REVIEW ANALYSIS & EVALUATION

ARTICLE TITLE AND

BIBLIOGRAPHIC
INFORMATION
The efficacy of interdental brushes
on plaque and parameters of
periodontal inflammation:
a systematic review.
Slot DE, Dorfer CE, Van der Weijden GA.
Int J Dent Hygiene 2008;6(4):253-64.

REVIEWER
Joan I. Gluch, RDH, PhD

PURPOSE/QUESTION
To determine the effect of
interdental brushes (IDBs) as an
adjunct to tooth brushing compared
with tooth brushing alone or other
interdental oral hygiene devices on
plaque, gingival inflammation,
bleeding, and pocket depth

SOURCE OF FUNDING
Information not available

As an Adjunct to Tooth Brushing,

Interdental Brushes (IDBs) are More
Effective in Removing Plaque as Compared
With Brushing Alone or the Combination
Use of Tooth Brushing and Dental Floss
SUMMARY
Selection Criteria
Two investigators independently screened 2 databases (MEDLINE-PubMed
and Cochrane CENTRAL) for titles and abstracts of articles written in English
from 1965 to November 2007 for any study that evaluated the effect of interdental brushes (IDBs). The MEDLINE-PubMed search compiled 222 citations
and the Cochrane CENTRAL search resulted in 122 citations, and after removing duplicate listings, 234 titles and abstracts remained. The inclusion criteria
for this systematic review included both randomized controlled clinical trials
and controlled clinical trials with subjects older than 18 years of age in good
general health with no systemic disorders and included information on plaque,
bleeding, gingivitis, and pocket depth. A review of publications identified 18
relevant studies. Five articles were excluded because they did not meet inclusion criteria, and 5 studies were excluded owing to insufficient data presented
on the clinical measures. One additional study was gleaned from the reference
list, for a total of 9 studies included in this systematic review.1-9 Both randomized
controlled clinical trails and controlled clinical trials were selected for review;
however, considerable heterogeneity was observed in the 9 studies related to
study design, number, gender and age of participants, and outcome variables.

TYPE OF STUDY/DESIGN

Key Study Factor

Systematic review with metaanalysis of data

The key study factor was use of IDBs among adults with sufficient interdental space to use an IDB. Eight different brands of conical or cylindrical IDBs
were used in the 9 studies in this review. Six studies noted that study product and/or financial support was received from industry.

LEVEL OF EVIDENCE
Level 2: Limited-quality patientoriented evidence

STRENGTH OF
RECOMMENDATION GRADE
Grade B: Limited-quality patientoriented evidence

J Evid Base Dent Pract 2012;12:81-83

1532-3382/$36.00
2012 Elsevier Inc. All rights reserved.
doi:10.1016/j.jebdp.2012.03.016

Main Outcome Measure

The main outcome measures were plaque, bleeding, gingivitis, and pocket
depth. All studies measured dental plaque, 5 studies measured gingival
bleeding, 3 studies measured gingival health, and 3 studies measured
pocket depth. Regarding the measurement of dental plaque, 4 studies
used the Silness and Loe index, 3 studies used variations of the QuigleyHein index (Turesky, Benson and Volpe modifications), 1 study used the
Wolffe index, and in 1 study, the authors developed their own plaque index.
Bleeding was measured in 2 studies using the Eastman bleeding index, in 1
study using the angulated bleeding index, and 4 studies recorded bleeding
on probing. Gingivitis was assessed in 2 studies using the Loe and Silness
gingival index, and 1 study used the modified gingival index of Lobene et al.

Main Results
When comparing IDBs as an adjunct to brushing to brushing alone, 2 of
the 3 studies showed reduction of plaque scores for groups using IDBs,
and 1 of 3 studies showed reduction in gingival index.

JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE

When comparing IDBs to other oral hygiene interventions, 5 studies showed greater plaque reduction with
IDBs as an adjunct to brushing as compared with combination use of dental floss and brushing. Three studies
showed no significant difference in gingival index and
5 studies showed no significant difference in bleeding
scores between IDBs and dental floss. Two of 3 studies
showed that IDBs significantly reduced pocket depth as
compared with floss. One study showed IDB reduces
more dental plaque than woodsticks.
Meta analysis was completed by the authors to pool data
for the comparison of IDBs with floss. The IDB group
showed greater plaque reductions than the floss group
in the 2 studies that used the Silness and Loe plaque index, with no significant difference in the other 2 studies
measuring plaque, and no significant difference in bleeding on probing or pocket depth in the meta analysis comparing IDBs with floss.

Conclusions
The authors conclude that IDBs remove more dental plaque as an adjunct to toothbrushing than brushing alone,
with inconclusive evidence available on the effect of IDB
on gingival inflammation. In addition, the authors found
that IDBs in combination with toothbrushing removes
more plaque as compared with dental floss or woodsticks
and found inconclusive evidence in comparing the effect
of IDBs and floss on the measures of gingival inflammation. However, use of IDBs does result in more pronounced reduction of pocket depth than dental floss as
an adjunct to toothbrushing.

COMMENTARY AND ANALYSIS

This systematic review highlights the effectiveness of IDBs
as an adjunct to toothbrushing for plaque removal in
adult patients with periodontal disease. Many patients request an alternative to the traditional use of dental floss,
citing the challenging nature of both the skills and motivation needed to thoroughly clean interproximal
spaces.10-13 In the 3 studies in this review that evaluated
patient preference, patients in all 3 studies preferred
IDBs as compared with floss and reported the IDB as
less time consuming and easier to use.
The authors of the systematic review urge caution in interpreting the results, however, owing to the hetereogeneity apparent among the 9 studies selected, including
variation in study design, patient selection characteristics,
and outcome variables. Regarding study design, all studies
used a short-term evaluation period ranging from 4 to
6 weeks, with 2 studies lasting 12 weeks. Short-term studies
are especially problematic because subjects motivation in
short-term studies may be biased toward greater compliance with the test products owing to participation in the
study (Hawthorne effect).10 All studies included patient instruction in the use of the IDB as part of the protocol, which
82

also may have increased the chance of greater compliance

and more positive study outcomes.11-13 Eight different
types of IDBs were used in the 9 studies, which represents
considerable variation among the design of studies
selected for inclusion in the systematic review. However,
a variety of IDB shapes and sizes are required in clinical
practice to accommodate all interdental spaces, making
a true random assignment and comparison among
products difficult; hence, the grouping of all IDBs into
one category.
Criteria for selecting adult patients varied throughout
the studies. Health status, which may have had an effect
on outcome variables, was omitted in 3 studies, and
health status was reported as good general health in 6
studies with no specific exclusion criteria. Use of tobacco
was not analyzed as part of the outcome variables, and 5 of
the 9 studies omitted any mention of tobacco use,
whereas only 2 studies included smoking as an exclusion
criteria. Although all studies included patients who had
interdental spaces that could accommodate use of an
IDB, 3 studies did not report on the subjects periodontal
status, 3 studies included patients during periodontal recall maintenance visits, 2 studies included patients diagnosed with periodontal disease before treatment, and 1
study included patients diagnosed with gingivitis or moderate periodontitis. The diversity in selection of study subjects is considerable among these 9 studies and may affect
the strength of the conclusions of the review.
Four outcome measures were used among the 9 studies:
plaque index, bleeding index, gingival index, and pocket
depth. Although the reduction in plaque was consistent in
comparing IDBs to brushing alone or compared with the
combination use of toothbrushing and dental floss, this
positive result did not apply uniformly to reductions in
bleeding or gingival index. None of the studies showed
significant differences with regard to bleeding or gingival
index with the use of IDBs and toothbrushing as compared with the combination use of dental floss and toothbrushing. In the 3 studies that measured pocket depth,
however, all studies showed greater reduction with IDBs
than with dental floss. As explanation, the authors cite
Baderstens hypothesis14 that mechanical depression of
the papilla from the IDB causes recession and reduces
pocket depth, rather than a reduction of inflammation.
Given the dual conclusions that IDBs remove more plaque and that there is no difference in gingival inflammation or bleeding when comparing the use of IDBs or floss
as adjuncts to brushing, clinicians should collaborate with
patients to determine the best oral hygiene methods
given the patients preferences and skill level. Clinicians
should also consider these results with caution with regard to expectations for outcomes with IDBs in relation
to the inconclusive evidence on gingival inflammation
and bleeding. The studies included in the systematic review that evaluated outcomes of gingival inflammation
and bleeding used manual toothbrushes with no
June 2012

JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE

antimicrobial products used by patients. Power toothbrushes were included in 1 study in the review that used
only the plaque index as an outcome measure. Further
recommendations for study include the inclusion of
power toothbrushing and/or antimicrobial toothpastes/
rinses in study design to simulate the common practice
of recommending multiple products with patients to improve measures of periodontal health.

REFERENCES
1. Bassiouny MA, Grant AA. Oral hygiene for the partially edentulous.
J Periodontol 1981;52:214-8.
2. Christou V, Timmerman MF, Van der Velden U, Van der Weijden GA.
Comparison of different approaches of interdental oral hygiene: interdental brushes versus dental floss. J Periodontol 1998;69:759-64.
3. Gjermo P, Flotra L. The effect of different methods of interdental
cleaning. J Periodontal Res 1970;5:230-6.
4. Ishak N, Watts TLP. A comparison of the efficacy and ease of use of
dental floss and interproximal brushes in a randomised split mouth
trial incorporating a assessment of subgingival plaque. Oral Health
Prev Dent 2007;5:13-8.
5. Jackson MA, Kellett M, Worthington HV, Clerehugh V. Comparison
of interdental cleaning methods: a randomized controlled trial.
J Periodontol 2006;77:1421-9.
6. Jared H, Zhong Y, Rowe M, Ebisutani K, Tanaka T, Takase N. Clinical
trial of a novel interdental brush cleaning system. J Clin Dent
2005;16:47-52.
7. Kiger RD, Nylund K, Feller RP. A comparison of proximal plaque removal using floss and interdental brushes. J Clin Periodontol
1991;18:681-4.

Volume 12, Number 2

8. Rosing CK, Daudt FA, Festugatto FE, Oppermann RV. Efficacy of interdental plaque control aids in periodontal maintenance patients:
a comparative study. Oral Health Prev Dent 2006;4:99-103.
9. Yost KG, Mallatt ME, Liebman J. Interproximal gingivitis and plaque reduction by four interdental products. J Clin Dent 2006;17:
79-83.
10. Feil PH, Grauer JS, Gadbury-Amyot CC, Kula K, McCunniff MD. Intentional use of the Hawthorne effect to improve oral hygiene compliance in orthodontic patients. J Dent Educ 2002;66:1129-35.
11. Warren PR, Chater BV. An overview of established interdental cleaning methods. J Clin Dent 1996;7:65-9.
12. Kinane DF. The role of interdental cleaning in effective plaque
control: need for interdental cleaning in primary and secondary
prevention. In: Lang NP, Attstr
om R, L
oe H, editors. Proceedings
of the European Workshop on Mechanical Plaque Control. Berlin:
Quintessenz Verlag; 1998. p. 156-16.
13. Claydon NC. Current concepts in toothbrushing and interdental
cleaning. Periodontology2000 2008;48:10-22.
14. Badersten A, Nilveus R, Egelberg J. Effect of nonsurgical periodontal
therapy II. Severely advanced periodontitis. J Clin Periodontol
1984;11:63-76.

REVIEWER
Joan I. Gluch, RDH, PhD
Associate Dean for Academic Policies, Director of Community
Health and Adjunct Associate Professor, University of
Pennsylvania School of Dental Medicine, 240 S. 40th St,
Philadelphia, PA 19104, Phone: 215-898-5279
gluchj@dental.upenn.edu

83