival health. clinicaltrials.gov/show/nct02836223 (first received 18 July 2016).

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