Oral Hygiene in The Prevention of Periodontal Diseases

Periodontology 2000, Vol. 55, 2011, 104123 Printed in Singapore.
All rights reserved
2011 John Wiley & Sons A/S
PERIODONTOLOGY 2000
Oral hygiene in the prevention of periodontal diseases: the evidence

FRIDUS
VAN DER
WEIJDEN & DAGMAR ELSE SLOT
There is increasing public awareness of the value of personal oral hygiene. People brush their teeth for a number of reasons: to feel fresh and condent, to have a nice smile, and to avoid bad breath and disease. Oral cleanliness is important for the preservation of oral health as it removes microbial plaque, preventing it from accumulating on teeth and gingivae (33). Maintenance of effective plaque control is the cornerstone of any attempt to prevent and control periodontal disease. Supragingival plaque is exposed to saliva and the natural self-cleansing mechanisms that exist in the oral cavity. However, although such mechanisms may eliminate food debris, they do not adequately remove dental plaque. Therefore, regular personal oral hygiene is required for proper elimination of supragingival plaque (132). The most widespread means of actively removing plaque at home is toothbrushing. There is substantial evidence showing that toothbrushing and other mechanical cleansing procedures can reliably control plaque, provided that cleaning is sufciently thorough and performed at appropriate intervals. Evidence from large cohort studies has demonstrated that high standards of oral hygiene will ensure the stability of periodontal tissue support (9, 64). Almost 50 years of experimental research and clinical trials in various geographical and social settings have conrmed that effective removal of dental plaque is essential for dental and periodontal health (84). Oral hygiene acts as a non-specic suppressor of plaque mass. This therapeutic approach is based on the rationale that any decrease in plaque mass benets the inamed tissues adjacent to bacterial deposits. Diminishing plaque mass through good oral hygiene will reduce the injurious load on these tissues. The assumption that gingivitis is the precursor of periodontitis and that maintenance of healthy
gingivae will prevent periodontitis is the basis on which primary prevention of gingivitis is founded. Consequently, preventing gingivitis could have a major impact on periodontal care expenditure (13). Primary prevention of periodontal disease includes educational interventions for periodontal disease and related risk factors, as well as regular, self-performed plaque removal and professional mechanical removal of plaque and calculus. As such, optimal oral hygiene requires appropriate patient motivation, adequate tools and professional oral hygiene instruction.
Oral hygiene instruction

Twice daily brushing with uoride toothpaste is now an integral part of most peoples daily hygiene routine in Western societies. However, it appears that most patients are unable to achieve total plaque control at each cleaning. A systematic review (132) was initiated to assess the effect of mechanical plaque control. The review was rened to address the effect of manual toothbrushing on plaque and gingivitis parameters. The authors systematically searched for papers that investigated the effect of mechanical oral hygiene with respect to gingivitis and plaque control in subjects with gingivitis in studies of at least 6 months duration. The US National Library of Medicine database (MEDLINE-PubMed) was used to search for appropriate papers for review. The database was searched up to and including September 2004. The search strategy produced 3,223 citations, 33 of which were identied as eligible for inclusion in this review. The 33 studies were randomized, controlled clinical studies involving adults (18 years old) with plaque and gingivitis. Table 1 shows the results of the
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Evidence-based oral hygiene methods
Table 1. Meta-analyses comparing baseline vs. end-of-trial data in studies of 6 months or more for manual toothbrushes in adults with gingivitis. Weighted mean differences (WMD) and 95% condence intervals are provided. A negative value favors oral hygiene instruction [Adapted from Van der Weijden & Hioe (132)]
Studies included Lobene et al. (82) Renvert & Birkhed (103) Stephen et al. (122) Svatun et al. (124) Svatun et al. (125) Svatun et al. (126) Svatun et al. (127) Svatun et al. (128) Stephen et al. (122) Svatun et al. (124) Svatun et al. (125) Svatun et al. (126) Svatun et al. (127) Svatun et al. (128) Index Plaque index; e Silness & Lo (119) WMD (random) )0.1 95% condence interval )0.20, 0.01 Test for overall effect (P value) 0.06 Test for heterogeneity (P value and I2) 0.00001 90.0%
Percentage bleeding on probing Bleeding index; Ainamo & Bay (2)
)5.84
)3.27, )8.41
0.00001
0.26
24.8%
)9.77
)6.42, )13.13
0.00001
0.75
0%
meta-analysis in terms of plaque and gingivitis for the manual toothbrush control groups in the eight trials in which both professional oral hygiene instruction and prophylaxis were provided at the start of the study. The plaque data in Table 1 are based on the e (119) and the data index described by Silness & Lo regarding occurrence of bleeding on probing and gingival inammation are based on the index described by Ainamo & Bay (2). For the eight selected studies, the mean baseline plaque index value varied between 0.29 and 0.72, and the mean plaque index value at the conclusion of the study ranged from 0.21 to 0.98. The plaque index weighted mean difference of 0.10 between baseline and the end of the trial was not signicant (P = 0.06). The level of gingivitis, assessed as the proportion of bleeding sites at baseline, varied between 23 and 31% and was reduced to 2024% at the conclusion of the study. The weighted mean difference of 5.84% between the values at baseline and the end of the trial was signicant (P < 0.00001). The two studies that used the Ainamo & Bay index for gingivitis showed a reduction from 25.6 to 29.8 at baseline to 16.319.4 at the end of these studies. The weighted mean difference of 9.77 indicated that these results were statistically signicant (P = 0.00001). During the meta-analysis concerning plaque, an obvious heterogeneity in the clinical outcomes of the selected studies was found. In cases where heterogeneity is signicant, readers should exercise caution as the weighted mean difference may not provide an exact measure of the results.
In the review by van der Weijden & Hioe (132), the major challenge was determining what to compare in these studies. For example, whether manual toothbrushing should be compared with no oral hygiene. Instead, the authors decided to systematically search the literature for controlled clinical trials of 6 months or longer that assessed the effects of various forms of plaque control in gingivitis subjects. In these trials, the manual toothbrush group provided data that could be analyzed according to whether the baseline intervention was professional oral hygiene instructions or prophylactic measures. Data for baseline and the end of the trial could then be compared with the effect of mechanical oral hygiene (Table 1). It was expected that, in most studies, the manual toothbrush group with standard uoride toothpaste would be the control group, as it indeed turned out to be. There were no negative control groups. It is therefore impossible to rule out that part of the observed effect was due to the Hawthorne effect, which is the change in behavior of participants involved in a study. Van der Weijden & Hioe (132) concluded that, in adults with gingivitis, the quality of selfperformed mechanical plaque removal was not sufciently effective and should be improved. Based on studies of 6 months or longer, it appears that a single oral hygiene instruction describing correct use of a mechanical toothbrush, in addition to a single professional session of oral prophylaxis at baseline, had a signicant, albeit small, positive
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van der Weijden & Slot
effect on the reduction of gingival inammation in adults with gingivitis (132).
Toothbrushes
Natural physiological forces that clean the oral cavity are inefcient at removing dental plaque. Tongue movement makes contact with the lingual aspects of the posterior teeth, and, to a lesser extent, can also clean their facial surfaces. The cheek covers the buccal aspects of the posterior maxillary teeth and can thereby help prevent the copious build-up of dental plaque on these surfaces. Saliva ow has some limited potential in cleaning debris from interproximal spaces and occlusal pits, but it is less effective in removing and or washing out plaque. These defenses can best be classied as supercial actions to control or mediate plaque build-up. Thus natural cleaning of dentition is virtually non-existent. To be controlled, plaque must be removed frequently by active methods. Hence, the dental community continues to encourage proper oral hygiene and more effective use of mechanical cleaning devices (28). Maintenance of oral hygiene has been an objective of man since the dawn of civilization. The exact origin of mechanical devices for cleaning teeth is unknown. In 1780, the Englishman William Addis manufactured a toothbrush that had a bone handle and holes for placement of natural hog bristles, which were held in place by wire. In the early 1900s, celluloid began to replace the bone handle, a change that was hastened by World War I, when bone and hog bristles were in short supply. Nylon laments were introduced in 1938. Nylon laments made toothbrushes inexpensive enough for nearly every person to own one. During the past 50 years, oral hygiene has improved, and, in industrialized countries, 8090% of the population brushes their teeth once or twice a day (108, 109). Today, numerous manual toothbrush types are available. However, there is still insufcient evidence that one specic toothbrush design is superior to another. Modern toothbrushes have bristle patterns that are designed to enhance plaque removal from hard-to-reach areas of the dentition, particularly proximal areas. The handle size is appropriate for the hand size of the prospective user, and much emphasis has been placed on new ergonomic designs (76, 85). There is no consensus as to the optimal frequency of toothbrushing. How often and how much plaque needs to be removed to prevent development of
dental disease is not known. From a practical viewpoint, it is generally recommended that patients brush their teeth at least twice daily, not only to remove plaque but also to apply uoride through the use of dentifrice to prevent caries. This advice is also provided based on reasons of practicality and feelings of oral freshness. Despite the fact that most individuals claim to brush their teeth at least twice a day, it is clear from both epidemiological and clinical studies that mechanical oral hygiene procedures, as performed by most subjects, are insufcient to control supragingival plaque formation and prevent gingivitis and more severe forms of periodontal disease (117). Recently, a systematic review was initiated by Wiggelinkhuizen et al. (unpublished results) to assess the effect of a single brushing exercise using a manual toothbrush. The MEDLINE and Cochrane Central register of Controlled Trials (CENTRAL) databases were searched up to December 2008 to identify appropriate studies. The variable plaque was selected as an outcome parameter. Independent screening of titles and abstracts of 1,949 MEDLINE Pubmed and 867 Cochrane papers resulted in identication of 50 publications that met the eligibility criteria. These papers described 167 experiments with 8,236 subjects. Based on the baseline and end scores, a plaque reduction percentage was calculated for each of the eligible experiments taken from the selected studies. Using these data, the weighted mean difference was calculated to be 43%, with a range of 2853%. This weighted mean is an approximation of the mean plaque reduction resulting from a single brushing. However, one cannot rule out the Hawthorne effect. This could potentially improve the outcome and result in an overestimation of the actual mean effect. The results of this review indicate that, on average, people are not effective brushers, and probably live with constant, large amounts of plaque on their teeth even though they brush once a day.
Electric toothbrushes
Maintaining nearly plaque-free teeth is not easy. The electric toothbrush represents an advance that has the potential to enhance both plaque removal and patient motivation. Electric toothbrushes were introduced to the market more than 50 years ago. The rst toothbrush powered by electricity was developed by Bemann & Woog in Switzerland, and was introduced in the United States in 1960 as the Broxodent. In 1961, a cordless rechargeable model was introduced by General Electric (36). Studies of
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Fig. 1. Conventional electric toothbrush moving back and forth and sideways, resulting in an elliptical movement.
the use of these early electric toothbrushes showed that there was no difference in plaque removal when compared with a manual toothbrush; they also had mixed effects on gingivitis. In 1986, an international workshop on oral hygiene concluded that, up to that time, neither powered nor manual toothbrushes had been found to remove more plaque, regardless of the brushing method (86). The rst generation of electric toothbrushes had a brush head designed as a manual toothbrush that made a (combined) horizontal and vertical motion (see Fig. 1). Because of the lack of clear superiority and many mechanical problems, powered toothbrushes fell out of favor. During the late 1960s, these toothbrushes gradually disappeared from the market. Since the 1980s, tremendous advances have been made in electrically powered toothbrush technology. A variety of electric toothbrushes have been developed to improve the efciency of plaque removal. These toothbrushes use increased lament velocity and brush stroke frequency and various lament patterns and motions. At the 1996 World Workshop in
Periodontics, it was carefully concluded that the limited evidence suggested that electric brushes provide additional benet compared to manual brushes (56). At the 4th European Workshop on Periodontology in 2001, Sicilia et al. (118) reviewed the available literature to evaluate the effectiveness of power-driven toothbrushes compared with manual toothbrushes in terms of gingival bleeding or inammation resolution in the treatment of patients with gingivitis or chronic periodontitis. A search was made of the MEDLINE and Cochrane Oral Health Group Specialised Trials Register databases up to July 2001. The search resulted in 343 titles and abstracts, and 21 studies were nally selected. Unfortunately, data heterogeneity prevented quantitative analysis. Table 2 shows a descriptive analysis of the studies, from which it was concluded that limited evidence exists for the higher efcacy of electric toothbrushes relative to manual brushes in reducing gingival bleeding or inammation. This advantage appears to be related to the ability of the electric toothbrushes to remove dental plaque. More recently, a systematic review compared manual and powered toothbrushes in everyday use, principally in relation to plaque removal and gingival health. This review was performed in collaboration with the Cochrane Oral Health Group (38). Five electronic databases were searched (up to the middle of 2002) to identify randomized controlled trials comparing powered and manual toothbrushes. Trials with a duration of at least 28 days were included. The initial search identied 354 studies, and 29 trials fullled the inclusion criteria and provided results that could be entered into a meta-analysis. At 1 3 months, the standardized mean differences for plaque and gingivitis were )0.44 (95% condence interval )0.66, )0.21) and )0.45 (95% condence interval )0.76, )0.15), respectively. These data represented an 11% reduction using the Quigley & Hein
Table 2. Summary of the number of studies that provide comparisons between power-driven and manual toothbrushes in reduction of gingival bleeding or inammation [Adapted from Sicilia et al. (118)]
Mode of action of the electric toothbrush Oscillating rotating Counter-rotational Sonic Ultrasonic Others Electric toothbrush more effective 4 4 0 0 2 No difference 1 1 2 1 3 Manual toothbrush more effective 0 0 1 0 0 Results are difcult to interpret 0 1 0 1 0
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Fig. 2. Oscillating rotating toothbrush.
e plaque index (100) and a 6% reduction using the Lo & Silness gingival index (87) in favor of the powered toothbrush. After 3 months, the standardized mean differences for plaque and gingivitis were )1.15 (95% condence interval )2.02, )0.29) and )0.51 (95% condence interval )0.76, )0.25), respectively. These values represented a 7% reduction using the Quigley & Hein plaque index and a 17% reduction using the Ainamo & Bay index (2) in favor of the powered toothbrush. Sensitivity analyses revealed that the results were robust when selecting trials of high quality. The authors concluded that, in general, there was no evidence of a statistically signicant difference between powered and manual brushes (38). However, rotation oscillation-powered brushes (see Fig. 2) signicantly reduced both short- and long-term plaque and gingivitis.
Dentifrices
The use of a toothbrush is usually combined with a dentifrice in order to facilitate plaque removal and apply agents to the tooth surfaces for therapeutic or preventive reasons. The term dentifrice is derived from dens (tooth) and fricare (to rub). A simple, contemporary denition of dentifrice is a mixture used on the tooth in conjunction with a toothbrush. Dentifrices are marketed as toothpowders, toothpastes and gels. The traditional role of dentifrice is primarily cosmetic, aiding the cleaning of teeth, and producing fresh breath. Dentifrices also make the procedure more pleasant. Conicting reports have been published concerning the added value of using dentifrice for plaque removal. Eid & Talic (41) compared the effectiveness
of toothbrushing with a dentifrice or toothbrushing with water after a 2-day period of plaque accumulation. They reported an overall reduction in plaque of 67% for manual toothbrushing with a dentifrice and an overall reduction of 59% for toothbrushing with water. Binney et al. (24) examined the effectiveness of rinsing before brushing on plaque removal. Water served as a negative control and was used as a both a pre-brushing rinse and while toothbrushing. rinsing with water and then brushing with water removed more plaque than any other combination of prebrushing mouth rinse and dentifrice. In conclusion, the function of dentifrice in the instant removal of plaque is questionable (that is the immediate effect of brushing as opposed to a prolonged effect beyond the brushing exercise) (98). Traditionally, it is believed that dentifrices should contain an abrasive. The addition of abrasives facilitates plaque and stain removal without producing gingival recession tooth abrasion or requiring alteration of the remaining components of the dentifrice (146). For many decades, abrasive systems such as calcium carbonate, alumina and dicalcium phosphate have been used. Today, most dentifrices contain silica. Although more expensive, silica can be combined with uoride salts and is very versatile. It has also been shown to increase the abrasivity of dentifrices, resulting in even more plaque removal (69). The results of obtained by Paraskevas et al. (98) questioned this traditional supposition. These authors found that an increase in dentifrice abrasiveness did not result in increased plaque removal. This result is in supported by a report from the American Dental Association Division of Science (4), which accepts that plaque removal is associated minimally with abrasives, which is another action attributed to the toothbrush. Another factor that may be involved in the process of plaque removal is the detergent (or surfactant) contained in the dentifrice formulation. Detergents are surface-active compounds that are added to the formulation because of their foaming properties. This foaming effect may be benecial in clearing the loosened plaque from the teeth and also provide the pleasant feeling of cleanness. However, insufcient evidence exists on the role of detergent in the plaqueremoving effectiveness of dentifrices. Today, dentifrice formulations contain ingredients that may also help improve oral health. Fluoride is almost omnipresent in commercially available toothpastes. Dentifrices are effective uoride carriers. Dentifrices deliver uoride as sodium uoride, sodium monouorophosphate, amine uoride or
108
stannous uoride. The contribution of uoride to the prevention of caries is well established. However, uoride has not exhibited consistent efcacy in controlling gingival inammation. For this reason, addition of chemical factors with anti-plaque and or anti-inammatory properties has been proposed to deal with the inefciencies of mechanical selfperformed plaque removal. As the most commonly used oral hygiene device is a toothbrush, it is reasonable to consider dentifrice as a possible delivery system for antimicrobials. With some imagination, this may indicate a paradigm shift toward use of an oral-care cream instead of an abrasive dentifrice. However, with few exceptions, chemical agents with antibacterial properties have not been successfully formulated into dentifrices. Problems with dentifrice formulation have involved nding compatible constituents to combine with the active ingredients in the dentifrice formula. There has been increased research interest in agents such as bisbiguanide, triclosan, sanguinarine, quaternary ammonium chloride compounds and metal salts. Tin combined with uoride (stannous uoride, SnF2) is a well-known agent that has been used in dentifrice formulations since the beginning of the 1940s. Several formulations, including dentifrices, gels and mouth rinses have been tested throughout the years. Although most studies agree that SnF2 products have a plaque-reducing effect, there is disagreement with regard to the effects of SnF2 formulations on the parameters of gingivitis. A systematic review by Paraskevas & Van der Weijden (97) searched for papers that investigated the effect of SnF2 on parameters of gingival inammation. Table 3 shows a summary of the meta-analysis. For dentifrice gel formulations, there was a signicant reduction in
gingivitis and plaque for SnF2-containing dentifrice compared to a conventional (NaF) dentifrice. The bisbiguanide compounds, including chlorhexidine gluconate and alexidine, are the most effective agents currently in use. Chlorhexidine is most commonly used in mouthwash form, and has been shown to be an effective inhibitor of plaque when used alone as well as in conjunction with other mechanical cleaning procedures. Although very effective when used as a mouth rinse, chlorhexidine has demonstrated limited efcacy when included in dentifrices, as it can be inactivated by avor and detergent (1, 15, 68). Even when a formulation has shown clinical efcacy, its side effects, such as development of stains on teeth and tongue, limit the use of chlorhexidine to specic indications and for short periods of time (107). Triclosan [5-chloro-2-(2,4-dichlorophenoxy) phenol] is a commonly used antimicrobial agent found in products such as acne creams, deodorants and hand soaps. Triclosan is used in many oral care products because it exhibits antibacterial as well as antifungal and antiviral properties. As triclosan is non-ionic, it is compatible with dentifrice formulations and has reasonable substantivity. It can be detected on the oral mucosa and in dental plaque at least 3 and 8 h, respectively, after use (59). It is a broad-spectrum antimicrobial agent, active against all major plaque bacteria. Triclosan alone has moderate anti-plaque properties (49), and has shown anti-inammatory effects on gingival tissues (50). Daily use of a triclosan copolymer dentifrice may have some effect on periodontitis progression (102), and the use of triclosan-containing products has been associated with very few adverse side effects. Hioe & Van der Weijden (59) performed a systematic review to assess the
Table 3. Meta-analyses between stannous uoride and sodium uoride dentifrices in subject with gingivitis. Weighted mean differences (WMD) and 95% condence intervals are provided. Negative values favor stannous uoride [Adapted from Paraskevas & Van der Weijden (97)]
Studies included Index WMD (random) Base End )0.02 )0.31 )0.01 )0.15 95% condence interval )0.14, 0.10 )0.54, )0.07 )0.03, 0.01 )0.20, )0.11 Test for overall Test for heterogeneity effect (P value) (P value and I2) >0.05 0.01 0.05 <0.0001 62.7% 91.7%
Mankodi et al. (88) Mankodi et al. (89) McClanahan et al. (91) Williams et al. (144)
Plaque index; Quigley & Hein (100)
Gingival index; Beiswanger et al. (19) e & Silness Lo Mankodi et al. (89) (87) McClanahan et al. (91) Shapira et al. (116) Sgan-Cohen et al. (115) Williams et al. (144)
Base End
>0.05 <0.00001
0.67 <0.00001
0% 91.1%
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effectiveness of self-performed mechanical plaque control with a triclosan-containing dentifrice in gingivitis subjects. The data show that both triclosan zinc citrate and triclosan copolymer have signicant, albeit small, positive effects on plaque reduction and gingivitis (Table 4). Dentifrices with claims of reducing supragingival calculus formation are also available. Currently available calculus-controlling dentifrices contain either a pyrophosphate or zinc system. Their aim is to inhibit the nucleation and crystal growth of calcium phosphate minerals, which, in turn, should lessen the amount of calculus deposited on the teeth. In this way, the mineralization of plaque is delayed, and the plaque becomes more susceptible to mechanical removal. These dentifrices do not have an effect on existing calculus. Some substances in dentifrices may induce local or systemic side effects. Chlorhexidine in dentifrices may result in tooth staining (147). Pyrophosphates, avorings and detergents, especially sodium lauryl sulfate, which are present in most commercially available dentifrices, have been implicated as causative factors in certain oral hypersensitive reactions such as aphthous ulcers, stomatitis, cheilitis (39, 105), burning sensations (75) and oral mucosal desquamation (57). In these cases, the dental professional should be identify these conditions and advise the patient to discontinue use of the suspected dentifrice.
Many different marketed products are designed to achieve this goal, including oss, woodsticks, rubbertip simulators, interdental brushes, single-tufted brushes and recently introduced electrically powered cleaning aids (i.e. oral irrigators). Flossing is the most commonly advocated method as it can be performed in nearly all circumstances. While picking ones teeth may be one of humanitys oldest habits (51), not all interdental cleaning devices suit all patients or all types of dentition. Factors such as the contour and consistency of gingival tissues, the size and form of the interproximal embrasure, tooth position and alignment, and patient ability and motivation should be taken into consideration when recommending an interdental cleaning method. The most appropriate interdental hygiene aid(s) must be selected for each individual patient. The selection is most dependent on the size and shape of the interdental space as well as the morphology of the proximal tooth surface. The level of dexterity and ability of the patient to use a particular hygiene aid should also be taken into account (36), even for evidence-based decisions. Practical efcacy is also inuenced by the acceptability of the method to patients and therefore their compliance (7, 11, 141).
Dental oss
Suggestions regarding the benets of ossing date back to the early 19th century, when it was believed that irritating matter between teeth was the source of dental disease (63, 99). Over the years, it has become generally accepted that dental oss has a positive effect on removing plaque (9, 36, 134, 143). The American Dental Association reports that up to 80% of plaque may be removed by this method (5). As dental plaque is naturally pathogenic and dental oss disrupts and removes some interproximal plaque (134), it was thought that ossing should reduce gingival inammation, and ossing as the sole form of oral hygiene has been shown to be effective in preventing the development of gingival inammation and reducing the level of plaque (14). Berchier et al. (20) performed a systematic review of the scientic literature to determine the effectiveness of dental oss in combination with toothbrushing on plaque and clinical inammatory symptoms of adults with periodontal disease. Eligible studies provided a test group that used dental oss as an adjunct to toothbrushing and a control group that used toothbrushing only. The MEDLINE and CENTRAL databases were searched up to December 2007 to identify appropriate studies. Plaque and gingivitis
Interdental devices
The interdental gingiva lls the embrasure between two teeth apical to their contact point. This is a sheltered area that is difcult to access when teeth are in their normal positions. In populations that use toothbrushes, the interproximal surfaces of the molars and premolars are the predominant sites of residual plaque. Removal of plaque from these surfaces remains a valid objective because, in patients susceptible to periodontal disease, gingivitis and periodontitis are usually more pronounced in this interdental area than on oral or facial aspects (83). Dental caries also occurs more frequently in the interdental region than on oral or facial smooth surfaces. A fundamental principle of prevention is that the effect is greatest where the risk of disease is greatest. Toothbrushing alone does not reach the interproximal areas of teeth, resulting in parts of the teeth that remain unclean. Good interdental oral hygiene requires a device that can penetrate between adjacent teeth.
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Table 4. Meta-analyses between triclosan and control dentifrices in subject with gingivitis. Weighted mean differences (WMD) and 95% condence intervals are provided. A negative value favor triclosan [Adapted from Hioe & Van der Weijden (59)]
Index Test for overall effect (P value) 0.85 <0.00001 WMD (random) Base End )0.07 )0.10, )0.05 )0.00 )0.04, 0.03 95% condence interval Test for heterogeneity (P value and I2) 1.00 0.53 0% 0%
Comparison
Studies included
Triclosan zinc citrate Plaque index; Silness & e (119) Lo
Renvert & Birkhed (103) Stephen et al. (122) Svatun et al. (124) Svatun et al. (125) Svatun et al. (126) Svatun et al. (128) Percentage bleeding on probing End )10.81 )12.69, )8.93 Base )0.83 )1.37, 3.03 0.46 <0.00001
Triclosan zinc citrate
0.98 0.48
0% 0%
Stephen et al. (122) Svatun et al. (124) Svatun et al. (125) Svatun et al. (126) Plaque index; Quigley & Hein (100) End )0.48 Base )0.01 )0.03, 0.05 )0.73, )0.24
Triclosan copolymer
0.72 <0.0001
0.98 <0.00001
0% 97.2%
Allen et al. (3) Bolden et al. (25) Deasy et al. (37) Denepitiya et al. (40) Garcia-Godoy et al. (52) Kanchanakamol et al. (73) Mankody et al. (90) McClanahan et al. (91) Tritana et al. (131) Gingival index; e & Silness (87) Lo Base End )0.01 )0.24
Triclosan copolymer
)0.03, 0.01 )0.35, )0.13
0.30 <0.0001
1.00 <0.00001
0% Evidence-based oral hygiene methods 98.30%
Allen et al. (3) Bolden et al. (25) Deasy et al. (37) Denepitiya et al. (40) Garcia-Godoy et al. (52) Kanchanakamol et al. (73) Mankody et al. (90) McClanahan et al. (91) Tritana et al. (131)
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Table 5. Descriptive overview of the results of the dental oss and toothbrush group compared to the toothbrush only group. [Adapted from Berchier et al. (20)]
Reference Finkelstein et al. (45) Gjermo et al. (53) Hague & Carr. (54) Hague et al. (55) Hill et al. (58) Jared et al. (67) Kiger et al. (74) Schiff et al. (110) Vogel et al. (133) Walsh et al. (137) Zimmer et al. (149) Plaque score 0 + ? 0 0 + + 0 0 0 0 Gingival score 0 x 0 0 0 0 0 0 0 x x Bleeding score 0 x x x x 0 x x x + 0
+, signicant difference in favor of toothbrush plus oss group; 0, no signicant difference; x, no data available; ?, unknown.
were selected as outcome variables. Independent screening of titles and abstracts of 1,166 MEDLINE Pubmed and 187 Cochrane papers resulted in identication of 11 publications that met the eligibility criteria. The majority of these studies showed that there was no benet of ossing on plaque or clinical parameters of gingivitis (see Table 5 for description). From the collective data of the studies, it was possible to perform a meta-analysis of plaque and gingival index scores. Table 6 provides a summary of the outcomes of the meta-analysis. In both instances,
baseline scores were not statistically different. Comparing brushing and ossing against brushing only, the plaque index weighted mean difference was )0.04 (95% condence interval )0.12, 0.04; P = 0.39) and the gingival index weighted mean difference was )0.08 (95% condence interval )0.16, 0.00; P = 0.06). The end scores also showed no signicant differences between groups for plaque (weighted mean difference )0.24, 95% condence interval )0.53, 0.04; P = 0.09) or gingivitis (weighted mean difference )0.04, 95% condence interval )0.08, 0.00; P = 0.06). The heterogeneity observed at the end point for the plaque scores (I2 = 76.4%) indicates that the weighted mean difference should not be used as an exact measure of the results. Based on the individual papers in this review, a trend that indicated a benecial adjunctive effect of oss on plaque levels was observed. However, this could only be substantiated as a non-signicant trend in the meta-analysis. Dental professionals should therefore determine, on an individual patient basis, whether high-quality ossing is an achievable goal. If this is likely to be the case, daily ossing may be introduced as the oral hygiene tool for interdental cleaning. However, a routine recommendation to use oss is not supported by scientic evidence as established by Berchier et al. (20) in their comprehensive literature search and critical analysis. One may ask why the review by Berchier et al. (20) does not show dental oss as a co-operative adjunct to toothbrushing. Advocacy of oss as an interdental cleaning device hinges, in large part, on common sense. However, common sense arguments are the lowest level of scientic evidence (104). A possible explanation is that previous narrative reviews were
Table 6. Meta-analyses between oss as an adjunct to toothbrushing and toothbrushing only. Weighted mean differences (WMD) and 95% condence intervals are provided. Negative values favor oss [Adapted from Berchier et al. (20)]
Studies included Jared et al. (67) Hague & Carr (54) Hague et al. (55) Schiff et al. (110) Index WMD (random) Base End )0.04 )0.24 )0.08 )0.04 95% condence interval )0.12, 0.04 )0.53, 0.04 )0.16, 0.00 )0.08, 0.00 Test for overall effect (P value) 0.39 0.09 Test for heterogeneity (P value and I2) 0.85 0.005 0% 76%
Plaque index; Quigley & Hein (100)
Gingival index; Hague & Carr (54) e & Silness Lo Hague et al. (55) (87) Hill et al. (58) (waxed) Hill et al. (58) (unwaxed) Kiger et al. (74) Schiff et al. (110)
Base End
0.06 0.06
0.11 0.89
43.3% 0%
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not performed systematically. These reviews also lack meta-analysis or descriptive analysis based on extracted data. The fact that dental oss has no additional effect on toothbrushing is apparent from more than one review. Hujoel et al. (63) found that ossing was only effective in reducing the risk of interproximal caries when applied professionally. High-quality professional ossing performed in rst-grade children on school days reduced the risk of caries by 40%. In contrast, self-performed ossing failed to show a benecial effect. The lack of an effect on caries and the absence of an effect on gingivitis in the review by Berchier et al. (20) are most likely the consequence of plaque not being removed efciently, as was also established by Berchier et al. (20). Research also shows that few individuals oss correctly (78). The inability to oss correctly may cause a lack of motivation (129). Historically, compliance with regular ossing has been far less than ideal. The routine use of dental oss has consistently been shown to be dramatically low (e.g. approximately 7% of the Dutch population osses on a regular basis). The reasons for this lack of compliance apparently relate to two issues: lack of patient ability (132) and lack of motivation (31). Studies are inconsistent in their ability to demonstrate that educational attempts to inuence oss frequency can be successful (7). However, it has also been shown that ossing is like any other skill in that it can be taught, and those who are given appropriate instruction will increase their ossing frequency (7, 113, 123). Sniehotta et al. (121) provided evidence for the effects of a concise intervention on oral self-care behavior. Other studies have shown that educational attempts to modify client behavior were not successful in improving ossing frequency (7, 79). The difculty in ossing probably makes application of this technique less than universal.
Woodsticks
Toothpicks are one of the earliest and most persistent tools used to pick teeth. The toothpick may date back to the days of the cave people, who probably used sticks to pick food from between their teeth. Originally, dental woodsticks were advocated by dental professionals as gum massagers, which were used to massage inamed gingival tissue in the interdental areas to reduce inammation and encourage keratinization of the gingival tissue (51). Woodsticks are designed to allow the mechanical removal of plaque from interdental surfaces. They
are fabricated from soft wood to improve adaptation into the interdental space and to prevent injury to the gingiva. They should not be confused with toothpicks, which are meant simply for removing food debris after a meal (141). Round toothpicks are too thick and too blunt to reach the lingual half of the tooth when trying to angle them, while the curved surface of the toothpick provides only point contact with the tooth surface. Rectangular woodsticks are also designed inappropriately for interdental cleaning as they are too pliable to be able to clean lingually (21). However, triangular woodsticks seem to have the correct shape to t the interdental space (135). A tapered form of triangular woodstick makes it possible for the patient to angle the device interdentally and even clean the lingually localized interdental surfaces (93). Based on the results of Bergenholtz et al. (21), it may be concluded that triangular woodsticks with low surface hardness and high strength values are preferred for interdental cleaning. Based on studies performed in vivo and from autopsy material, it was shown that a triangular pointed woodstick inserted interdentally can maintain a subgingival plaque-free region of 23 mm (93). The resilience of the gingival papilla allows cleaning apical to the subgingival margins of llings (risk surfaces for recurrent caries). For open interdental spaces, common among adults, woodsticks appear most appropriate (76). In periodontitis patients, the woodstick will depress the papilla, which may help in re-contouring the interdental tissues and consequently preclude the need for periodontal surgery (18). Woodsticks can only be used effectively where sufcient interdental space is available. Woodsticks have the advantage of being easy to use and can be used throughout the day without the need for a bathroom or mirror (51). How effective is the woodstick in maintaining oral health? Does it offer any particular advantage over ossing or interdental brushes? Hoenderdos et al. (60) performed a systematic review to evaluate and summarize the available evidence on the effectiveness of using triangular woodsticks in combination with toothbrushing to reduce both plaque and clinical inammatory symptoms of gingival inammation. The MEDLINE and CENTRAL databases were searched up to February 2008 to identify appropriate studies. Plaque and gingivitis were selected as outcome variables. Independent screening of the titles and abstracts of 181 MEDLINE and 65 CENTRAL papers yielded seven publications with eight clinical experiments that met the eligibility criteria.
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Table 7. Descriptive overview of the results for woodsticks compared to other interventions [Adapted from Hoenderdos et al. (60)]
Reference Barton (16) Bassiouny & Grant (17) Caton et al. (30) Finkelstein & Grossman (44) tra (53) (part 1) Gjermo & Flo Bergenholtz & Brithon (22) Finkelstein & Grossman (44) tra (53) (part 1) Gjermo & Flo tra (53) (part 3) Gjermo & Flo Wolffe (145) Bassiouny & Grant (17) tra (53) (part 3) Gjermo & Flo Plaque score x 0 x 0 0 x 0 0 0 0 ? x Bleeding score + x + + x x ? x x x x x Gingival score x x x 0 x x 0 x x x x x Comparison Toothbrush only Toothbrush only Toothbrush only Toothbrush only Toothbrush only Dental oss Dental oss Dental oss Dental oss Dental oss Interdental brush Interdental brush
+, signicant difference in favor of the test group; 0, no signicant difference; x, no data available; ?, unknown.
The heterogeneity of the data prevented quantitative analysis. However, Table 7 summarizes the differences between woodsticks and other devices in the form of a descriptive analysis. In seven studies, use of triangular woodsticks resulted in a signicant incremental improvement in gingival health. None of the studies that scored visible interdental plaque demonstrated any signicant advantage of using woodsticks as opposed to alternative methods (toothbrushing only, dental oss or interdental brushes) in patients with gingivitis. A series of histological investigations in patients with periodontitis has shown that the papillary area with the greatest inammation corresponds to the middle of the interdental tissue. It is difcult to clinically assess the mid-interdental area, as it is usually not available for direct visualization (137). When used on healthy dentition, woodsticks depress the gingivae by up to 2 mm and therefore clean part of the subgingival area. Thus, woodsticks may specically remove subgingivally located interdental plaque that is not visible and therefore not evaluated by the plaque index. This physical action of woodsticks in the interdental area may produce a clear benecial effect on interdental gingival inammation (45). The included studies from the review by Hoenderdos et al. (60) show that changes in gingival inammation, as assessed by the gingival index, are not as obvious as bleeding as an indicator of disease. Numerous studies have shown that sulcular
bleeding is a very sensitive indicator of early gingival inammation. Bleeding following the use of woodsticks can also be used to increase patient motivation and awareness of their gingival health. Several studies have shown the clinical effectiveness of gingival self-assessment (71, 72, 139). The presence of bleeding provides immediate feedback on the level of gingival health. The dentist or dental hygienist can also easily demonstrate the gingival condition to the patient by using the interdental bleeding index for this obvious clinical manifestation. Such monitoring may encourage patients to include woodsticks as part of their own oral hygiene regimen (22).
Interdental brushes
Interdental brushes are frequently recommended by dental professionals to patients with sufcient space between their teeth. Interdental brushes are small, specially designed brushes for cleaning between the teeth. They have soft nylon laments twisted into a ne stainless steel wire. They may be conical or cylindrical in shape and are available in different widths to match the interdental space, ranging from 1.914 mm in diameter. Upon examination of extracted teeth from individuals who habitually used interdental brushes, Waerhaug (136) showed that the supragingival proximal surfaces (the central part of the interdental space and the embrasures) were free of plaque, and that some subgingival deposits were
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removed up to a depth of 22.5 mm below the gingival margin. Slot et al. (120) systematically reviewed the literature to determine the effectiveness of interdental brushes used as adjuncts to toothbrushes in terms of the presence of plaque and clinical parameters of periodontal inammation in patients with gingivitis or periodontitis. This situation was compared to toothbrushing alone or toothbrushing in combination with oss or woodsticks. The MEDLINEPubMed and CENTRAL databases were searched up to November 2007 to identify appropriate studies. Clinical parameters of periodontal inammation such as plaque, gingivitis, bleeding and pocket depth were selected as outcome variables. Independent screening of the titles and abstracts of 218 MEDLINE PubMed and 116 Cochrane papers resulted in identication of nine publications that met the eligibility criteria. Table 8 summarizes differences between interdental brushes and various intervention strategies. All three studies that compared interdental brushes as an adjunct to brushing showed a signicant difference in favor of the use of interdental brushes for plaque removal. The majority of the studies showed a positive signicant difference on the plaque index when using interdental brushes compared with oss. No differences were found for the gingival or bleeding indices. Two of three studies showed that interdental brushes, when compared with oss, had a signicant
positive effect on pocket reduction in patients with periodontitis. One of the two comparative studies showed that interdental brushes remove more dental plaque than woodsticks. From the collective data it appeared to be possible to perform a meta-analysis for the comparison of interdental brushes or oss as adjuncts to toothbrushing. Table 9 provides a summary of the outcome of the meta-analysis. In all instances, baseline scores were not statistically different. End scores only e showed a signicant effect for the Silness & Lo plaque index in favor of the interdental brush group relative to the oss group (weighted mean difference )0.48, 95% condence interval )0.65, )0.32; P < 0.00001). Comparisons using the other indices (Quigley & Hein plaque index, bleeding on probing and pocket depth) were not statistically signicant. e The heterogeneity observed with the Silness & Lo index (P = 0.001, I2 = 85.4%) reects the different behaviors of the study populations to the study product, differences in study design and other factors that may inuence outcome. Again, readers should therefore exercise caution when using this weighted mean difference as an exact measure of the outcomes. Within the limitations of the search and selection strategy of the review, Slot et al. (120) concluded that, as an adjunct to toothbrushing, interdental brushes remove more dental plaque than ossing. In young individuals in whom the papillae ll out the interdental spaces, dental oss is the only tool
Table 8. Descriptive overview of the results for interdental brushes and other interventions [Adapted from Slot et al. (120)]
Reference Bassiouny & Grant (17) Jared et al. (67) Kiger et al. (74) Christou et al. (32) tra (53) Gjermo & Flo Ishak & Watts (65) Jackson et al. (66) Jared et al. (67) Kiger et al. (74) sing et al. (101) Ro Yost et al. (148) Bassiouny & Grant (17) tra (53) Gjermo & Flo Plaque score ? + + + + 0 + 0 + + 0 ? + Gingival score x + 0 x x x x 0 0 x 0 x x Bleeding score x 0 x 0 x 0 0 0 x x 0 x x Pocket depth x x x + x 0 + x x x x x x Comparison Toothbrush only Toothbrush only Toothbrush only Dental oss Dental oss Dental oss Dental oss Dental oss Dental oss Dental oss Dental oss Woodstick Woodstick
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Table 9. Meta-analyses between interdental brushes and oss. Weighted mean differences (WMD) and 95% condence intervals are provided. A negative value favors interdental brushes [Adapted from Slot et al. (120)]
Studies included Jackson et al. (66) sing et al. (101) Ro Christou et al. (32) Jared et al. (67) Christou et al. (32) Ishak & Watts (65) Jackson et al. (66) Christou et al. (32) Ishak & Watts (65) Jackson et al. (66) Index WMD 95% Test for Test for heterogeneity (random) condence overall effect (P value and I2) interval (P value) Base End Base End Base End Base End )0.01 )0.48 )0.01 )0.25 0.01 )0.04 0.14 )0.04 )0.08, 0.06 )0.65, )0.32 )0.28, 0.26 )0.57, 0.06 )0.04, 0.06 )0.10, 0.02 )0.19, 0.47 )0.28, 0.21 0.84 <0.00001 0.94 0.12 0.62 0.17 0.39 0.77 0.97 0.001 1.0 0.74 0.86 0.74 0.28 0.77 0% 85.40% 0% 0% 0% 0% 22.00% 0%
Plaque index; e (119) Silness & Lo Plaque index; Quigley & Hein (100) Bleeding on probing Pocket depth
that can reach into this area. This space only increases when the interdental papilla recedes. The size of the interdental brush should t snugly in this interdental space. Therefore, patients require interdental brushes of various sizes. Schmage et al. (111) assessed the relationship between the interdental space and the position of teeth. Most interproximal spaces in anterior teeth were small, and their size was most suited to the use of oss. Premolars and molars have larger interproximal spaces and are accessible by interdental brushes. Most studies did not discuss the different interdental brush sizes, nor did they indicate whether the interdental brushes were used at all available approximal sites. This need to account for different sizes of interdental spaces makes a true random assignment of interdental brushes in clinical trials difcult. Two out of the three studies that assessed probing pocket depth (32, 66) showed that reduction was more pronounced with interdental brushes than with oss. Only Ishak & Watts (65) could not support this nding. A possible reason why the meta-analysis does not support this advantage is the large difference between the interdental brush and oss groups in these studies at baseline. To overcome this imbalance, an elegant approach would be to use the difference between baseline and end scores as a measure of effect. Only one study (32) provides this information. Jackson et al. (66) proposed that the reduced pocket depth may have been related to the reduction in swelling with concomitant recession. However, given the lack of effect on signs of gingival inammation (see meta-analysis, Table 7), the effect on pocket depth cannot readily be explained by a
reduction in the level of gingival inammation. As an explanation for the observed effect, the proposition by Badersten et al. (12) seems plausible. They suggested that mechanical depression of the interdental papilla is induced by interdental brushes, which in turn causes recession of the marginal gingival. This, together with good plaque removal, could be the reason for the reduction in pocket depth. Patient acceptance is a major issue to be considered when it comes to the long-term use of interdental cleaning devices (141). Patient preferences were evaluated in three studies (32, 65, 74). Comparing interdental brushes and dental oss, patients preferred the interdental brushes. The interdental brushes were considered to be simpler to use, despite their tendency to bend, buckle and distort (65), which made the procedure somewhat complicated at times. Interdental brushes were considered to be less timeconsuming and more efcacious than oss for interdental plaque removal (32), which is consistent with previous work (23).
Oral irrigators
Additional oral hygiene aids have been developed in an attempt to augment the effect of toothbrushing on reducing interdental plaque (141). The oral irrigator was introduced in 1962. This device has been demonstrated to be safe (34, 80) and probably provides a particular benet with regard to gingival health for the large proportion of the general public who does not clean interproximal spaces on a regular basis (48). Oral irrigators are designed to remove plaque and soft debris through the mechanical action of a
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stream of water. Oral irrigator devices can also be used with antimicrobial agents (77). Patients report that oral irrigators facilitate the removal of food debris in posterior areas, especially in cases of xed bridges or orthodontic appliances, when the proper use of interdental cleaning devices is difcult (27). Since its introduction, the oral irrigator has at times been a popular device (95). However, there has been considerable controversy regarding the appropriate use and efcacy of this instrument (8, 95). Studies using an oral irrigator have reported both positive (43, 62, 81, 130) and negative results (10, 138) in terms of periodontal inammation and plaque. This inconsistency causes confusion about the efcacy of the oral irrigator. Husseini et al. (64) performed a systematic review of the existing literature to evaluate the effectiveness of oral water irrigation as an adjunct to toothbrushing on plaque and clinical parameters of periodontal inammation relative to toothbrushing alone or regular oral hygiene. Papers in the MEDLINE-PubMed and CENTRAL databases up to January 2008 were searched to identify appropriate studies. Clinical parameters of periodontal inammation such as plaque, bleeding, gingivitis and pocket depth were selected as outcome variables. Independent screening of the titles and abstracts of 809 PubMed and 105 Cochrane papers resulted in identication of seven publications that met the eligibility criteria. The heterogeneity of the data prevented quantitative analysis. Table 10 shows a descriptive analysis of the selected studies. None of the selected studies showed a signicant difference between toothbrushing plus use of an oral irrigator and toothbrushing alone. When use of the oral irrigator was compared to regular oral hygiene, there were some signicant differences for the clinical parameters of
periodontitis. With respect to plaque, no signicant differences were observed. All three studies that presented data on bleeding scores showed signicant reductions in the oral irrigator group compared to the regular oral hygiene group (46, 47, 95). When observing visual signs of gingival inammation, three out of four studies (46, 47, 95) found a signicant effect with use of an oral irrigator as an adjunct to regular oral hygiene. Two of the four studies (46, 95) showed a signicant reduction in probing depth as a result of using an oral irrigator as an adjunct to regular oral hygiene. Plaque reduction is a prerequisite for an oral hygiene device to be considered valuable (95). The selected papers for this review reported no statistically signicant reduction in plaque with use of an oral irrigator. Despite a lack of effect on the plaque index, studies did nd a signicant effect on the bleeding index. The mechanisms underlying these clinical changes in the absence of a clear effect on plaque are not understood. Various hypotheses have been put forward by the authors to explain the results. One of the hypotheses is that, when patients with gingivitis perform supragingival irrigation on a daily basis, the population of key pathogens (and their associated pathogenic effects) may be altered, reducing gingival inammation (46). There is also the possibility that water pulsations may alter the specic hostmicrobe interaction in the subgingival environment and that inammation is reduced independent of plaque removal (31). Another possibility is that the benecial activity of the oral irrigator is at least partly due to removal of food deposits and other debris, ushing away of loosely adherent plaque, removal of bacterial cells, interference with plaque maturation and stimulation of immune responses (48). Other explanations include mechanical stimulation of the gingiva
Table 10. Descriptive overview of the results of the toothbrush and oral irrigation group relative to the toothbrush only or regular oral hygiene only group [Adapted from Husseini et al. (64)]
Reference Frascella et al. (48) Hoover et al. (61) Walsh et al. (138) Flemmig et al. (46) Flemmig et al. (47) Meklas et al. (92) Newman et al. (95) Plaque score 0 ? 0 0 0 0 0 Bleeding score 0 x 0 + + x + Gingival score 0 ? 0 + + 0 + Pocket depth x x ? + 0 x + Comparison Toothbrush only Toothbrush only Toothbrush only Regular oral hygiene Regular oral hygiene Regular oral hygiene Regular oral hygiene
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or a combination of previously reported factors (47, 48). Irrigation may reduce plaque thickness, which may not be easily detected using two-dimensional scoring systems (70). This may be the reason for an absence of an effect on plaque but a positive effect on gingival inammation (Table 10). Irrigation devices may increase the delivery of uid beneath the gingival margin (47). Greater penetration of a solution into periodontal pockets is achieved by patient-applied supragingival irrigation compared with mouth rinsing (46). Studies that evaluated the ability of supragingival irrigation to project an aqueous solution (H2O or medicinal uids) subgingivally determined that supragingival irrigation with a standard irrigation tip was capable of delivering H2O or a medicinal uid 3 mm subgingivally or to approximately half the probing depth in a 6 mm pocket (41, 82). Two studies demonstrated that H2O irrigation had little effect on the composition of the subgingival ora in sites with pocket probing depths of 4 mm or less (106, 142). An accessory for an oral irrigator device, the Pik Pocket subgingival irrigation tip (WaterPik Technologies, Fort Collins, CO), facilitates subgingival penetration of irrigants to 90% of the depth of 6 mm pockets when placed 1 mm subgingivally (26). Supragingival irrigation applies considerable force to the gingival tissues. Irrigation was shown to have the potential to induce bacteremia relative to brushing (112, 114), ossing (29, 140), scaling and root planing (42), and chewing (35). Given the collective evidence, it appears that irrigation is safe for healthy patients. Husseini et al. (64) concluded that use of an oral irrigator as an adjunct to toothbrushing does not have a benecial effect on reducing plaque scores. However, there is evidence that suggests a positive tendency toward improved gingival health when using an oral irrigator as an adjunct to toothbrushing as opposed to regular oral hygiene (i.e. selfperformed oral hygiene without any specic instruction).
Discussion and conclusions

This paper summarizes the highest level of evidence that is currently available with respect to various aspects of oral hygiene. The systematic reviews included here attempted to collate all empirical evidence that tted pre-specied eligibility criteria to answer a specic research question. They used explicit, systematic methods that are selected to minimize bias, providing more reliable ndings from
which conclusions can be drawn and decisions can be made (6, 96). These methods include hypothesis formulation, literature searches, critical appraisal, trial planning, ethical review, trial conduct, trial reporting, systematic reviews and meta-analyses. Systematic reviews of randomized controlled trials are seen as the gold standard for assessing the effectiveness of healthcare interventions. The method of collecting information from a systematic review provides a solid basis for clinical decision-making (94). The Cochrane Collaboration declares in the Cochrane Handbook for Systematic Reviews (http:// www.cochrane-handbook.org) that reviews are needed to help ensure that healthcare decisions throughout the world can be based on informed, high-quality, timely research evidence. Using metaanalyses, systematic reviews can provide a quantitative distillation of apparently conicting clinical data or identify a trend that might not be evident in a narrative review. As valuable as systematic reviews can be, their usefulness depends on the focus and quality of the previously published studies. According to the American Dental Association, evidence-based dentistry is an approach to oral health care that requires judicious integration of systematic assessments of clinically relevant scientic evidence, integrating the patients oral and medical condition and history with the dentists clinical expertise and the patients treatment needs and preferences (http://ebd.ada.org/about.aspx). For example, the results established following the systematic review on use of oss disappointed many dental professionals and believers in the use of oss. The fact that oss does not appear to be effective in the hands of the general public does not preclude its use. For instance, in interdental situations that only allow the penetration of a string of dental oss, this would be the best available tool. Although oss should not be the rst tool recommended for cleaning open interdental spaces, if the patient does not like any other tool, ossing could still be part of oral hygiene instruction. However, dental professionals should realize that proper instruction, sufcient motivation of the patient and a high level of dexterity are necessary to make the ossing effort worthwhile. Based on the available literature, it can be concluded that a single oral hygiene instruction has a small positive effect that will last 6 months or more. Further research should establish the effect of repeated oral hygiene instructions. Toothbrushing using a manual toothbrush is effective to the extent that it results in reduction of the plaque scores by
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approximately half. Using an oscillating rotating toothbrush, additional efcacy can be obtained. In studies 3 months in duration, a 7% increase in plaque reduction and a 17% increase in gingivitis reduction were observed for electric toothbrushing relative to manual toothbrushing. With respect to interdental cleaning, the best available data suggest the use of interdental brushes. These brushes should therefore be the rst choice in patients with open interdental spaces. Meta-analysis showed superiority of the interdental brush to oss with respect to plaque removal. A dentifrice is usually used in combination with toothbrushing. To enhance the mechanical action of the toothbrush, abrasive ingredients have been added to dentifrices. Research has shown that these do not contribute to the instant cleaning effect. However, data on stannous uoride and triclosan support use of these products in the prevention of gingival inammation. In light of the results of this comprehensive literature review and critical analysis, it is evident that mechanical oral hygiene plays an important part in the prevention and treatment of periodontal disease.
11. 12.
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17. 18. 19.
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Oral Hygiene in The Prevention of Periodontal Diseases

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Periodontology 2000, Vol. 55, 2011, 104123 Printed in Singapore.

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Oral hygiene in the prevention of periodontal diseases: the evidence

WEIJDEN & DAGMAR ELSE SLOT

Oral hygiene instruction

Evidence-based oral hygiene methods

Percentage bleeding on probing Bleeding index; Ainamo & Bay (2)

van der Weijden & Slot

effect on the reduction of gingival inammation in adults with gingivitis (132).

Evidence-based oral hygiene methods

van der Weijden & Slot

Fig. 2. Oscillating rotating toothbrush.

Evidence-based oral hygiene methods

Plaque index; Quigley & Hein (100)

van der Weijden & Slot

Triclosan zinc citrate Plaque index; Silness & e (119) Lo

Triclosan zinc citrate

)0.03, 0.01 )0.35, )0.13

0% Evidence-based oral hygiene methods 98.30%

van der Weijden & Slot

Plaque index; Quigley & Hein (100)

Evidence-based oral hygiene methods

van der Weijden & Slot

Evidence-based oral hygiene methods

van der Weijden & Slot

Evidence-based oral hygiene methods

van der Weijden & Slot

Discussion and conclusions

Evidence-based oral hygiene methods

17. 18. 19.

van der Weijden & Slot

Evidence-based oral hygiene methods

van der Weijden & Slot

108. 109. 110.

Evidence-based oral hygiene methods

145. 146. 147.

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