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Literature Review (Group Assignment)

Jiawen Guan, Julianne Reese Cruz, Maria Isabel Sandoval

Effectiveness of Interdental
and Toothbrush Aids in the
Reduction of Gingivitis
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Introduction
Gingivitis, commonly known as gum disease, is an inflammation of the gums caused by a

buildup of plaque and bacteria.5 There are a myriad of risk factors that are associated with the

development of gingivitis, such as smoking, diabetes, age, and even genetic factors. As gingivitis

can lead to serious dental issues and overall health complications if left untreated, it is crucial

that people use the proper tools and techniques for their oral care.8 In this paper, we will delve

into the causes, symptoms, and treatments of gingivitis, with a focus on the importance of

maintaining good oral health. We will also consider the efficacy of oral hygiene tools, namely

interdental aids (e.g., floss, interdental brushes, water flossers), in the facilitation of reducing

gingivitis-causing bacteria.

Evidence Supporting Plaque Causes Gingivitis

Periodontal disease is a multifactorial oral health condition that consists of a diverse

family of pathological bacteria found in plaque that affects the periodontium, which is a

collective term that comprises gingival tissue, periodontal ligaments, cementum, and alveolar

bone.¹⁰ Gingivitis is the presence of gingival inflammation without loss of connective tissue

attachment and appears as red, puffy, and shiny gums that bleed easily. Periodontitis is

inflammation that causes destruction of the supportive tissues of teeth and can be characterized

as either aggressive or chronic.¹⁰ Periodontitis can influence quality of life through psychosocial

impacts as a result of negative effects of pain, function, appearance, and lack of socialization. ¹⁰

The presence or absence of plaque is considered when measuring the health of gums. Research

suggests that there are not just one or two types of bacteria that cause periodontal disease, instead

there are several that contribute to gingival disease.⁴ These bacteria include Aggregatibacter

actimomycetemcomitans, Porphyromonas gingivalis, Tannerella forsythia, Prevotella intermedia,

Campylobacter rectus, and Spirochetes. It is suspected that there could also be more bacteria
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responsible that have yet to be identified.⁴ An experimental study that measured the effect of

accumulated plaque in the gingival sulcus over a period of two weeks also proved that plaque

that stays in contact with the gingiva over a long period of time will cause gingivitis.⁹ This is

because when subgingival plaque goes undisturbed, it causes irritation, redness, and bleeding

that then triggers an inflammatory response. The inflammation of the gums is also called

gingivitis and when it is left untreated it progresses to periodontitis. It is important to note that

after gingivitis has advanced to periodontitis and oral hygiene interventions or treatment are not

implemented the risk of tooth loss becomes significantly increased.⁴ Therefore, it is very

important for oral health care clinicians to educate patients who present with a plaque on the

importance of using interdental cleaning devices and proper tooth brushing techniques.

How Are Interdental Cleaning Devices Effective

Interdental cleaning devices are various aids such as dental floss, interdental brushes, and

rubber-tipped water flossers (irrigators). These tools are used coupled with tooth brushing to aid

in the removal of plaque in between the teeth where toothbrush bristles cannot reach. Prevention

of periodontal diseases is a priority for oral healthcare professionals because it is more

cost-efficient than treating it. This involves educating patients on the importance of mechanical

disruption and removal of dental plaque which is important for oral health maintenance.¹⁰

Collected research shared in the Journal of Clinical Periodontology verifies that it is ideal to

remove inter-dental plaque once every 24 hours to adequately prevent the onset of gingivitis and

even interdental caries.⁷ The interdental gingiva fills the embrasure between two teeth apical to

their contact point creating a sheltered area and when it becomes inflamed it presents with

conditions that permit the establishment and maturation of bacterial plaque which develops into

periodontal disease if it is not mechanically removed.⁷ The American Dental Association shared
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that the most common self-care recommendation for interdental cleaning has been flossing,

which can be considered the most universally applicable method.⁷ The interdental brush was

found to have an excellent effect both on the central part of the interdental space and on the

embrasures and may remove plaque as far as 2–2.5 mm below the gingival margin.⁷ When

deciding on the type of technique that would be most effective, the dental clinician should take

into consideration the characteristics of the interdental spaces whether they are open or closed.⁷

In addition to choosing the interdental aid that works best for the existing dentition and its

condition, educating the patient on the proper use and techniques that maximize their ability to

reduce gingivitis-causing bacteria is essential. Good oral hygiene is the gold standard in the

maintenance of periodontal health and patients need to be educated about the correct technique,

frequency, and force of brushing, frequent replacement of the toothbrush, and indicated usage of

interdental aids.³

Efficacy of Manual Toothbrush Versus Power Toothbrush in Reduction of Gingivitis

Toothbrush design has undergone significant evolution to enhance its efficacy in plaque

biofilm removal and improve tooth brushing effectiveness. Designs have traditionally been based

on the premise that the majority of the population utilizes a simple horizontal brushing action.

However, improvements in design have led to the integration of multiple tufts of bristles, often

angled in various directions within the brush head. Manufacturers now offer a variety of

toothbrushes with handles tailored to different hand sizes, emphasizing ergonomic considerations

to enhance user experience.¹ On the other hand, powered toothbrushes were initially

commercially marketed in the early 1960s and have since established themselves as an

alternative to manual toothbrushing methods. The powered brush provides clinical and statistical

improvements in total plaque evaluations by enabling individuals to brush their teeth in an ideal
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manner in terms of eliminating plaque and enhancing gingival health, conferring effective

brushing techniques on those who use them, regardless of manual dexterity or training. ¹ Across

studies focusing on plaque/gingival inflammation, approximately 68% favored powered

toothbrushes in adults, 40% favored them in children/special needs (with no supporting manual),

and 50% showed better results among orthodontic individuals using powered toothbrushes. 6

Another research with 56 people randomly divided into two groups sought to shed light on the

subject. According to the study, individuals were assessed over a six-week period using revealing

agents and the Loe and Silness Gingival Index to determine plaque and gingival scores,

respectively.2 Oral hygiene instructions were reinforced, and brushing techniques were

standardized. The findings were compelling: at two weeks, there was a significant difference in

plaque scores between manual and power toothbrushes (60.253 20.672 vs. 44.031 16.484, P =

0.0020), with a similar trend found at six weeks (43.784 22.647 vs. 20.489 10.336, P = 0.0001).2

These data highlight the significant benefit of powered toothbrushes over manual equivalents in

plaque reduction. Electric toothbrushes' predetermined power and force found to contribute

considerably to increased plaque clearance and gingival health.

Patient Education
The quest for a healthier mouth often hinges on the diligent upkeep of oral hygiene, and

gingivitis is a common adversary in this realm. Understanding the effectiveness of interdental

aids (such as floss, and interdental brushes) and toothbrush aids in mitigating gingivitis

emphasizes the importance of patient education in preventing this prevalent oral disease. The

essential role of interdental aids in reducing gingivitis cannot be overstated. These aids,

including floss and interdental brushes, offer a targeted approach to plaque removal from areas

where conventional toothbrushes struggle to reach. Effective removal of plaque curtails the

inflammation process, thereby thwarting the progression of gingivitis. Studies consistently affirm
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the pivotal role of interdental aids in plaque removal, thus corroborating their efficacy in

preventing gingival inflammation.

Concurrently, toothbrush aids like electric toothbrushes or manual brushes designed for

better reach and effectiveness also contribute significantly to maintaining oral health. They assist

in plaque removal from tooth surfaces, thereby complementing the efforts of interdental aids.

However, the efficacy of toothbrush aids alone may fall short in tackling plaque accumulation in

interdental spaces, emphasizing the indispensable role of comprehensive oral care routines that

encompass interdental aids. Nonetheless, the effectiveness of these aids hinges not only on their

mechanical capability but also on the correct usage technique. This is where patient education

plays a pivotal role. Education empowers individuals to comprehend the nuances of oral hygiene

practices, including the proper use of interdental aids and toothbrush aids. Guided instruction

ensures optimal usage, maximizing the benefits of these aids in preventing gingivitis.

Furthermore, education acts as a catalyst in shaping positive oral health behaviors, promoting

consistency in oral care routines, and reinforcing the importance of adherence to proper

techniques. It cultivates a sense of responsibility and empowerment, transforming patients into

active participants in their oral health practices. Effective tooth brushing involves using a

soft-bristled brush and fluoride toothpaste in gentle, circular motions at a 45-degree angle. The

horizontal technique was found to be the most beneficial to children up to 6-7 years of age,

though the modified Bass technique is frequently advocated by dentists and textbooks, and is

utilized in clinical investigations for adults. 2 Duration is also one of the critical factors affecting

the efficacy of tooth brushing for dental plaque removal. 2 Brushing for two minutes, twice a day,

targeting all surfaces of the teeth and the tongue, ensures thorough cleaning.

Conclusion
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Gingivitis is a common condition that affects many people, particularly those with poor

oral hygiene habits and those who have not received regular dental care. The presence of

excessive dental plaque and poor oral health behaviors are all associated with an increased risk

of developing gingivitis. Ensuring effective tooth brushing techniques and adhering to a proper

frequency stands as a cornerstone in maintaining oral health and preventing various dental issues,

including gingivitis and cavities. Guidance on these fundamental practices plays a pivotal role in

empowering individuals to achieve optimal oral hygiene. In conjunction with effective brushing

techniques, interdental aids such as dental floss and interdental brushes play a pivotal role in

reaching areas between teeth and along the gumline that toothbrushes might not access

effectively. Educating individuals about the proper use of interdental aids ensures a more

comprehensive removal of plaque and food debris, significantly reducing the risk of gingivitis

and gum disease. By taking these preventative measures, individuals can maintain optimal oral

health and reduce their risk of developing gingivitis.

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