Highlighted review: Home use of devices for cleaning between the teeth (in addition to toothbrushing) to prevent and control gum diseases and tooth decay

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

Plain language summary: Home use of devices for cleaning between the teeth (in addition to toothbrushing) to prevent and control gum diseases and tooth decay

Review question
How effective are home‐use interdental cleaning devices, plus toothbrushing, compared with toothbrushing only or use of another device, for preventing and controlling periodontal (gum) diseases (gingivitis and periodontitis), tooth decay (dental caries) and plaque?

Background
Tooth decay and gum diseases affect most people. They can cause pain, difficulties with eating and speaking, low self‐esteem, and, in extreme cases, may lead to tooth loss and the need for surgery. The cost to health services of treating these diseases is very high.

As dental plaque (a layer of bacteria in an organic matrix that forms on the teeth) is the root cause, it is important to remove plaque from teeth on a regular basis. While many people routinely brush their teeth to remove plaque up to the gum line, it is difficult for toothbrushes to reach into areas between teeth ('interdental'), so interdental cleaning is often recommended as an extra step in personal oral hygiene routines. Different tools can be used to clean interdentally, such as dental floss, interdental brushes, tooth cleaning sticks, and water pressure devices known as oral irrigators.

Study characteristics
Review authors working with Cochrane Oral Health searched for studies up to 16 January 2019. We identified 35 studies (3929 adult participants).

Participants knew that they were in an experiment, which might have affected their teeth cleaning or eating behaviour. Some studies had other problems that might make their findings less reliable, such as people dropping out of the study or not using the assigned device.

Studies evaluated the following devices plus toothbrushing compared to toothbrushing only: floss (15 studies), interdental brushes (2 studies), wooden cleaning sticks (2 studies), rubber/elastomeric cleaning sticks (2 studies) and oral irrigators (5 studies).

Four devices were compared with floss: interdental brushes (9 studies), wooden cleaning sticks (3 studies), rubber/elastomeric cleaning sticks (9 studies), oral irrigators (2 studies). Three studies compared rubber/elastomeric cleaning sticks with interdental brushes.

No studies evaluated decay, and few evaluated severe gum disease. Outcomes were measured at short (one month to six weeks) and medium term (three and six months).

Key results
We found that using floss, in addition to toothbrushing, may reduce gingivitis in the short and medium term. It is unclear if it reduces plaque.

Using an interdental brush, in addition to a toothbrush, may reduce gingivitis and plaque in the short term.

Using wooden tooth cleaning sticks may be better than toothbrushing only for reducing gingivitis (measured by bleeding sites) but not plaque in the medium term (only 24 participants).

Using a tooth cleaning stick made of rubber or an elastomer may be better than toothbrushing only for reducing plaque but not gingivitis in the short term (only 30 participants).

Toothbrushing plus oral irrigation (water pressure) may reduce gingivitis in the short term, but there was no evidence for this in the medium term. There was no evidence of a difference in plaque.

Interdental brushes may be better than flossing for gingivitis at one and three months. The evidence for plaque is inconsistent. There was no evidence of a difference between the devices for periodontitis measured by probing pocket depth.

There is some evidence that oral irrigation may be better than flossing for reducing gingivitis (but not plaque) in the short term.

The available evidence for interdental cleaning sticks did not show them to be better or worse than floss or interdental brushes for controlling gingivitis or plaque.

The studies that measured 'adverse events' found no serious effects and no evidence of differences between study groups in minor effects such as gum irritation.

Certainty of the evidence
The evidence is low to very low‐certainty. The effects observed may not be clinically important. Studies measured outcomes mostly in the short term and many participants had a low level of gum disease at the beginning of the studies.

Future research
Future studies should use the new periodontal diseases classification to describe the gum health of participants, and they should last long enough to measure periodontitis and tooth decay.

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Citation: Worthington  HV, MacDonald  L, Poklepovic Pericic  T, Sambunjak  D, Johnson  TM, Imai  P, Clarkson  JE. Home use of interdental cleaning devices, in addition to toothbrushing, for preventing and controlling periodontal diseases and dental caries. Cochrane Database of Systematic Reviews 2019, Issue 4. Art. No.: CD012018. DOI: 10.1002/14651858.CD012018.pub2.