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

Abstract

BACKGROUND Dental caries and periodontal diseases (gingivitis and periodontitis) affect the majority of people worldwide, and treatment costs place a significant burden on health services. They can cause pain, eating and speaking difficulties, low self-esteem, and even tooth loss and the need for surgery. As dental plaque is the primary cause, self-administered daily mechanical disruption and removal of plaque is important for oral health. Toothbrushing can remove supragingival plaque on the facial and lingual/ palatal surfaces, but special devices (such as floss, brushes, sticks, and irrigators) are often recommended to reach into the interdental area. OBJECTIVES Primary objective was to evaluate the effectiveness of interdental cleaning devices used at home, in addition to toothbrushing, compared with toothbrushing alone, for preventing and controlling periodontal diseases, caries, and plaque. A secondary objective was to compare different interdental cleaning devices with each other. SEARCH METHODS Cochrane Oral Health’s Information Specialist searched up to 16 January 2019: Cochrane Oral Health’s Trials Register, Medline Ovid, Embase Ovid and CINAHL EBSCO. The Cochrane Central Register of Controlled Trials (CENTRAL), the US National Institutes of Health Trials Registry (ClinicalTrials. gov) and the World Health Organization International Clinical Trials Registry Platform were also searched. SELECTION CRITERIA AND DATA ANALYSIS Randomised controlled trials (RCTs) that compared toothbrushing and a home-use interdental cleaning device versus toothbrushing alone or with another device (minimum duration four weeks) were included. Indices measured on interproximal surfaces were extracted, where possible, and used for random- effects meta-analyses. MAIN RESULTS 35 RCTs (3929 randomised adult participants) were included, most of them evaluated the floss plus toothbrushing versus toothbrushing. No trials assessed interproximal caries, and most did not assess periodontitis, but more commonly they reported gingival inflammation, bleeding or plaque indices. Low-certainty evidence suggested that flossing, in addition to toothbrushing, may reduce gingivitis (measured by gingival index - GI) at one month, three months or six months; interdental brushes may reduce plaque more than toothbrushing alone; oral irrigators, instead, did not reduce bleeding sites at one month or three months, or plaque at one month, three months or six months. Interdental brushes may reduce gingivitis more than floss at one and three months (low-certainty evidence). Studies that measured adverse events found no severe events caused by devices, and no evidence of differences between study groups in minor effects such as gingival irritation. AUTHORS’ CONCLUSIONS Using floss or interdental brushes, in addition to toothbrushing, may reduce gingivitis or plaque, or both, more than toothbrushing alone. Interdental brushes may be more effective than floss. Available evidence for tooth cleaning sticks and oral irrigators is limited and inconsistent. Outcomes were mostly measured in the short term and participants in most studies had a low level of baseline gingival inflammation. Overall, the evidence was low to very low-certainty, and the effect sizes observed may not be clinically important. Future trials should report participant periodontal status according to the new periodontal diseases classification, and last long enough to measure interproximal caries and periodontitis.