Efficacy+of+Different+Interproximal+Aids

= = **  Efficacy of Different Interproximal Aids  **

Maria: There are many dental products on the market for proper plaque removal. However, for most people, the dental aisle in most stores can be frightening. Therefore, as dental professionals, it is up to us to make recommendations to patients. A common question a dental professional may encounter is, “what kind of tooth brush should I use?” In a study conducted by Ren et al. (2007), researchers found that manual toothbrushes with a cross-angled soft bristle design provided superior plaque removal compared to a soft, straight-bristled toothbrush. This was due to the cross-angled bristles’ ability to reach interproximal embrasures more effectively than a toothbrush with straight bristles. Another question a dental professional may encounter is, “which are better; power or manual tooth brushes?” In a systematic review on Cochrane conducted by Robinson et al. (2005), authors concluded that powered toothbrushes with a rotation oscillating action reduce plaque and gingivitis more than manual tooth brushing.

Other interdental aids as adjuncts to tooth brushing can also be recommended. For periodontally involved patients with exposed embrasures or furcations, interdental brushes may be indicated. These brushes are available in a variety of sizes and provide a safe and effective alternative to floss. Interdental brushes can also be indicated for patients with bridges, crowns, implants and also with orthodontic appliances. End tuft brushes can also provide effective plaque removal for patients with third molars, open embrasures and orthodontic appliances. If a patient with open embrasures or exposed furcations is unwilling to try interdental brushes or end-tuft brush, they can use a toothpick to remove plaque.

There are a variety of toothbrushes and dental aids available on the market and as dental professionals, we should make recommendations according to individual needs.

Melrose, D. (2005). Floss alternatives. Dimensions of Dental Hygiene, 3(10): 22-26.

Ren, Y., Cacciato, R., Whelehan, M., Ning, L., and Malmstrom, H. (2007). Effects of toothbrushes with tapered and cross angled soft bristle design on dental plaque and gingival inflammation: A randomized and controlled clinical trial. Journal of Dentistry, 35(7), 614-622.

Robinson, P.G., Deacon, S.A., Deery, C., Heanue, M., Walmsley, A.D., et al. (2005) Manual versus powered tooth brushing for oral health. Cochrane Database of Systematic Reviews, Issue 2. Art. No.: CD002281. DOI: 10.1002/14651858.CD002281.pub2.

Marcia: When using floss ortho patients seemed to prefer a WaterPik ® Flosser over normal floss and superfloss. It is good to note that patient education and patient motivation is really important since the patients with good tooth brushing habits removed plaque much better using any other interdental aids in removing plaque than patients with bad tooth brushing habits. Newman, M. G., Takei, H. H., Klokkevold, P. R., & Carranza, F. A. (2006). Carranza’s clinical periodontology (10th ed.). St. Louis: Saunders Elsevier. Kossack, C., Jost-Brinkmann, P. (2006). Plaque and gingivitis reduction in patients undergoing orthodontic treatment with fixed appliances- comparison of toothbrushes and interdental cleaning aids. //Journal of orofacial orthopedicas.66.// 20-38.Recived on May 19, 2009 from http://www.springerlink.com.lib-proxy.fullerton.edu/content/kxkg2kmx31efqlj1/fulltext.pdf

Reina: As an adjunct to brushing, the interdental brush removes more dental plaque than brushing alone. Studies showed a positive significant difference using interdental brushes with respect to plaque scores, bleeding scores, and probing pocket depth. The majority of the studies presented a positive significant difference in the plaque index when using the interdental brush compared with floss.

Slot, D. E., Dorfer, C. E., & Van de Weijden, G. A. (2008, November). The efficacy of interdental brushes on plaque and parameters of periodontal inflammation: A systematic review. //International Journal of Dental Hygiene//, //6//(4), 253-264.

Natalie As oral educators, it is essential that we understand the variety of toothbrushes and interproximal aids that are available in the marketplace. I think we should try a variety of products and understand the unique uses for each product. I found a study that compared the Sonicare Elite to the Oral B 3D power toothbrush and their ability to remove interproximal plaque. Both brushes removed more plaque when they were activated rather than used as a manual brush; however, the amount of interproximal plaque removed by the Sonicare was 32% compared to the Oral B at 9.5%. This demonstrates to me that power brushes are more effective at removing interproximal plaque than manual brushes. The Sonicare FlexCare is great at removing biofilm from hard to access areas in the mouth. We also teach our patients the importance of brushing and using an interdental aid such as floss, tepe brush, perio-aid, floss holders or other aids. Each case is individualized to meet the needs of the pts’ dentition. If they have Class III furcations, a perio aid is an excellent option. For Class II or III embrasures and orthodontic appliances, the tepe-brush works great. The rubber tip stimulator is helpful in massaging the gums. As we learn about all the interproximal aids and toothbrushes available, we can help our pt’s make educated decisions to improving and maintaining their oral health.

Hope CK, & Wilson M. (2002). Comparison of the interproximal plaque removal efficacy of two powered toothbrushes using //in vitro// oral biofilms. //American Journal of Dentistry.// 15:7B-11B.

Milleman J, Putt MS, Sturm D, Master A, Jenkins W, Schmitt P, & Hefti AF. (2007) Comparison of plaque removal by Sonicare FlexCare and Sonicare Elite. Compendium Continuing Education in Dentistry. 28   **  Diem:  ** Interdental aids are another important tool to help reduces plaque and caries interproximally. Not many patients like to floss because it requires dexterity and time consuming for naive individual. Understand each interdental aid to recommend for each patient is essential. Interdental brushes or tepe brushes are good for diastema, recession, bridge, and crown areas. They come with different color coded for different size. They are manufactured for easy to use and soft to the oral tissue. Another interdental aids is rubber or plastic tip stimulators, which are good for gingival stimulation and plaque removal. It shrinks the edematous gingiva and helps to bring blood supply to the gingiva. The technique of using a rubber tip stimulator is to press the rubber tip part hard against the gum, release, and press it again. Do not do it too hard that hurt yourself, but do it hard enough to stimulate the blood flow to the areas. If the gum is inflamed, it may feel uncomfortable at first. After using it for a few week, the gum gets strong like a work-out muscle. Finally, Stick and picks are used to reduce bleeding and inflammation. They are used at 90 degree angle with a back and forth motion. Each interdental aid has its special function based on patient’s dexterity and teeth position. Melrose, D. (2005). Floss alternatives. //The Journal of Professional Excellence// //Dimensions of Dental// Hygiene//, 3//(10): 22-26 Britney

When working with patients to improve OHI it is important to know about as many OH aids as you can, as well as knowing what they are used for and what patients they work best on. When giving any patient a new OH aid it is important to show them how to properly use it so that they don’t damage their tissue and also so that they are getting the full effectiveness out of the product. I have had patients that own and use great toothbrushes and oral hygiene aids but had not been shown how to use them properly, because of this they had not been getting the full effect of the product and were really not as satisfied with the product as they thought they would have been. When I go over the proper usage instructions with them they are usually very happy with the results and are more motivated to take care of their oral hygiene. I think it is also important to be aware of different ways that a patient might use a product so that you can identify signs of misuse that the patient might not know about which could then help you as a clinician to educate them on the proper way to use the product and show them the signs that you saw that indicated to you that they were using the product incorrect.

Sources: Rethman, J. (2008). Focus on Toothbrushes. Dimensions of Dental Hygiene, 6(5).

Focus on alternatives to dental floss (2007). Dimensions of dental hygiene

Here is a link to a chart from Dimensions in 2007 featuring different interproximal aids and their features. [] Noo:

Dental hygienist provide more oral health education services than all other oral professionals. We have to be well aware of advantages and disadvantages of different kinds of interdental cleaning aids, then use our knowledge to educate our patients to help them maintain oral health. Dental floss is needed to remove the plaque and debris that collect between the teeth and under the gum line. Study showed waxed and unwaxed dental floss are both effective. Study also shows is most effective when the interdental papillae are intact and the teeth are in contact. As we know that there are alternative methods to floss. They include interdental brushes, wooden devices, interdental tips, gauze strips, knitting yarn and pipe cleaners. Each patient, each case is unique. For example of furcations, pipe cleaner, interdental brush, and perio aids are great choices depending on the severity of furcations. Always discuss the proper use of these cleaning aids with patients to avoid injury to soft tissue. Another misconception that many patients need to have a better understanding is oral irrigator. These devices direct a stream of water to remove particles of food from around and between the teeth. They may be helpful to people with braces or fixed partial dentures. They are useful for cleaning hard-to-reach areas and may help reduce gingivitis. Study shows, however, an oral irrigator is not a substitute for brushing and flossing. Slot, D. E., Dorfer, C. E., & Van de Weijden, G. A. (2008, November). The efficacy of interdental brushes on plaque and parameters of periodontal inflammation: A systematic review. International Journal of Dental Hygiene, 6(4), 253-264. Wilkins, E.(2005). Oral infection control: toothbrushes and tooth brushing. Clinical Practice of the Dental Hygienist (9th ed). Goucher, J., Dietz, K., & Define, C. (Ed). Lippincott Williams & Wilkins. Baltimore, MD.

Lia: There are many different types of aids available for helping to clean and reach the interdental areas, for example: tooth picks, proxy brushes, floss, floss aids, interdental stimulators & water piks. This is a good thing because what may work for one persons needs may not work out for the next individual. As a clinician we need to have used and understand how to use the products that are available and that we recommend to our patients. This is to prevent patients from damaging their gums and to help our patients maximize the products benefits so they can help us and themselves by maintaining their periodontal health.

Wilkins, E.(2005). Oral infection control: toothbrushes and tooth brushing. Clinical Practice of the Dental Hygienist (9th ed). Goucher, J., Dietz, K., & Define, C. (Ed). Lippincott Williams & Wilkins. Baltimore, MD.

Tawnya: As dental professionals it is important to know the products that are available to our patients, the indication for use and situations when the product should be recommended. With such a wide variety of dental products, choosing a toothbrush at the grocery store could be an overwhelming process for some. A study was conducted evaluating different shapes of bristles including flat, wave, bi-level and zig zag in soft bristles. The participants were instructed to use the Bass technique for 2 minutes and all the brushes yielded a 60% plaque decrease. To me, this means proper technique is far more important than a fancy manual brush. Another study compared 2 electric brushes: the Sonicare Elite and the Oral B 3D. They tested the brushes with the power off and then with the power on. Both brushes removed more interproximal plaque with the power on with Sonicare at 32% and the Oral B at 9.5%. I feel this study doesn't confirm that electric brushes are better than manual, just that the electric toothbrushes yield better results when they are used how they were intended...with the power on.

Melrose, D. (2005). Floss alternatives. The Journal of Professional Excellence Dimensions of Dental Hygiene, 3(10): 22-26

Milleman J, Putt MS, Sturm D, Master A, Jenkins W, Schmitt P, & Hefti AF. (2007) Comparison of plaque removal by Sonicare FlexCare and Sonicare Elite:Compedium Continuing Education in Dentistry.

Sripriya, N., Hyder, S. (2007). A comparative study of the efficacy of four different bristle designs of tooth brushes in plaque removal. Journal of Indian Society of Pedodontics and Preventive Dentistry, 25(2), 76-81.

Jennifer Teaching our patients OHI is one of the most important things we can do. Studies show that the size and shape of the tooth brush can have an effect on the outcome of brushing. Along with brushing our patients need to take one more step in there oral hygiene habit, and that is to remove plaque from the interproximal space. This is one of the tougher things to get our patients to do, we need to consistently motivate them. Determining which technique to use to remove the interproxamal plaque is patient specific. Patients with tight contacts would be good candidates for floss those with spaces may benefit from interdental brushes. A study I read was conducted on patients with moderate to severe periodontal disease. The study concluded that the interdental brushes worked better at removing plaque then the floss did in these patients. Another study I read found that the triangular wooden tip removed plaque as well as floss however the wooden tip had decrease in inflammation were the floss did not. I think this is because the wooden tip may stimulate the tissue more because of the technique. I feel that when we recommend an oral hygiene aid we need make our discussion off of our patients needs. If we give the wrong aid to someone it will not work as well as the proper aid. Hoenderdos,N., Slot,D., Paraskevas,S., Vanderweijden,G. The efficacy of wood sticks on plaque and gingival inflammation a systemic review.(2008). International Journal of dental hygiene.6(4):251-2.

Christou,V.,Timmerman,M.,Vandervelden,U.,Vanderweijden,F. Comparison of different approaches of interdental brushes versus dental floss.(1998). Journal of Periodontology.69(7).

Lia: What I learned from this topic was that as clinicians we need to be aware of the oral hygiene aids that are available. As clinicians we need to know how to use them and for what circumstance to recommend them. Every patient has an individual need and we must help provide them with the resources to take care of their needs.

We need to educate our patients so that they do not cause damage to their tissues and so they use the products correctly to maximize the products benefits. There is no clear cut aid that is superior for anyone one person. The research indicates that power brushes are superior but, not for all people. We need to speak to our patients and find out what they are currently using and what they have used in the past. Then from there analyze what their current oral needs are after taking their assessments. We then can give out personal individualized recommendations for each patient.

Ceri: One study I found compared different electric toothbrushes. I was very interested in this because it compared a more expensive rechargeable toothbrush and a less expensive battery operated toothbrush. The rechargeable battery operated toothbrush overall had better results. 70 subjects were studied, but the plaque reduction was not substantial which makes me think that obviously brushing alone is not enough.

So I looked for some articles related to flossing and brushing, but I found one that was very interesting comparing mouth rinses and flossing and which is more effective at removing interproximal plaque and the amount of gingivitis present. In this study what was found is in conjunction with regular dental cleanings using a mouth rinse twice a day compared to flossing once a day removes about the same amount of plaque interproximally. And also has the same effect on gingivitis. I do not know how much I agree with this. The study did give a disclaimer saying we shouldn’t recommend mouth rinse instead of floss. I believe that flossing still ultimately is more effective. What are your thoughts?

Bauroth, K., Charles, C. H., Mankodi, S. M. Simmons, K., Zhao, Q. and Kumar, L. D. (March 2003). The efficacy of an essential oil antiseptic mouth rinse vs. dental floss in controlling interproximal gingivitis. The Journal of the American Dental Association. (134) 359-365.

Sharma, N.C., Qagish, J. G, Galustians, H. J., Goyal, C. R., Cugini, M. A., Thompson, M. C. and Warren, P. R. (2001). A comparison of a battery-operated power toothbrush and a manual toothbrush with respect to safety and plaque control. American Journal of Dentistry (14) 98-128.