Interdental Cleaning a Peer-Reviewed Publication Written by Patty Bonasso Byrd, RDH, BS

Earn 4 CE credits This course was written for dentists, dental hygienists, and assistants.

Interdental Cleaning A Peer-Reviewed Publication Written by Patty Bonasso Byrd, RDH, BS

PennWell is an ADA CERP Recognized Provider

Go Green, Go Online to take your course

This course has been made possible through an unrestricted educational grant. The cost of this CE course is $59.00 for 4 CE credits. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. Educational Objectives Introduction Upon completion of this course, the clinician will be able to Interdental plaque control is an essential part of every do the following: patient’s self-care program. Toothbrushing alone cannot re- 1. Discuss the current status of caries, gingivitis, and move plaque between tooth surfaces and adjacent gingiva,4 periodontal disease in the United States and many patients are noncompliant. Dental conditions 2. List the dental implications associated with inad- resulting from infrequent or ineffective interdental cleaning equate/ineffective interdental plaque control include caries, gingivitis and periodontal diseases. 3. Recognize the clinical signs of infrequent interdental plaque control and identify patients who are at a high Prevalence of Caries, Gingivitis, risk for periodontal diseases and Periodontal Disease 4. Recommend appropriate interdental cleaning methods and devices for specific patient needs, and explain the Caries necessity of interdental plaque control as part of the The National Health and Nutrition Examination Survey patient’s complete self-care program (NHANES) documents improvements in the oral health of the U.S. civilian population. The decline in the prevalence Abstract and severity of dental caries in permanent teeth, reported Interdental plaque control is essential to every patient’s in previous national surveys, continued from 1988 to 1994 self-care program. Bacteria have a causal relationship in and 1999 to 2002. Declines in dental caries were seen in both the etiology of caries and periodontal disease. Excellent crowns and roots, and an overall decline in dental caries oral hygiene is necessary to remove dental plaque to pre- was seen in the U.S. population irrespective of age, gender, vent oral disease, and clinical examination should include ethnicity, poverty status, education level, or smoking status. an assessment of plaque levels interdentally as well as a While the overall decline is a positive trend, it has been review of diet, risk factors and medical history. It has estimated that 68 percent of people experience caries before been shown that toothbrushes are relatively ineffective the age of 20, and by the age of 59 approximately 95 percent interdentally, and it is also known that periodontal disease have experienced some decay.5 Despite the decrease in car- typically begins interstitially. Toothbrushing alone can- ies prevalence and severity in the permanent dentition and not remove plaque between tooth surfaces and adjacent the increase in the proportion of children and adolescents gingiva. It is also known that only a minority of patients who benefit from dental sealants, disparities remain. Ethnic are compliant flossers.1 In one survey, more than half of minorities and those with lower income or lower education respondants indicated that the majority of their patients level, and current smokers across all age groups have larger (70 percent to 80 percent) did not floss daily.2 Amongst unmet needs compared with their counterparts. There are implant patients—a patient population for whom floss- currently around 36 million baby boomers, and this number ing has been particularly stressed—few floss.3 Several is anticipated to increase over the next four decades to reach dental conditions result from infrequent or ineffective around 80 million baby boomers by 2050.6 Concomitantly, interdental cleaning, including caries and periodontal more people are keeping all of their natural teeth or retain- diseases. These two, in combination, suggest a need for ing more teeth. As the U.S. population ages, preventive effective interdental cleaning. Ongoing patient education interventions will be needed for these age groups at the is also an integral part of patient compliance.While most individual, clinical, and community level to help prevent patients brush at least for a short period of time, fewer use coronal, root, and recurring caries. interdental devices. Adjunctive aids, including interdental brushes, floss, and mechanical devices, are available to Gingivitis remove interdental plaque. Clinical studies have shown Gingivitis is first found in early childhood and increases in that manual interdental brushes are particularly effective both prevalence and severity in adolescence before leveling at reducing plaque and gingivitis. Selecting with the pa- off in older age groups.7 In the United States, the prevalence tient the sizes and types of interdental device(s) that are of gingivitis among schoolchildren has been found in a best for him or her includes an assessment of the interden- number of surveys to range from 40 percent to 60 percent. tal space; contact points; retentive areas; gingival shape, In adults, 50 percent were found to have gingivitis around at position, and pockets; and patient demonstration to help least three or four teeth.8 motivate them and increase the likelihood of effective interdental cleaning. Ultimately, the goal of patient care Periodontal Disease is to prevent, arrest or control periodontal disease and/ Moderate periodontal disease is found in the majority of or caries. The patient’s ability to remove plaque effec- the adult population. However, it is only in a minority of tively and thoroughly is essential to every patient’s self- people that this progresses to generalized periodontitis. care program. Data from the National Center for Health Statistics and

2 www.ineedce.com the National Institute of Dental and Craniofacial Research controlled diabetics are at increased risk for periodontal in- indicates that only 5 to 15 percent of any population suf- fections. Diabetics respond abnormally to inflammation and fers from generalized periodontitis.9 infection, demonstrating differences in gingival crevicular Ideally, gingivitis and/or periodontal disease should be fluid and vascular abnormalities. A thorough understanding prevented through excellent oral hygiene. Factors related to of the relationship between diabetes, periodontal disease, the attainment of good oral hygiene include the individual and professional and personal dental care is imperative in oral anatomy, age, gender, socioeconomic status, motivation the care of diabetic patients.17 and dexterity. Strong risk factors for periodontal disease include smok- While advancing age may cause a decrease in a patient’s ing and tobacco use. Smoking has been shown to increase the dexterity and, consequently, difficulty in performing oral risk of both periodontitis and refractory periodontitis. It is hygiene procedures, and while with increasing age there is a estimated that 90 percent of refractory chronic periodontitis greater likelihood of systemic conditions that may influence cases are smokers,18 and healing following mechanical treat- the intraoral environment and of intraoral conditions having ment is slower in smokers than in nonsmokers. Smoking had more time to progress, in and of itself age is not considered inhibits the growth and attachment of fibroblasts associated a risk factor for periodontal disease. Tooth retention, good with healing in periodontal ligaments, and is associated with oral hygiene, and periodontal health are closely associated, re- changes to the vascularization of the local area. This results gardless of age. With respect to gender, national surveys have in a slower reduction in the number of blood cells, including consistently shown that oral hygiene is poorer in males than neutrophils, following periodontal therapy.19 It is this poor in females, measured in terms of either soft plaque deposits vascularization (rather than less or less severe gingivitis and or calculus. A further indication of this in the absence of other periodontal disease) that results in lower bleeding upon influencing factors is the higher level of clinical attachment probing levels found in smokers with deep pockets.20 loss (CAL) found in males than females.10 Recent research also suggests that heavy drinking is a risk Socioeconomic status (SES) can influence the level of factor, and that excessive alcohol consumption is associated oral hygiene and the presence of gingivitis in individuals. with poorer oral hygiene. Generally, people who are better educated, wealthier and live in more desirable circumstances enjoy better systemic Plaque and Pocket Formation and oral health than people who are less educated and finan- Microbial plaque is the primary etiologic factor in the cially disadvantaged.11 While gingivitis is clearly correlated development of gingival and periodontal diseases.21 As to SES, there is no clear-cut correlation between SES and the bacterial plaque accumulates on the tooth surface adjacent prevalence of periodontitis.12 to the gingival margin, an inflammatory response begins Bacteria are the causal agents in the onset of gingivitis within two to four days. Initially the plaque is supragingival and periodontal disease, but the presence of bacteria does and consists mainly of gram-positive bacteria, especially A. not determine periodontal disease progression. Factors in- actinomycetemcomitans and Streptococcal species.22,23 This fluencing the development of inflammation and the progres- changes after day three, when filamentous bacteria begin to sion of periodontal disease may include genetics, hormonal be seen on the surface of the plaque and later penetrate it. changes, stress, and systemic diseases such as diabetes. Over the next seven to 14 days, bacterial plaque becomes A genetic role was first identified in periodontal disease in thicker. The connective tissue becomes infiltrated with 1997.13 The proinflammatory cytokine IL-1 is a key regulator fluid, lymphocytes, neutrophils, and plasma cells. Collagen of the host response to microbial infection14 and is tied to the fibers begin to break down, epithelium proliferates, and genetic makeup of the individual, but is unlikely to be the epithelial extensions are formed. Clinically, slight gingival only gene involved.15 More research will be necessary before enlargement occurs and gingival pockets (“pseudopockets”) the genetic contribution to periodontitis can be determined. are formed. Gingivitis at this stage can be reversed if plaque In women, hormonal issues (puberty, pregnancy and is controlled and inflammation reduced. If undisturbed, the birth control pills) may cause an exaggerated response disease process continues and clinically marginal redness, to bacterial plaque, and can result in gingivitis and bleeding upon probing, and spongy marginal gingiva are ap- possibly periodontitis. parent. While not all gingivitis leads to periodontal disease, Stress has been studied from the perspective of the plaque removal while the gingivitis is reversible will prevent mind-body connection and disease and assessed in terms the development of destructive periodontal disease. of adverse life events, clinical depression, and coping skills. Bacteria from supragingival plaque enter the gingival High levels of stress seem to be associated with progressive sulcus as subgingival plaque develops. Mature subgingi- periodontitis as well as a number of systemic diseases.16 val plaque consists mainly of gram-negative anaerobes, Diabetes lowers resistance to infections and delays and between the third and 12th week after supragingival healing. Periodontal infections can affect glycemic control, plaque forms, the subgingival plaque is well-differentiated which ultimately can be life threatening. Conversely, poorly and organized.24 www.ineedce.com 3 The bacteria in plaque release biological irritants. The aids. Frequent professional supragingival cleaning and good host response includes the release of antibodies, lympho- personal oral hygiene have been shown to have a beneficial cytes, and white blood cells. As periodontitis develops in re- effect on subgingival microbiota in moderately deep pock- sponse to the bacterial invasion and inflammation, soft- and ets. The benefits of scaling and root planing combined with hard-tissue destruction occurs with the release of cytokines, personal plaque control in the treatment of chronic peri- prostaglandins, and MMPs (associated with the destruction odontitis have been clinically proven.30 of hard tissue, or alveolar bone). Pockets can be divided into gingival and true periodontal Devices Used for Removing pockets, depending upon the degree of anatomic involve- Interdental Plaque ment (Table 1). Vibratory and sulcular toothbrushing techniques are useful for removing interdental plaque (Charter’s, Stillman and Anatomy Bass methods), and are successful to some degree in remov- A healthy sulcus should measure from 0.5mm to 1.8mm in ing bacterial plaque near the line angles of the facial and lin- depth and should have no evidence of infection.25 The in- gual embrasures.31 However, for complete plaque removal terdental gingiva is located between two adjacent teeth and interdentally, other devices are needed (Table 2). may be flat or saddle-shaped (spaces between teeth), tapered Interdental devices include the use of interdental or narrow (overlapping or crowded), pointed or pyramidal brushes, tips, and floss. These have all been found to be (anterior), or flat with two papillae (facial and lingual) con- effective, depending upon the targeted area of the inter- nected by a col on posterior teeth. Most periodontal infec- dental space. tions begin in the col area.26 Interdental brushes offer the advantage of being available While gram-negative organisms in the periodontal crev- in wider and new thinner versions, such as Go-Betweens® ice are closely associated with periodontitis, an important (Sunstar Butler), to accommodate the various dimensions finding is that supragingival plaque can serve as a natural of the interdental spaces. Patients who have dexterity is- reservoir for them.27 sues often find interdental brushes easier to use. Effective When the bacterial insult is strong enough to overwhelm at removing interdental plaque, brushes have the added the host defense, bacteria in supragingival plaque migrate advantage of serving as vehicles for the local application subgingivally to form a subgingival biofilm.28 of antibacterial agents such as 0.12 percent chlorhexidine Since most periodontal infections begin in the col area, gluconate or desensitizing agents to exposed sensitive root it is critical that all interdental plaque be removed.29 Tooth- areas. Interdental brushes are available with both coated brushing alone has been proven to be ineffective at removing and uncoated wire, and some include antibacterial agents interdental plaque; it is necessary to use interdental cleaning (chlorhexidine) on the bristles.

Table 1. Gingival and Periodontal Pockets Pockets Gingival Pocket Periodontal Pocket Formed as a result of disease or degeneration that Definition Formed by gingival enlargement without causes the junctional epithelium to migrate apically apical migration of junctional epithelium along the cementum Margin of gingiva has moved toward inci- Structures involved sal or occlusal without deeper periodontal Cementum, periodontal ligament, bone structures becoming involved Tooth wall Enamel Cementum or cementum/enamel Base of pocket on cementum at level of Base Base of sulcus near CEJ attached periodontal tissue Suprabony: Base of pocket is coronal to crest of alveolar bone Type Suprabony Intrabony: Base of pocket is below or apical to the crest of aveolar bone Actinomyces actinomycetemcomitans (Aa), Bacte- roides forsythus (Bf) (now Tannerella forsythensis), Broad gram-negative pathogens Porphyromonas gingivalis (Pg), Prevotella intermedia (Pi), Treponema denticola 8 Slight gingival enlargement/sponginess, Edema, erythema, bleeding upon probing and/or sup- Clinical signs and symptoms marginal redness, bleeding upon probing puration, tooth mobility, furcation involvement

Adapted from Wilkins, Clinical Practice of the Dental Hygienist. 8th ed. p. 227.

4 www.ineedce.com Table 2. Mechanical Device Indications for Use Proximal tooth surfaces adjacent to open embrasures, orthodontic appliances, fixed prostheses, dental implants, periodontal splints, space maintainers, concave proximal surfaces, exposed Class IV furcations; ap- Interdental brushes plications of fluorides for prevention of decay, particularly root surface caries and for surfaces adjunct to any prosthesis; antibacterial agents for control of plaque and gingivitis; desensitizing agents Interdental tips Plaque forming on tooth surface or just below gingival margin Floss Proximal surface of each tooth and line angles Wide embrasures; mesial and distal abutments of fixed partial dentures; under pontics; Tufted dental floss orthodontic appliance Proximal surfaces of widely spaced teeth; distal and mesial surfaces of abutment teeth; distal portions of Gauze strips dentures supported by implants Plaque forming at or below gingival margin; interdental cleaning; concave proximal tooth surfaces; exposed Toothpicks in holders furcation areas; orthodontic appliances Wooden dental cleaners Exposed proximal tooth surfaces

Adapted from Wilkins, Clinical Practice of the Dental Hygienist. 8th ed. Ch. 24.

Adjuncts. Chemotherapeutic Irrigation Indications for Use Reduce gingivitis; reduce or alter microbial flora; penetration onto pocket; Irrigation delivery of antimicrobial agents; periodontal maintenance Preprocedural rinse, dental caries pre- Mouthrinse vention; after nonsurgical periodontal therapy Floss is able to reach into narrow interdental spaces Control dental caries; remineralization; where use of an interdental brush may be difficult and will Dentifrice gingival health, calculus prevention; also remove plaque at the interproximal contact. Preference, desensitization availability, interdental anatomy, and dexterity all play roles Adapted from Wilkins, Clinical Practice of the Dental Hygienist. 8th ed. Ch. 24. in the selection of an interdental device. In addition to these interdental devices, there are a number of mechanical and chemotherapeutic adjuncts that brushes. In this study, it was found that only 5 percent of may be useful in reducing and removing interdental plaque. interdental plaque remained following patient use of manual Recent research on a novel electric interdental cleaning aid interdental brushes.33 In two other studies, the same device (Hummingbird™, Oral B) compared patients using either was compared to the use of dental floss, and the device and the cleaning aid with floss or manual floss interdentally over manual dental floss were found to be equally effective in a period of 30 days. Manual floss was equally effective in reducing plaque.34,35 reducing plaque and gingivitis, and, while safe and effective, Based upon the results of these clinical studies, while the mechanical device offered no advantage.32 there may be a subjective perception of improved inter- A study of another mechanical interdental device dental cleaning with mechanical devices, from a clinical (Interclean) in a German population revealed signifi- perspective manual interdental brushes are superior cantly less plaque reduction than with manual interdental and floss is equally effective in reducing and removing plaque interdentally. Irrigators help remove plaque and debris interdentally and may also be used in conjunction with an antimicrobial agent. Irrigation can also be achieved through the use of blunt-ended cannulae to syringe antimicrobial agents into shallow to moderate periodontal pockets. The use of a chlorhexidine gluconate rinse has been shown to reduce plaque by 64.9 percent.36 Other adjuncts include the use of essential oil mouthrinses, zinc nitrate, CPC, and triclosan copolymer dentifrice. www.ineedce.com 5 Conclusion Paper: Epidemiology of periodontal diseases p 1412. 17. Wilkins Esther M. Clinical Practice of the Dental Hygienist. 8th Clinical judgment, clinical skills, patient-related factors, ed. Philadelphia: Lippincott, Williams and Wilkins; 1999. and the patient’s current dental status affect oral health. 18. American Academy of Periodontology Research, Science and Therapy Committee Position Bacteria have a causal relationship in the etiology of caries Paper: Epidemiology of periodontal diseases and periodontal disease. Excellent oral hygiene is necessary 19. Ibid. 20. Ibid. to remove dental plaque to prevent oral disease, and clinical 21. Wilkins Esther M. Clinical Practice of the Dental Hygienist. 8th ed. Philadelphia: Lippincott, examination should include an assessment of plaque levels Williams and Wilkins; 1999. aproximally and interdentally as well as a review of diet, risk 22. Lovegrove, J.M. Dental plaque revisited: bacteria associated with periodontal disease. J factors, and medical history. NZ Soc Periodontol 2004;87:7–21. 23. Li J, Helmerhorst EJ, Leone CW, Troxler RF, Yaskell T, Haffajee AD, Socransky SS, Oppenheim While most patients brush for at least a short period FG. Identification of early microbial colonizers in human dental biofilm. J Appl Microbiol. of time, fewer use interdental devices in addition to tooth- 2004;97(6):1311–8. brushes. It has been shown that toothbrushes are relatively 24. Lovegrove, J.M. Dental plaque revisited: bacteria associated with periodontal disease. J ineffective interdentally, and it is also known that periodon- NZ Soc Periodontol 2004;87:7–21. 25. Wilkins Esther M. Clinical Practice of the Dental Hygienist. 8th tal disease typically begins interstitially. Adjunctive aids, ed. Philadelphia: Lippincott, Williams and Wilkins; 1999. including interdental brushes, floss, and mechanical devices, 26. Ibid. are available to remove interdental plaque. Clinical studies 27. American Academy of Periodontology Research, Science and Therapy Committee Position have shown that manual interdental brushes are particularly Paper: Epidemiology of periodontal diseases 28. Page RC, Offenbacher S, Schroeder HE, Seymour GJ, Kornman KS. Advances in the effective at reducing plaque and gingivitis. Selecting the pathogenesis of periodontitis: Summary of developments, clinical implications and sizes and types of interdental devices that are best for the future directions. Periodontal 2000 1997; 14:216–248. patient in conjunction with him or her should include an 29. Wilkins Esther M. Clinical Practice of the Dental Hygienist. 8th ed. Philadelphia: Lippincott, assessment of the interdental space, contact points, reten- Williams and Wilkins; 1999:372. tive areas, gingival shape and position, and pockets. Patient 30. American Academy of Periodontology Research, Science and Therapy Committee Position Paper: Treatment of Plaque-Induced Gingivitis, Chronic Periodontitis, and Other Clinical demonstration can provide additional motivation and in- Conditions crease the likelihood of proper interdental cleaning. 31. Wilkins Esther M. Clinical Practice of the Dental Hygienist. 8th ed. Philadelphia: Lippincott, Ultimately, the goal of patient care is to prevent, arrest, Williams and Wilkins; 1999. and control periodontal disease and caries. The patient’s 32. Cronin MJ, Dembling WZ, Cugini M, Thompson MC, Warren PR. A 30-day clinical comparison of a novel interdental cleaning device and dental floss in the reduction of ability to remove plaque from all areas, including inter- plaque and gingivitis. J Clin Dent. 2005;16(2):33–7. proximal areas, is an essential part of every patient’s self- 33. Schmage P, Platzer U, Nergiz I. Comparison between manual and mechanical methods of care program. interproximal hygiene. Quintessence Int. 1999 Aug;30(8):535–9. 34. Isaacs RL, Beiswanger BB, Crawford JL, Mau MS, Proskin H, Warren PR. Assessing the efficacy and safety of an electric interdental cleaning device. J Am Dent Assoc. 1999 References Jan;130(1):104–8. 1. Ciancio S. Improving oral health: current considerations. J Clin Periodontol. 2003; 30 35. Gordon JM, Frascella JA, Reardon RC. A clinical study of the safety and efficacy of a novel Suppl 5:4–6. electric interdental cleaning device. J Clin Dent. 1996;7(3 Spec No):70–3. 2. www.docere.com/Hygienetown/Article. Accessed June 2006. 36. Brightman LJ, Terazhalmy GT, Greenwell H, Jacobs M, Enlow DH. The effects of 0.12 3. Clarizio, L.F. Peri-implant infections. Oral and Maxillofacial Infections 2000;8(1):35–54. percent chlorhexidine gluconate mouthrinse on orthodontic patients aged 11 through th 4. Wilkins Esther M. Clinical Practice of the Dental Hygienist. 8 ed. Philadelphia: Lippincott, 17 with established gingivitis. Am J Orthod Dentofac Orthop 1991;100:324–329. Williams and Wilkins; 1999:371. 5. Center for Disease Control;accessed June 2006 Author Profile 6. Available at: “www.census.gov/population/www/projections/natsum-T3.html (accessed May, 2006.) Patty Bonasso Byrd, RDH, BS, is a graduate of the Uni- 7. Stamm JW. Epidemiology of gingivitis. J Clin Periodontal 1986; 13:360–370. versity of Louisville (1978) Dental Hygiene Program. She 8. Oliver RC, Brown LJ, Loe H. Periodontal diseases in the United States population. J lectures nationwide on a variety of topics related to dental Periodontal 1998;69:269–278. 9. U.S. Public Health Service, National Institute of Dental Research. Oral Health of United hygiene and is adjunct clinical faculty at UL and an author. States Adults; National Findings. Bethesda, MD: National Institue of dental research; She has been actively involved in the Kentucky State Dental 1987. NIH Publication number 87–2868. Hygiene Association, serving as president (1998–99) and 10. American Academy of Periodontology Research, Science and Therapy Committee Position delegate to the ADHA. Paper: Epidemiology of periodontal diseases 11. Ibid. 12. U.S. Public Health Service, National Institute of Dental Research. Oral Health of United Disclaimer States Adults; National Findings. Bethesda, MD: National Institue of dental research; The author of this course has no commercial ties with the 1987. NIH Publication number 87–2868. sponsors or the providers of the unrestricted educational 13. Kornman KS, Crane A, Wang HY, et al. The interleukin-1 genotype as a severity factor in adult periodontal disease. J. Clinical Periodontal 1997; 24:72–77. grant for this course. 14. McDevitt MJ, Wang HY, Knobleman C. et al. Interleukin-1 genetic association with periodontitis in clinical practice. J Periodontal 2000; 71: 156–163. Reader Feedback 15. Mark LL, Haffejee AD, Socransky SS, et al. Effect of the interleukin-1 genotype on We encourage your comments on this or any PennWell course. monocyte IL-1beta expression in subjects with adult periodontitis. J Periodontal Res 2000;35: 172–177. For your convenience, an online feedback form is available at 16. American Academy of Periodontology Research, Science and Therapy Committee Position www.ineedce.com.

6 www.ineedce.com Questions

1. Ineffective or infrequent interdental 12. The structures involved in a 22. Which of the following plays cleaning may result in: periodontal pocket include: a role in the selection of an a. Caries a. Bone b. Gingivitis b. Cementum interdental device? c. Periodontitis c. Periodontal ligament a. Preference d. All of the above d. All of the above b. Availability 2. National surveys have consistently 13. Bacteria from supragingival plaque c. Dexterity shown that oral hygiene is: can enter the sulcus and be a source d. All of the above a. Poorer in females than males for subgingival plaque development. 23. In addition to floss and interdental b. Poorer in males than females a. True c. Equal in males and females b. False brushes, there are a number of me- d. Poorer in elderly males and females chanical adjuncts that may be useful 14. As periodontitis develops in 3. Despite the decrease in caries response to bacterial invasion in reducing interdental plaque. prevalence and severity in the and inflammation, soft- and hard- a. True permanent dentition and the tissue destruction occurs with the b. False increase in proper prevention release of: 24. The indications for use of treatments, disparities remain. a. MMPs a. True b. Prostaglandins dentifrice include: b. False c. Cytokines a. Reduction of gingivitis 4. Factors related to the attainment of d. All of the above b. Delivery of antimicrobial agents good oral hygiene are: 15. Depending upon the degree of c. Calculus prevention a. Oral anatomy anatomic involvement, pockets can d. All of the above b. Motivation be divided into: 25. Irrigation can be achieved through c. Dexterity a. Gingival and subgingival d. All of the above b. Gingival and true periodontal the use of: 5. Gingivitis is clearly correlated c. Periodontal and microbial a. A syringe with blunt-ended cannula to SES and the prevalence d. Gram-negative and pseudopockets b. A syringe with cartridge of periodontitis. 16. The interdental gingiva is located c. Essential oil mouthrinses a. True between two adjacent teeth and d. Diet b. False may be: 26. The use of a chlorhexidine 6. Age is not considered a risk factor a. Pointed or pyramidal for periodontal disease. b. Flat or saddle-shaped gluconate rinse has been shown a. True c. Tapered or narrow to reduce plaque by: b. False d. All of the above a. 46.9 percent 7. Statement 1: Bacteria are the causal 17. When the bacterial insult is strong b. 64.9 percent agents in the onset of gingivitis and enough to overwhelm the host de- c. 94.6 percent periodontal disease. fense, bacteria in the supragingival d. A factor of 10 Statement 2: The presence of bacte- plaque will: 27. While most patients brush for at ria does not determine periodontal a. Stay in the supragingival plaque disease progression. b. Migrate subgingivally to form a least a short period of time: a. Statement #1 is true. Statement #2 is true. subgingival biofilm a. They use interdental devices as much b. Statement #1 is true. Statement #2 is false. c. Die within a couple of days as toothbrushes c. Statement #1 is false. Statement #2 is true. d. Not cause inflammation b. They also use interdental devices more d. Statement #1 is false. Statement #2 is false. 18. It is critical that all interdental than toothbrushes 8. ______seem(s) to be associated with plaque is removed, since most c. Fewer use interdental devices in addition progressive periodontitis as well as a periodontal infections begin in: to toothbrushes number of systemic diseases. a. The col d. Fewer use adjunctive chemotherapeutics b. The pseudopocket a. Hormonal status with interdental devices in addition to b. Gender c. The gingival pocket c. Stress d. The base toothbrushes d. Socioeconomic status 19. Devices used to remove plaque 28. It has been shown that 9. Risk factors for periodontal interdentally include: toothbrushes are relatively disease include: a. Wooden dental cleaners ineffective interdentally. a. Smoking and tobacco use b. Tufted dental floss b. Diabetes c. Interdental brushes a. True c. Poor oral hygiene d. All of the above b. False d. All of the above 20. What toothbrushing 29. Ultimately, the goal of patient care 10. Poor vascularization results in techniques are useful for is to: lower bleeding upon probing levels removing interdental plaque? a. Arrest periodontal disease and caries found in smokers with deep pockets. a. Stillman and Bass methods b. Control periodontal disease and caries a. True b. Vibratory b. False c. Sulcular c. Prevent periodontal disease and caries d. All of the above 11. As bacterial plaque accumulates d. All of the above on the tooth surface adjacent to the 21. What type of device offers the 30. The patient’s ability to remove gingival margin, an inflammatory advantage of being available in plaque effectively and thoroughly response begins within: wider and new thinner versions? is not essential to every patient’s a. Twenty-four hours a. Floss b. Two to four days b. Interdental brushes self-care program. c. Five to seven days c. Toothpicks a. True d. Seven to 14 days d. Tips b. False www.ineedce.com 7 ANSWER SHEET Interdental Cleaning

Name: Title: Specialty:

Address: E-mail:

City: State: ZIP:

Telephone: Home ( ) Office ( )

Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn you 4 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp.

Mail completed answer sheet to Educational Objectives Academy of Dental Therapeutics and Stomatology, 1. Discuss the current status of caries, gingivitis, and periodontal disease in the United States A Division of PennWell Corp. 2. List the dental implications associated with inadequate/ineffective interdental plaque control P.O. Box 116, Chesterland, OH 44026 or fax to: (440) 845-3447 3. Recognize the clinical signs of infrequent interdental plaque control and identify patients who are at a high risk for periodontal diseases For immediate results, go to www.ineedce.com 4. Recommend appropriate interdental cleaning methods and devices for specific patient needs, and explain the necessity of and click on the button “Take Tests Online.” Answer sheets can be faxed with credit card payment to interdental plaque control as part of the patient’s complete self-care program (440) 845-3447, (216) 398-7922, or (216) 255-6619. Payment of $59.00 is enclosed. (Checks and credit cards are accepted.) Course Evaluation If paying by credit card, please complete the Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0. following: MC Visa AmEx Discover 1. Were the individual course objectives met? Objective #1: Yes No Objective #3: Yes No Acct. Number: ______Objective #2: Yes No Objective #4: Yes No Exp. Date: ______2. To what extent were the course objectives accomplished overall? 5 4 3 2 1 0 Charges on your statement will show up as PennWell

3. Please rate your personal mastery of the course objectives. 5 4 3 2 1 0

4. How would you rate the objectives and educational methods? 5 4 3 2 1 0

5. How do you rate the author’s grasp of the topic? 5 4 3 2 1 0

6. Please rate the instructor’s effectiveness. 5 4 3 2 1 0

7. Was the overall administration of the course effective? 5 4 3 2 1 0

8. Do you feel that the references were adequate? Yes No

9. Would you participate in a similar program on a different topic? Yes No

10. If any of the continuing education questions were unclear or ambiguous, please list them. ______

11. Was there any subject matter you found confusing? Please describe. ______

12. What additional continuing dental education topics would you like to see? ______AGD Code 490

PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.

AUTHOR DISCLAIMER INSTRUCTIONS COURSE CREDITS/COST RECORD KEEPING The author of this course has no commercial ties with the sponsors or the providers of All questions should have only one answer. Grading of this examination is done All participants scoring at least 70% (answering 21 or more questions correctly) on the PennWell maintains records of your successful completion of any exam. Please contact our the unrestricted educational grant for this course. manually. Participants will receive confirmation of passing by receipt of a verification examination will receive a verification form verifying 4 CE credits. The formal continuing offices for a copy of your continuing education credits report. This report, which will list form. Verification forms will be mailed within two weeks after taking an examination. education program of this sponsor is accepted by the AGD for Fellowship/Mastership all credits earned to date, will be generated and mailed to you within five business days SPONSOR/PROVIDER credit. Please contact PennWell for current term of acceptance. Participants are urged to of receipt. This course was made possible through an unrestricted educational grant. No EDUCATIONAL DISCLAIMER contact their state dental boards for continuing education requirements. PennWell is a manufacturer or third party has had any input into the development of course content. The opinions of efficacy or perceived value of any products or companies mentioned California Provider. The California Provider number is 3274. The cost for courses ranges CANCELLATION/REFUND POLICY All content has been derived from references listed, and or the opinions of clinicians. in this course and expressed herein are those of the author(s) of the course and do not from $49.00 to $110.00. Any participant who is not 100% satisfied with this course can request a full refund by Please direct all questions pertaining to PennWell or the administration of this course to necessarily reflect those of PennWell. contacting PennWell in writing. Machele Galloway, 1421 S. Sheridan Rd., Tulsa, OK 74112 or [email protected]. Many PennWell self-study courses have been approved by the Dental Assisting National Completing a single continuing education course does not provide enough information Board, Inc. (DANB) and can be used by dental assistants who are DANB Certified to meet © 2008 by the Academy of Dental Therapeutics and Stomatology, a division COURSE EVALUATION and PARTICIPANT FEEDBACK to give the participant the feeling that s/he is an expert in the field related to the course DANB’s annual continuing education requirements. To find out if this course or any other of PennWell We encourage participant feedback pertaining to all courses. Please be sure to complete the topic. It is a combination of many educational courses and clinical experience that PennWell course has been approved by DANB, please contact DANB’s Recertification survey included with the course. Please e-mail all questions to: [email protected]. allows the participant to develop skills and expertise. Department at 1-800-FOR-DANB, ext. 445.

8 www.ineedce.com