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Interdental cleaning

March 30, 2011
FOCUS Editorial Director Maria Perno Goldie, RDH, MS, discusses the benefits of interdental cleaning by use of dental floss, oral irrigation, and interdental brushes and other aids.
By Maria Perno Goldie, RDH, MS

Self-care is a deliberate action that individuals, family members and the community should engage in to maintain good health. Ability to perform self-care varies according to many social determinants and health conditions. Self-care is emphasized by the World Health Organization (WHO) as the key strategy for health promotion and disease prevention.(1)

In the context of oral health, we view oral self-care as removal of biofim by toothbrushing, interdental cleaning, and rinsing. As well, minimizing harmful behaviors, such as tobacco use, will help to prevent oral disease. This column will feature the benefits of interdental cleaning by use of dental floss, oral irrigation, and interdental brushes and other aids.

According to one study, the chief reason leading to the use of self-care behaviors is need. Oral pain increases the use of self-care behaviors, as do bleeding gums and dry mouth. We should encourage self-care behaviors for prevention of oral health problems, rather than pain as the indicator to take action. We could also expand analysis of dental self-care behavior and the relationship of self-care behavior to the use of professional services.(2)

In order to plan effective interventions which encourage patient self-care, it is first important to collect basic information regarding self-care behavior and perception. Currently, there is no universally accepted or recommended assessment tool for oral health behavior of periodontitis patients. Because of the limited amount of time available at clinical appointments, utilizing complex instruments based on health behavior models may not always be practical. Thus, there is a need for concise assessment of such data.(3) Use of Motivational Interviewing is one method of assessing the values and needs of a patient.

Studies show that 10% to 21% of the people in the USA floss daily.(4,5) Interdental cleaning is necessary for the prevention of periodontal disease and tooth decay, and may also affect bacteria levels and systemic health. Dental floss is an excellent tool for removing plaque biofilm from the sides of the teeth.(6) However, some patients will not floss for a variety of reasons, such as laziness, lack of dexterity, difficulty with tight or large embrasure areas, or concave tooth surfaces. Restorations may also pose a problem regarding floss use.

A variety of floss aids exist to make flossing easier, such as (but not limited to) the TePe Floss Holder, TePe Mini Flosser, Sword Floss, Reach Access Flosser, Plackers Dental Flossers, Oral-B Advantage Floss Picks, and StaiNo Floss 'n Toss Flossers. There are even products for children such as DenTek Fun Flossers and Dr. Fresh Firefly Flossers for Kids. There are also floss threaders and Oral-B Super Floss, DenTek Floss Threaders, and a variety of floss aids to clean under bridges, around implants, and around orthodontic brackets, like the Platypus Ortho Flosser.

For those who cannot or will not floss, other options for interdental cleaning should be suggested. Finding the appropriate method requires us to assess and interview the patient regarding their periodontal condition, anatomical challenges, restorations, manual dexterity, and desire and motivation. Interdental cleaning should be performed one or two times each day, preferably prior to toothbrushing. With a clean tooth surfaces, fluoride, remineralizing agents, and antimicrobial agents may be better able to prevent disease.

Interdental brushes (IDB) are effective alternatives to floss.(7) IDB come in a variety of shapes and sizes, and those with nylon or nylon coated wores are safe to use around implants. The Squirt Brush is an IDB with an attached refillable bottle to deliver a variety of mouth rinses for irrigation and disinfection. IDBs can also be used to deliver medicaments to the proximal surfaces of the teeth.

In short, IDBs have shown to remove more dental plaque biofilm than brushing alone in a systematic review.(8) Studies reviewed showed a positive significant difference using IDB with respect to the 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 IDB compared with floss.(8)

Wooden and plastic sticks have been shown to reduce plaque, bleeding and inflammation.(9) One study found that the use of dental floss or a toothpick holder resulted in no significantly different effect in the improvement of gingival health. Stim-U-Dent Plaque Removers and toothpicks (Perio-Aid) are also often used.

Power-assisted devices for interdental cleaning are also available. New research has demonstrated that oral irrigators reduce bleeding and gingivitis.(10) A new product was introduced last week at the International Dental Show (IDS).(11) The Philips Sonicare AirFloss features a "microburst technology" that combines the forces of air and water droplets to remove biofilm from between teeth. Philips released several product guides and results of studies to attendees. Stayed tuned for more information on this new product!

The bottom line is that we need to encourage and guide patients to clean interdentally, whether with floss or one of the many alternative methods.

And last but not least, April is National Child Abuse Prevention Month. It is time to raise awareness about child abuse and neglect, in the dental office and in other venues, and to create strong communities to support children and their families.(12)

1. World Health Organization, Regional Office for South-East Asia. Self-care in the Context of Primary Health Care. Report of the Regional Consultation Bangkok, Thailand, 7–9 January 2009, p. 1-71.
2. Arcury TA, Bell RA, Anderson AM, Chen H, Savoca MR, Kohrman T, and Quandt SA. Oral Health Self-Care Behaviors of Rural Older Adults. J Public Health Dent. 2009 Summer; 69(3): 182–189.
3. Saito A, Kikuchi M, Ueshima F, Matsumoto S, Hayakawa H, Masuda H, and Makiishi T. Assessment of oral self-care in patients with periodontitis: a pilot study in a dental school clinic in Japan. BMC Oral Health. 2009; 9: 27.
4. Macgregor ID, Regis D, Balding J. Self-concept and dental health behaviours in adolescents. J Clin Periodontol. 1997;24:335-339.
5. Rimondini L, Zolfanelli B, Bernardi F, Bez C. Self-preventive oral behavior in an Italian university student population. J Clin Periodontol. 2001;28:207-211.
6. Consensus Report: Discussion, Section II. Proceedings of the World Workshop on Clinical Periodontics. Chicago, American Academy of Periodontology. 1989;13-17.
7. Christou V, Timmerman MF, Van der Velden U, Van der Weijden FA. Comparison of different approaches of interdental oral hygiene: interdental brushes versus dental floss. .J Periodontol. 1998;69:759.
8. Slot DE, Dörfer DE, and Van der Weijden GA. The efficacy of interdental brushes on plaque and parameters of periodontal inflammation: a systematic review. International Journal of Dental Hygiene, Volume 6, Issue 4, pages 253–264, November 2008.
9. Lewis MW, Holder-Ballard C, Selders RJ Jr, Scarbecz M, Johnson HG, Turner EW. Comparison of the use of a toothpick holder to dental floss in improvement of gingival health in humans. J Periodontol. 2004;75:551-556.
10. Rosema NAM et al. The effect of different interdental cleaning devices on gingival bleeding. J Int Acad Periodontol 2011; 13:2-10.


Maria Perno Goldie, RDH, MS