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Dental Mechanical Plaque Control In  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 gingivi- tis 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 mag- nitude 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.
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