Dental Mechanical Plaque Control In&#Xa0

J Clin Periodontol 2015; 42 (Suppl. 16): S92–S105 doi: 10.1111/jcpe.12363

Sonja Salzer€ 1, Dagmar E. Slot2, Efﬁcacy of inter-dental Fridus A. Van der Weijden2 and Christof E. Dorfer€ 1 1Clinic for Conservative Dentistry and mechanical plaque control Periodontology, School for Dental Medicine, Christian-Albrechts-University Kiel, Kiel, – Germany; 2Department of Periodontology, in managing gingivitis Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and VU University Amsterdam, Amsterdam, The a meta-review Netherlands

Salzer€ S, Slot DE, Van der Weijden FA, Dorfer€ CE. Efﬁcacy of inter-dental mechanical plaque control in managing gingivitis – a meta-review. J Clin Periodontol 2015; 42 (Suppl. 16): S92–S105. doi: 10.1111/jcpe.12363.

Abstract Focused question: What is the effect of mechanical inter-dental plaque removal in addition to toothbrushing, on managing gingivitis using various formats of inter- dental self-care in adults based on evidence gathered from existing systematic reviews? Material & Methods: Three Internet sources were searched by a strategy designed to include systematic reviews on inter-dental cleaning devices. Plaque and gingivitis scores were the primary parameters of interest. Characteristics of selected papers were extracted. The potential risk of bias was estimated and the acquired evidence was graded. Results: Screening of 395 papers resulted in six systematic reviews. Two papers evaluated the efficacy of dental floss, two of inter-dental brushes (IDB), one of woodsticks and one of the oral irrigator. Weak evidence of unclear or small magnitude was retrieved that supported dental floss, woodsticks and the oral irrigator to reduce gingivitis in addition to toothbrushing. No concomitant evidence for an effect on plaque emerged. There is moderate evidence that IDBs in combination with toothbrushing reduce both plaque and gingivitis. Conclusion: Evidence suggests that inter-dental cleaning with IDBs is the most Key words: dental plaque; floss; gingivitis; effective method for inter-dental plaque removal. The majority of available stud- inter-dental brushes; Inter-dental cleaning; ies fail to demonstrate that flossing is generally effective in plaque removal. All meta-review; systematic review investigated devices for inter-dental self-care seem to support the management of gingivitis, however, to a varying extend. Accepted for publication 20 December 2014

Oral cleanliness is important for the ing it from accumulating on teeth to state that achieving ideal plaque preservation of oral health as it and gingivae (Choo et al. 2001). As control by toothbrushing, combined removes microbial plaque, prevent- a point of principle, it is reasonable with the removal of inter-dental plaque once every 24 h, is adequate to prevent the onset of gingivitis and Conflict of interest and source of funding statement inter-dental caries (Axelsson 1994, The authors declare that they have no conflict of interest. Lang et al. 1973). The rationale for This study was self-funded by the authors and their institutions. considering inter-dental cleaning as a Ethical approval was not required. separate item is related to the fact o€ D rfer, Slot and Van der Weijden have formerly received either external advisor that toothbrushing does not effi- fees, lecturer fees or research grants from companies that produce interdental clean- - ciently reach into the inter-dental ing devices. Among these were Colgate, Dentaid, GABA, Lactona, Oral B, Philips, areas between adjacent teeth result- Procter & Gamble, Sara Lee, Sunstar, and Unilever. ing in parts of the teeth that remain S92 © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Inter-dental cleaning & gingivitis control S93 unclean. The reason for this is that (Van der Weijden & Slot 2011), and discussion between members of the the inter-dental gingiva fills the thereby touching as much of the research team. This work complies embrasure between two teeth apical exposed surface as possible. with PRISMA (2014) guidelines for to their contact point. This is a Dental professionals have choices reporting systematic reviews. “sheltered” area, which is difficult to and make decisions everyday as they access when the teeth are in their provide care for patients (Suvan & Focused question normal position. The inter-dental D’Aiuto 2008). Success in delivering area, when exposed by initial inflam- evidence-based health care advice What is the effect of mechanical mation of the papillae, presents local relies heavily on the ready availabil- inter-dental plaque removal in addi- conditions, which permit the estab- ity of current best evidence. An evi- tion to tooth brushing, on managing lishment and maturation of bacterial dence-based clinical decision gingivitis using various formats of plaque. This favours periodontal dis- integrates and concisely summarizes inter-dental self-care in adults based ease, for which an effective inter- all relevant and important research on evidence gathered from existing dental hygiene helps to reduce the evidence. The model to guide a clini- systematic reviews? extension and severity (Sicilia et al. cal decision begins with original sin- 2002). Traditionally, self-care recom- gle studies at the foundation. Search strategy mendations for inter-dental cleaning Evidence-based research methodolo- most commonly have consisted of gies integrate the best available evi- For the comprehensive search strat- flossing (ADA 2014), which is prob- dence from original individual egy, electronic databases were que- ably the most universally applicable studies as its foundation and help ried. Three Internet sources were method. However, the inter-dental synthesize evidence for the reader. used to search for appropriate brush was found to have an excellent The synthesis (or systematic review) is papers that satisfied the study pur- effect both on the central part of the a comprehensive summary of all the pose. These sources included the inter-dental space and on the embra- research evidence related to a focused National Library of Medicine, sures and may remove plaque as far clinical question (Shea et al. 2007). Washington, D. C. (MEDLINE- as 2–2.5 mm below the gingival mar- By combining the results from many PubMed), the Cochrane Library gin (Waerhaug 1976). The choice of trials, it has more power to detect which also includes the DARE data- the type of technique must, however, small but clinically significant effects base of systematic reviews and the be made in relation to the character- and is a more advanced information evidence database of the ADA Cen- istics of the inter-dental spaces service in the topic area of concern ter for Evidence-based Dentistry whether they are open or closed (Walker et al. 2008). At the next regarding home care products in the (Sicilia et al. 2003). level, a synopsis summarizes the find- preventive density category. All three Today numerous inter-dental ings of systematic reviews and can databases were searched for eligible cleaning devices on the market help often provide sufficient information studies up to and including August patients’ self-care needs. The pleth- to support the clinical action that 2014. The structured search strategy ora of products makes it difficult for matches the patient’s specific circum- was designed to include any system- patients to decide themselves, which stances (Dicenso et al. 2009). Such a atic review published on inter-dental is the appropriate device. But also meta-review or “overview of reviews” cleaning devices. For details regard- for the dental professional, it can be is a systematic review that includes ing the search terms used, see Box 1. challenging to give individualized only systematic reviews, and is suit- All of the reference lists of the recommendations to patients about able whenever relevant systematic selected studies were hand searched the appropriate selection and use of reviews are available (Sarrami-Foro- for additional published work that these devices. Patient preferences ushani et al. 2014). Evidence-based could possibly meet the eligibility and the expected likelihood of using research methodologies do not pro- criteria of the study. The PROS- the inter-dental cleaning product is vide answers, but rather, they are a PERO (2014) database, an interna- one aspect to consider. Another is tool, a form of information and guid- tional database of prospectively the knowledge about the evidence ance based on research evidence that registered systematic reviews, was specific to each device and the assists the clinician in formulating the checked for reviews in progress. Fur- expected results from using the answer appropriate for each individ- ther unpublished work was not device. An ideal inter-dental cleaning ual patient (Suvan & D’Aiuto 2008). sought. device should be user friendly, The purpose of the present meta- remove plaque effectively and have review was to summarize and Inclusion and exclusion criteria no deleterious soft-tissue or hard- appraise the evidence emerging from The inclusion criteria were as tissue effects. However, not all inter- systematic reviews on the efficacy follows: dental cleaning devices suit all of various inter-dental devices for patients, all types of dentitions and mechanical plaque control in manag- • Systematic reviews with or with- even not every inter-dental space. ing gingivitis. out a meta-analysis The dental professional should, • Papers written in the English, Ger- therefore, navigate the patient to the man, French or Dutch language Material and Methods optimal devices tailored to their spe- • Reviews evaluating studies con- cific needs. Good inter-dental oral The protocol of this meta-review ducted in humans hygiene requires a device that can detailing the evaluation method was s ≥18 years old penetrate between adjacent teeth developed “a priori” following initial s In good general health © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd S94 Salzer€ et al.

Box 1 Search terms used for PubMed-MEDLINE, Cochrane Library and ADA Center for Evidence-based Dentistry The search strategy was customized appropriately according to the database being searched taking into account differences in controlled vocabulary and syn- tax rules. The following strategy was used in the search inter-dental cleaning devices: {[MeSH terms] (Home Care Dental Devices) OR [text words] floss OR (Dental floss) OR Flossing OR Tape OR (Dental tape) OR Superfloss OR Ultrafloss OR (Interdental cleaning devices) OR (Interproximal cleaning devices) OR (Interspace cleaning devices) OR toothpick* OR woodstick* OR woodpoint* OR (wooden interdental cleaner) OR (wedge stimulator*) OR (wooden stimulator*)OR (rubber interdental stimulator) OR (interdental stimulator) OR (gingival stimulator) OR (interproximal brushing) OR (interproximal brushes) OR (interproximal brush) OR (interproximal brush*) OR (interproximal cleaning devices) OR (interdental brushing) OR (interdental brushes) OR (interdental brush) OR (interdental brush*) OR proxabrush OR (interspace brushes) OR (interspace brush) OR (interspace brush*) OR (interspace brushing) OR proxabrush OR (dental water jet) OR (water pick) OR (water pik) OR waterpik OR (perio pik) OR (pick pocket) OR pickpocket OR (pik pocket) OR (oral irrigation) OR (oral irrigator) OR (oral irrigation jet) OR (water jet irrigator) OR (monojet oral irrigator) OR (subgingival irrigation) OR (subgingival tip) OR (dental irrigator) OR (dental irrigation) OR airfloss OR softpick OR softpik OR (power interdental cleaning) OR (electric interdental cleaning) OR (mechanical interdental cleaning)} Used filter/limits: systematic review OR meta-analysis

The asterisk (*) was used as a truncation symbol.

• Intervention: inter-dental self-care • Methodological heterogeneity Grading the “body of evidence” products for controlling plaque (variability in study design and The Grading of Recommendations and/or managing gingivitis. risk of bias) Assessment, Development and Evalu- • Analysis performed (Descriptive ation (GRADE) system, as proposed The exclusion criteria were as fol- or Meta-analysis). by the GRADE working group, was lows: used to grade the evidence emerging from this meta-review of systematic • Orthodontic patients Quality assessment reviews (GRADE 2014). Two review- • Dental implants ers (GAW & DES) rated the quality Two reviewers (DES & SS) estimated of the evidence as well as the strength At the outset of this meta-review, the risk of bias by scoring the report- of the recommendations according to no attempt was made to separate ing and methodological quality of the the following aspects: Study design, specific variables associated with included systematic reviews according risk of bias; consistency and precision inter-dental cleaning. to a combination of items described among outcomes; directness of by the PRISMA (2014) guideline for results, detection of publication bias reporting systematic reviews and the and magnitude of the effect. Screening and selection (AMSTAR 2014) checklist for assess- ing the methodological quality of sys- Two reviewers (DES & SS) inde- Results pendently screened the titles and tematic reviews. A list of 27 items was assessed and if all individual items abstracts for eligible papers. If eli- Search & selection results gibility aspects were present in the were given a positive rating by sum- title, the paper was selected for fur- ming these items an overall score of The searches resulted in 395 unique ther reading. If none of the eligibil- 100% was obtained. Only systematic papers (for details, see Fig. 1) out of ity aspects were mentioned in the reviews including meta-analysis could which six full-text articles were title, the abstract was read in detail achieve a full score of 100% (Hidding obtained and screened to confirm eli- et al. 2014). The estimated risk of bias gibility. Hand searching of the refer- to screen for suitability. After selec- – tion, the full-text papers were read was interpreted as follows: 0 40% ence lists did not reveal any may represent a high risk of bias; additional suitable systematic in detail by two reviewers (DES & – SS). Any disagreement between the 40 60% may represent a substantial reviews. Neither did the PROSPERO risk of bias; 60–80% may represent a database (2014). As a result, a final two reviewers was resolved after – additional discussion. The papers moderate risk of bias 80 100% a low six studies were selected to be that fulfilled all of the selection risk of bias. included in this meta-review, out of criteria were processed for data which two papers were identified extraction. which evaluated the efficacy of Data extraction dental floss, two papers on inter- Information extracted from the stud- dental brushes, one on woodsticks Assessment of heterogeneity ies included publication details, and one evaluating the oral irrigator. focused question, search results, The heterogeneity across studies was descriptive or (weighted) mean out- detailed according to the following comes and conclusions. Disagree- Assessment of heterogeneity factors: ments between the reviewers (DES & Considerable heterogeneity was • Study and subject characteristics SS) were resolved by discussion. observed in the six systematic

ity criteria. The majority of these Cochrane-Library PubMed-MEDLINE ADA-EBD 97 328 53 studies showed that there was no beneﬁt from ﬂoss on plaque scores (7 of 10 studies) and no effect on clinical parameters of gingivitis (8 of Identification 8 studies). From the collective data of the studies, it appeared possible to perform a meta-analysis evaluat- Unique Excluded by ing plaque and gingival index scores. Ɵtle and abstract title & abstracts 389 Baseline scores were not statistically 395 different. Comparing toothbrushing

Screening and flossing against toothbrushing only, the Quigley & Hein plaque index (Quigley & Hein 1962) weighted mean difference (WMD) was À0.04 (95% CI: À0.12; 0.04, Excluded aŌer Selected p = 0.39) and the Lo€e & Sillness gin- for full-text full text reading reading gival index (Loe€ & Silness 1963). 0 6 À À Eligibility WMD was 0.08 (95% CI: 0.16; 0.00, p = 0.06). End scores also Included from the showed no significant differences reference list or PROSPERO database between those groups that flossed in (2014) comparison with those that did not Final selecƟon floss for the Quigley & Hein plaque 6 (WMD: À0.24, 95% CI: À0.53; 0.04, Included p = 0.09) or Lo€e & Sillness gingival Index (WMD: À0.04, 95% CI: À0.08; 0.00, p = 0.06). Dental Floss Woodsticks Interdental brushes Oral irrigator More recently, also the Cochrane 2 1 2 1 Oral Health group evaluated the effects of flossing in combination with toothbrushing, as compared Analyzed with toothbrushing alone, in the management of periodontal diseases Fig. 1. Search and selection results. in adults (Sambunjak et al. 2011). Twelve trials were included in this reviews with respect to the databases et al. 2013). Critical items in this review, with a total of 582 partici- searched, study and subject charac- evaluation were found to be the pants in the flossing plus toothbrush- teristics of the original individual development of a protocol “a priori” ing (intervention) groups and 501 papers description of inclusion and and its registration, searches in addi- participants in toothbrushing (con- exclusion criteria, quality assessment tional sources including non-English trol) groups. All included trials scale used, reporting of effect scores, literature, contacting of authors of reported the outcomes of plaque and presence of meta-analysis and con- included papers for additional infor- gingivitis. Seven of the included clusions made. Information regard- mation, grading obtained evidence trials were estimated as having an ing the included papers is displayed and the assessment of publication unclearriskofbiasandfivewere in detail in Table 1. Various clinical bias. considered to have a high risk of indices and their modifications have bias. The results of the meta-analyses been evaluated. are presented as standardized mean Study outcomes results differences (SMD), which do not Quality assessment Table 1 shows the results from the relate to tangible differences in data extraction. The conclusion of clinical indices. With regard to the Estimation of the risk of bias by the original review authors and the reduction of gingivitis, there seems to scores related to the reporting comments of the authors of this syn- be some evidence that flossing in and methodological quality of the opsis together with a descriptive combination with toothbrushing pro- included systematic reviews is pre- summary are presented for each vides a statistically significant benefit sented in Table 2. Four reviews were inter-dental device. in reducing gingivitis compared with considered to have a moderate esti- toothbrushing alone. To help inter- Dental floss mated potential risk of bias (Berchier pret the magnitude of the effect, the et al. 2008, Hoenderdos et al. 2008, Berchier et al. (2008) evaluated the data retrieved by different indices Husseini et al. 2008, Slot et al. 2008). effect of flossing as an adjunct to were standardized in translating Two more recent Cochrane reviews toothbrushing. Independent screen- them back to the most commonly had a low estimated risk of bias ing of titles and abstracts resulted in reported gingivitis index. The 1- (Sambunjak et al. 2011, Poklepovic 11 publications that met the eligibil- month SMD estimate back translates © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Table 1. Overview of the characteristics of the included systematic reviews processed for data extraction S96 Device ID Author (year) Databases searched Number of included Mode of analysis Original review authors’ COMMENTS of the Up to studies/trails (methodology of conclusions synopsis authors # participants meta-analysis, S le tal. et alzer € descriptive analysis)

Dental Floss Berchier et al. 2008 PubMed-Medline 11 studies Meta-analysis The dental professional Two included studies Cochrane CENTRAL 559* participants Weighted Mean should determine, on reported the same December 2007 Difference an individual patient experiment, however, Descriptive analysis basis, whether high-quality with two different with vote counting flossing is an achievable goal. observational periods. In light of the results of this comprehensive literature search and critical analysis, it is concluded that a routine instruction to use floss is not supported by scientific evidence.

Sambunjak et al. 2011 Ovid-Medline 12 trials Meta-analysis There is some evidence from 12 studies Two studies included OVID-EMBASE 1083 participants Standardized Mean that flossing in addition to toothbrushing a control group using Cochrane CENTRAL Difference reduces gingivitis compared to a 5% hydro alcohol. Cochrane OHG trails toothbrushing alone. There is weak, One study included LILAC-BIREME very unreliable evidence from 10 an intervention group CINAHL-EBSCO studies that flossing plus toothbrushing using a hummingbird ZETOC may be associated with a small reduction power flosser which is

05Jh ie osAS ulse yJh ie osLtd Sons & Wiley John by Published A/S. Sons & Wiley John 2015 mRCT reported the effectiveness of ﬂossing plus rubber stimulator. clinicaltrails.gov toothbrushing for preventing dental caries. October 2011

Woodsticks Hoenderdos et al. 2008 PubMed-Medline 8 experiments Descriptive analysis Evidence from controlled trials, No statistical analysis Cochrane CENTRAL 438* participants with vote counting most of which were also could be performed. February 2008 randomized, shows that Only triangular woodstick woodsticks do not have an were evaluated. additional effect on visible inter-dental plaque or gingival index, but do, however, provide an improvement in inter-dental gingival inﬂammation by reducing the bleeding tendency. © Table 1. (continued) 05Jh ie osAS ulse yJh ie osLtd Sons & Wiley John by Published A/S. Sons & Wiley John 2015 Device ID Author (year) Databases searched Number of included Mode of analysis Original review authors’ COMMENTS of the Up to studies/trails (methodology of conclusions synopsis authors # participants meta-analysis, descriptive analysis)

Inter-dental Slot et al. 2008 PubMed-Medline 9 experiments Meta-analysis As an adjunct to brushing, the No subanalysis provide Brushes Cochrane CENTRAL 510* participants Weighted Mean inter-dental brush removes more based on the shape of November 2007 Difference dental plaque than brushing alone. the inter-dental brush Descriptive analysis Studies showed a positive significant with vote counting difference using inter-dental brush with respect to the plaque scores, bleeding scores and probing pocket depth. The majority of the studies presented a positive significant difference in the plaque index when using the inter-dental brush compared with floss.

Poklepovic et al. 2013 Ovid-Medline 7 trials Meta-analysis Only one study looked at One included study OVID-EMBASE 354 participants Standardized Mean whether toothbrushing concerns brush picks, Cochrane CENTRAL Difference with inter-dental brushing which is not an Cochrane OHG trails was better than toothbrushing inter-dental brushes LILAC-BIREME alone, and there was very but a plastic toothpick CINAHL-EBSCO low-quality evidence for a with plastic ﬁlaments ZETOC reduction in gingivitis and Web of science plaque at 1 month. There mRCT is also low-quality evidence

clinicaltrails.gov from seven studies that control gingivitis & cleaning Inter-dental March 2013 inter-dental brushing reduces gingivitis when compared with flossing, but these results were only found at 1 month. There was insufficient evidence to determine whether inter-dental brushing reduced or increased levels of plaque when compared to flossing.

Oral Irrigator Husseini et al. 2008 PubMed-Medline 7 experiments Descriptive analysis As an adjunct to brushing, the No differentiation Cochrane CENTRAL 590* participants with vote counting oral irrigator does not have a between different January 2008 beneﬁcial effect in reducing oral irrigator visible plaque. However, technologies was made. there is a positive trend in favour of oral irrigation improving gingival health over regular oral hygiene or toothbrushing only. S97 *Calculated by the review authors. S98 Salzer€ et al.

Table 2. Estimated the risk of bias by scoring a list of items related to the reporting and methodological quality of the included systematic reviews Author Berchier Sambunjak Hoenderdos Slot Popklevic Husseini (year) et al. et al. et al. et al. et al. et al. Quality criteria: 2008 2011 2008 2008 2013 2008 Interdental Interdental Oral Interdental oral hygiene device Dental Floss Dental Floss Woodsticks brush brush Irrigator 1) Defined outcome criteria of interest + + + + + +

2) Describes the rationale + + + + + + 3) Describes the focused (PICO)[S] question / hypothesis + + + + + + 4) Describes if a protocol was developed ‘a pirori’. – + – – + – 5) Protocol registration/publication NA + NA NA + NA 6) Presented eligibility criteria (in/exclusion criteria) + + + + + + 7) Presents the full search strategy + + + + + +

8) Various databases searched + + + + + + 9) Performed (hand) search in additional – + – – + – sources (f.i. grey literature or trial 10) Review selection by more than 1 reviewer + + + + + + 11) Non-English papers included – + – – + – 12) Provide details on the performed study selection process/ flow chart + + + + + + 13) Report included study characteristics + + + + + + 14) Provide data of the selected studies on the outcome measures of interest + + + + + + 15) Data were extracted by more than 1 reviewer + + + + + + 16) Contacted authors for additional information – + – – + – 17) Report heterogeneity of the included studies + + + + + + 18) Estimated risk of bias in individual studies + + + + + + 19) Performed a meta analysis + + – + + –

20) Performed a descriptive analysis + ± + + ± +

21) Describe additional sub analysis – + + + + +

22) Grading of the obtained evidence – + – – + – 23) Present limitations of the systematic review – + – – + – 24) Provide a conclusion that respond to the objective + + + + + + 25) Publication bias assessed – + – – + –

26) Funding source – + – – + –

27) Conflict of interest statement – + – – + – Original Review authors estimated level Not Weak, very Not Not Very low Not of evidence reported unreliable reported reported quality reported Synopsis authors estimated quality score 62% 96% 62% 65% 96% 62% Synopsis authors estimated risk of bias moderate low moderate moderate low moderate

Each aspect of the reporting and methodological quality item score list was given a rating of a plus “+” for informative description of the item at issue and a study design meeting the quality standard was assigned, plus-minus (Æ) was assigned if the item was incompletely described, and minus “À” was used if the item was not described at all (Hidding et al. 2014). NA = not applicable. For the quality assessment score individual items with a positive rating were summed to obtain an overall percentage score.

Table 3. Estimated evidence proﬁle (GRADE 2014) for the effect of various methods and aspects of inter-dental mechanical plaque removal

to a 0.13-point reduction on a 0- to drical, conical or other shapes of other indices (Quigley & Hein plaque 3-point scale for Loe€ & Silness gingi- inter-dental brushes. Synonyms used index (1962), bleeding on probing,) vitis index (1964), and the 3- and 6- in different countries are “interproxi- were not statistically significant. The month results translate to a 0.20 and mal brush” or “mini-inter-dental heterogeneity observed with the Sil- 0.09 reduction respectively. Although brush”. There may be even more. ness & Loe€ plaque index (p = 0.001, the differences are statistically signifi- However, single tufted brushes and I2 = 85.4%) reflects the different cant, the difference is minor which inter-dental cleaning devices without behaviours of the study populations questions the clinical relevance even a twisted wire as stem were not to the study product, differences in more when considering the very low regarded as inter-dental brushes and study designs and other factors that level of evidence. not taken into account. Slot et al. may have influenced the outcome. (2008) evaluated the differences Slot et al. (2008) showed that inter- Woodsticks between inter-dental brushes and var- dental brushes are a useful device to Hoenderdos et al. (2008) evaluated ious intervention strategies in a sys- complement toothbrushing. The evi- the effect of woodsticks in combina- tematic review. All three studies that dence suggests that inter-dental tion with toothbrushing. After evaluated inter-dental brushes as an brushing is the most effective method screening by title and abstract 15 adjunct to toothbrushing showed a to interdentally remove plaque. papers were selected for full-text significant difference in favour of the More recently also the Cochrane reading of which 10 papers had to additional use of inter-dental brushes Oral Health group evaluated the be excluded. Three additional papers for plaque removal as compared to effect of inter-dental brushing in addi- were retrieved from the reference brushing alone. The majority (8 of 13 tion to toothbrushing, as compared lists. After full-text reading, seven studies) of the studies showed a posi- with toothbrushing alone (Poklepovic publications with eight clinical exper- tive significant difference on the pla- et al. 2013). Only one study with an iments met the eligibility criteria and que index when using inter-dental estimated high risk of bias was provided data. No meta-analysis brushes relative to floss. No clear retrieved that looked at this compar- could be performed. In their qualita- benefits over toothbrushing alone ison. The low-quality evidence that tive summary in nine of 10 studies with regard to the gingival index (1 of emerged from this review, which that scored plaque no significant 5 studies) or bleeding indices (0 of 6 was evaluated in a meta-analysis advantage was demonstrated with studies) were observed. Inter-dental using a statistical approach with the respect to the use of woodsticks in brushes remove more dental plaque standard mean difference (SMD), combination with toothbrushing, as than woodsticks, as shown by one of showed a significant reduction in opposed to toothbrushing alone. the two comparative studies. From plaque and gingivitis. Back translat- However, in three of three studies the collective data of the studies, a ing the SMD outcome, the authors reporting gingivitis data, they meta-analysis appeared to be possible concluded that this represents a 34% observed a statistically significant for the comparison of inter-dental reduction in gingivitis and a 32% improvement in inter-dental gingival brushes to floss as adjuncts to manual reduction in plaque. Seven selected inflammation by a reduced tendency toothbrushing. In all instances, there studies provided data on inter-dental of bleeding upon probing by the use was no statistically significant differ- brushing in addition to toothbrush- of triangular woodsticks. ence for the baseline scores. End ing, as compared with toothbrushing scores only showed a significant effect and flossing showing a reduction in Inter-dental brushes when evaluated according to the Sil- gingivitis in favour of inter-dental The term “inter-dental brush” was ness & Loe€ plaque index (1964) in brushing at 1 month: This translated used for brushes with a helical align- favour of the inter-dental brush group to a 52% reduction in gingivitis ment of filaments fixed to a twisted relative to the floss group (WMD: (Eastman Inter-dental Bleeding central wire. The filaments may vary À0.48, 95% CI: À0.65; À0.32, Index (Caton & Polson 1985). in lengths and, therefore, form cylin- p < 0.00001). Comparisons using Although a high effect size in the © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd S100 Salzer€ et al. same direction was observed at bacterial populations that adhere presence of an inflationary increase 3 months, the confidence interval of organisms together and adhere to of systematic reviews and gives the the meta-analysis did not exclude the surfaces or interfaces. A bacterial dental community better guidance. It possibility of no difference. There biofilm is the common cause of a is in that sense a step forward in the was insufficient evidence to claim a number of human diseases. Recently, direction of a clinical guideline. benefit for inter-dental brushing over an enormous increase in knowledge Toothbrushing is successful in flossing for reducing plaque. about the complexity and the tena- removing plaque at buccal, lingual ciousness of the oral biofilm as well and occlusal surfaces, but does not Oral irrigator as on its essential role in maintaining reach the inter-dental areas of teeth, Husseini et al. (2008) performed oral health has been demonstrated resulting in parts of the teeth that a systematic review on the efficacy (Marsh 2000). Although the biofilm remain unclean. Good inter-dental of oral irrigation in addition to appearance depends upon the condi- oral hygiene requires a device that toothbrushing. Screening of 813 tions of the host, it also varies can penetrate between adjacent teeth titles and abstracts initially resulted between specific sites. What is in (van der Weijden & Slot 2011). The in 27 full-text papers. In total, 20 common is the need for mechanical current meta-review intended to eval- studies were excluded, searching the removal, however, not with the sim- uate various inter-dental oral hygiene reference lists of the selected studies ple aim of complete removal but products with the goal to provide resulted in no new papers. Conse- more a sense of cultivating and shap- guidance for clinical decision making. quently, seven studies were identified ing the oral biofilm and supporting as eligible for inclusion in this the bacterial haemostasis (Marsh Dental floss review according to defined eligibil- et al. 2011). In the inter-dental space, ity criteria. Due to their heterogene- the access to the colonized surfaces is Based on the individual papers as ity, the data prevented quantitative crucial for the success of the preven- retrieved in the review by Berchier analysis, and a descriptive analysis tive measure. One of the challenges et al. (2008), a trend was observed of the selected studies was pre- of measuring the efficacy of inter- that indicated a beneficial adjunctive sented. Six of seven selected studies dental cleaning aids is that these sites effect of floss on plaque levels. How- showed no differences between are not directly visible in their full ever, this could not be substantiated toothbrushing in combination with extension and – in addition to the in the meta-analyses. Routine recom- the use of an oral irrigator and general shortcomings of measuring mendation to use floss was not con- toothbrushing or regular oral intra-oral plaque removal clinically – sidered to be supported by scientific hygiene. One study provided incon- evaluations have to rely on areas evidence. More recently, Sambunjak clusive data. Three of five studies being the margin of the inter-dental et al. (2011) in their Cochrane review that presented data on bleeding space only. found that in terms of reducing gin- scores showed significant reductions Following the idea of evidence- gival inflammation, flossing plus in the oral irrigator group compared based dentistry, the highest degree of toothbrushing showed a statistically to the control oral hygiene group. scientific evidence is the presence of significant benefit compared to When focusing of the comparison a systematic review. Emphasizing the toothbrushing alone. Harms and with regular oral hygiene three of necessity for high evidence resulted adverse effects were reported in five three showed a significant beneficial in an increasing number of system- studies. The most frequent harm effect. For gingivitis, this was three atic reviews, often on the same or identified was soft tissue/gingival of four studies. The authors con- similar subjects. However, the evi- trauma, a reversible event. Most cluded that as an adjunct to brush- dence of a systematic review depends patients would avoid flossing in trau- ing, the oral irrigator provides a on the quality of the studies, which matized areas and the areas would positive trend in favour of oral irri- were reviewed, a fact, which is often heal. The desirable benefits of floss- gation improving gingival health not discussed in systematic reviews, ing in reducing gingivitis seem to over regular oral hygiene. as the quality is primarily related to outweigh the potential harms. the rigidness of methodology to However, grading the evidence it minimize bias. In the case of no new was determined to be of very low Grading the “body of evidence” data to review, it is, therefore, help- quality. It implies that the evidence The evidence which emerges from this ful to make a synopsis of the system- flossing to effectively reduce gingivi- systematic meta-review indicates that atic reviews already published tis is very low and the evidence to there is moderate evidence to support instead of re-reviewing the same suggest that flossing reduces plaque the efficacy of inter-dental brushes on published data with the same meth- is unreliable (Matthews 2012). The plaque removal and reduction of gin- odology. Recently, a structured pro- Cochrane review agreed with the givitis (table 3). There is weak evi- cedure, similar to the methodology Berchier et al. (2008) findings with dence supporting the use of dental of a systematic review (Sarrami- respect to plaque removal. However, floss, woodsticks and the oral irrigator. Foroushani et al. 2014), was devel- it found a small but statistically sig- oped to evaluate and embrace nificant benefit for flossing in reducing gingivitis. Both systematic Discussion already published systematic reviews and to help the reader to understand reviews (Berchier et al. 2008, Sam- The human oral cavity contains the strengths and limitations of such bunjak et al. 2011) had seven of the microorganisms in the form of bio- publications. This next step, known 12 articles in common and one study films which are matrix-enclosed as a meta-review, is necessary in the was common in the meta-analysis. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Inter-dental cleaning & gingivitis control S101

Different outcomes would be available. When used on a dentition Inter-dental brush expected with different studies with a reduced but inflammation free The systematic review by Slot et al. included (Bowen 2012). Sambunjak periodontium, woodsticks depress (2008) highlights the effectiveness of et al. (2011) used a broader study the gingivae by up to 2 mm and, inter-dental brushes as an adjunct to selection and included two studies therefore, clean parts of the subgin- toothbrushing for plaque removal in with a control group using a 5% gival area (Morch & Waerhaug adult patients. The evidence derived hydro alcohol and one study that 1956). The systematic review by Ho- from this review supports recom- included as intervention the hum- enderdos et al. (2008) focuses on the mendations by dental care profes- mingbird power flosser. This is, in effectiveness of woodsticks as an sionals for their patients to use fact, not a string of dental floss but adjunct to toothbrushing for plaque inter-dental brushes in addition to a motorized rubber inter-dental stim- removal in adult patients. Data toothbrushing since it reduces dental ulator. The differences between the analysis revealed considerable heter- plaque (Rasines 2009). The studies two systematic reviews, therefore, ogeneity in many aspects of the also presented a positive significant may be explained by the different included studies and, therefore, a difference in the plaque index when study selection and the more positive meta-analysis could not be carried using inter-dental brushes as com- valuation of the more recent system- out. Descriptive analysis indicated pared to floss. Included studies, atic review does not necessarily rela- that hand-held triangular woodsticks however, show that there was no tivize the conclusion of the Berchier do provide an improvement in inter- difference in gingival inflammation systematic review with respect to the dental gingival inflammation by or bleeding. Criteria for selecting use of dental floss in the more com- reducing the bleeding tendency. adult patients varied throughout the mon understanding. However, no evidence for a concom- studies. Health status was omitted That dental floss has limited itant effect on visible inter-dental in three studies, and health status additional effects as adjunct to plaque was retrieved. Of the seven was reported as “good general toothbrushing is apparent from studies included for data abstraction, health” in six studies with no spe- more than one review. Hujoel et al. four were of a crossover design and cific exclusion criteria. Although all (2006) found that flossing was only four of a parallel arm. One study studies included patients, who had effective in reducing the risk of included both designs. The study inter-dental spaces that could interproximal caries when applied sizes ranged from 10 to 161 subjects accommodate use of an inter-dental professionally. This absence of evi- and control groups were toothbrush- brush, three studies did not report dence on caries reduction was sub- ing only or either in combination on the subjects’ periodontal status. stantiated by Sambunjak et al. with dental floss or inter-dental The diversity in selection of study (2011). Although the systematic brush. The indices used for plaque subjects was considerable among reviews did not strongly support and bleeding also differed between these nine studies and may have flossing as a useful periodontal self- the studies. With the lack of correla- affected the strength of the conclu- care adjunct, the very low evidence tion between the collected data, it is sions of the review (Gluch 2012). for the efficacy, however, does not clear that more studies with larger On the other hand, the sample size preclude the use of floss. For numbers of subjects and study of the different trials can be consid- instance, in inter-dental situations designs are needed to clarify the effi- ered large enough to allow identifi- that only allow for the penetration cacy of woodsticks on plaque reduc- cation of statistically and clinically of a string of dental floss, floss is tion and their effect on gingival significant differences (Rasines the best available tool. Although inflammation. With the limited data 2009). floss should not be the first tool rec- within this review, it is difficult to More recently, in their Cochrane ommended for cleaning open inter- draw a meaningful conclusion on the review, Poklepovic et al. (2013) dental spaces, if the patient does not efficacy of woodsticks (Tucker 2009). retrieved with respect to inter-dental like any other tool, flossing could still The explanation suggested for reduc- brushes seven studies (total 354 be part of oral hygiene instruction. tion of bleeding scores but the lack participants analysed). Only one of The dental professional should realize of evidence of a concomitant effect the included studies reported on the that proper instruction, sufficient on plaque scores is that the papillary objective comparing toothbrushing motivation of the patient and a high area with the greatest inflammation with and without inter-dental level of dexterity are necessary to corresponds to the middle of the brushing. The review found very make the flossing effort worthwhile inter-dental tissue (Walsh & Heck- low-quality evidence that inter-den- (Hujoel et al. 2006). Routine instruc- man 1985), which is not accessible tal brushing plus toothbrushing is tion in using floss is not supported for direct visualization. It was also more beneficial than toothbrushing by scientific evidence. The dental care suggested that bleeding following the alone for gingivitis and plaque at professional should therefore deter- use of woodsticks can be used to 1 month. There was also low-quality mine, on an individual patient basis, increase patient motivation and evidence from seven studies that whether high-quality flossing is an awareness of gingival health. Several inter-dental brushing reduces gingivi- achievable goal. studies have illustrated the clinical tis when compared with flossing, but effectiveness of gingival self-assess- these results were only found at ment (Walsh et al. 1985). The pres- Woodsticks 1 month. There was insufficient evi- ence of bleeding provides immediate dence to determine whether inter- Woodsticks can be used effectively feedback on the level of gingival dental brushing reduced or increased where sufficient inter-dental space is health. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd S102 Salzer€ et al. levels of plaque when compared to Oral irrigator research the effectiveness of the oral flossing. Heterogeneity was substan- The oral irrigator is one of the oral irrigator as an adjunct to regular oral tial for both the gingivitis and pla- hygiene aids developed to enhance hygiene measures for controlling the que analyses probably due to the effectiveness of plaque control plaque biofilm and long-term mainte- methodological and clinical variabil- and to bring benefits for gingival nance of gingival health, to explore ity between the studies. One included health. Oral irrigators are designed the mechanisms involved (Jin 2009). study concerns brush picks which to disturb and remove plaque and The included systematic review are not inter-dental brushes but a soft debris through the mechanical on oral irrigators did not evaluate plastic toothpick with plastic fila- the specially designed blunt-ended action of a stream of water. There â ments. The two systematic reviews has been considerable controversy cannulae (Pik Pocket subgingival on inter-dental brushes (Slot et al. regarding the appropriate use and irrigation tip - WaterPik Technolo- 2008, Poklepovic et al. 2013) had efficacy of this instrument (van der gies, Fort Collins, CO, USA). five papers in common. The Weijden & Slot 2011). Husseini et al. difference in selection was due to (2008) systematically reviewed the Appraisal of the evidence alternative inclusion criteria and it is literature on the adjunctive effect of recognized that different studies will the oral irrigator in addition to A meta-review is a systematic over- provide different outcomes (Bowen toothbrushing on controlling plaque view of reviews, in which an attempt 2012). and bleeding index gingival inflam- is made to include all available sys- The result of a scanning electron mation and pocket probing depth. tematic reviews and to undertake rig- microscopic study of fourteen inter- Unfortunately, the selected studies orous appraisal on each of the dental brushes showed that all could not generate sufficient data to systematic reviews included (Sarrami- products had an insufficient finish perform a meta-analysis. Despite Foroushani et al. 2014). The list of of bristle ends. It showed that these limitations, descriptive analysis appraisal criteria was based on a inter-dental brushes have besides suggests that the oral irrigator, as an combination of items described by the beneficial effect a potential of a adjunct to toothbrushing, does the PRISMA (2014) guideline for damaging the periodontal tissues improve gingival health more than reporting systematic reviews and the which has however so far not been regular oral hygiene measures or AMSTAR (2014) checklist for assess- shown ‘in vivo’ (Reiter & Wetzel toothbrushing alone, although no ing the methodological quality of sys- 1991). evidence for a beneficial effect in tematic reviews. The outcome of the A variety of IDB shapes and sizes reducing visible plaque was retrieved. adapted checklist is presented in are required in clinical practice to More recently, a 4-week study indi- Table 2 which shows the estimated accommodate all inter-dental spaces. cated that when combined with man- risk of bias to be mainly low to mod- Schmage et al. (1999) assessed the ual toothbrushing the daily use of an erate. For the next level of appraisal relationship between the inter-dental oral irrigator is significantly more that is the body of evidence, which space and the position of the teeth. effective in reducing gingival bleed- emerges from this systematic meta- Most of the inter-dental spaces in ing scores than is the use of dental review, the GRADE (2014) criteria the anterior teeth are small and sized floss (Rosema et al. 2011). were used indicating that there is for the use of floss. Premolars and The exact mechanisms of action moderate evidence in support of the molars have larger inter-dental accounting for these observations efficacy of inter-dental brushes on spaces and are accessible with inter- remain unclear. Although oral irriga- plaque removal and reduction of gin- dental brushes. In addition, the main tion does not generate a beneficial givitis. There is weak evidence in sup- advantage of inter-dental brushes lies effect by reducing visible plaque, it porting the use of dental floss, in their superiority in reaching inter- may flush away only loosely adhered woodsticks and the oral irrigator. dental groves or fissures, which can plaque and thus interfere with matu- physically not be touched by any ration of the microbial biofilm every Patient compliance other inter-dental cleaning device. day, therefore, and to some extent This morphological component had modifying its components virulence There is not one aid that works for not been used in any of the studies factors. Another possible effect is the all. There is also not one aid that published so far. This makes match- mechanical action of a jet stream of does not work for anyone. Best care ing in the random assignment and a wateranditspulsations,whichmight for each patient rests neither in clini- true comparison among products reduce the levels of inflammatory cian judgement nor scientific evi- difficult; hence, the grouping of all mediators in the gingival crevice/ dence but rather in the art of inter-dental brushes into one cate- pocket, and alter the gingival response combining the two through interac- gory (Gluch 2012). to microbial challenge, thereby con- tion with the patient to find the best No systematic reviews were tributing to improved gingival option for each individual (Suvan & retrieved which appraised aspects homeostasis and health (Chaves et al. D’Aiuto 2008). This meta-review that have been evaluated in individ- 1994, Flemmig et al. 1990, Frascella provides a summary of the achiev- ual studies such as angled or straight et al. 2000). It is also conceivable that able efficacy of inter-dental oral inter-dental brushes (Jordan et al. any benefit of the oral irrigator in hygiene devices adjunctive to brush- 2014), waist-shaped inter-dental reducing inter-dental plaque may be ing under the uniform conditions of brushes (Chongcharoen et al. 2012), undetectable clinically. Further well- a RCT. Due to the extreme variety hard or soft filaments (Wolff et al. designed RCTs are warranted to in morphology, accessibility, individ- 2006), durability (Hotta et al. 2004). © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Inter-dental cleaning & gingivitis control S103 ual skills and preferences, the results characteristics of the spray and the ent in the form of systematic reviews have to be translated to the unique design of the nozzles (Sharma et al. with respect to the efficacy of vari- conditions in daily practice. In gen- 2012b,a), as well as an inter-dental ous inter-dental devices for mechani- eral, to apply any evidence to clinical device constructed of a plastic core cal plaque control in managing practice, communication with the with soft elastomeric fingers protrud- gingivitis. There is weak evidence patient, use of clinical judgment and ing perpendicularly (Yost et al. 2006, that flossing plus toothbrushing common sense are key steps. Clini- Abouassi et al. 2014). However, due compared to toothbrushing alone cians should collaborate with to a limited body of published data, has a small but significant effect on patients to determine the best oral a detailed and systematic evaluation gingivitis. However, there is a lack hygiene methods given the patients’ of the evidence for these devices is of evidence for a concomitant reduc- preferences and skill level. This is not possible. Future systematic tion in plaque scores. The evidence even more important in this topic, reviews should include the evalua- for woodsticks and toothbrushing as where patient acceptance is a major tion of these new inter-dental clean- compared to toothbrushing alone issue to be considered when it comes ing devices to help guide the dental was weak and showed that there is a to the long-term use of inter-dental care professional in making an evi- benefit of unclear magnitude with cleaning devices (Warren & Chater dence-based decisions. respect to bleeding scores but lacking 1996). For instance, flossing has dis- evidence for a concomitant reduction advantages, in that it is an addi- of plaque. Moderate evidence was tional expense, is time consuming Limitations available for the efficacy of inter- and thus negatively influences the dental brushes in addition to tooth- ability or desire of many patients to • The available evidence as col- brushing as compared with tooth- participate in this activity (Drisko lected in the systematic review by brushing alone. This corresponded 2013). When patient preferences are Hoenderdos et al. (2008) with to a 34% reduction in gingivitis and evaluated comparing inter-dental regard to woodsticks only refers a 32% reduction in plaque scores, brushes and dental floss, patients to triangular shaped woodstick. when standardizing the results preferred the inter-dental brushes. No data were gathered with retrieved from the use of different The inter-dental brushes were con- respect to round or square tooth- indices. There is weak evidence that sidered to be simpler to use, despite picks. the oral irrigator plus toothbrushing their tendency to bend, buckle and • With respect to woodsticks and compared to regular oral hygiene distort (Ishak & Watts 2007). the oral irrigator, only few stud- has an effect on gingivitis. The mag- ies were available for inclusion in nitude remained unclear and it also the reviews and therefore no lacked evidence on a concomitant Inter-dental plaque assessment meta-analyses were available. reduction of plaque scores. In all Plaque reduction is a prerequisite for • Evidence of practical efficiency is there is consistent evidence that sug- an oral hygiene device to be consid- lacking and may continue to be gests that inter-dental brushes are ered valuable (Newman et al. 1994). limited due to the challenge of the most effective devices to remove The selected papers for this meta- designing studies to address these inter-dental plaque. In addition, they review report for some inter-dental areas. are appreciated best by the patients. cleaning devices no reduction in pla- • Within the evidence of the sys- que whereas a reduction of gingivitis tematic review included in this Acknowledgements was, observed. The mechanisms of analysis, there was no evidence action underlying these clinical indicating that bacteraemia follow- The initiative for this work came changes in the absence of a clear ing flossing is a concern. However, from the European Federation of effect on plaque are not fully under- there is also no evidence indicating Periodontology. Dorfer,€ Slot and stood. One explanation may be that it is not (Tomas et al. 2012). Van der Weijden have formerly the inter-dental cleaning device • As evidence pertaining to mechan- received either external advisor fees, reduces the thickness of plaque inter- ical control in patients with lecturer fees or research grants from dentally, which may not be easily implants was not in the scope of companies that produce inter-dental detectable using two-dimensional this review, it is hereby not possi- cleaning devices. Among these were scoring system which primarily scores ble to make recommendations Colgate, Dentaid, GABA, Lactona, the visible surfaces. This may be the pertaining to plaque control spe- Oral-B, Philips, Procter & Gamble, reason for an absence of an effect on cific to implants. However, Sara Lee, Sunstar and Unilever. plaque scores but a positive effect on according to a recent systematic gingival inflammation parameters. review, there appears to be an urgent need for studies on this References topic (Louropoulou et al. 2014). Abouassi, T., Woelber, J. 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Clinical Relevance Practical Implications: Good inter- number of published articles to pro- Scientific rationale for the study: dental oral hygiene requires a device vide a clear understanding of the Maintenance of effective plaque that can penetrate between adjacent topic under review. With respect to control is the cornerstone of any teeth. The choice must be made in woodsticks and the oral irrigator, attempt to prevent and control relation to the characteristics of the no meta-analyses were available. periodontal diseases. To be con- inter-dental spaces and whether they The available evidence as collected trolled, plaque must be removed are accessible or not for the particu- in the systematic review with regard frequently by mechanical self-care lar device by the respective patient. to woodsticks only refers to triangu- methods. Over the last two dec- In patients with accessible inter- lar-shaped woodstick. No data were ades, more and more systematic dental spaces the inter-dental brush gathered with respect to other reviews have been published in is the most effective inter-dental shapes of woodsticks. relation to various oral hygiene cleaning device in reducing plaque Further research: New develop- interventions and devices. System- and gingivitis. The use of floss, ments in inter-dental cleaning such atic reviews provide a synthesis woodsticks and the oral irrigator as rubber inter-dental cleaners and that embraces rigorously all pri- may be effective in controlling gingi- new technologies in oral irrigators mary research evidence that could vitis. Based on the selected system- need to be systematically evaluated. be found relevant to a particular atic reviews, it would appear that if The efficacy and safety of extra focused question. A meta-review the patient or the clinician prefers to small inter-dental brushes in summarizes the findings and impli- limit the number of inter-dental patients with intact papillae is an cations of these systematic reviews. cleaning devices, inter-dental brushes item of interest. Furthermore, the Principle findings: In the absence of of the appropriate size should be the investigation of optimized self- a concomitant effect on plaque first choice providing inter-dental performed inter-dental oral hygiene scores, there is weak evidence that spaces are accessible. around dental implants deserves dental floss, woodsticks and the Limitation: A caution to the reader investigation. Patient preference is oral irrigator reduce gingivitis in is that the strength of systematic an aspect that needs to be assessed addition to toothbrushing. Com- reviews relies on the quality of the in relation to motivation of the pared to toothbrushing alone inter- original research and the methodol- patient so that adding inter-dental dental brushes in combination with ogy of the review. Systematic reviews devices to daily oral cleaning does toothbrushing provide a significant may fail to provide strong guidance not become a stumbling block. reduction of both plaque and gingi- on the topic explored, and are some- vitis scores. times biased or contain an insufficient