Abstract
Objectives
To systematically review the literature on the efficacy of interdental cleaning devices (ICDs) used with active substances, as adjuncts to toothbrushing, in comparison with toothbrushing alone or with ICDs without active substances.
Materials and methods
Searches for randomized clinical trials were performed in PubMed, Embase, Scopus, Cochrane (CENTRAL), and Web of Science. Two independent researchers performed study selection, data extraction, and risk-of-bias assessment; a third one resolved any disagreement. Meta-analysis was not feasible, and a narrative approach was used to synthesize the evidence.
Results
Seven studies were included. Dental floss with chlorhexidine was used in five studies, whereas interdental brushes with chlorhexidine and cetylpyridinium chloride were used in one study each. ICDs with active substances resulted in significantly higher antiplaque and antigingivitis efficacies than without ICDs (n = 3). ICDs with and without active substances demonstrated contrasting results. For this comparison, six studies were included for each outcome. Significantly higher antigingivitis efficacy of ICDs with active substances was noted in four studies, whereas significantly higher antiplaque efficacy of ICDs with active substances was reported in three studies. All comparisons demonstrated a very low certainty of evidence.
Conclusions
There is no robust evidence for the additional clinical efficacy of ICDs with active substances regarding their antiplaque and antigingivitis efficacies. These devices may have additional clinical efficacy when compared with the absence of interproximal hygiene.
Clinical relevance
The use of ICDs helps maintain or achieve periodontal health. However, the adjunct use of active substances may not provide additional benefits.
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References
Benjamin RM (2010) Oral health: the silent epidemic. Public Health Rep 125:158–159. https://doi.org/10.1177/003335491012500202
Kassebaum NJ, Bernabé E, Dahiya M, Bhandari B, Murray CJ, Marcenes W (2014) Global burden of severe periodontitis in 1990-2010: a systematic review and meta-regression. J Dent Res 93:1045–1053. https://doi.org/10.1177/0022034514552491
Nazir MA (2017) Prevalence of periodontal disease, its association with systemic diseases and prevention. Int J Health Sci (Qassim) 11:72–80
Joseph S, Curtis MA (2021) Microbial transitions from health to disease. Periodontol 2000 86(1):201–209. https://doi.org/10.1111/prd.12377
Jakubovics NS, Goodman SD, Mashburn-Warren L, Stafford GP, Cieplik F (2021) The dental plaque biofilm matrix. Periodontol 2000 86(1):32–56. https://doi.org/10.1111/prd.12361
Loe H, Theilade E, Jensen SB (1965) Experimental gingivitis in man. J Periodontol 36:177–187. https://doi.org/10.1902/jop.1965.36.3.177
Scannapieco FA, Gershovich E (2020) The prevention of periodontal disease-an overview. Periodontol 2000 84:9–13. https://doi.org/10.1111/prd.12330
Axelsson P, Nyström B, Lindhe J (2004) The long-term effect of a plaque control program on tooth mortality, caries and periodontal disease in adults. Results after 30 years of maintenance. J Clin Periodontol 31:749–757. https://doi.org/10.1111/j.1600-051X.2004.00563.x
Abusleme L, Hoare A, Hong BY, Diaz PI (2021) Microbial signatures of health, gingivitis, and periodontitis. Periodontol 2000 86:57–78. https://doi.org/10.1111/prd.12362
Jönsson B, Abrahamsson KH (2020) Overcoming behavioral obstacles to prevent periodontal disease: behavioral change techniques and self-performed periodontal infection control. Periodontol 2000 84:134–144. https://doi.org/10.1111/prd.12334
Langa GPJ, Muniz FWMG, Wagner TP, Silva CFE, Rösing CK (2021) Anti-plaque and anti-gingivitis efficacy of different bristle stiffness and end-shape toothbrushes on interproximal surfaces: a systematic review with meta-analysis. J Evid Based Dent Pract 21:101548. https://doi.org/10.1016/j.jebdp.2021.101548
Haas AN, Wagner TP, Muniz FWMG, Fiorini T, Cavagni J, Celeste RK (2016) Essential oils-containing mouthwashes for gingivitis and plaque: meta-analyses and meta-regression. J Dent 55:7–15. https://doi.org/10.1016/j.jdent.2016.09.001
Salvi GE, Della Chiesa A, Kianpur P, Attström R, Schmidlin K, Zwahlen M et al (2009) Clinical effects of interdental cleansing on supragingival biofilm formation and development of experimental gingivitis. Oral Health Prev Dent 7:383–391
Sälzer S, Graetz C, Dörfer CE, Slot DE, Van der Weijden FA (2020) Contemporary practices for mechanical oral hygiene to prevent periodontal disease. Periodontol 2000 84:35–44. https://doi.org/10.1111/prd.12332
Hugoson A, Koch G (1979) Oral health in 1000 individuals aged 3-70 years in the community of Jönköping, Sweden. A review. Swed Dent J 3:69–87
Marchesan JT, Morelli T, Moss K, Preisser JS, Zandona AF, Offenbacher S et al (2018) Interdental cleaning is associated with decreased oral disease prevalence. J Dent Res 97:773–778. https://doi.org/10.1177/0022034518759915
Langa GPJ, Muniz FWMG, Costa RDSA, da Silveira TM, Rösing CK (2021) The effect of cetylpyridinium chloride mouthrinse as adjunct to toothbrushing compared to placebo on interproximal plaque and gingival inflammation-a systematic review with meta-analyses. Clin Oral Investig 25:745–757. https://doi.org/10.1007/s00784-020-03661-2
Worthington HV, MacDonald L, Poklepovic Pericic T, Sambunjak D, Johnson TM, Imai P et al (2019) Home use of interdental cleaning devices, in addition to toothbrushing, for preventing and controlling periodontal diseases and dental caries. Cochrane Database Syst Rev 4:CD012018. https://doi.org/10.1002/14651858.CD012018.pub2
Figuero E, Roldán S, Serrano J, Escribano M, Martín C, Preshaw PM (2020) Efficacy of adjunctive therapies in patients with gingival inflammation: a systematic review and meta-analysis. J Clin Periodontol 47(Suppl 22):125–143. https://doi.org/10.1111/jcpe.13244
James P, Worthington HV, Parnell C, Harding M, Lamont T, Cheung A et al (2017) Chlorhexidine mouthrinse as an adjunctive treatment for gingival health. Cochrane Database Syst Rev 3:CD008676. https://doi.org/10.1002/14651858.CD008676.pub2
Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD et al (2021) The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. J Clin Epidemiol 134:178–189. https://doi.org/10.1016/j.jclinepi.2021.03.001
Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I et al (2019) RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 366:l4898. https://doi.org/10.1136/bmj.l4898
Guyatt G, Oxman AD, Akl EA, Kunz R, Vist G, Brozek J et al (2011) GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables. J Clin Epidemiol 64:383–394. https://doi.org/10.1016/j.jclinepi.2010.04.026
Guyatt GH, Thorlund K, Oxman AD, Walter SD, Patrick D, Furukawa TA et al (2013) GRADE guidelines: 13. Preparing summary of findings tables and evidence profiles-continuous outcomes. J Clin Epidemiol 66(2):173–183. https://doi.org/10.1016/j.jclinepi.2010.04.026
Imai PH, Putnins EE, Brunette DM (2008) The effects of flossing with a chlorhexidine solution on interproximal gingivitis: a randomized controlled trial. Can J Dent Hyg 42:8–14
Kinane DF, Jenkins WM, Paterson AJ (1992) Comparative efficacy of the standard flossing procedure and a new floss applicator in reducing interproximal bleeding: a short-term study. J Periodontol 63:757–760. https://doi.org/10.1902/jop.1992.63.9.757
Pal M, Kumar S, Shenoy PA, Chaitanya T, Pratibha G, Bhat GS (2020) Evaluation of plaque removal efficacy of dental floss with/without chlorhexidine gel coating in patients with gingivitis-a clinical and microbological study. Open Access Maced J Med Sci 8:118–123
Lee YC, Charles SL, Holborow DW (1996) The effect of local application of chlorhexidine on plaque and gingivitis. N Z Dent J 92:13–15
Muniz FW, Sena KS, de Oliveira CC, Veríssimo DM, Carvalho RS, Martins RS (2015) Efficacy of dental floss impregnated with chlorhexidine on reduction of supragingival biofilm: a randomized controlled trial. Int J Dent Hyg 13:117–124. https://doi.org/10.1111/idh.12112
Muniz FWMG, da Silva LH, Rösing CK, Martins RS, Moreira MMSM, Carvalho RS (2018) Efficacy of an unwaxed dental floss impregnated with 2% chlorhexidine on control of supragingival biofilm: a randomized, clinical trial. J Investig Clin Dent 9(1):12280. https://doi.org/10.1111/jicd.12280
Schmidt B, Jentsch H (2015) Comparison between two interproximal cleaning procedures in periodontitis patients: a six-month, single-blind, randomised controlled clinical trial. Oral Health Prev Dent 13:205–211. https://doi.org/10.3290/j.ohpd.a32680
Carr MP, Rice GL, Horton JE (2000) Evaluation of floss types for interproximal plaque removal. Am J Dent 13:212–214
Zanatta FB, Moreira CH, Rösing CK (2011) Association between dental floss use and gingival conditions in orthodontic patients. Am J Orthod Dentofacial Orthop 140:812–821. https://doi.org/10.1016/j.ajodo.2011.06.028
Kotsakis GA, Lian Q, Ioannou AL, Michalowicz BS, John MT, Chu H (2018) A network meta-analysis of interproximal oral hygiene methods in the reduction of clinical indices of inflammation. J Periodontol 89:558–570. https://doi.org/10.1002/JPER.17-0368
Chapple IL, Van der Weijden F, Doerfer C, Herrera D, Shapira L, Polak D et al (2015) Primary prevention of periodontitis: managing gingivitis. J Clin Periodontol 42(Suppl 16):S71–S76. https://doi.org/10.1111/jcpe.12366
Slot DE, Valkenburg C, Van der Weijden GAF (2020) Mechanical plaque removal of periodontal maintenance patients: a systematic review and network meta-analysis. J Clin Periodontol 47(Suppl 22):107–124. https://doi.org/10.1111/jcpe.13275
Slot DE, Dörfer CE, Van der Weijden GA (2008) The efficacy of interdental brushes on plaque and parameters of periodontal inflammation: a systematic review. Int J Dent Hyg 6:253–264. https://doi.org/10.1111/j.1601-5037.2008.00330.x
Elías-Boneta AR, Toro MJ, Rivas-Tumanyan S, Rajendra-Santosh AB, Brache M, Collins CJR (2018) Prevalence, severity, and risk factors of gingival inflammation in Caribbean adults: a multi-city, cross-sectional study. PR Health Sci J 37:115–123
Albandar JM, Kingman A (1999) Gingival recession, gingival bleeding, and dental calculus in adults 30 years of age and older in the United States, 1988-1994. J Periodontol 70:30–43. https://doi.org/10.1902/jop.1999.70.1.30
Carvajal P, Gómez M, Gomes S, Costa R, Toledo A, Solanes F et al (2016) Prevalence, severity, and risk indicators of gingival inflammation in a multi-center study on South American adults: a cross sectional study. J Appl Oral Sci 24:524–534. https://doi.org/10.1590/1678-775720160178
U.S.A. Department of Health and Human Services and U.S. Department of Agriculture (2015) 2015–2020 Dietary Guidelines for Americans. 8th Edition. https://health.gov/our-work/food-nutrition/previous-dietary-guidelines/2015. Accessed August 9th, 2021.
Acknowledgements
This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior–Brasil (CAPES)–Finance Code 001. All other funding was self-supported by the authors.
Funding
This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior–Brasil (CAPES). The authors self-funded the other part of the study.
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Appendix 1. Search strategies performed on all databases
Appendix 1. Search strategies performed on all databases
PUBMED
#1 - Dental Devices, Home Care[Mesh Terms] OR floss[Text word] OR flossing[Text word] OR rubber picks[Text word] OR toothpick[Text word] OR toothpicks[Text word] OR rubber sticks[Text word] OR interdental brush[Text word] OR chewing stick[Title/abstract] OR chewing sticks[Title/abstract] OR interproximal[Text word] OR interdental[Text word]
#2 - Anti-Infective Agents[Mesh Terms] OR Anti-Infective Agents [Text word] OR impregnated[Title/abstract] OR active ingredients[Text word] OR local antimicrobial[Title/abstract] OR Cetylpyridinium[Mesh Terms] OR Cetylpyridinium[Text word] OR CPC[Text word] OR cepacol[Text word] OR plax[Text word] OR Biguanides[MeSH Terms] OR chlorhexidine [Text word] OR Periogard[Text word] OR stannous fluoride[Title/abstract] OR amine fluoride[Title/abstract] OR sodium monofluorophosphate[Text word] OR xylitol[MeSH Terms] OR xylitol[Text word] OR Triclosan[MeSH Terms] OR triclosan[Text word] OR essential oil[Text word] OR Oils, Volatile[MeSH Terms] OR Thymol[MeSH Terms] OR Menthol[MeSH Terms] OR Monoterpenes[MeSH Terms] OR Phenol[MeSH Terms] OR Listerine[Text word] OR eucalyptol[Title/abstract] OR phenol[Title/abstract] OR delmopinol[Title/abstract] OR zinc sulphate[Text word] OR zinc citrate[Title/abstract] OR mutanase[Text word] OR protease[Text word] OR hydrogen peroxide[Text word] OR sanguinarine [Text word] OR hexetidine[Text word] OR povidone iodine[Text word]
#3 - #1 AND #2
SCOPUS
( TITLE-ABS-KEY ( dental AND devices, AND home AND care ) OR TITLE-ABS-KEY ( “Home Care Dental Devices” ) OR TITLE-ABS-KEY ( “Dental Devices” ) OR TITLE-ABS-KEY ( floss ) OR TITLE-ABS-KEY ( flossing ) OR TITLE-ABS-KEY ( “rubber picks” ) OR TITLE-ABS-KEY ( toothpick ) OR TITLE-ABS-KEY ( toothpicks ) OR TITLE-ABS-KEY ( “rubber sticks” ) OR TITLE-ABS-KEY ( “interdental brush” ) OR TITLE-ABS-KEY ( “chewing stick” ) OR TITLE-ABS-KEY ( “chewing sticks” ) OR TITLE-ABS-KEY ( interproximal ) OR TITLE-ABS-KEY ( interdental ) ) ) AND ( ( TITLE-ABS-KEY ( “Anti-Infective Agents” ) OR TITLE-ABS-KEY ( impregnated ) OR TITLE-ABS-KEY ( “active ingredients” ) OR TITLE-ABS-KEY ( “local antimicrobial” ) OR TITLE-ABS-KEY ( cetylpyridinium ) OR TITLE-ABS-KEY ( cpc ) OR TITLE-ABS-KEY ( cepacol ) OR TITLE-ABS-KEY ( plax ) OR TITLE-ABS-KEY ( biguanides ) OR TITLE-ABS-KEY ( chlorhexidine ) OR TITLE-ABS-KEY ( periogard ) OR TITLE-ABS-KEY ( “stannous fluoride” ) OR TITLE-ABS-KEY ( “amine fluoride” ) OR TITLE-ABS-KEY ( “sodium monofluorophosphate” ) OR TITLE-ABS-KEY ( xylitol ) OR TITLE-ABS-KEY ( triclosan ) OR TITLE-ABS-KEY ( “essential oil” ) OR TITLE-ABS-KEY ( “oils, volatile” ) OR TITLE-ABS-KEY ( thymol ) OR TITLE-ABS-KEY ( menthol ) OR TITLE-ABS-KEY ( monoterpenes ) OR TITLE-ABS-KEY ( phenol ) OR TITLE-ABS-KEY ( listerine ) OR TITLE-ABS-KEY ( eucalyptol ) OR TITLE-ABS-KEY ( delmopinol ) OR TITLE-ABS-KEY ( “zinc sulphate” ) OR TITLE-ABS-KEY ( “zinc citrate” ) OR TITLE-ABS-KEY ( mutanase ) OR TITLE-ABS-KEY ( protease ) OR TITLE-ABS-KEY ( “hydrogen peroxide” ) OR TITLE-ABS-KEY ( sanguinarine ) OR TITLE-ABS-KEY ( hexetidine ) OR TITLE-ABS-KEY ( “povidone iodine” ) ) )
WEB OF SCIENCE
#1 – TS = (Dental Devices, Home Care OR “Dental devices” OR floss OR flossing OR “rubber picks” OR toothpick OR toothpicks OR “rubber sticks” OR “interdental brush” OR “chewing stick” OR “chewing sticks” OR interproximal OR interdental)
#2 – TS = (“Anti-Infective Agents” OR impregnated OR “active ingredients” OR “local antimicrobial” OR Cetylpyridinium OR CPC OR cepacol OR plax OR Biguanides OR chlorhexidine OR Periogard OR “stannous fluoride” OR “amine fluoride” OR “sodium monofluorophosphate” OR xylitol OR Triclosan OR “essential oil” OR “Oils, Volatile” OR Thymol OR Menthol OR Monoterpenes OR Phenol OR Listerine OR eucalyptol OR phenol OR delmopinol OR zinc sulphate OR zinc citrate OR mutanase OR protease OR hydrogen peroxide OR sanguinarine OR hexetidine OR povidone iodine)
#3 -, #1, and #2
COCHRANE LIBRARY
#1 - Dental Devices, Home Care OR “Dental devices” OR floss OR flossing OR “rubber picks” OR toothpick OR toothpicks OR “rubber sticks” OR “interdental brush” OR “chewing stick” OR “chewing sticks” OR interproximal OR interdental
#2 – “Anti-Infective Agents” OR impregnated OR “active ingredients” OR “local antimicrobial” OR Cetylpyridinium OR CPC OR cepacol OR plax OR Biguanides OR chlorhexidine OR Periogard OR “stannous fluoride” OR “amine fluoride” OR “sodium monofluorophosphate” OR xylitol OR Triclosan OR “essential oil” OR “Oils, Volatile” OR Thymol OR Menthol OR Monoterpenes OR Phenol OR Listerine OR eucalyptol OR phenol OR delmopinol OR “zinc sulfate” OR “zinc citrate” OR mutanase OR protease OR “hydrogen peroxide” OR sanguinarine OR hexetidine OR “povidone iodine”
#3 -, #1, and #2
EMBASE
#1 – ‘dental devices’ OR ‘home care’ OR floss OR flossing OR ‘rubber picks’ OR ‘toothpick’ OR toothpick OR toothpicks OR ‘rubber sticks’ OR ‘interdental brush’ OR ‘chewing stick’ OR ‘chewing sticks’ OR interproximal OR interdental
#2 – ‘anti-infective agents’ OR impregnated OR ‘active ingredients’ OR ‘local antimicrobial’ OR cetylpyridinium OR cpc OR cepacol OR plax OR biguanides OR chlorhexidine OR periogard OR ‘stannous fluoride’ OR ‘amine fluoride’ OR ‘sodium monofluorophosphate’ OR xylitol OR triclosan OR ‘essential oil’ OR ‘oils, volatile’ OR thymol OR menthol OR monoterpenes OR listerine OR eucalyptol OR phenol OR delmopinol OR ‘zinc sulfate’ OR ‘zinc citrate’ OR mutanase OR protease OR ‘hydrogen peroxide’ OR sanguinarine OR hexetidine OR ‘povidone iodine’
#3 -, #1, and #2 AND [embase]/lim
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Langa, G., Dantas, P., Lemus, G. et al. Effectiveness of interdental cleaning devices with active substances: a systematic review. Clin Oral Invest 26, 2253–2267 (2022). https://doi.org/10.1007/s00784-021-04327-3
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DOI: https://doi.org/10.1007/s00784-021-04327-3