Quintessence Int 1989:20:249-255

Penodontics

Interproximal tooth morphology and its effect on plaque removal

Hyman Stnukier, BDS, DMD. HDD* / Martin C. Nager, DMD* / Paul C. Tolmie. DDS*

Introduction

The role of bacterial plaque in tbe initiation and promotion of inflammatory periodonta! disease has been well established by bacterial sampling procedures and in data obtained from controlled clinical studies.'"' From a therapeutic perspective, mechanical removal of bacterial plaque has been shown to be effective in reducing gingivitis,'"' maintaining periodontal heaith in humans/ and controlling periodontitis in animals.^ Becanse the greatest incidence and severity of periodontal disease is found interproximally, effective tnechanical control of bacterial plaque in these areas is of paramount importance.*' Since toothbrushing alone has not been an effective measure of controling bacterial plaque interproximally,*"'- other aids have been recomrnended specifically for interproximal plaque removal.'-' -" The effectiveness of dental tloss as an interproximal plaque remover and its relationship to the maintenance of interdental tissue health have been exhaustively investigated.''^-^'"-^ Other chnical studies-^'^"' have not been able to demonstrate the superiority of any one type of dental floss in removing dental plaque from interproximal tooth surfaces. When the phystcal and morphologic characteristics of toothpicks and their effectiveness on interproximal plaque removal were compared, it was noted'*"" that the triangular-shaped toothpick was the most effective plaque remover. However, when this type of toothpick was compared to dental floss, the latter was found to be more efflcient, particularly on the linguoaxial surfaces."^ In evaluating the efficiency of the single tufted interspace toothbrush, wooden toothpicks, and waxed dental oss in cleansing of proximal tooth surfaces, noted no significant differences among the

devices. Nayak and Wade'^ compared an interproximal brush with a rubber cone stimulator and the effectiveness of each in removing proximal plaque. They found that the interproximal brush was more effective, but that neither device achieved complete retnoval of plaque. The morphology of the interproxirnal root surface and its influence on proximal cleansing have been discussed by Gher and Vernino'" and Fox and Bosworth." The former concluded that proximal surfaces are inaccessible to cleansing by routine oral hygiene measures, while the latter demonstrated that even tninimal attachment loss would nearly always expose concavities on the proximal surfaces, and special means would be required to cleanse such areas. The present study was designed to observe tbe relationship between interproximal root morphoiogy and its effect on the cleansing ability of various ora! hygiene measures and devices.
IVlethod and materials

Department of Periodontology, School of Graduate Dentistry. Boston tjniversity, Boston, Massachusetts 2tl8.

One representative extracted tooth from the incisor, c;mine, premolar, and molar groups of maxillary and mandibular teeth was randomly collected for this investigation. The selected ieeth were hghtly scaled by hand; appropriate care was taken to prevent alteration of the existing root surface anatomy. A thin coat of petroleum jelly was evenly applied to the proximal surfaces in question. Ground coffee was carefully dusted onto the coated surface to color the petroleum, so that changes could easily be seen and photographed during the study (Figs 1 and 2). U si tig generally accepted methods, unwaxed dental floss was used to retnove the coated adherent jelly from the proximal surfaces. After the flossing method had removed all tbe adherent material it could reach, the interproximal brush was used to attempt further removal ofthe artificial coating from the tooth (Figs 1 and 2).

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Figs la to 1e Cleansing ot a coated maxiliary first premoiar.

Fig la

Coated tooth.

Fig Ib

Fiossing activity.

Fig Ic

Tooth surface after flossing.

Fjg "id Interproximal brush activity.

Fig Ie

Tooth surface after brushing.

Color transparencies (1:2 magnification) were rnadc of the relevant proximal surfaces before the application of the coating matertal, irnmediately after coating, and following the use of dental tloss and interproximal toothbrush. The teelh were cleaned thoroughly to remove any adherent coating and horizontally sectioned 3 to 4 mm apical to the interproxirnal cementoenamel junction {CEJ) of each looth, using a diamond disk (Figs 3 and 4), This arbitrary distance was selected to simulate the attachment level that could be expected with an attachment loss of approximately 25%. About three fourths of the remaining apical portion of each cut tooth was embedded vertically, apex down, into red (maxillary teeth) or blue (mandibular teeth) modeling clay. A color transparency was made of eaeh cut sur250

face at a 1;1 magnification, Unwaxed dental fioss, Superfioss (Educational Heath Products Inc), trianguiars toothpicks, and interproximal brushes were apposed to the proximal surfaces to simulate, in vitro, accepted cleansing methodology; these were photographed. The developed transparencies were projected onto a screen to examine the relative removal of the petroleum and coffee coating and the intirnate relationship of each device with the interproximal surface of the individual teeth. !n this purely ohservattonal study, no atternpt was made to quantify the cleansing ability of the various devices. On the projected slides, the exact relationship of the cleansing devices to the proximal surface of each tooth and the abihty of each to reach the bottom of surface concavities were observed.

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Periodontics
Figs 2a to 2e Cleansing ot a coated mandibular first premolar

Fig 2a Coated tooth.

Fig 2b Flossing aclivity.

Fig 2c Tooth surtace after flossing.

Fig 2d Interproximal brush activity.

Fig 2e Tooth surface after brushing.

Results

reach the deeper parts of the eoncavities when it was properly angulated horizontally (see Figs 3 and 4).
Discussion

Use of unwaxed dental fioss ibr removal of the coated petroleum from the proximal surfaces resulted in satisfactory cleansing of only convex or flat root surfaces. The vicinity of the line angles was adequately managed with this method (see Figs 1 and 2). The concavities of the proximal root surfaces were adequately cleansed hy the interproximal toothbrush after the fioss had failed to clean these areas (see Figs 1 and 2). Examination of the projected images of the cleansing devices applied to the proximal root surfaces revealed that only the interproximal toothbrush could reliably reach the depths of the concavities. In very shallow concavities, the Superfioss did come close to the fioor of some concavities. The toothpick could

Wherever the interproximal surface curvature of the tooth was convex, all the devices were adequately applied to the interproximai surfaces and could be expected to cleanse these areas in vivo. However, as most teeth do not have uniformly convex or flat surfaces below the CEJ, the ability of dental fioss, Superfioss, and possibly even toothpicks to cleanse these predominantly concave areas must be seriously questioned. In the absence of disease, or in early periodontal disease, where the gingival tissues are still attached at or near the CEJ and where tooth surfaces are more likely to

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Figs 3a to 3e Application of oral hygiene devices to the mesioproximal surface of a maxillary first premolar

Fig 3a Tooth exhibiting level of section.

Fig 3b Fioss on proximal surface.

Fig 3c Superfioss appiication.

Fig 3d interprcximai brush m position.

Fig 3e Tooffipici< apposed to tooth surface.

be convex or flat, these deviees appear to be effective in the removal of interproximal plaque and debris. Thus they can still play a role in prevention and treatment of incipient periodontal changes. When periodontal disease progresses apically, the gingival tissues are hkely to be apposed to more concave or convoluted interproximal root surfaces. The same holds true in instances of treated periodontal disease, where the tissues are more apically situated on concave root surfaces. In such instances, based on these observations, it would appear that the interproximal brush is the only device that reliably can reach concave surfaces. When the interproximal brush is apposed to the proximal tooth surfaces, the bristles in the line angle areas are compressed, while the remaining bristles, noncompressed in the interproximal areas, reach and cleanse the concavities (Figs 3 to 5).

The toothpick, by careful manipulation and angulation, can also be made to reach most concavities. In vivo this may not always be possible because of proximity of adjacent teeth and questionable dexterity of many patients. Only the most shallow concavities can be cleansed with Superfioss. Further investigations are now under way to quantify, in clinical situations, the observations made in this study.

Conclusions

Within the parameters of this study it can be concluded that (1) concave proximal root surfaces ean be rehably reached and cleansed by interproximal brushes; (2) with very careful horizontal angulation.
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Figs 4a to 4e Application of oral hygiene devices to the mesioproximal surface of a mandibuiar central incisor.

Fig 4a Tooth exhibiting level of section.

Fig 4b Floss on proximal surface.

Fig 4c Superfloss application,

Fig 4d tjon.

Interproxitnal brush applica-

Fig 4e Toothpick apposed fo footh surface.

Figs 5a to 5e Clinical use of oral hygiene devices on maxillary first premolar.

Fig 5a Stained to disclose proximal plaque accumulation.

Fig 5b Plaque at line angle during flossing.

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Fig 5c Plaque remaining n concavity after tlossing.

Fig 5d Cleansing with interproxtmal brush.

Fig 5e

Results after use ot interproximal brush.

toothpicks can negotiate sotnc concavities; (3) dental floss appears to reach only flat or convex surfaces near tbe line angles of the teeth: (4) Superfloss may reach the fioor or some ofthe most shallow concavities; (5) the effectiveness of some oral hygiene devices currently being used should be questioned when proximal surfaces are concave; (6) further studies are necessary to evaluate tnore properly the effect of traditional home care devices and methods. Analysis of tbe material examined in this study leads the authors to conclude tbat the interproximal brush appears to be the most effective device tested in this study for the removal of plaque and debris from concave proximal tootb surfaces. Further research is needed to determine the effectiveness of interdental cleansing devices in vivo. 254

References
t. Lindhe J. Hamp S. Loe H: Esperimetitat periodontitis iti the beagie dog. J Periodon! Res 1973;8:l-l(3. 2. Loe H, Theilade E, Jensen S: Experimental gingiviHs in man. J Periodontol t965;36:177-187. 3. Theiiade H, Wright W, Jensen S, et ai: Experimental gingivitis in man. II A longitudinal clinicai and bacteriological investigation. J Periodon! Res t966;t;l-13. 4. Aselsson P, Lindhe J; Effects of controlled oral hygiene procedures on caries and periodontal disease in adults. Results after six years. / Clin Periodontol l9Sl;8;239-248. 5. Lindhe J, Axelsson P: The effect of controlled oral hygiene and topicai Iluoride application on caries and gingivitis m Swedish school chiidren. Community Dent Otat Epidemiol t973;t:9-16. 6. Hiigosan A, Koch G, Hallonsten A, et al; Denial health 1973 and 197B in individuals aged 3-20 years in the community of Jonkoping, Sweden. A cross-sectional study. Swed Dem J l9S;4:217-229.

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Penodontics
7, O'Leary T; Plaque control: realistic goal , . , or impossible dream? Alumni Bull Sch Dent Indiana Utiiv 1980; Spring, 4-9. 76-77, 8, Betgenholz A, Hugoson A, Lundgren D, et al: The plaqueinhibiting property or some tnoulh-washes and their elTett on the oral mueosa, Svensk Tandlak Tidskr 1969;62:7-I4, 9, Hansen F, Gjermo P: The plaque-removing eflecl of lour toothbrushing methods, Scand J Dent Re,i 1971 ;79:502-506. 10, HendonG, Keller S, Manson-Hing L: Clearance studies of proximal tooth surfaces, I. Ala J Med Sei 1969;6:213-227, 11, Keller S, Manson-Hing L: Clearance studies of proximal tooth surfaces. HI and IV, In vivo removal of interproximal plaque, Ala J Med Sei I969;6:39-4O5, 12, Sangnes G. Zachtisson B, Gjemio P: Efectiveness of vertical and horizontal brushitig techniques in plaque removal, J Dent Child 1972;39:94-97, l, Anaise J: Plaque-removing effect of dental floss and toothpicks in children l2-t3 years of age. Community Dent Oral Epidemiol 1976;4:t37-139, 14, Bassiouny M, Grant A: Oral hygiene for the ptirtjully edentulous, / Periodontol t9Rl;52:2l4-31S, 15, Bergenholz A, Bjome A, Vikstrom B: The plaque-removing ability of some common interdental aids. An individual study. J Clin Periodoniol 1974;l:160-165, 16, Bergenholz A, Brithon J: Plaque removal by dental floss or toothpicks. An intra-individual comparative study, J Clin Periodontol 1980:7:516-524. 17, Bergenholz A, Bjrn A, Glantz P: Plaque removal by various triangular toothpicks, J Clin Periodontol 1980;?: 121-128. 18, Carter G, Barnes G. Radentz W, et al: Effects of using various types of dental floss on gingival sulcular bleeding, Fu Dem J 1975;52:lS-32, 19, DeWitt K, Brady J: Evaluation of plaque debridement by scanning electron microscopy. /"/ Assoe DenI Re.i 1972; abstr No, 696, 20, Gjermo P, hlotra L: The effect of different methods of interdental cleaning. J Periodom Re.i 1970:5:230-236, 21, Abelson D, Barton J, Maietti G, et al: Evaluation ofinterproximal cleaning by two types f dental floss. Clin Prey Dem 1981:3:19-21, 22, t-inkelstein P, Grossman E: The effectiveness of dental tloss in reducing gingival innamniiUJon, J Dent Res 1979;58:1034-l39, 23, Limberw D, Wunderlich R, Caffcssc R: The effect of wa\ed and unwaged dental floss on gingival liealtb. I. ,/ Periodontol 1982;53:393-399, 24, Lobene R. Soparkar P, Newman M: Use of dental floss. Effect on plaque and gingivitis. Clin Prey Dent t982;4:i, 25, Stevens A: A comparison of the effectiveness of variable diameter vs, unwaxed iloss, J Periodontol 1980;51:666-667. 26, Hill H, Levi P, Glickman I: Tbe effects of waxed and unwased dental floss on interdental plaque accumulation and Interdental gingival health. J Periodoniol I97;44:411^13. 27, Wunderlich R, Lamberts D, Caffesse R: The effect of wased and unwaxed dental floss on gingival healtb, II, Crevicular fluid ilow and gingival bleeding, / Periodontol 1982;53:397-400, 28, Wolffe G: An evaluation of proximal surface cleaning agents, ,/ Clin Periodnto! 1976:3:148-156, 29, Nayak R. Wade A: Tbe relative effectiveness of plaque removal by Proxabrush and rubber cone stimulator, / Clin Periodontol 1977;4:128-133, 30, Gher M, Vemino A: Root morphologyclinical significance in pathogenesis and treatment of periodntat disease, J ^ J I Dem 31, Fox S, Bosworth B: A morphological survey of proximal root concavities: a consideration in periodontal therapy, J Am Dent Assoe 1987;114:81]-8I4, D

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