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Luz et al., Dent Health Curr Res 2016, 2:3
DOI: 10.4172/2470-0886.1000119
Dental Health: Current Research
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Review Article
Comparison between Interdental
Brush and Dental Floss for
Controlling Interproximal
Biolm in Teeth and Implants
Mariana Luz1, Maria Fátima Guarizo Klingbeil2, Paulo
Henriques3* and Hugo Roberto Lewgoy4
*Corresponding author: Paulo Henriques, Institute and Research Center,
Campinas, São Paulo, Brazil, E-mail: phenriques@mpc.com.br
Received: June 08, 2016 Accepted: August 11, 2016 Published: August 16,
2016
Introduction
Brushing is the most practiced oral hygiene method for plaque
removal [1]. e presence of dental plaque is the primary etiological
factor in the development of periodontal disease, which is dened as
an inammatory response in the gingival tissue [2]. e prevalence
of plaque associated with periodontal disease in adults aged 35 to
44 years is 99% for gingivitis and up to 52.7% for periodontitis [3].
Brushing only is not sucient for removing plaque, especially at the
gingival margin and interproximal region [4].
Conventional toothbrushes are not capable of reaching the
proximal surfaces as eectively as the buccal, lingual and occlusal
surfaces, nor can they reach the interproximal areas of adjacent
teeth. Some studies point to large regions of plaque stagnation, such
Abstract
The presence of dental biolm is the primary etiological factor in the
development of periodontal disease. Dental oss and interdental
brushes as adjuncts to dental hygiene provides a greater benet for
disrupting the oral biolm in the interproximal areas. To compare
the use of an interdental brush and dental oss for controlling the
dental biolm around teeth and implants, twelve volunteers (men
and women) aged 18 to 50 years were randomly selected. During
the rst thirty days, patients used the conventional Bass method
of brushing associated with cleaning the interproximal space only
with dental tape. At the end of this month, a new plaque index was
measured. At the beginning of the second month, the patients were
instructed to use conventional brushing, and then only interproximal
cleaning with interdental. At the end of this second month, a new
plaque index was measured. The analysis of variance for randomized
blocks revealed a signicant difference in the effectiveness of the
two cleaning methods used for controlling the interproximal biolm
(p=0.023), showing that the plaque index was signicantly lower
(39.6%) with the interdental brush than when dental oss was used
(58.3%).We concluded that, compared with using dental oss,
interdental brushes is more effective at controlling the interproximal
dental biolm around teeth and implants.
Keywords
Dental oss; Toothbrushes; Interproximal brushes; Oral biolm
a SciTechnol journal
as interproximal spaces, gingival margins and areas with defects [5].
erefore, additional methods have been used to assist in controlling
plaque in places with dicult access [6,7]. Individuals who only use
conventional brushes oen have residual interproximal plaque in
their molars and premolars. Plaque removal from these surfaces is
crucial because patients susceptible to periodontal disease, gingivitis
and periodontitis have a more pronounced accumulation of plaque in
these interdental areas [8].
ese regions are protected against the natural cleaning
mechanisms of the oral tissues; thus emphasis should be placed on the
importance of the devices used to facilitate oral hygiene in these areas
[9]. Conventional brushes do not adequately penetrate these regions,
preventing complete cleaning [1]. e use of dental tape as an adjunct
to brushing provides a greater benet for disrupting biolm, especially
in the interproximal region [10,11]. In addition to being an integral and
eective part of a broader regime of daily self-care, the use of conventional
toothbrushes is fundamental to maintaining oral health [12].
Biolm accumulation, which results in the development
of periodontal disease, also aects dental implants. Implants are
currently the standard treatment for rehabilitating totally or partially
edentulous patients due to the mechanical and biological characteristics
that contribute to their increasing success rates [13]. Despite these
advantages, there are still many losses of implants, and the major causes
are inammation of the mucosa and peri-implantitis [14].
According to the literature, approximately 79% of individuals
rehabilitated with implants are aected by mucositis, and 50% of
implants are aected [15]. e prevalence of peri-implantitis also
shows alarming rates of 5% to 15% [16,17].
e correct mechanical disruption of the oral biolm [the
preconized clinical protocol of sanitization for rehabilitation with
endosseous dental implants] should be performed with the use of
small head brushes with medium-sized and extra-so (ultraso)
bristles. [18]. Moreover, patients should be instructed to perform the
modied Bass technique. To achieve high standards of hygiene, both
in teeth and implants, the use of dental oss or interdental brushes
is important (added to brushing) for eective biolm removal [19].
Careful plaque removal techniques can modify both the quantity
and the composition of the gingival plaque, changing the composition
of the micro biota of the pocket and reducing the percentage of
periodontal bacteria [20].
e increased use of oral hygiene products and investments in
advertisements directed at consumers [21] is evidence of the increased
awareness of the value of good oral care.
e ideal brushing technique is one that allows for complete
plaque removal in the shortest time possible, without causing tissue
damage [22]. us, a comparison between the eectiveness of dental
oss versus the interdental brush is crucial.
Aim
e aim of this study was to evaluate the ecacy of an interdental
brush compared with dental tape for controlling interproximal
plaque around teeth and dental implants.
• Page 2 of 4 •
doi: 10.4172/2470-0886.1000119
Volume 2 • Issue 3 • 1000119
Citation: Luz M, Klingbeil MFG, Henriques P, Lewgoy HR (2016) Comparison between Interdental Brush and Dental Floss for Controlling Interproximal
Biolm in Teeth and Implants. Dent Health Curr Res 2:3.
e best method for cleaning the oral spaces that have dicult
access must be dened for each patient. e method selection
depends on the size and shape of the interdental space, as well as the
morphology of the proximal surface of the tooth. us, interdental
plaque removal, which cannot be performed with conventional
toothbrushes, is paramount to most patients [35].
Among all the methods used for interproximal plaque removal,
dental oss is the most common. Some studies have shown that when
dental oss is used in addition to a toothbrush, a greater amount of
interproximal plaque is removed compared with using conventional
brushes alone [36,37]. Waerhaug [38] states that when dental oss is
properly used, it removes more than 80% of the interproximal plaque.
Moreover, dental oss can even remove sub gingival plaque if it is
introduced 2.0 to 3.5 mm into the gingival sulcus.
Studies that compare the use of dental oss with interdental
brushes are still scarce in the literature. e sole use of toothbrushes
is not indicative of high standards of oral hygiene. In adults, most
studies have demonstrated that conventional toothbrushes are not
as eective in plaque removal as would be expected. Jepsen [39]
demonstrated that most individuals remove only 50% of plaque with
conventional brushing, whereas Lindheand and Lang [35] asserted
that most people do not properly perform oral hygiene and most
likely carry much plaque on their teeth, although they brush their
teeth at least once a day.
Regarding the results obtained in this study, a statistical analysis
demonstrated a signicantly lower rate of plaque with the use of
interdental brushes compared with dental oss, which corroborates
the ndings of Christou et al. [40] and Jackson et al. [41]. Christou
demonstrated that patients with moderate to severe periodontitis who
used an interdental brush [to remove plaque and reduce periodontal
pockets] obtained a higher ecacy than those individuals who used
dental oss. Jackson, in his most recent work, observed a signicant
greater reduction in all parameters [plaque index, level of papillae
and probing depth] in the group using interdental brushes compared
Methods
is study was approved by the Research Ethics Committee of
the Faculty of Dentistry and CPO São Leopoldo Mandic (approval
number 280.809).
is study was performed in the Clinic of Periodontology of the
College of Dentistry São Leopoldo Mandic in Campinas, Brazil.
In total, 12 volunteers of both genders, with ages between 18
and 50 years, were selected. All volunteers met the inclusion criteria
and did not meet any of the exclusion criteria. e inclusion criteria
were as follows: good health; age between 18 and 50 years; having
sucient motor skills for the suggested interproximal cleaning;
plaque index greater than 20%; presence of premolar and molar teeth
or the correspondent implants; interproximal space that allowed
entry of interdental brushes; and diagnosis of periodontitis and
peri-implantitis. e exclusion criteria were as follows: smoking;
decompensated diabetics; low motor skills; plaque index lower than
20%; missing posterior teeth or implants that made interproximal
contacts impossible; patients who did not wish to participate; patients
who showed no motivation; and patients who did not commit
to following the recommended daily use of the dental tape and
interproximal brush. An informed consent form was signed by all the
volunteers.
e medical history and plaque index [23] were assessed during
the rst and second months. During the rst thirty days, patients
used the conventional Bass method of brushing associated with
cleaning the interproximal space only with dental tape. At the end
of the month, a new plaque index was measured. At the beginning of
the second month, the patients were instructed to use conventional
brushing, and then only interproximal cleaning with interdental
brushes 07 (access diameter of 0.7 mm and eectiveness diameter
of 2.5 mm) and 09 (access diameter of 0.9 mm and eectiveness
diameter of 4.0 mm) (CURADEN, Switzerland). At the end of this
second month, a new plaque index was measured. e study used the
plaque index data collected in the rst and second months and thus
can be considered a crossover study. e statistical calculations were
performed with the statistical package SPSS 20 (SPSS Inc., Chicago,
IL, USA), and the level of signicance was 5%.
Results
e analysis of variance for randomized blocks revealed a
signicant dierence in the eectiveness of the two cleaning methods
used for controlling the interproximal biolm (p=0.023). Table 1 and
Figure 1 show that the plaque index was signicantly lower (39.6%)
with the interdental brush than when dental oss was used (58.3%).
Discussion
e periodontal and peri-implant diseases and their incidence
have been studied over the years, and the presence of an oral biolm
has been characterized as the main etiological factor of these diseases
[24-31].
Maintaining good oral hygiene is essential for promoting oral
health and prevention of these diseases [32]. Although some studies
have shown that plaque and gingivitis/periodontitis are safely
controlled with brushing and interproximal cleaning [7,33,34], there
are still questions as to which interproximal cleaning method is the
most eective. Nonetheless, in the eld of implants, virtually nothing
has been studied [18].
100
90
80
70
60
50
40
30
20
10
0
Interdental Brush Dental Floss
Figure 1: Plaque index according to the cleaning method used for
controlling the interproximal biolm (vertical bars indicate the standard
deviations).
Interproximal biolm
Mean
Standard Minimum Maximum
Cleaning method Deviation
value
value
Interdental brush
39.6% A
17.4%
7.4%
64.4%
Dental oss
58.3% B20.0%
24.0%
99.1%
Obs: Standard deviation in parenthesis. The means followed by different letters
indicate statistically signicant differences between the methods.
Table 1: Means and standard deviations of the plaque index according to the
cleaning method used to control the interproximal biolm.
• Page 3 of 4 •
doi: 10.4172/2470-0886.1000119
Volume 2 • Issue 3 • 1000119
Citation: Luz M, Klingbeil MFG, Henriques P, Lewgoy HR (2016) Comparison between Interdental Brush and Dental Floss for Controlling Interproximal
Biolm in Teeth and Implants. Dent Health Curr Res 2:3.
12. Garcia RI (2008) Automated ossing device reduces plaque but not gingivitis.
J Evid Based Dent Pract 8: 78-80.
13. Casado PL, Guerra RR, Fonseca MA, Costa LC, Granjeiro
JM, et al. (2011) Tratamento das doençasperi-implantares:
experiênciaspassadaseperspectivasfuturas. Uma revisão de literatura. Braz
J Periodontol 21: 25-35.
14. Esposito M, Grusovin MG, Worthington HV (2011) Interventions for replacing
missing teeth: treatment of peri-implantitis. Cochrane Database Syst Rev 1:
CD004970.
15. Roos-Jansåker AM, Lindah lC, Renvert H, Renvert S (2006) Nine- to fourteen-
year follow-up of implant treatment. part II: Presence of peri-implant lesions. J
ClinPeriodontol 33:290-295.
16. Mombelli A, Lang NP (1998) The diagnosis and treatment of peri-implantitis.
Periodontol 2000 17: 63-76.
17. Brägger U, Karoussis I, Persson R, Pjetursson B, Salvi G, et al. (2005)
Technical and biological complications/failures with single crowns and xed
partial dentures on implants: a 10-year prospective cohort study. Clin Oral
Implants Res 16: 326-334.
18. Lewgoy HR, Matson MR, Matsushita MM, Forger SI, Tortamano P, et al.
(2012) Estabelecimento de um protocolo de higienização para prevenção de
mucositeseperi-implantites. Implant News 9: 11-19.
19. Chapple LCI, Hill K (2008) Getting the message across to periodontitis
patients: the role of personalised biofeedback. Int Dent J 58: 294-306.
20. Dahlén G, Lindhe J, Sato K, Hanamura H, Okamoto H (1992) The effect of
supragingival plaque control on the subgingival microbiota in subjects with
periodontal disease. J Clin Periodontol 19: 802-809.
21. Bakdash B (1995) Current patterns of oral hygiene product use and practices.
Periodontol 2000 8: 11-14.
22. Hansen F, Gjermo P (1971) The plaque-removing effect of four tooth brushing
methods. Scand J Dent Res 79: 502-506.
23. O’Leary TJ, Drake RB, Naylor JE (1972) The plaque control record. J
Periodontol 43: 38.
24. Lindhe J, Hamp SE, Löe H (1975) Plaque induced periodontal disease in
beagle dogs. A 4-year clinical, roentgenographical and histometrical study. J
Periodontal Res 10: 243-255.
25. Berglundh T, Lindhe J, Marinello C, Ericsson I, Liljenberg B (1992) Soft tissue
reaction to de novo plaque formation on implants and teeth. An experimental
study in the dog. Clin Oral Implants Res 3: 1-8.
26. Berglundh T, Gislason O, Lekholm U, Sennerby L, Lindhe J (2004)
Histopathological observations of human periimplantitis lesions. J Clin
Periodontol 31: 341-347.
27. Susin C, Dalla Vecchia CF, Oppermann RV, Haugejorden O, Albandar
JM (2004) Periodontal attachment loss in an urban population of Brazilian
adults: effect of demographic, behavioral, and environmental risk indicators.
J Periodontol 75: 1033-1041.
28. Covani U, Marconcini S, Crespi R, Barone A (2006) Bacterial plaque
colonization around dental implant surfaces. Implant Dent 15: 298-304.
29. Greenstein G, Cavallaro J Jr, Tarnow D (2010) Dental implants in the
periodontal patient. Dent Clin North Am 54: 113-128.
30. Heitz-Mayeld LJ, Salvi GE, Botticelli D, Mombelli A, Faddy M, et al. (2011)
Anti-infective treatment of peri-implant mucositis: a randomised controlled
clinical trial. Clin Oral Implants Res 22: 237-241.
31. Lang NP, Bosshardt DD, Lulic M (2011) Do mucositis lesions around implants
differ from gingivitis lesions around teeth? J Clin Periodontol 38 Suppl 11:
182-187.
32. Chu R, Craig B (1996) Understanding the determinants of preventive oral
health behaviours. Probe 30: 12-18.
33. Hujoel PP, Löe H, Anerud A, Boysen H, Leroux BG (1998) Forty-ve-year
tooth survival probabilities among men in Oslo, Norway. J Dent Res 77: 2020-
2027.
34. 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.
with the group that used dental oss, aer 12 weeks of observation.
Waerhaug [42,43] also showed that individuals who habitually
employed interdental brushes were able to keep the proximal
supragingival surface free of plaque and even remove some of the sub
gingival plaque. In addition to the results found in our study, patient
compliance is to be evaluated with regard to the long-term use of
interproximal cleaning devices.
e ease of using an interdental brush compared with dental
oss, as reported by the patients, might have been instrumental in the
results. is is an important factor to be considered, as it highlights
the major diculties reported by our patients regarding using dental
oss. We must also note that even patients with lower motor skills can
consider interdental brushes easier to use; thus, their use should be
encouraged.
e method of interproximal cleaning with interdental brushes
can be used with condence for biolm removal in the proximal
region because no articles in the literature contradict this idea.
However, employing any of the two methods associated with
brushing with the Bass technique provides more complete oral
hygiene, thereby leading to a lower risk for developing periodontal
and peri-implant disease, especially in the interproximal space-which
was the focus of this study.
Compared with dental oss, the use of an interdental brush showed
greater ecacy in controlling the interproximal biolm around teeth
and dental implants. us, we must educate and encourage our
patients to use these specic methods of interdental cleaning on a daily
basis for eective biolm control. Because of the lack of publications
on this subject, further clinical trials should be conducted to discuss
and improve the use of these interproximal cleaning methods.
References
1. Hotta M, Imade S, Kotake H, Sano A, Yamamoto K (2009) Articial plaque
removal from interproximal tooth surfaces (maxillary premolar and molar) of a
jaw model. Oral Health Prev Dent 7: 283-287.
2. Kornman KS, Löe H (1993) The role of local factors in the etiology of
periodontal diseases. Periodontol 2000 2: 83-97.
3. Micheelis W, Reiter F (2006) Sociodemographic and behavior related
aspects of oral risk factors in four age cohorts. In: MicheelisW, SchiffnerU
(eds). Fourth German Oral Health Study (DMS IV) Köln, Germany:
DeutscherZahnärzteVerlag 375-398.
4. Bergenholtz A, Gustafsson LB, Segerlund N, Hagberg C, Ostby N (1984) Role
of brushing technique and toothbrush design in plaque removal. Scand J Dent
Res 92: 344-351.
5. Perry DA, Schmid MO (1995) Plaque control. In: CarranzaFA, NewmanMG
(eds). Clinical Periodontology (8th edtn.), Chicago: WB Saunders Co 493-508.
6. Lang NP, Cumming BR, Löe HA (1977) Oral hygiene and gingival health in
Danish dental students and faculty. Community Dent Oral Epidemiol 5: 237-
242.
7. 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.
8. Löe H (1979) Mechanical and chemical control of dental plaque. J Clin
Periodontol 6: 32-36.
9. Echeverria JJ, Sanz M (2003) Mechanical supragingival plaque control.
In: LindheJ, KarringT, LangNP (eds). Clinical Periodontology and Implant
Dentistry. (4th edtn.), Munksgaard, Denmark: Blackwell Publishing.
10. Kiger RD, Nylund K, Feller RP (1991) A comparison of proximal plaque
removal using oss and interdental brushes. J Clin Periodontol 18: 681-684.
11. Biesbrock A, Corby PM, Bartizek R, Corby AL, Coelho M, et al. (2006)
Assessment of treatment responses to dental ossing in twins. J Periodontol
77: 1386-1391.
• Page 4 of 4 •
doi: 10.4172/2470-0886.1000119
Volume 2 • Issue 3 • 1000119
Citation: Luz M, Klingbeil MFG, Henriques P, Lewgoy HR (2016) Comparison between Interdental Brush and Dental Floss for Controlling Interproximal
Biolm in Teeth and Implants. Dent Health Curr Res 2:3.
35. Lindhe J, Lang NP (2010) Tratado de Periodontia Clínicae Implantologia
Oral. (5th edtn.), Rio de Janeiro: Guanabara Koogan.
36. Reitman WR, Whiteley RT, Robertson PB (1980) Proximal surface cleaning
by dental oss. Clin Prev Dent 2: 7-10.
37. Kinane DF, Jenkins WM, Paterson AJ (1992) Comparative efcacy of
the standard ossing procedure and a new oss applicator in reducing
interproximal bleeding: a short-term study. J Periodontol 63: 757-760.
38. Waerhaug J (1981) Effect of tooth brushing on sub gingival plaque formation.
J Periodontol 52: 30-34.
39. Jepsen S (1998) The role of manual toothbrushes in effective plaque control:
advantages and limitations. In: LangNP, AttströmR, LöeH (eds).Proceedings
of the European Workshop on Mechanical Plaque Control. London:
Quintessence 121-137.
40. Christou V, Timmerman MF, Van der Velden U, Van der Weijden FA (1998)
Comparison of different approaches of interdental oral hygiene: interdental
brushes versus dental oss. J Periodontol 69: 759-764.
41. Jackson MA, Kellett M, Worthington HV, Clerehugh V (2006) Comparison
of interdental cleaning methods: a randomized controlled trial. J Periodontol
77: 1421-1429.
42. Waerhaug J (1976) The interdental brush and its place in operative and
crown and bridge dentistry. J Oral Rehabil 3: 107-113.
43. Silverstein LH, Kurtzman GM (2006) Oral hygiene and maintenance of dental
implants. Dent Today 25: 70-75.
Author Afliation Top
1Periodontist, São Leopoldo Mandic School of Dentistry, Brazil
2Institute of Energy and Nuclear Research, IPEN/CNEN- SP, Brazil
3Institute and Research Center, Campinas, São paulo Brazil
4São Leopoldo Mandic School of Dentistry, Brazil
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