Interdental Brushing For The Prevention and Control of Periodontal Diseases and Dental Caries in Adults (Review)

Cochrane Database of Systematic Reviews
Interdental brushing for the prevention and control of

periodontal diseases and dental caries in adults (Review)
Poklepovic T, Worthington HV, Johnson TM, Sambunjak D, Imai P, Clarkson JE, Tugwell P
Poklepovic T, Worthington HV, Johnson TM, Sambunjak D, Imai P, Clarkson JE, Tugwell P.
Interdental brushing for the prevention and control of periodontal diseases and dental caries in adults.
Cochrane Database of Systematic Reviews 2013, Issue 12. Art. No.: CD009857.
DOI: 10.1002/14651858.CD009857.pub2.
www.cochranelibrary.com
Interdental brushing for the prevention and control of periodontal diseases and dental caries in adults (Review)
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
SUMMARY OF FINDINGS FOR THE MAIN COMPARISON . . . . . . . . . . . . . . . . . . . 4
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Figure 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
ADDITIONAL SUMMARY OF FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . 22
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Analysis 1.1. Comparison 1 Interdental brushing versus flossing, Outcome 1 Gingivitis at 1 month. . . . . . . 49
Analysis 1.2. Comparison 1 Interdental brushing versus flossing, Outcome 2 Gingivitis at 3 months. . . . . . . 50
Analysis 1.3. Comparison 1 Interdental brushing versus flossing, Outcome 3 Plaque at 1 month. . . . . . . . 51
Analysis 1.4. Comparison 1 Interdental brushing versus flossing, Outcome 4 Plaque at 3 months. . . . . . . . 52
ADDITIONAL TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . . 60
INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Interdental brushing for the prevention and control of periodontal diseases and dental caries in adults (Review) i
[Intervention Review]
Interdental brushing for the prevention and control of

periodontal diseases and dental caries in adults
Tina Poklepovic1 , Helen V Worthington2 , Trevor M Johnson3 , Dario Sambunjak1 , Pauline Imai4 , Jan E Clarkson5 , Peter Tugwell6
1
Department of Research in Biomedicine and Health, School of Medicine, University of Split, Split, Croatia. 2 Cochrane Oral Health
Group, School of Dentistry, The University of Manchester, Manchester, UK. 3 Yorkshire Area, Faculty of General Dental Practice, York,
UK. 4 MTI Community College, Vancouver, Canada. 5 Dental Health Services Research Unit, University of Dundee, Dundee, UK.
6 Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Canada
Contact address: Tina Poklepovic, Department of Research in Biomedicine and Health, School of Medicine, University of Split,
Soltanska 2, Split, 21 000, Croatia. [email protected].
Editorial group: Cochrane Oral Health Group.

Publication status and date: New, published in Issue 12, 2013.
Citation: Poklepovic T, Worthington HV, Johnson TM, Sambunjak D, Imai P, Clarkson JE, Tugwell P. Interdental brushing for the
prevention and control of periodontal diseases and dental caries in adults. Cochrane Database of Systematic Reviews 2013, Issue 12. Art.
No.: CD009857. DOI: 10.1002/14651858.CD009857.pub2.
ABSTRACT
Background
Effective oral hygiene is a crucial factor in maintaining good oral health, which is associated with overall health and health-related
quality of life. Dental floss has been used for many years in conjunction with toothbrushing for removing dental plaque in between
teeth, however, interdental brushes have been developed which many people find easier to use than floss, providing there is sufficient
space between the teeth.
Objectives
To evaluate the effects of interdental brushing in addition to toothbrushing, as compared with toothbrushing alone or toothbrushing
and flossing for the prevention and control of periodontal diseases, dental plaque and dental caries.
Search methods
We searched the following electronic databases: the Cochrane Oral Health Group’s Trials Register (to 7 March 2013), the Cochrane
Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 2), MEDLINE via OVID (1946 to 7 March
2013), EMBASE via OVID (1980 to 7 March 2013), CINAHL via EBSCO (1980 to 7 March 2013), LILACS via BIREME (1982
to 7 March 2013), ZETOC Conference Proceedings (1980 to 7 March 2013) and Web of Science Conference Proceedings (1990 to
7 March 2013). We searched the US National Institutes of Health Trials Register (http://clinicaltrials.gov) and the metaRegister of
Controlled Trials (http://www.controlled-trials.com/mrct/) for ongoing trials to 7 March 2013. No restrictions were placed on the
language or date of publication when searching the electronic databases.
Selection criteria
We included randomised controlled trials (including split-mouth design, cross-over and cluster-randomised trials) of dentate adult
patients. The interventions were a combination of toothbrushing and any interdental brushing procedure compared with toothbrushing
only or toothbrushing and flossing.
Interdental brushing for the prevention and control of periodontal diseases and dental caries in adults (Review) 1
Data collection and analysis
At least two review authors assessed each of the included studies to confirm eligibility, assessed risk of bias and extracted data using
a piloted data extraction form. We calculated standardised mean difference (SMD) and 95% confidence interval (CI) for continuous
outcomes where different scales were used to assess an outcome. We attempted to extract data on adverse effects of interventions. Where
data were missing or unclear we attempted to contact study authors to obtain further information.
Main results
There were seven studies (total 354 participants analysed) included in this review. We assessed one study as being low, three studies as
being high and three studies as being at unclear risk of bias. Studies only reported the clinical outcome gingivitis and plaque data, with
no studies providing data on many of the outcomes: periodontitis, caries, halitosis and quality of life. Three studies reported that no
adverse events were observed or reported during the study. Two other studies provided some data on adverse events but we were unable
to pool the data due to lack of detail. Two studies did not report whether adverse events occurred.
Interdental brushing in addition to toothbrushing, as compared with toothbrushing alone
Only one high risk of bias study (62 participants in analysis) looked at this comparison and there was very low-quality evidence for a
reduction in gingivitis (0 to 4 scale, mean in control): mean difference (MD) 0.53 (95% CI 0.23 to 0.83) and plaque (0 to 5 scale):
MD 0.95 (95% CI 0.56 to 1.34) at one month, favouring of use of interdental brushes. This represents a 34% reduction in gingivitis
and a 32% reduction in plaque.
Interdental brushing in addition to toothbrushing, as compared with toothbrushing and flossing
Seven studies provided data showing a reduction in gingivitis in favour of interdental brushing at one month: SMD -0.53 (95% CI -
0.81 to -0.24, seven studies, 326 participants, low-quality evidence). This translates to a 52% reduction in gingivitis (Eastman Bleeding
Index). Although a high effect size in the same direction was observed at three months (SMD -1.98, 95% CI -5.42 to 1.47, two studies,
107 participants, very low quality), the confidence interval was wide and did not exclude the possibility of no difference. There was
insufficient evidence to claim a benefit for either interdental brushing or flossing for reducing plaque (SMD at one month 0.10, 95%
CI -0.13 to 0.33, seven studies, 326 participants, low-quality evidence) and insufficient evidence at three months (SMD -2.14, 95%
CI -5.25 to 0.97, two studies, 107 participants very low-quality evidence).
Authors’ conclusions
Only one study looked at whether toothbrushing with interdental brushing was better than toothbrushing alone, and there was very
low-quality evidence for a reduction in gingivitis and plaque at one month. There is also low-quality evidence from seven studies
that interdental brushing reduces gingivitis when compared with flossing, but these results were only found at one month. There was
insufficient evidence to determine whether interdental brushing reduced or increased levels of plaque when compared to flossing.
PLAIN LANGUAGE SUMMARY

Cleaning between the teeth using interdental brushes for the prevention and control of gum diseases and tooth decay in adults
Review question
This review, carried out by the Cochrane Oral Health Group, seeks to evaluate the effects of interdental (between the teeth) brushing
in addition to toothbrushing as compared with toothbrushing on its own or toothbrushing plus flossing for the prevention and control
of periodontal (gum) diseases, dental plaque (a sticky film containing bacteria) and dental caries (tooth decay).
Background
Gum disease and tooth decay are the main reasons for tooth loss. Unless brushed away, plaque can build up on the teeth. A build up
of plaque can lead to gum inflammation and gum disease and is also a key factor in the development of tooth decay.
Conventional toothbrushing alone is not very effective at removing plaque between teeth. Dental floss has been used for many years
together with toothbrushing for removing dental plaque in between teeth. However, recently, interdental brushes to use between the
teeth have been developed and many people find them easier to use than floss. If interdental brushes are to be used there must be
enough space between the teeth to enable this.
Interdental brushes are small-headed toothbrushes available in a range of different widths to match the space between teeth. They can
be cone shaped or cylindrical. Brushes for use for cleaning around implants have coated wire to avoid scratching them or causing a
shock.
Together with dental floss interdental brushes are one of the most commonly recommended, advertised and available aids for cleaning
between the teeth.
Study characteristics
The evidence on which this review is based was current as of 7 March 2013. Seven studies with a total of 354 participants were included
in this review. Participants were aged 16 years and over and had teeth. In terms of deciding which studies to include in this review there
was no distinction made on the basis of race, gender, jobs (socioeconomic status), place, background exposure to fluoride, initial health
status, setting or time of the intervention. Studies were excluded from the review if the majority of participants had any orthodontic
appliances (braces), if participants were selected on the basis of special health conditions or if the majority of participants had severe
gum disease.
Key results
There is some very low-quality evidence that using interdental brushes plus toothbrushing is more beneficial than toothbrushing alone
for plaque and gingivitis at one month. There is also low-quality evidence that using interdental brushes reduces gingivitis (gum
inflammation) by 52% when compared with flossing at one month. There was insufficient evidence to claim a benefit for either
interdental brushing or flossing for plaque.
None of the studies reported on tooth decay as none were long enough for the changes brought about by early tooth decay between
teeth to be detected or found. Three studies reported that no adverse effects or harms were observed or reported during the study. Two
other studies provided some data on adverse effects/harms/problems ranging from difficulties manipulating floss, reaching back teeth,
interdental brushes distorting and buckling and also (noted to be the most serious) the fact that floss can make gums sore, however
we could not formally analyse the data as studies did not provide enough detail. Two studies did not report whether adverse events
occurred.
Quality of the evidence
The quality of the only study to compare toothbrushing with interdental brushing and toothbrushing alone was assessed as being very
low. The quality of evidence for the comparison between interdental brushing and flossing both in addition to toothbrushing was low.
No studies reported the development of tooth decay.
Interdental brushing for the prevention and control of periodontal diseases and dental caries in adults (Review) S U M M A R Y O F F I N D I N G S F O R T H E M A I N C O M P A R I S O N [Explanation]
Interdental brushing for periodontal diseases and dental caries in adults
Patient or population: Adults, 16 years and older

Settings: Everyday self care
Intervention: Interdental brushing plus toothbrushing
Comparison: Toothbrushing
Outcomes Illustrative comparative risks* (95% CI) Relative effect No of participants Quality of the evidence Comments
(95% CI) (studies) (GRADE)
Assumed risk Corresponding risk
No IDB IDB
Gingivitis The m ean gingivitis in The m ean gingivitis in 62 ⊕ 34% reduction in gin-
Scale f rom : 0 to 4 the control group was the intervention groups (1 study) very low1 givitis
Follow-up: m ean 1 1.56 was 0.53 lower (95% CI
m onth 0.23 to 0.83)
Periodontitis Not estim able 0 See com m ent No included study as-
(0) sessed periodontitis as
an outcom e
Plaque The m ean plaque in the The m ean plaque in 62 ⊕ 32%reduction in plaque
Scale f rom : 0 to 5 control groups was the intervention groups (1 study) very low1
Follow-up: m ean 1 2.97 was 0.95 lower (95% CI
m onth 0.56 to 1.34)
Interproximal caries Not estim able 0 See com m ent No included study as-
(0) sessed caries as an out-
com e
Harms and adverse Not estim able 0 See com m ent Only 1 study re-
outcomes (0) ported adverse out-
com es in term s of prob-
lem s with the use of
4
the assigned interden-

tal cleaning aids
Bad breath Not estim able 0 See com m ent No included study as-
(halitosis) (0) sessed bad breath as
an outcom e
Quality of life Not estim able 0 See com m ent No included study as-
(0) sessed quality of lif e as
an outcom e
* The basis f or the assumed risk (e.g. the m edian control group risk across studies) is provided in f ootnotes. The corresponding risk (and its 95% conf idence interval) is
based on the assum ed risk in the com parison group and the relative effect of the intervention (and its 95% CI).
CI: conf idence interval; IDB: interdental brushing; RR: risk ratio
GRADE Working Group grades of evidence

High quality: Further research is very unlikely to change our conf idence in the estim ate of ef f ect.
M oderate quality: Further research is likely to have an im portant im pact on our conf idence in the estim ate of ef f ect and m ay change the estim ate.
Low quality: Further research is very likely to have an im portant im pact on our conf idence in the estim ate of ef f ect and is likely to change the estim ate.
Very low quality: We are very uncertain about the estim ate.
1
Single study at high risk of bias.
5
BACKGROUND Description of the condition
Introduction Periodontal diseases

Effective oral hygiene is a crucial factor in maintaining good oral Periodontal diseases are multifactorial oral health conditions
health, which is associated with overall health and health-related (Llorente 2006; Timmerman 2006), consisting of a diverse fam-
quality of life (McGrath 2002; Sheiham 2005). Poor oral health ily of pathological conditions affecting the periodontium (a col-
may affect appearance in terms of stained or missing teeth (Exley lective term that comprises gingival tissue, periodontal ligament,
2009) and can contribute to bad breath (Morita 2001) thus nega- cementum and alveolar bone), that commonly affect the popu-
tively influencing confidence, self expression and communication lation (Adult Dental Health Survey 2009; Eke 2012). Periodon-
(Exley 2009; McGrath 2002). Poor oral health is often accompa- tal diseases are comprised of two main conditions: gingivitis and
nied by pain arising from carious lesions (Exley 2009) which can periodontitis. Gingivitis is defined as the presence of gingival in-
lead to discomfort when eating (Dahl 2011; McGrath 2002). flammation without loss of connective tissue attachment and ap-
Individuals with high levels of dental plaque are more likely to pears as red, puffy, shiny gums that bleed easily (Mariotti 1999).
experience dental caries and periodontal disease (Broadbent 2011). Periodontitis is defined as inflammation and destruction of the
Dental plaque-induced gingivitis and incipient, non-cavitated car- supportive tissues of teeth and is, by its behaviour, characterised
ious lesions are reversible (Mariotti 1999; Silverstone 1983). The as aggressive or chronic (Armitage 1999). Susceptibility to peri-
progression in either disease may be attributed to a tip in the en- odontal disease is variable and depends upon the interaction of
vironmental equilibrium that favours disease conditions. For ex- factors such as genetic predisposition, smoking, stress, immuno-
ample, in periodontal disease the key is to treat gingivitis when compromising diseases and drugs, and certain systemic diseases,
inflammation is only in the gingival tissues and has not affected for example diabetes (Mariotti 1999). Socioeconomic factors, for
other parts of the periodontal system (Mariotti 1999). Early car- instance, educational and income levels have been found to be
ious lesions can be arrested in the enamel and may or may not strongly associated with the prevalence and severity of periodontal
progress to the dentine depending on the dynamic equilibrium diseases (Borrell 2012).
between demineralisation and remineralisation (Marinho 2002b; The prevalence of periodontitis is difficult to establish across stud-
Marinho 2002a; Marinho 2003). ies because of non-standardised criteria, different study popula-
Periodontal diseases and dental caries are found in high, middle tion characteristics, different clinical measurements, and the use of
and low-income countries. Although the incidence of periodon- partial versus full mouth examinations (Cobb 2009; Savage 2009).
tal disease and dental caries differs, based on regional, social and Of particular concern is the differing definitions and clinical mea-
genetic factors, the prevention of these diseases has a significant surements being used (Cobb 2009; Savage 2009). Recent national
healthcare and economic benefit, to both society as a whole and studies have assessed oral cleanliness, periodontal disease and oral
individual patients. hygiene behaviour. In the UK only 17% of adults had healthy
The effective removal of dental plaque is important in the preven- gums, 66% had visible plaque and, of those with plaque, 65%
tion of these common diseases. In conjunction with profession- had bleeding gums compared with 33% with no plaque (Adult
ally provided plaque removal services, for example as provided by Dental Health Survey 2009). Whilst the most severe forms of pe-
a dental hygienist, daily mechanical self care disruption of den- riodontal disease, with alveolar bone loss, are much less common,
tal plaque is considered important for oral health maintenance gingivitis is prevalent at all ages and is the most common form
(Needleman 2005; Rösing 2006; Zaborskis 2010). Besides tooth- of periodontal disease (Mariotti 1999). Some form of periodon-
brushing, which is the most common method for removing den- titis affects the majority of the population (Adult Dental Health
tal plaque (Addy 1986; Mak 2011; Richardson 1977), different Survey 2009; Eke 2012). Periodontitis can influence quality of
interdental aids to plaque removal, such as dental floss and inter- life through psychosocial impacts as a result of negative effects on
dental brushes, are widely available and are recommended to be comfort, function, appearance and socialisation (Durham 2013;
used in addition to toothbrushing (Bosma 2011; Särner 2010). Needleman 2004). It can also lead to tooth loss (Broadbent 2011),
Whilst floss can be used in all interdental spaces, the interdental which negatively impacts on both aesthetics and function. Since
brush requires sufficient interdental space to be used by patients. periodontal diseases are inflammatory, bacterially mediated dis-
The choice of brush will depend on the size of the space. eases that trigger the host’s immune system, it is postulated that
This review will evaluate the evidence for interdental brushes and the individual’s oral health status may influence their systemic
is similar to the Cochrane review on flossing (Sambunjak 2011). health. Studies have demonstrated associations between periodon-
Together these two reviews will provide a comprehensive assess- tal diseases and coronary heart disease (Machuca 2011), hyperlip-
ment of the evidence for the two most common means of inter- idaemia (Fento lu 2012), preterm births (Huck 2011) and lack
dental cleaning to aid clinical decision-making and consumer un- of glycaemic control in people with diabetes mellitus (Columbo
derstanding. 2012; Simpson 2010).
Dental plaque is the primary aetiological factor in the development Berchier 2008; Berglund 1990; Casey 1988). Interdental plaque is
of periodontal diseases and dental caries (Dalwai 2006; Kuramitsu more prevalent (Lindhe 2003), forms more readily (Igarashi 1989)
2007; Marsh 2006; Periasamy 2009; Selwitz 2007). Dental plaque and is more acidogenic than plaque on other tooth surfaces in the
is a highly organised and specialised biofilm comprising of an in- mouth. Therefore interdental cleaning is often recommended as
tercellular matrix consisting of various micro-organisms and their an adjunctive self care therapy.
by-products. The bacteria found within dental plaque mutually
support each other, using chemical messengers, in a community
that protects them from an individual’s immune system and chem-
ical agents such as antimicrobial mouth rinses. Bacteria in biofilm Description of the intervention
are 1000 to 1500 times more resistant to antibiotics than in their
free-floating state, reducing the effectiveness of chemical agents as
a solo treatment option. Therefore disruption of the oral biofilm Interdental brushes
via mechanical methods remains one of the best treatment options Interdental brushes are small cylindrical or cone-shaped bristles
(Chandki 2011). Calcified plaque (calculus) is not involved in the on a thin wire that may be inserted between the teeth. They have
pathogenesis of periodontal disease but it provides an ideal surface soft nylon filaments aligned at right angles to a central stiffened
to collect further dental plaque and acts as a ’retention web’ for rod, often twisted stainless steel wire, very similar to a bottle brush.
bacteria, protecting plaque from appropriate preventive and ther- Interdental brushes used for cleaning around implants have coated
apeutic periodontal measures (Ismail 1994; Lindhe 2003). wire to avoid scratching the implants or causing galvanic shock.
They are available in a range of different widths to match the in-
Dental caries terdental space and their shape can be conical or cylindrical. Most
Dental caries is a multifactorial, bacteriologically mediated, are round in section, although interdental brushes with a more tri-
chronic disease (Addy 1986; Richardson 1977; Rickard 2004). Ac- angular cross-section can also be found in the market. Originally,
cording to the World Oral Health Report 2003 (Petersen 2003), interdental brushes were recommended by dental professionals to
dental caries affects 60% to 90% of school children and the vast patients with large embrasure spaces between the teeth (Slot 2008;
majority of adults, making it one of the most common diseases Waerhaug 1976), caused by the loss of interdental papilla mainly
in the world population (WHO 1990). Although the prevalence due to periodontal destruction. Patients who had interdental papil-
and severity of dental caries in most industrialised countries has lae that filled the embrasure space were usually recommended to
substantially decreased in the past two decades (Marthaler 1996), use dental floss as an interdental cleansing tool. However, with
this preventable disease continues to be a common public health the greater range of interdental brush sizes and cross-sectional di-
problem for other parts of the world (Burt 1998). ameters now available, they are considered a potentially suitable
Deep pits and fissures, as well as interdental spaces, represent ar- alternative to dental floss for patients who have interdental papil-
eas of increased risk for the collection and accumulation of dental lae that fill the interdental space (Imai 2011). Daily dental floss-
plaque and are therefore regarded as susceptible tooth surfaces for ing adherence is low among patients because it requires a certain
the occurrence of carious lesions. The presence and growth of den- degree of dexterity and motivation (Asadoorian 2006), whereas
tal plaque is further encouraged by compromised host response fac- interdental brushes have been shown as being easier to use and
tors, for example reduced salivary flow (hyposalivation) (Murray are therefore preferred by patients (Christou 1998; Imai 2010).
1989). Fermentation of sugars by cariogenic bacteria within the Furthermore, when compared to dental floss, they are thought to
plaque results in localised demineralisation of the tooth surface, be more effective in plaque removal because the bristles fill the
which may ultimately result in cavity formation (Marsh 2006; embrasure and are able to deplaque the invaginated areas on the
Selwitz 2007). tooth and root surfaces (Bergenholtz 1984; Christou 1998; Imai
Patients with carious teeth may experience pain and discomfort 2011; Jackson 2006; Kiger 1991; Waerhaug 1976). However, there
(Milsom 2002; Shepherd 1999) and, if left untreated, may lose are conflicting study results regarding the efficacy of interdental
their teeth. In the United Kingdom, tooth decay accounts for brushes in the reduction of clinical parameters of gingival inflam-
almost half of all dental extractions performed (NHS 1999). mation (Jackson 2006; Noorlin 2007) and whether they are only
Prevention of dental caries and periodontal disease is generally suitable for patients with moderate to severe attachment loss and
regarded as a priority for oral healthcare professionals because it open embrasures, or whether they are a suitable aid for healthy
is more cost-effective than treating it (Brown 2002; Burt 1998). patients to prevent gingivitis who have sufficient interdental space
Effective plaque control by toothbrushing is a key self care strat- to accommodate them (Gjermo 1970; Imai 2011).
egy for oral health (Addy 1986; Richardson 1977). Patients rou-
tinely use toothbrushes to remove supragingival dental plaque, but
toothbrushes are unable to penetrate the interdental area where pe- Why it is important to do this review
riodontal disease first develops and is prevalent (Asadoorian 2006;
Together with dental floss, interdental brushes are one of the most health status, setting or time of the intervention. Studies were ex-
commonly recommended, advertised and available aids for inter- cluded if the majority of participants had any orthodontic appli-
dental cleaning. It is unclear whether they are as good or better ances. Likewise, studies were excluded if participants were selected
than dental floss as an adjunct to toothbrushing in reducing den- on the basis of special (general or oral) health conditions (for ex-
tal disease. A systematic review and meta-analysis combining the ample, severely immunocompromised patients), or if the majority
results of randomised controlled trials will provide practitioners of participants had severe periodontal disease.
with evidence as to the effects of the use of interdental brushes on The minimum age of the participants was decided because by the
oral health. age of 16 all permanent teeth, except third molars, should be fully
evolved and erupted in the mouth (Proffit 2006). The exclusion
of children with primary (or mixed) dentition was predefined be-
cause the primary dentition is characterised by generalised spacing
OBJECTIVES between teeth, which is most visible in the anterior part of the
dentition. Such spacing is essential for future alignment of perma-
To evaluate the effects of interdental brushing in addition to tooth- nent dentition and decreases with eruption of permanent teeth at
brushing, as compared with toothbrushing alone or toothbrush- the early mixed dentition when proximal contacts start to develop
ing and flossing for the prevention and control of: (Proffit 2006). The lack of interdental spacing is considered to be
associated with the increased accumulation of plaque (Mathewson
1. periodontal diseases (gingivitis and periodontitis); 1995) and higher susceptibility of interproximal surfaces to caries
(Ben-Basset 1997; Parfitt 1956; Warren 2003).
2. dental plaque;
Moreover, the exclusion of primary dentition is based on varying
3. dental caries. morphological, chemical and physiological aspects between decid-
uous and permanent teeth enamel (Mortimer 1970; Sonju-Clasen
This also includes assessing the safety of interdental brushing pro-
1997). Primary tooth enamel has lower levels of mineralisation,
cedures, in terms of potential harms and adverse effects, balancing
80.6% as opposed to permanent tooth enamel which is 89.7%
important benefits against important harms.
mineralised (Mortimer 1970). Differences in enamel mineralisa-
In this review we focused exclusively on interdental brushing, in tion are particularly observed in the outermost layers of the enamel
addition to toothbrushing (with or without flossing). The effects (Wang 2006). Furthermore, permanent tooth enamel is up to two
of dental flossing in addition to toothbrushing compared to tooth- times thicker than primary tooth enamel (Araújo 1995; Mortimer
brushing alone have been assessed in another Cochrane review 1970). Because of lower mineral density and lower thickness of the
(Sambunjak 2011). enamel, primary teeth are believed to respond differently to caries
than permanent teeth (Hunter 2000; Marquezan 2008; Wang
2006) with possibly faster and higher rates of dental caries progres-
METHODS sion due to such differences (Amaechi 1999; Featherstone 1981;
Johansson 2001; Wang 2006).
A subgroup analysis based on the participants’ age or dental status
could have been conducted, but the preliminary search found no
Criteria for considering studies for this review eligible studies involving children.
Types of studies Types of interventions

We included randomised controlled trials (including split-mouth We included all studies that compared a combination of tooth-
design and cross-over trials) and cluster-randomised trials. Studies brushing and any interdental brushing procedure with tooth-
where random allocation was not used or indicated were excluded. brushing only or toothbrushing and flossing. Interventions could
The second part of cross-over trials was included only if they had have been self performed, supervised or unsupervised. The pri-
a minimum washout period of two weeks before the cross-over. mary comparison was self performed, unsupervised, interdental
Studies were included regardless of their publication status and brushing plus toothbrushing versus toothbrushing alone.
language. We included studies exploring other comparative interventions
(for example, mouthrinsing) if they contained study arms with
interventions of interest to this review (i.e. interdental brushing
Types of participants plus toothbrushing and toothbrushing alone or toothbrushing and
The review included studies of dentate participants 16 years of age flossing).
and older, regardless of race, gender, socioeconomic status, geo- We excluded studies where the intervention group alone or both
graphical location, background exposure to fluoride, initial dental the intervention and control groups received any additional ac-
tive agent(s) (i.e. caries preventive agents) as part of the study can see some tissue healing within four weeks (or one month)
(e.g. chlorhexidine mouthwash, additional fluoride-based proce- in patients with gingivitis and consequent reductions in the clin-
dures, oral hygiene procedures, xylitol chewing gum) in addition ical indices used in the outcomes (bleeding, gingival, plaque).
to interdental brushing, flossing or toothbrushing. However, we The three months mark is important because microbiologically,
included studies using floss impregnated with active agents such the periopathogens return in sufficient numbers to cause disease.
as chlorhexidine or fluoride. We included studies that included Hence, patients with periodontal disease are recommended to be
participants receiving additional measures as part of their routine on three-month periodontal maintenance recall visits (Haffajee
oral care, such as oral hygiene advice, supervised brushing, fissure 1997; Haffajee 2006).
sealants, etc. For the outcome of clinical attachment loss, it was anticipated
The minimum duration of the intervention was set at four weeks. that this would be assessed after at least six months of follow-up,
Based on what was found in the included studies, we made a and for assessment of interproximal caries the time of assessment
decision on which time points to include in the analyses. should be at least one year.
Types of outcome measures Minor outcomes

1. Bad breath (halitosis).
Major outcomes 2. Quality of life.
We considered the following outcomes to be most relevant and
important to clinicians and patients.
1. Gingivitis - assessed by gingival indices (both inflammatory Search methods for identification of studies
and bleeding).
2. Periodontitis - assessed by clinical attachment loss. For the identification of studies included or considered for this
3. Interproximal caries - assessed by (a) progression of caries review, we developed detailed search strategies for each database
into enamel or dentine, (b) change in decayed, missing and filled searched. These were based on the search strategy developed for
tooth surfaces (D(M)FS) index, (c) radiographic evidence. MEDLINE (OVID) (Appendix 1) but revised appropriately for
Studies had to contain explicit criteria for diagnosing dental each database.
caries. As caries increment could be reported differently in The search strategy used a combination of controlled vocabulary
different trials, we used a set of a priori rules to choose the and free-text terms and was linked with the Cochrane Highly Sen-
primary outcome data for analysis from each study (Marinho sitive Search Strategy (CHSSS) for identifying randomised trials
2003). (RCTs) in MEDLINE: sensitivity-maximising version (2008 revi-
4. Plaque indices. sion) as referenced in Chapter 6.4.11.1 and detailed in box 6.4.c of
5. Harms and adverse effects. the Cochrane Handbook for Systematic Reviews of Interventions Ver-
We analysed gingival and plaque indices according to the primary sion 5.1.0 (updated March 2011) (Higgins 2011). The searches of
outcome data presented in the included studies. EMBASE and CINAHL were linked to the Cochrane Oral Health
When full-mouth and interdental indices were presented, we con- Group filters for identifying RCTs, and the search of LILACS was
sidered interdental indices for the analyses. linked to the Brazilian Cochrane Center filter (see Appendix 2,
For the studies that used both gingival and bleeding indices, we Appendix 3 and Appendix 4 for details).
used gingivitis scores in the meta-analyses because gingivitis in-
dices assess clinical signs of inflammation in the gingivae and are
based on visual (non-invasive) and bleeding (invasive) components Electronic searches
(Armitage 1996). The following databases were searched:
As for the bleeding indices, for studies in which both bleeding on • the Cochrane Oral Health Group’s Trials Register (to 7
probing (BOP) and Eastman Interdental Bleeding Index (EIBI) March 2013) (Appendix 5);
were used, we included EIBI in the meta-analyses. The suitability • the Cochrane Central Register of Controlled Trials
of the EIBI is justified by its reproducibility and high inter-exam- (CENTRAL) (The Cochrane Library 2013, Issue 2) (Appendix 6);
iner and intra-examiner reliability (Blieden 1992). • MEDLINE via OVID (1946 to 7 March 2013) (Appendix
Based on what was found in the included studies and to facili- 1);
tate comparison between this review and the Cochrane reviews • EMBASE via OVID (1980 to 7 March 2013) (Appendix 2);
on flossing and toothbrushing (Deacon 2010; Robinson 2005; • CINAHL via EBSCO (1980 to 7 March 2013) (Appendix
Sambunjak 2011), we planned to include the four to six-week data 3);
(combined) and 12-week (or nearest) time points in the analyses • LILACS via BIREME (1982 to 7 March 2013) (Appendix
of gingivitis and plaque indices. From a clinical viewpoint one 4).
We placed no restrictions on the language or date of publication • sample size;
when searching the electronic databases. • inclusion and exclusion criteria;
• demographic characteristics of participants: age, gender,
country of origin, ethnicity, gender, socioeconomic status,
Searching other resources
comorbidity, caries and periodontal disease risk status. We
We searched for conference proceedings and abstracts by using the recorded demographic characteristics for the study as a whole
following resources: and for each intervention group, if available.
• ZETOC Conference Proceedings (1980 to 7 March 2013)
(Appendix 7); (3) Intervention: we collected details of the experimental and the
• ISI Web of Science Conference Proceedings (1990 to 7 comparison interventions:
March 2013) (Appendix 8). • type of interdental brushing, type of floss (automated or
manual, waxed or non-waxed, with or without fluoride), type of
We checked references of all the included studies, other reviews,
toothbrush (powered or manual), type of toothpaste (with or
guidelines and related articles for other relevant studies.
without fluoride);
We searched for ongoing studies in the following trial registries:
• frequency of interdental brushing, duration of the
• the US National Institutes of Health Trials Register (
intervention period and of the individual interdental brushing
www.clinicaltrials.gov) (to 7 March 2013) (Appendix 9);
procedure;
• the metaRegister of Controlled Trials (mRCT) (
• were the participants trained/instructed how to brush
www.controlled-trials.com) (to 7 March 2013) (Appendix 10).
interdentally, floss and/or toothbrush, and by whom?
For abstracts whose results could not be confirmed in subsequent • length of follow-up, loss to follow-up;
publications, we contacted trial authors to collect unpublished • assessment of adherence;
data. We contacted manufacturers of interdental cleaning devices • level of fluoride in the water supply.
and asked them about their knowledge of any unpublished or
ongoing clinical trials. (4) Outcomes:
• detailed description of the outcomes of interest (both
beneficial and adverse), including the definition and timing of
measurement;
Data collection and analysis
• methods of assessment.
Furthermore, we made a list of other outcomes found in the in-

Selection of studies cluded studies. We extracted results for prespecified outcomes of
Two review authors independently carried out the selection of interest.
studies and made decisions about eligibility; one of them a Other data that we extracted included:
methodologist and the other a topic area specialist. If the relevance • ethical approval;
of a report was unclear, we reviewed the full text and resolved all • sample size calculation (yes/no);
disagreements by discussion. • funding sources;
In case of doubt regarding eligibility of studies, data extraction or • key conclusions of the included studies as reported by their
data analysis, the third review author was consulted. authors.
We designed the data extraction form for this review and piloted
Data extraction and management it before use. When needed, coding instructions accompanied the
Three review authors independently extracted data; one of them a data extraction form. We extracted data from multiple reports of
methodologist and other two topic area specialists. We compared the same studies in a single form. In cases of studies reporting both
extracted data against each other and identified disagreements, preliminary and final results, only the final report (including full
which we then resolved by consensus. The review authors were number of participants) was included. We consulted a statistician
not be blinded to the authors, interventions or results obtained in in cases of doubt about data extraction, as well as with regard to
the included studies. data analysis. We contacted authors for missing information.
We extracted and entered the following data into a customised
collection form.
(1) Study characteristics: study design, including details of how Assessment of risk of bias in included studies
the study differs from standard parallel-group design (e.g. split- We carried out assessment of risk of bias by using The Cochrane
mouth or cross-over); date and duration of study; setting of the Collaboration’s ’Risk of bias’ tool as described in Chapter 8 of the
study. Cochrane Handbook for Systematic Reviews of Interventions (Higgins
(2) Participants: 2011). The tool addresses the six following domains: sequence
generation, allocation sequence concealment, blinding, incom- institutions, journal or results of a study. At least two review au-
plete outcome data, selective outcome reporting and other issues. thors independently, and in duplicate, carried out the assessment
Since blinding of the study participants for the interventions of of risk of bias; one of them a methodologist and the other a topic
interest was not possible, the primary consideration was given to area specialist. If any piece of information important for the as-
the blinding of the outcome assessors. For split-mouth and cross- sessment of risk of bias was missing in the included reports, we
over designs, assessment of risk of bias included additional con- made attempts to contact the study investigators and obtain the
siderations, such as suitability of the design, risk of carry-over or required information by use of open-ended questions.
spill-over effects, and appropriateness of the statistical analysis. We
recorded each piece of information extracted for the ’Risk of bias’
tool together with the precise source of this information and used Summarising risk of bias for a study
this to assign a judgement of low, high or unclear risk of bias for After taking into account the additional information provided by
each domain within each included study. We tested data collection the authors of the trials, we grouped studies into the following
forms and assessments of the risk of bias on a pilot sample of arti- categories. We assumed that the risk of bias was the same for all
cles. The assessors were not blinded to the names of the authors, outcomes and assessed each study as follows.
Risk of bias Interpretation Within a study Across studies
Low risk of bias Plausible bias unlikely to alter the Low risk of bias for all key domains Most information is from studies at
results seriously low risk of bias
Unclear risk of bias Plausible bias that raises some Unclear risk of bias for one or more Most information is from studies at
doubt about the results key domains low or unclear risk of bias
High risk of bias Plausible bias that seriously weak- High risk of bias for one or more The proportion of information
ens confidence in the results key domains from studies at high risk of bias is
sufficient to affect the interpreta-
tion of results
of the control group.

We planned to enter data from cross-over and split-mouth studies,
Measures of treatment effect
and for the prevented fraction, into RevMan using the generic
For gingivitis and plaque outcomes, we expected the measures inverse variance outcome type (Review Manager (RevMan)).
of treatment effect would mostly be continuous. In such cases,
the mean difference (or difference in means) and standardised Unit of analysis issues
mean difference, when combining different clinical indices, were The unit of analysis was individual patients or groups of mea-
the effect measures used. We calculated the corresponding 95% suring sites within individual patients (e.g. interproximal sites:
confidence intervals for each study. proportion of sites that have bleeding averaged over the number
Clinical attachment loss can be a continuous measure, but the in- of patients). Contact with study authors was necessary to obtain
cidence is often so low that it can be dichotomised on a patient data in the right form. We analysed split-mouth studies taking the
basis and considered a binary measure. We planned to use risk ra- pairing into account as described in Chapter 16 of the Cochrane
tios together with 95% confidence intervals to combine dichoto- Handbook for Systematic Reviews of Interventions (Higgins 2011).
mous data. For completeness, raw values (mean, standard devia- Appropriate methods would also have been applied to cross-over
tion (SD), N) were to be presented for clinical attachment loss. and cluster trials had any been included.
For caries outcomes, we planned to calculate the prevented fraction
(PF) where appropriate. The PF is expressed as the mean increment
in the control group minus the mean increment in the intervention Dealing with missing data
group divided by the mean increment in the control group, i.e. the As described in Table 16.1.a in the Cochrane Handbook for Sys-
caries increment in the treatment group expressed as a percentage tematic Reviews of Interventions (Higgins 2011), there are several
types of missing data in a systematic review or meta-analysis. The assess a possible between-study reporting bias. If an asymmetry of
problems of missing studies and outcomes are addressed in the the funnel plot was found either by inspection or statistical tests,
Assessment of reporting biases part of this review. A common we planned to consider possible explanations and take this into
problem is missing summary data, such as standard deviations for account in the interpretation of the overall estimate of treatment
continuous outcomes, or separate sample sizes for each interven- effects.
tion group. Missing summary data was not a reason to exclude
a study from the review and we used the methods outlined in
section 16.1.3 of the Cochrane Handbook for Systematic Reviews of Data synthesis
Interventions (Higgins 2011) for imputing missing standard devi- Meta-analysis included only the studies reporting the same out-
ations. In some studies, data on individuals were missing from the comes. Since there are a number of different indices measuring
reported results. When necessary, we made attempts to contact the what we consider the same basic concept (plaque or gingivitis),
study authors to ask them for more information. we used the standardised mean difference (SMD), along with the
We made assumptions about the reasons why the data were miss- appropriate 95% confidence intervals (CI), to combine the re-
ing explicit. For the data judged to be ’missing at random’, i.e. their sults of different indices in meta-analysis. Some studies measured
being missing is unrelated to their actual values, analysis included plaque and gingivitis on selected sites and we used indices based on
only the available data and ignored the missing data. If data were these data. Risk ratios were also combined for binary data. As con-
judged to be ’not missing at random’, we performed a sensitiv- siderable heterogeneity was expected in the included studies, we
ity analysis to assess how the changes in assumptions might have planned a random-effects model to be used as a primary method
affected the results. The potential impact of missing data on the of meta-analysis.
findings of the review will be addressed in the ’Discussion’ section
of the review.
Subgroup analysis and investigation of heterogeneity
We planned the following subgroup analyses.
Assessment of heterogeneity • Periodontal status.
• Conical versus cylindrical interdental brushes.
Prior to meta-analysis, we first assessed studies for clinical homo-
• Trained (instructed) versus untrained (uninstructed)
geneity with respect to type of therapy, control group and the
interdental brushing.
outcomes. Clinically heterogeneous studies were not combined
in the analysis. For studies judged as clinically homogeneous, we
tested statistical heterogeneity using the Chi2 test and I2 statistic. Sensitivity analysis
We interpreted a Chi2 test resulting in a P value less than 0.10 Primary meta-analysis included all eligible studies irrespective of
as indicating significant statistical heterogeneity. In order to assess their risk of bias. Sensitivity analysis excluded those studies at high
and quantify the possible magnitude of inconsistency (i.e. hetero-
risk of bias to assess how the results of meta-analysis might be
geneity) across studies, we used the I2 statistic with a rough guide
affected.
for interpretation as follows: 0% to 40% might not be important;
We performed sensitivity analysis taking into account the sources
30% to 60% may represent moderate heterogeneity; 50% to 90% of funding of the included studies. We carried out primary analysis
may represent substantial heterogeneity; 75% to 100% consider- on all included studies, and compared the results against the results
able heterogeneity. of analysis that included only non-industry funded studies.
We also performed sensitivity analysis to evaluate the impact of
restricting the analysis to studies where we did not need to estimate
Assessment of reporting biases
standard deviations.
We assessed possible reporting biases on two levels: within-study
and between-study. Within-study selective outcome reporting was
examined as a part of the overall ’Risk of bias’ assessment (see Summary of findings
Assessment of risk of bias in included studies). We made attempts We adopted the GRADE system for evaluating the quality of
to find protocols of included studies and compare the outcomes the evidence of systematic reviews (Guyatt 2008a; Guyatt 2008b;
stated in the protocols with those reported in the publications. If Higgins 2011) and used it to construct ’Summary of findings’ ta-
protocols were not found, we compared the outcomes listed in the bles. We assessed the quality of the body of evidence with reference
methods sections on a publication against those whose results are to the overall risk of bias of the included studies, the directness of
reported. In case some indications of reporting bias were found, the evidence, the inconsistency of the results, the precision of the
we contacted study authors for clarification. If there were at least estimates and the risk of publication bias. We classified the quality
10 studies included in a meta-analysis, we would have created of the body of evidence into four categories: high, moderate, low
a funnel plot of effect estimates against their standard errors to and very low.
RESULTS without abstracts. Of these 865 references, two authors indepen-
dently judged 840 as irrelevant for the review. We obtained the
Description of studies 25 studies that both authors who screened the records could not
confidently exclude, based on their titles and abstracts, in full-text
versions and two authors carefully reviewed them independently.
As a result, 17 studies were found ineligible for inclusion and they
Results of the search are presented in the Characteristics of excluded studies table. The
Figure 1 shows the study selection flow chart with the search strat- remaining seven studies (8 articles) were finally included in this
egy that yielded 865 unique records, consisting of titles with or review (Figure 1).
Figure 1. Study selection flow diagram.
Design
Included studies
Four studies had a parallel design (Jared 2005; Jackson 2006;
Yankell 2002; Yost 2006) and three studies had a split-mouth
design (Christou 1998; Imai 2011; Ishak 2007). Regarding the • Participants had to have at least one shallow pocket of 4 to
number of study arms, five studies had two arms (Christou 1998; 5 mm or at least one deep pocket > 6 mm (Jackson 2006).
Imai 2011; Ishak 2007; Jackson 2006; Yankell 2002), one study • Participants were selected if they had plaque-induced
had four arms (Yost 2006) and one study had five arms (Jared gingivitis, determined by red gingival tissue that bleeds upon
2005). stimulation with probing depths < 4 mm (Imai 2011).
• Participants had to have at least one test site defined as an
interproximal space of 1.0 mm that exhibited bleeding from the
Sample sizes facial and lingual side (Jared 2005).
For the analyses of interdental brushing versus flossing the total Smokers were excluded from three studies (Imai 2011; Ishak 2007;
number of study participants that provided data for the analyses Jared 2005). Two studies included smokers (Jackson 2006; Yost
was 326, 197 of which were enrolled in the interdental brushing 2006) and in two studies smoking as a criteria was not reported
plus toothbrushing study arms and 195 participants in the flossing (Christou 1998; Yankell 2002).
plus toothbrushing control groups. None of the included studies reported the participants’ socioeco-
The median number of participants, calculated as the median of nomic status.
the sample sizes of the included studies, was 59 (range 10 to 77).
As for toothbrushing versus toothbrushing plus interdental brush-
ing, only one study (Jared 2005) provided data. The total number Intervention
of participants enrolled in these two study arms was 62, of which Seven studies provided data for the comparison between tooth-
30 participants were enrolled in the toothbrushing plus interden- brushing and interdental brushing with toothbrushing and floss-
tal brushing study arm and 32 participants in the toothbrushing ing. One study consisted of an interdental brushing study arm
only study arm. with a placebo gel (Jared 2005) but we extracted the data for the
Only one study reported a sample size calculation (Jackson 2006). meta-analyses for the interdental brushing group without gel. One
Imai 2011 derived the sample size from the sample sizes of Jackson study (Yost 2006) had flossers and regular floss study arms. Be-
2006 and Yost 2006. cause they both refer to manual flossing, we combined data from
the two intervention groups into a single intervention group us-
ing methods outlined in Chapter 7 of the Cochrane Handbook for
Setting
Systematic Reviews of interventions (Higgins 2011).
Three trials were conducted in the United States of America (Jared Only one study (Jared 2005) included the interdental brushing
2005; Yankell 2002; Yost 2006), two in the United Kingdom plus toothbrushing study arm and compared it to the toothbrush-
(Ishak 2007; Jackson 2006), one in Canada (Imai 2011) and one ing alone study arm.
in the Netherlands (Christou 1998). Four studies reported frequency of interdental brushing and floss-
ing, whereas the frequency in three studies was once daily (Imai
2011; Jared 2005; Yost 2006) and in one study the frequency
Participants was twice daily (Yankell 2002). Three studies did not report the
Except for two studies which did not report the oral health status frequency of the assigned interdental cleaning method (Christou
of the participants (Yankell 2002; Yost 2006), all other included 1998; Ishak 2007; Jackson 2006).
studies selected participants based on their existing periodontal No specific instructions were given for the use of any of the dis-
diseases. Three studies included patients with moderate to severe tributed oral hygiene materials in one study (Yankell 2002), where
periodontitis (Christou 1998; Ishak 2007; Jackson 2006) and two only one brush size was used. In all remaining studies participants
studies included patients that showed clinical signs of gingivitis were provided with detailed instructions on the use of the assigned
(Imai 2011; Jared 2005). product. There was often detailed information on the size of the
Details of the participants’ oral health status included in these brushes to be used, and how this was determined for each indi-
studies are as follows. vidual patient (see Characteristics of included studies).
• Participants had to have probing depth > 5 mm, assessed by Baseline cleaning that was performed in order to facilitate applica-
a force-controlled probe, radiographic evidence of alveolar bone tion of the assigned interdental device was reported in all included
loss and inflamed gingiva, that was assessed by the bleeding on studies except in one study (Yankell 2002).
probing (Christou 1998). Participants’ adherence was assessed in five studies (Christou 1998;
• Measurements taken at 10 sites in each quadrant at the Imai 2011; Ishak 2007; Jared 2005; Yost 2006) but two studies did
baseline visit were presented as mean and standard deviations not report adherence assessments (Jackson 2006; Yankell 2002).
and are as follows: bleeding on probing (BOP): 10.3 + 4.22 -
11.3 + 4.16; % sites > 3 mm probing depth (PD): 26 + 20.38 -
29.5 + 22.78 (Ishak 2007). Outcomes
All data concerning the means and standard deviations extracted
from the studies and used in the analyses are presented in Addi-
tional Table 1 and Table 2.
The indices reported for each trial (those included are indicated
by an asterisk) are shown below.
Study Time points Gingivitis index (scale) Plaque index (scale)
Christou 1998 1 month* Bleeding on probing (nr)* Quigley & Hein Plaque Index (Volpe modifica-
tion)*
Imai 2011 1, 3 months Eastman Interdental Bleeding Index (0/1)* Silness & Löe Plaque Index (0 to 3)*
Ishak 2007 1 month Bleeding on probing* (nr) Supragingival plaque* and subgingival plaque us-
ing dental floss (+/-)
Jackson 2006 1, 3 months Eastman Interdental Bleeding Index (0/1)* Plaque Index (Silness & Löe) (0 to 3)*
Bleeding on probing (0/1)
Jared 2005 1 month Löe-Silness Gingival Index (Lobene modifica- Quigley & Hein Plaque Index (Turesky modifi-
tion) (0 to 4)* cation) (0 to 5)*
Bleeding on probing (Van der Weijden modifi-
cation) (+/-)
Yankell 2002 1 month Eastman Interdental Bleeding Index (0/1) Quigley & Hein Plaque Index (Turesky modifi-
Löe-Silness Gingival Index (Lobene modifica- cation) (0 to 5)*
tion)*
(0 to 4)
Yost 2006 1 month Eastman Interdental Bleeding Index Quigley & Hein Plaque Index (Benson modifi-
Löe-Silness Gingival Index* (0 to 3) cation)*
*One month includes four to six weeks data.

mouth.
Gingivitis
The following bleeding indices were used in the included studies:
Gingivitis as an outcome was assessed in all seven included studies.
• Bleeding on probing index (BOP) in Christou 1998; Ishak
Four studies used only bleeding indices (Christou 1998; Imai
2007 and Jackson 2006.
2011; Ishak 2007; Jackson 2006), whereas one study used two
• Modified bleeding on marginal probing (Van der Weijden
bleeding indices (Jackson 2006). The remaining three studies used
1994) was used in Jared 2005.
bleeding and gingivitis indices to assess the progression of the
• Eastman Interdental Bleeding Index (EIBI) in Imai 2011;
disease (Jared 2005; Yankell 2002; Yost 2006).
Jackson 2006; Yankell 2002 and Yost 2006.
Gingivitis data from the included studies were used in meta-anal-
ysis. Two studies (Imai 2011; Jackson 2006) presented data using EIBI
• Two studies used the Lobene modification of the Löe- dichotomous bleeding scores, three studies scored bleeding using
Silness gingival index (Lobene 1985) with one study (Yankell ordinal indices (Jared 2005; Yankell 2002; Yost 2006) and in two
2002) reporting the gingival index on facial and lingual margins studies scoring of the bleeding indices used remained unclear (
of the Ramfjord teeth and the other study (Jared 2005) reporting Christou 1998; Ishak 2007).
scores on the interproximal surfaces of test teeth. Examiner’s reliability was assessed in three studies (Ishak 2007;
• Yost 2006 used the Löe-Silness gingival index in whole Jackson 2006; Jared 2005), whereas in Ishak 2007 it was stated
that an experienced examiner performed all the measurements and 1998; Ishak 2007), reporting problems with the use of the assigned
in the Jared 2005 examiner was trained and calibrated. As for the products. In another study the participants completed a diary for
remaining four studies (Christou 1998; Imai 2011; Yankell 2002; adherence (Yost 2006). In a further study (Jared 2005) participants
Yost 2006) the intra-examiner’s training and reliability was not were requested to keep a log of any symptoms experienced during
reported. the study but no such results were reported.
Two studies (Christou 1998; Ishak 2007) used a force-controlled
probe to assess gingival bleeding and Jared 2005 used a manual
probe, while for two studies (Yankell 2002; Yost 2006) no infor- Data considerations for exploration of heterogeneity
mation was given on the kind of probe that was used in the as- To further explore the clinical heterogeneity, we intended to per-
sessment of bleeding. In two studies (Imai 2011; Jackson 2006) form a subgroup analysis on the periodontal status by categorising
bleeding was assessed by the EIBI in which a wooden interdental the studies based on the participants’ baseline periodontal status.
cleaner is used to elicit bleeding. This categorisation of studies was undertaken according to the Pe-
Yost 2006 used Löe-Silness gingival index and reported it as means riodontal Disease Classification System of the American Academy
without standard deviations. The study’s results were nevertheless of Periodontology (Armitage 1999) in which slight periodontitis
included in meta-analyses with standard deviations estimated from is described with 1 to 2 mm clinical attachment loss (CAL), mod-
standard errors presented in a very poor graph. erate with 3 to 4 mm CAL and severe > 5 mm CAL, whether it
was localised or generalised with > 30% of sites involved. Only
three studies (Christou 1998; Ishak 2007; Jackson 2006) stated
Plaque the degree of CAL among the participants, and we therefore de-
• One study (Christou 1998) used the Volpe modification of cided that the data available were insufficient to conduct a sub-
the Quigley and Hein plaque index (Quigley 1962; Volpe 1993) group analysis.
on approximal sites. The subgroup analysis for conical versus cylindrical interdental
• Two studies (Yankell 2002; Jared 2005) used the Turesky brushes was also not possible since neither of the included studies
modification of the Quigley and Hein plaque index (Turesky provided information on the shape of the interdental brushes used.
1970), whereas one study (Jared 2005) assessed interproximal
scores only and other (Yankell 2002) evaluated plaque levels on
Excluded studies
the gingival areas on the facial and lingual surfaces of the
Ramfjord teeth. After having screened the full texts of the studies, we judged 17
• Whole mouth plaque assessment was performed in Yost studies as ineligible for inclusion in this review based on the fol-
2006 using the Benson modification of the Quigley and Hein lowing reasons: cross-over study without sufficient washout period
index (Benson 1993). (two), intervention period less than four weeks (five), no inter-
• Imai 2011 and Jackson 2006 used the Löe and Silness dental brush among treatment groups (five), article was a prelim-
plaque index on interproximal surfaces (disto-buccal, disto- inary report/abstract (three), special toothbrush compared with a
lingual, mesio-buccal, mesio-lingual). regular toothbrushing (one), results presented without standard
• Ishak 2007 assessed plaque on proximal surfaces as positive errors and in a manner that cannot be used in the review (one). A
or negative. list of the excluded studies with explanation of the decisions for
exclusion is presented in Characteristics of excluded studies.
Adverse events Risk of bias in included studies

Three studies reported adverse events. This was done through Summaries of the risk of bias are presented for each study and
participants completing a questionnaire in two studies (Christou domain in Figure 2.
Figure 2. Risk of bias summary: review authors’ judgements about each risk of bias item for each included
study.
Allocation
Other potential sources of bias
Randomisation was mentioned in all included studies. The allo- We judged the risk of other potential sources of bias as low in four
cation sequence generation was clearly described in three studies studies (Christou 1998; Imai 2011; Ishak 2007; Jackson 2006)
(Imai 2011; Jackson 2006; Jared 2005). One study (Ishak 2007) and unclear in the remaining three studies (Jared 2005; Yankell
reported that a statistician generated the randomisation sequence 2002; Yost 2006).
so it was assumed that it was done properly despite the lack of Two of these studies (Jared 2005; Yost 2006) were financially sup-
further details about the randomisation process. However, in three ported by industry.
studies (Christou 1998; Yankell 2002; Yost 2006) randomisation Adherence was not assessed and intra-examiner’s reliability was not
was only mentioned with no adequate description of the sequence reported in two studies (Yankell 2002; Yost 2006). In one study
generation method. (Jared 2005) compliance was not reported although participants
Allocation concealment is not as important in split-mouth studies were asked to keep log of their dental cleaning habits, but the
so these have all been assessed as at low risk of bias (Christou examiner’s reliability was tested.
1998; Imai 2011; Ishak 2007). There were no reports of allocation
concealment in the other four studies (Jackson 2006; Jared 2005;
Yankell 2002; Yost 2006) and we assessed these as unclear. Overall risk of bias
We assessed one study as at low risk of bias (Imai 2011) and
three studies as high (Ishak 2007; Jared 2005; Yost 2006), with
Blinding the remainder being assessed as unclear (Christou 1998; Jackson
2006; Yankell 2002).
Blinding of the examiner on clinical outcomes was clearly reported
in four studies (Christou 1998; Imai 2011; Ishak 2007; Jackson
2006). The other studies were described as either double or single- Effects of interventions
blind and so we also assessed this as at low risk of bias (Jared 2005; See: Summary of findings for the main comparison Interdental
Yankell 2002; Yost 2006). brushing with toothbrushing compared to toothbrushing alone
There was no blinding of the participants in any of the included for periodontal diseases and dental caries in adults; Summary
studies, and this did not form part of the ’Risk of bias’ assessment. of findings 2 Interdental brushing compared to flossing for
periodontal diseases and dental caries in adults
Incomplete outcome data

Comparison: Interdental brushing and toothbrushing
Withdrawals were adequately reported in all included studies. In versus toothbrushing alone
one study (Yost 2006) the number of drop-outs was reported but
The first objective of this review was to examine whether or not
reasons and breakdown by study arms were not provided. Never-
interdental brushes are effective in reducing the progression of pe-
theless, having considered the number of participants that were
riodontal diseases or dental caries when used together with regular
lost from the study, we judged attrition as unlikely to affect the
toothbrushing. Only one study, at high risk of bias, compared in-
results.
terdental brushing plus toothbrushing versus toothbrushing alone
(Jared 2005), so a meta-analysis was not possible.
Selective reporting
Gingivitis
We judged four studies (Christou 1998; Imai 2011; Jackson 2006;
Yankell 2002) as having low risk of bias regarding selective out- Interproximal gingival index was observed and measured at two
come reporting. In Jared 2005 data on possible adverse effects were and four weeks. The mean difference (MD) for gingivitis at four
not reported although participants were asked to keep a log, so we weeks between the two study groups was -0.53 (95% confidence
assessed this as at high risk of bias. We also assessed a further two interval (CI) -0.83 to -0.23; P value = 0.001) in favour of tooth-
studies as at high risk of bias for selective reporting: in one study brushing plus interdental brushing.
(Ishak 2007) the mean difference and standard deviations were not
reported for the clinical outcomes taking into account the split-
mouth nature of the data, and in Yost 2006 standard deviations Periodontitis
were not reported. Periodontitis was not reported as an outcome in this study.
Interproximal caries Gingivitis at three months
Interproximal caries was not reported as an outcome in this study. Analysis 1.2.
Two studies were included in the meta-analysis assessing gingivitis
at the three-month time point (Imai 2011; Jackson 2006). We
judged one as low and one as unclear risk of bias. The SMD was
Plaque
-1.98 (95% CI -5.42 to 1.47; P value = 0.26). We therefore con-
Interproximal plaque index was observed and measured at two and clude that there is insufficient evidence to support or refute the
four weeks. The mean difference for plaque at four weeks was - claim that interdental brushing is effective in reducing gingivitis
0.95 (95% CI -1.34 to -0.56; P value < 0.0001), again in favour at three months when compared to flossing. Considerable hetero-
of interdental brushing. geneity was observed (Chi2 23.14 (df = 1); P value < 0.00001; I2 =
96%). It is, however, difficult to interpret such heterogeneity since
there are only two studies available for the analysis, both differing
methodologically in terms of study design. Clinical heterogene-
Harms and adverse effects
ity among the two studies refers to the participants’ baseline peri-
No adverse effects were reported in this study. odontal status and the inclusion of smokers in the Jackson 2006
study (Analysis 1.2).
Overall, there is some evidence that interdental brushing plus
toothbrushing reduces gingivitis at one month when compared
Comparison: Interdental brushing plus toothbrushing with flossing plus toothbrushing. More evidence is needed to sup-
versus flossing plus toothbrushing port the conclusions about the effect at three months.
All seven studies contributed data for gingivitis and plaque at one
month and two studies provided data on both conditions at three
months. Periodontitis
Periodontitis was not reported as an outcome in any included

study.
Gingivitis
Interproximal caries
Gingivitis at one month Interproximal caries was not reported as an outcome in any in-
cluded study.
Analysis 1.1.
All seven studies were included in the meta-analysis for gingivitis
at the one-month time point (Christou 1998; Imai 2011; Ishak
2007; Jackson 2006; Jared 2005; Yankell 2002; Yost 2006). One Plaque
was assessed as low risk of bias, three as unclear risk of bias and
three as at high risk of bias.
The standardised mean difference (SMD) was -0.53 (95% CI -
Plaque at one month
0.81 to -0.24) with a P value of 0.0003, indicating that there is evi-
dence of benefit for using interdental brushing plus toothbrushing Analysis 1.3.
for the reduction of gingivitis at one month when compared to The meta-analysis of plaque at one month included all seven stud-
flossing plus toothbrushing. ies. We assessed one as at low risk of bias, three as at unclear risk of
Statistical analysis of the I2 statistic (79%), Chi2 (28.09 (degrees bias and three as at high risk of bias. The pooled estimate resulted
of freedom (df ) = 6)) and the corresponding P value (P < 0.0001) in a SMD of 0.10 (95% CI -0.13 to 0.33; P value = 0.39), which
indicates substantial statistical heterogeneity among studies. showed low-quality evidence of no difference in the effectiveness
We examined the pre-specified subgroups where appropriate to de- of interdental brushing plus toothbrushing compared to flossing
termine possible reasons for any heterogeneity. For trained versus plus toothbrushing in the reduction of plaque parameters at one
untrained interdental brushing we undertook a subgroup analysis month. Considerable heterogeneity among studies was observed
and the results for gingivitis at one month for the two subgroups (I2 = 85%; Chi2 = 39.36 (df = 6); P value < 0.00001). We car-
are presented: trained (six trials) and untrained interdental brush- ried out subgroup analysis of trained versus untrained interdental
ing (one trial). There was no evidence of a difference between sub- brushing but this was not significant (P value = 0.34) (Analysis
groups (P value = 0.74) (Analysis 1.1). 1.3).
Plaque at three months Economic cost and halitosis were not reported in any of the in-
Analysis 1.4. cluded studies.
Two studies (Imai 2011; Jackson 2006) assessed the plaque out-
come at the three-month time point. The studies were at low and
Sensitivity analysis for gingivitis and plaque
unclear risk of bias. The resulting effect estimate was SMD -2.14
(95% CI -5.25 to 0.97; P value = 0.18). We conclude that there is We conducted sensitivity analyses omitting Yost 2006 (which did
insufficient evidence to determine whether there is a difference be- not report standard deviations and was judged as at high risk of
tween the two interventions. Considerable heterogeneity between bias) at the one-month time point; this led to similar effect esti-
studies was observed (Chi2 = 18.84 (df = 1); I2 = 95%; P value < mates. For gingivitis the resulting SMD was -0.59 (95% CI -0.95
0.0001), but it is difficult to interpret such heterogeneity because to -0.23) and for plaque the SMD was 0.09 (95% CI -0.16 to
only two studies were included in the analysis, as for gingivitis at 0.34). Sensitivity analysis omitting the three studies at high risk
three months (Analysis 1.4). of bias (Jared 2005; Yankell 2002; Yost 2006) also led to similar
estimates for gingivitis and plaque at one month, the SMD values
being -0.69 (95% CI -1.25 to -0.12) and SMD 0.06 (95% CI -
Harms and adverse effects 0.28 to 0.40), respectively. We performed sensitivity analysis based
on funding, excluding the two industry-sponsored studies (Jared
Adverse effects assessed in this review are regarded in terms of po- 2005; Yost 2006) from the analysis at the one-month time point,
tential harms or damages of to oral soft tissue caused by interdental resulting in a SMD of -0.63 (95% CI -1.06 to -0.21) for gingivitis
brushing or flossing. and SMD 0.07 (95% CI -0.20 to 0.34) for plaque.
One study (Christou 1998) reported 14 patients experiencing
problems with the use of dental floss, two patients experiencing
problems with the use of interdental brushes and two patients Converting SMDs back to original indices
reported problems with the use of both interdental brushes and As the results for plaque and gingivitis in all of the included studies
dental floss. However, no detailed information was given on the were presented as continuous data, but with different instruments
nature of these problems, but they were most commonly associ- (i.e. indices to measure the gingivitis and plaque), we used the
ated with difficulty in manipulating the dental floss. In one study standardised mean difference as the statistic for the meta-analysis.
(Ishak 2007) participants reported that interdental brushes tended As standardised mean differences are unitless and difficult to in-
to buckle or distort while for dental floss they reported that it terpret, we have re-expressed them in the original scales and pre-
sometimes stuck between teeth or caused soreness. Considering sented them as the indices used in these studies.
the ways in which the adverse outcomes were presented, a meta- Jackson 2006 was selected for the gingivitis outcome at one month
analysis was not appropriate. because the study was representative of the population and inter-
Three studies reported that no adverse effects were observed or vention, was judged to have unclear risk of bias and used the East-
reported during the study (Imai 2011; Jackson 2006; Yankell man Interdental Bleeding Index. However, for the plaque outcome
2002). at one month, we selected Imai 2011 instead because it used the
Two studies did not report data on adverse effects. In one of these most common plaque index, the Silness & Löe Plaque Index. We
studies (Jared 2005) participants were asked to keep a log with judged it to have low risk of bias.
details of any symptoms that might be experienced during the trial We calculated the mean difference by multiplying the standard
but no data on adverse effects were reported in the trial. Another deviation of the control group (flossing) by the pooled SMD. We
study (Yost 2006) reported that examination of the oral soft tissue calculated the reduction of control mean by dividing the reduction
was performed at six weeks (i.e. at the final visit), but provided no in mean scores by the control mean and multiplying it by 100 in
data on adverse effects. order to present the data as percentages.
The tables below represent these calculations for the gingivitis in-
dex and plaque indices at one month. The differences are expressed
Other outcomes as percentage reductions of the control (flossing) mean.
Gingivitis index Study Time Reduction in mean Control mean (SD) Reduction as % of control
scores (95% CI) mean
Eastman Interden- Jackson 2006 1 month - 0.12 (95% CI -0.18 to - 0.23 (0.22) 52
tal Bleeding Index 0.05)
Plaque index Study Time Difference in mean scores Control mean Difference as % of control mean
Silness & Löe Imai 2011 1 month 0.02 (95% CI -0.02 to 0. 1.23 (0.18) 2
Plaque Index 06)
All data concerning the means and standard deviations extracted

from the studies and used in the analyses are presented in Addi-
tional Table 1 and Table 2.
Interdental brushing for the prevention and control of periodontal diseases and dental caries in adults (Review) A D D I T I O N A L S U M M A R Y O F F I N D I N G S [Explanation]
Interdental brushing compared to flossing for periodontal diseases and dental caries in adults
Patient or population: Adults, 16 years and older

Settings: Everyday self care
Intervention: Interdental brushing plus toothbrushing
Comparison: Flossing plus toothbrushing
Outcomes Illustrative comparative risks* (95% CI) Relative effect No of participants Quality of the evidence Comments
(95% CI) (studies) (GRADE)
Assumed risk Corresponding risk
Flossing IDB
Gingivitis The m ean gingivitis in The m ean gingivitis in 390 ⊕⊕ The estim ate is f or the
Score 0 or 1 Scale f rom : the f lossing groups was the intervention groups (7 studies) low2,3 1-m onth (4 to 6 weeks)
0 to 1 0.23 points1 was tim e point and converts
Follow-up: m ean 1 0.53 standard devia- back to 52% reduc-
m onth (4 to 6 weeks) tions lower tion (of control m ean)
(0.81 to 0.24 lower) f or IDB (based on 1
study). Results (based
on 2 studies, very low-
quality evidence) at 3
m onths show a large
SM D but we are unable
to draw conclusions on
the ef f ect due to the
wide conf idence inter-
val including no ef f ect
Periodontitis Not estim able 0 See com m ent No included study as-
(0) sessed clinical attach-
m ent loss, a m easure
of progression of peri-
odontitis
23
Plaque The m ean plaque in the The m ean plaque in 326 ⊕⊕ The estim ate is f or the
Scale f rom 0 to 3 f lossing groups was the intervention groups (7 studies) low2,3,5 1-m onth (4 to 6 weeks)
Follow-up: m ean 1 1.23 points4 was tim e point, and con-
m onth (4 to 6 weeks) 0.10 standard devia- verts back to 2% reduc-
tions higher tion (of control m ean)
(0.13 lower to 0.33 f or IDB (based on 1
higher) study). The ef f ect f or
the 3 m onths tim e point
som ewhat dif f ers, with
a large SM D but we are
unable to draw conclu-
sions on the ef f ect due
to the wide conf idence
interval including no ef -
f ect (based on 2 stud-
ies, very low-quality ev-
idence)
Interproximal caries Not estim able 0 See com m ent No included study as-
(0) sessed caries as an out-
com e
Harms and adverse Not estim able 0 See com m ent 2 studies reported ad-
outcomes (0) verse outcom es in
term s of problem s
with the use of
the assigned interden-
tal cleaning aids. We
were unable to pool
data
Bad breath Not estim able 0 See com m ent No included study as-
(halitosis) (0) sessed bad breath as
an outcom e
24
Quality of life Not estim able 0 See com m ent No included study as-
(0) sessed quality of lif e as
an outcom e
* The basis f or the assumed risk (e.g. the m edian control group risk across studies) is provided in f ootnotes. The corresponding risk (and its 95% conf idence interval) is
based on the assum ed risk in the com parison group and the relative effect of the intervention (and its 95% CI).
CI: conf idence interval; IDB: interdental brushing; RR: risk ratio; SM D: standardised m ean dif f erence
GRADE Working Group grades of evidence

High quality: Further research is very unlikely to change our conf idence in the estim ate of ef f ect.
M oderate quality: Further research is likely to have an im portant im pact on our conf idence in the estim ate of ef f ect and m ay change the estim ate.
Low quality: Further research is very likely to have an im portant im pact on our conf idence in the estim ate of ef f ect and is likely to change the estim ate.
Very low quality: We are very uncertain about the estim ate.
1 Re-expressed f rom SM D into Eastm an Interdental Bleeding Index score. The results should be interpreted with caution since
back-translation of the ef f ect size is based on the results of only one study (Jackson 2006). The estim ate is f or the one-
m onth tim e point with a SM D of -0.53. A larger ef f ect was observed f or the three m onths tim e point with a SM D of -1.98.
2 Three studies at high risk of bias, three unclear. Two studies were industry-sponsored, whilst in three studies the source of
f unding was not declared.

3 Heterogeneity I 2 = 85%, P value < 0.001.
4 Re-expressed f rom the SM D into the Silness and Löe Plaque Index score. Results should be interpreted with caution since
back-translation of the ef f ect size is based on the results of only one study (Im ai 2011). The estim ate is f or the one-m onth
tim e point, with a SM D of 0.10. The three m onths tim e point shows a larger ef f ect with a SM D of -2.14.
5 Im precision is due to heterogeneity, which we have already downgraded f or.
25
63% female and 37% male, although one study did not report
DISCUSSION
on gender proportions. It is possible that the greater number of
Summary of main results female participants in the studies included in this review may have
influenced the gingivitis outcomes, as gingivitis is more preva-
This review found very low-quality evidence, based on a single
lent in males than females. The observed epidemiological differ-
study, of the effectiveness of interdental brushing plus toothbrush-
ences between males and females are explained by females’ greater
ing when compared to toothbrushing alone for gingivitis and
knowledge and a more positive approach to oral health compared
plaque.
to their male counterparts (Furuta 2011).
This review also found low-quality evidence of the benefit of in-
None of the studies provided data about periodontitis, as assessed
terdental brushing plus toothbrushing when compared to flossing
by clinical attachment loss (CAL). This is not surprising as the
plus toothbrushing for the outcome of gingivitis at one month.
maximum study length was only 12 weeks, which is not long
This result is based on seven studies and translates to a 52% reduc-
enough for changes in CAL to be detected. Also, none of the studies
tion in bleeding. There is low-quality evidence of no difference
provided data about bad breath (halitosis) or quality of life: it
in plaque at one month and insufficient evidence to determine
would be very useful for future studies to report on halitosis, as bad
whether there is a difference when using interdental brushes or
breath is frequently seen by patients to be a possible consequence
flossing for plaque reduction at three months.
of failure to adequately clean their teeth and supporting tissues.
No studies were identified that reported dental caries as an out-
The participants in three of the studies had periodontal disease,
come, although the presence of a plaque biofilm is implicit in the
which was described as moderate to severe (two studies) or chronic
development of caries. Therefore it is not possible to demonstrate
periodontitis (one study). It is important that studies are con-
the effectiveness, or not, of interdental brushing plus toothbrush-
ducted on participants who have periodontitis, so that the effects
ing for managing dental caries. The studies also did not report
of interdental brushing can be analysed in participants who are
clinical attachment loss, halitosis or quality of life.
representative of the whole population, some of whom will have
Harms and adverse effects were reported in five studies and un-
periodontal disease, rather than those with only gingivitis.
reported in two. In one of these five studies participants reported
Inclusion of smokers in two studies (Jackson 2006; Yost 2006)
problems with the use of interdental brushing and flossing. This
may also contribute to the overall representativeness of the sam-
was more frequent with dental floss and was most commonly asso-
ple. Smokers experience less gingival bleeding on probing which
ciated with difficulty in manipulating the dental floss in the pos-
may cause problems in the diagnosis of gingivitis (Axelsson 1998).
terior areas of the mouth. In another study, problems listed for
Decreased gingival bleeding in smokers has been explained by a
the interdental brushes were that they tended to buckle or distort.
vasoconstricting effect of nicotine on the peripheral blood vessels
With flossing, participants again reported difficulty in manipulat-
(Axelsson 1998; Newbrun 1996). However, we are not able to
ing the dental floss in the posterior areas of the mouth and that
conclude to what extent smoking has affected the results of this
it sometimes stuck between teeth. However, the most important
review as we are not confident about the total number of smok-
harm identified for dental floss was that it may cause soreness of
ers included, since in two studies (Christou 1998; Yankell 2002)
the soft tissue.
smoking as a criteria was not taken into account.
Summary of findings 2 (summary of findings for the main com-
For plaque, there is almost no difference between smokers and
parison) shows the seven main outcomes and the quality of evi-
non-smokers (Axelsson 1998), so smoking is unlikely to influence
dence associated with them, using the GRADE approach (Atkins
the results.
2004).
There is also evidence (Christou 1998; Imai 2010; Ishak 2007)
that people find interdental brushing easier to perform than floss-
Overall completeness and applicability of ing and are thus more likely to continue doing so. One of these
evidence studies (Christou 1998) provided evidence that patients regarded
interdental brushes as more effective in cleaning their teeth than
Only one study reported on one of our objectives, comparing
dental floss.
toothbrushing with and without interdental brushing. All seven
included studies addressed our second objective in comparing
toothbrushing with interdental brushing with toothbrushing and
flossing.
Quality of the evidence
We did not find any studies fitting the inclusion criteria that re- We assessed the quality of the body of evidence for the com-
ported on the effects of interdental brushing on the development parison between toothbrushing with interdental brushing with
of dental caries. toothbrushing alone as very low for both plaque and gingivitis
A total of 326 participants from seven studies aged between 18 (Summary of findings for the main comparison).
and 75 provided data for analysis for our second objective. There We assessed the quality of the body of evidence for the compar-
were more female than male participants, the percentages being ison between interdental brushing and flossing as low for both
plaque and gingivitis at one month and very low at three months AUTHORS’ CONCLUSIONS
(Summary of findings 2).
There is a possibility of publication bias, as studies are more likely Implications for practice
to be published if the results are positive. However, the number of
This review has found very low-quality evidence that interdental
studies was insufficient for us to undertake a funnel plot analysis
brushing plus toothbrushing is more beneficial than toothbrush-
to check for the existence of publication bias.
ing alone for gingivitis and plaque at one month. There is also
We assessed three of the studies included in this review as being
low-quality evidence that interdental brushing reduces gingivitis
at high risk of bias (Jared 2005; Yankell 2002; Yost 2006). We
when compared with flossing but these results were only found at
assessed three as being at unclear risk of bias and the remaining one
one month. There was insufficient evidence to determine whether
as being at low risk. Allocation concealment was unclear in four
interdental brushing reduced or increased levels of plaque when
studies. The outcome assessor was blinded in all studies. Attrition
compared to flossing.
bias due to participants dropping out of the studies was low and
was not thought to affect the results. We tried to obtain further
Implications for research
information about missing data, particularly if the data were ’not
missing at random’. We undertook a sensitivity analysis omitting Only one study compared toothbrushing alone versus either tooth-
the studies assessed as at high risk of bias; thisled to similar effect brushing and interdental brushing or toothbrushing and flossing:
estimates at one month for gingivitis and plaque and thus did not more studies are needed for this comparison. The length of the in-
affect the results overall. cluded studies was relatively short, ranging from four to 12 weeks,
Heterogeneity was substantial for both the gingivitis and plaque and longer randomised controlled trials are needed to provide ev-
analyses at the one-month interval and considerable for both at idence for using interdental brushes as part of a daily routine and
the three-month interval. We have been unable to account for this in comparison to dental floss. Longer study durations would also
degree of heterogeneity but is probably due to methodological and reduce the ’trial effect’ which may bias studies of short duration.
clinical variability between the studies. No studies were found that considered caries as an outcome and
using present methods of caries detection, based on porosity, a
period of at least 12 months is necessary to observe any effect.
Potential biases in the review process
We carried out a subgroup analysis on trained versus untrained
The search strategy used was sensitive and did not exclude studies participants and the results were similar. However, there was only
based on language nor unpublished studies. We contacted manu- one study with untrained participants and it is difficult to draw
facturers of interdental brushes to identify any unpublished stud- reliable conclusions from this without further studies using un-
ies or studies in progress. It is possible that studies in non-indexed trained participants being undertaken. It is an important question
journals, particularly from developing countries, may not have as it would provide information about the resources needed to
been identified. train participants in using interdental brushes.
For future studies, accurate reporting about instructions given to
Agreements and disagreements with other participants when using interdental brushes should be given. For
studies or reviews example, whether interdental brushing should be undertaken prior
to, or after, toothbrushing, with information about the frequency
The findings of this review are generally in keeping with those of with which the interdental brush is inserted interdentally. These
other reviews (Imai 2012; Slot 2008). The systematic review by instructions should be reported in the study and participants in the
Slot 2008 found nine randomised controlled trials (RCTs) and re- trained groups should have hands-on training, together with daily
ported that there was a statistically significant reduction in plaque reminders. Compliance assessment should be accurately recorded
scores in five out of the eight studies that compared interdental and reported in detail, especially as study lengths increase.
brushing to floss. However, we only found weak and unreliable
evidence to support or deny any difference in effectiveness. The Three studies had participants with periodontal disease and clin-
Slot 2008 systematic review did not find a statistically significant ical attachment loss (CAL), but more studies including partic-
difference in gingivitis between interdental brushing and floss, but ipants with periodontal disease and CAL are needed, especially
we did. The systematic review by Imai 2012 identified seven RCTs, when comparing interdental brushing and flossing, when teeth
six being the same that we identified, but included one that we with wider embrasures and greater interdental surface areas are
had excluded and excluded one that we had included. The overall involved.
findings of Imai 2012 are similar to our review, that interdental
brushing is more effective than floss in reducing gingivitis, but are
dissimilar in that we found no evidence for a reduction in plaque
scores, when comparing interdental brushing to flossing. ACKNOWLEDGEMENTS
We would like to thank the Cochrane Oral Health Group editorial
base for their support during the completion of this review. We
would also like to thank the following referees for their helpful,
constructive comments on the review: Anne Littlewood, Phil Ri-
ley, Ian Needleman, Tanya Walsh, Aubrey Sheiham and Edward
Lo.
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CHARACTERISTICS OF STUDIES
Characteristics of included studies [ordered by study ID]
Christou 1998
Methods Design: RCT, split-mouth, 2 interventions

Duration of the study: 6 weeks
Attrition: no subjects were lost from the study
Participants Randomised: n = 26
Completed: n = 26
Age range: 27 to 72 years; mean age = 37.4
Males/females: 14/12
Oral health status: untreated patients suffering from moderate to severe periodontitis
Inclusion criteria: at least 3 natural teeth present in each quadrant, clinical diagnosis of
generalised moderate to severe periodontitis defined as the presence of at least 1 site in
each quadrant for fulfilling all following criteria: probing depths > 5 mm, bleeding on
probing and radiographic evidence of alveolar bone loss, 25 years of age or older; gingiva
with little or no recession showing overt signs of inflammation
Exclusion criteria: use of antibiotics over last 3 months before baseline, use of interdental
cleaning aids on a regular basis
Location: Netherlands
Interventions Comparison: interdental brushing (IDB) versus dental flossing (DF)

Both groups used manual toothbrush
Training: participants received detailed instructions for use of a manual toothbrush,
dental floss and interdental brushes by a dental hygienist and were provided with by
take-home written instructions. After 3 weeks oral hygiene instructions were reinforced
by the dental hygienist
After 1 week, compliance with the study protocol was confirmed by a telephone call by
the dental hygienist
Baseline cleaning: supragingival calculus was removed at sites where interference with
interdental cleaning occurred
Information on brushes
“Figure 1. Different interdental brushes (2.5, 3, 4, 5, 6.5, and 8 mm in diameter) were
used according to the size of the interdental space”
“Interdental spaces which could not be entered by the assigned interdental device were
recorded and excluded from the analysis”
Outcomes Measurements: at baseline, 6 weeks

Plaque, bleeding and probing depth were evaluated at 4 approximal sites, mesial and
distal from both buccal and lingual aspects
Plaque measured by the Volpe modification of Quigley and Hein plaque index
Periodontal disease-gingivitis measured by bleeding on probing (BOP) assessed by an-
gulated bleeding index (ABI) and periodontal pocket bleeding index (PPBI)
Probing depth (PD) evaluated using a force controlled probe
Compliance assessment: compliance was confirmed by a telephone call after a week of
treatment
Adverse outcomes: self reported; participants completed a questionnaire concerning any
problems with DF and IDB
Christou 1998 (Continued)
Source of funding State Scholarship Foundation of Greece gave a grant; Entra - Lactona BV provided
brushes and interdental brushes
Notes Interdental spaces which could not be entered by the assigned interdental device were
recorded and excluded from the analysis (12 sites for any size of the IDB and 2 sites for
the DF)
Risk of bias Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection Unclear risk Quote: “The use of DF was randomly as-
bias) signed to the left or the right side of the
mouth and the use of IDB to the other side
of the mouth”
Comment: no further information given
on the sequence allocation
Allocation concealment (selection bias) Low risk Split-mouth study
Blinding (performance bias and detection Low risk Quote: “All procedures concerning instruc-
bias) Researcher-assessed outcomes tion, cleaning and exclusion of sites from
the analyses were performed in the absence
of the examiner keeping these recordings
blind throughout the study”
Incomplete outcome data (attrition bias) Low risk There were no drop-outs. 12 sites, not
All outcomes accessible to any size of the interdental
brushes and 2 sites not accessible to floss
were excluded from the analysis. Total
number of assessed sites not reported
Selective reporting (reporting bias) Low risk No protocol available. All outcomes stated
in the ’Methods’ section were addressed in
the ’Results’. No evidence of other out-
comes
Other bias Low risk Compliance was confirmed by a telephone

call after a week of treatment
Examiner reliability was not reported, but
a force-controlled probe was used allowing
confidence in the outcome assessment
No obvious other biases
Imai 2011
Methods Design: RCT, split-mouth, 2 interventions

Attrition: 4 patients failed to attend the 6-week visit; 2 participants were no longer inter-
ested and withdrew, 1 subject began antibiotic therapy and was dismissed. 1 participant
did not attend the 6 weeks study due to a family emergency, but was there at the 12-
week visit
Completed: n = 30
Age range: adults, not specified
Oral health status: plaque-induced gingivitis determined by having red, bleeding upon
stimulation tissues, probing depths < 4 mm
Inclusion criteria: a minimum of 4 interproximal areas per side with intact interdental
papillae that could accommodate a minimum 0.6 mm IDB width; a minimum of 4
interproximal bleeding sites per side upon stimulation; dexterity to use DF; ability to
attend 5 visits
Exclusion criteria: participants requiring antibiotic premedication prior to dental ther-
apy; smokers; orthodontic patients; participants receiving antibiotic therapy 1 month
prior to the study; use of chlorhexidine or over-the-counter mouthwash
All participants were right handed
Location: Canada
Interventions Comparison: IDB versus DF

All participants used a soft manual toothbrush
Training: participants were instructed to brush their teeth twice a day, once in the
morning and again at night using the modified Bass method and to use the DF and IDB
once a day on the assigned side, preferably at night
Instructions on the dental flossing and the interdental brushing techniques were pro-
vided. IDB was inserted once horizontally under the contact point and removed. Oral
hygiene instructions provided at baseline and at 6-week visit
Baseline cleaning: non-surgical debridement using ultrasonic and hand scaling was per-
formed 2 weeks prior to the baseline visit to allow for tissue healing and to stabilise
baseline scores
Throughout the study, the examiner assessed the participants for soft tissue trauma,
indicated by clinically visible gingival cuts, redness, abraded areas or damaged interdental
papilla
“The inclusion criteria consisted of: 1. a minimum of 4 interproximal areas per side
with intact interdental papillae that could accommodate a minimum 0.6 mm interdental
brush width”
“The study organizer measured the subjects’ embrasures with the colour coded probe
(Curaprox Prime Series, Curaden Swiss, Amlehnstrasse, Switzerland), which was inserted
horizontally from the buccal aspect until snug and observing the visible colour. Each
colour on the probe corresponds to a matching colour coded interdental brush. The
interdental brush diameters range from 0.6 mm (dark green on the probe) to 1.1 mm
(light green). Five brush diameters were available: 0.6 mm, 0.7 mm, 0.8 mm, 0.9 mm,
and 1.1 mm. A maximum of three interdental brush sizes were chosen per subject. When
more than three brush sizes were required, a smaller already identified diameter was used
for that site”
Imai 2011 (Continued)
Outcomes Measurements: at baseline, 6 weeks and 12 weeks

Plaque scores were collected on 4 interproximal surfaces (mesial-buccal, distal-buccal,
mesial-lingual, distal-lingual) of the premolars and 1st and 2nd molars and determined
by the modified Silness and Löe plaque index
Periodontal disease-gingivitis measured by the Eastman Bleeding Index was used to assess
interproximal bleeding posterior to the canines
Other outcomes: participant’s embrasures were measured using a colour-coded probe.
Each colour on the probe corresponded to a matching colour-coded interdental brush
Compliance assessment: determined by self reported journals given to the participants
at baseline which were to be placed in their bathroom as a reminder
Adverse outcomes: throughout the study the examiner assessed the participants for soft
tissue trauma. Participants’ concerns were also addressed during the study
Source of funding Study supported by: grants from the Canadian Foundation of Dental Hygiene Research
and Education and the British Columbia Dental Hygienists’ Association
Toothbrushes and interdental brushes supplied by Enterprise Dentalink Inc
Quote: “The authors have not received any financial support and are not affiliated with
the Enterprise Dentalink Inc. or Curaden Swiss”
Notes Examiner was unaware of the product randomisation throughout the study
Random sequence generation (selection Low risk Randomisation of the products was deter-
bias) mined by a flip of coin by the study orga-
nizer
Quote: “The interdental brush was ran-
domly assigned to the left or right side of
the subject’s mouths with the dental floss
assigned to the remaining side”
Blinding (performance bias and detection Low risk This was an examiner-blinded study; blind-
bias) Researcher-assessed outcomes ing was adequate
Incomplete outcome data (attrition bias) Low risk Attrition adequately reported and ex-
All outcomes plained; unlikely to affect the results
Selective reporting (reporting bias) Low risk All primary outcomes reported in the ab-
stract and in the ’Methods’ section of the
article were addressed in the ’Results’
Other bias Low risk Compliance assessed by self reported diary

entries and approximation of product use
Intra-examiner reliability was not reported
Imai 2011 (Continued)
but the EIBI was used, which is believed to

have high reproducibility
Ishak 2007
Methods Design: RCT, split-mouth, 2 arms

Duration of the study: 1 month
Attrition: no participants were lost from the study; 1 participant was excluded from the
analysis due to lack of baseline data
Completed: n = 11 (with data: n = 10)
Age range: 33 to 56 years (mean age = 43.6)
Males/females: 3/7
Oral health status: patients diagnosed with gingivitis or moderate adult periodontitis
and not having received periodontal treatment in the past 6 months
Inclusion criteria: age 18 to 60 years old, visible proximal plaque deposits present, lifetime
non-smokers, at least 6 teeth present in each quadrant from lateral incisor distally, with
proximal contact areas in contact or not separated by more than 1 mm, and accessible
to an IDB
Exclusion criteria: gingival enlargement or regrowth; local plaque retention factors; drugs
affecting the gums, e.g. phenytoin, cyclosporin, calcium-channel blockers in the past 6
months; systemic disease which could affect the periodontal tissue, e.g. diabetes; preg-
nancy
Location: United Kingdom

All participants used a manual toothbrush
Training: participants received detailed instruction on the use of a manual toothbrush
and interdental cleaning devices. Training was accompanied by written instructions
Participants were given a printed reminder to fix on the bathroom mirror showing which
instrument to use on each side of the mouth and a diary sheet on which they were asked
to tick off each day when they had cleaned their teeth
Baseline cleaning: as much supragingival calculus as necessary for application of the
assigned device was removed
“The subjects also fulfilled the following requirements: At least 6 teeth present in each
quadrant of lateral incisor distally, with proximal contact areas in contact or not separated
by more that 1 mm”
“IDB (cylindrical bottlebrush, applied buccaly): all materials were provided by Glaxo-
SmithKline UK (Sensodyne brand)”
Outcomes Measurements: at baseline and 1 month

10 sites in each quadrant were examined, from the distal of the lateral incisors to the
mesial of the second molars. Supra- and subgingival plaque were examined using dental
floss. Teeth were dried and floss was taken to each proximal surface from the gingival
margin coronally for supragingival plaque and subgingivally for subgingival plaque.
Visible plaque deposits were scored as positive
Ishak 2007 (Continued)
Periodontal disease-gingivitis measured by the Bleeding on Probing Index

Other outcomes: probing depth, recession, attachment level
Compliance assessment: self reported; all patients returned the diary paper assigned to
them at the beginning of the study
Adverse effects: a questionnaire was given to all participants concerning any problems
with the use of the DF and the IDB
Source of funding Not reported
Notes Examiner was blinded to treatment randomisation
Random sequence generation (selection Low risk Quote: “A statistician who was not directly
bias) involved in recruiting patients generated
the randomisation sequence. IDB was ran-
domly assigned to the left or right half of
the mouth and the use of DF to the other
side”
It is not clear how exactly the randomisa-
tion was done, but it is probable that it was
done adequately

Recruitment and assignment of patients to
their groups was carried out by another
member of the team following the ran-
domisation sequence done by the statisti-
cian
Blinding (performance bias and detection Low risk Quote: “...the allocation methods were not
bias) Researcher-assessed outcomes revealed to the examiner.” “Examiner was
adequately blinded”
Incomplete outcome data (attrition bias) Low risk All 11 participants completed the trial;
All outcomes 1 was excluded due to lack of baseline
data. Attrition adequately reported and ex-
plained; unlikely to affect the results
Selective reporting (reporting bias) High risk No protocol available. All primary out-
comes in the ’Methods’ section were ad-
dressed in the ’Results’. Supra- and subgin-
gival plaque was scored as a binary outcome
(positive/negative), but reported as mean
Ishak 2007 (Continued)
Other bias Low risk Compliance assessed by self reported diary

entries
Intra-examiner reliability was tested and a
force-controlled probe was used
Financial support not declared. It is clearly
stated that GlaxoSmithKline UK provided
all oral hygiene materials used. Not likely
that it could affect the results
Jackson 2006
Methods Design: RCT, parallel, 2 arms

Attrition: 5 patients were lost from the IDB group: 1 was subsequently found not to
have the required number of sites and was therefore excluded, 2 patients were prescribed
antibiotics for non-dental reasons and 2 patients failed to complete the 3 visits during
the study
In the floss group 6 patients were lost; 1 was withdrawn due to periodontal-endodontic
lesion that required emergency treatment and 5 failed to complete the 3 visits of the
study
Completed: n = 77
Age range: 26 to 75; greatest prevalence of recruits: 46 to 55
Oral health status: patients diagnosed as having chronic periodontitis and on a waiting
list for treatment
Inclusion criteria: minimum of 18 teeth; presence of at least 1 shallow pocket of 4 to 5
mm or at least 1 deep pocket > 6 mm in 4 of 6 sextants; informed consent
Exclusion criteria: non-consent; unavailability for the study duration; pregnancy; an-
tibiotics; warfarin; drugs associated with gingival overgrowth; requirement for antibiotic
prophylaxis; oral infection such as periodontal-endodontic lesion and any medical prob-
lem that might affect the results of the study
Location: United Kingdom

All participants used manual toothbrush
Training: patients received a demonstration of both interdental cleaning methods and
toothbrushing. Full details of these oral instructions were given in patient leaflets for
home reference
At 2 weeks written reminders were sent to each participant. Oral hygiene instructions
were repeated for both interdental cleaning methods and toothbrushing
Baseline cleaning: scaling using a single double-ended sickle scaler hand instrument was
provided with a time limit of 10 minutes, to remove easily accessible calculus and plaque
deposits and to facilitate access for subsequent interdental cleaning
“interdental spiral wire brushes in six sizes without handles”
“Subjects were instructed to begin with the largest size and move down to the smallest
Jackson 2006 (Continued)
size in turn to select the brush that provided the most snug interdental fit”
“Interdental brushes, from smallest to largest size: long-stem 632, long-stem 635, long-
stem 635g, long-stem 636, Curaprox LSR; MACRO ”P“ plastic coated, Brage Nilsson;
long-stem 626, Dent-O-Care”
Outcomes Measurements: at baseline, 6 weeks, 12 weeks

Plaque measured by the Plaque Index (PI) at 4 sites per tooth (disto-buccal, mesio-
buccal, disto-lingual, mesio-lingual)
Periodontal disease - gingivitis measured by the Eastman Interdental Bleeding Index
(EIBI)
Other outcomes: relative interdental papillae level (RIPL), pocket depths (PD) and
bleeding on probing (BOP)
Compliance assessment: not assessed
Adverse effects: none reported from either of the interdental cleaning regimens
Notes Among 77 patients that completed the study, 29 were smokers. More smokers in the
brush group
Random sequence generation (selection Low risk Randomisation performed using a com-
bias) puter-generated random numbers
Allocation concealment (selection bias) Unclear risk 4 allocation envelopes were prepared and
labelled for gender and smoking habit. Pa-
tients were randomly allocated to a floss or
interdental brush group by a research assis-
tant, after the appointment time with the
hygienist examiner
Blinding (performance bias and detection Low risk At all times the hygienist examiner was un-
bias) Researcher-assessed outcomes aware of the group to which the patient was
allocated. Adequate measures were taken to
keep the examiner blinded throughout the
trial
Incomplete outcome data (attrition bias) Low risk Attrition 11 out of 88, equally distributed
All outcomes between the study arms. Reasons for attri-
tion adequately reported and explained -
unlikely that it could affect the results
Selective reporting (reporting bias) Low risk No protocol available. All outcomes in the
’Methods’ section were addressed in the
’Results’
Jackson 2006 (Continued)
Other bias Low risk Compliance was encouraged at regular in-

tervals throughout the trial
Intra-examiner reliability was tested
Financial support not declared
Colgate-Palmolive provided toothbrushes,
dental floss and toothpaste; Dentsply pro-
vided dental instruments; Dental Health
Boutique, Oral Healthcare, Leatherhead,
United Kingdom provided interdental
brushes. Not likely that it could affect the
results
Jared 2005

Attrition: from the 162 enrolled patients, 9 patients withdrew prior to baseline and
therefore prior to randomisation. 1 participant dismissed due to health issues. None of
the withdrawals were product-related
Participants Enrolled: total n = 162

Completed: total n = 152
Age range: mean age: 36.38 to 42.20
Interventions of interest: n = 91
Oral health status: oral health status of the 3 treatment groups of interest (IDB; tooth-
brush + DF; toothbrush alone) presented in a table as Interproximal Plaque Score (IPS)
and Interproximal Gingival Score (IGS) among treatment groups
- mean IPS value range: 2.85 to 2.99
- mean IGS value range: 2.09 to 2.30
Inclusion criteria: > 18 years old; at least 1 “test site” defined as an interproximal space of
1.0 mm that exhibited bleeding from the facial and lingual sides, excluding third molars
Exclusion criteria: regular use of interdental cleaning devices currently or in the past 6
months; no appropriately sized interdental space; participants that have brushed their
teeth less than once a day in the past 6 months; oral disease requiring immediate treat-
ment; smoking within the last 6 months; pregnancy; current use of antibiotics or any
other medication known to cause gingival enlargement; chronic use of non steroidal
anti-inflammatory medications; immunocompromised patients; patients with a disease
that affects the gingiva; need for antibiotic prophylaxis; orthodontic patients; patients
who have undergone scaling in the last 6 months; presence of interproximal calculus
sufficient enough to interfere with interdental cleaning; participation in another study
Location: USA
Interventions Comparisons:
Interdental brushing + toothbrushing versus toothbrushing alone
Interdental brushing + toothbrushing versus toothbrushing + flossing
Other intervention groups: interdental brush with investigational (CPC) gel, interdental
brush with placebo gel
Jared 2005 (Continued)
Training: all participants received verbal and written oral hygiene instructions, as well as
appropriate demonstrations of the cleaning procedures
Participants were requested to brush their teeth twice a day, after breakfast and before
bedtime, to use the IDB nightly after toothbrushing and to use DF nightly before
toothbrushing. All participants used a standard toothbrush
Patients were requested to keep a log of the number of times they cleaned their teeth,
if their cleaning deviated from the assigned group and details of any symptoms, if any,
that were experienced
Baseline cleaning: dental plaque was removed from all teeth using a rubber cup and fine
grit prophy paste
“the following inclusion; having at least one ’test site’ defined as an interproximal space
of 1.0 mm”
“The brush is mounted on the top of the body and its minimum passage hole is 1.0 mm”
Outcomes Measurements: baseline, 2 weeks, 4 weeks

Plaque measured by the Turesky modification of the Quigley-Hein Plaque Index
Periodontal disease - gingivitis measured by the Lobene modification of the Gingival
Index
Periodontal disease - gingivitis measured by the Van der Weijden, et al modified Bleeding
on Marginal Probing
GI and PI measured at a “test site”, preferably a maxillary test site
Compliance assessment: not reported
Adverse effects: not reported
Source of funding Industry: Sunstar Inc., Japan
Notes Examiner-blinded study
Random sequence generation (selection Low risk Quote: “Block randomisation was used,
bias) and was based on baseline dental plaque
scores to assure greater baseline com-
parability among treatment groups for
plaque levels and, presumably, gingivitis
and bleeding scores. While block randomi-
sation can introduce bias, the groups were
stratified based on plaque scores, likely to
reduce bias”
Allocation concealment (selection bias) Unclear risk Not reported
Blinding (performance bias and detection Low risk Quote: “This study was designed as a sin-
bias) Researcher-assessed outcomes gle-blind trial.” Assume the outcome asses-
sor is blinded
Jared 2005 (Continued)
Incomplete outcome data (attrition bias) Low risk Attrition adequately reported and ex-
All outcomes plained: “Of the ten subjects who did not
complete the study, nine withdrew prior
to baseline, and one was dismissed due to
health issues. None of the withdrawals were
product-related.” Attrition was judged as
unlikely to affect the results
Selective reporting (reporting bias) High risk Previously published abstract available
All primary outcomes in the ’Methods’ sec-
tion were addressed in the ’Results’
However, data concerning possible adverse
effects were not reported although the par-
ticipants were asked to keep logs
Other bias Unclear risk Compliance was not reported, although

participants were asked to keep a log of their
dental cleaning habits
Examiner was trained and calibrated to in-
crease validity and intra examiner reliabil-
ity
The company that produces oral hygiene
cleaning devices financially supported the
study and provided the interdental brushes,
dental floss and toothbrushes. Co-authors
employed by the manufacturer
Yankell 2002

Attrition: 1 participant in the Glide Floss group could not have the bleeding on probing
index performed due to medical reasons and did not report for the 2- and 4-week
assessment. Drop-out was not reported to be caused by the use of any of the products
Completed: n = 62
Age range: 18 to 60 years
Males/females: not reported
Oral health status: not reported
Inclusion criteria: ages between 18 and 60 years; at least 18 natural teeth present; informed
consent signed; no prophylaxis taken within 4 weeks prior to the baseline examination
Exclusion criteria: prophylaxis within 4 weeks prior to baseline examination; antibiotic
use; use of steroidal or non-steroidal anti-inflammatory agents; acute illness; orthodontic
treatment; pregnancy; sensitivity or reactions to dentifrice; any kind of disease or lesion
of the hard or soft tissues of the mouth present
Location: USA
Yankell 2002 (Continued)
Interventions Comparison: interdental brushing (BrushPicks) versus dental flossing (Glide floss)
Both groups used toothbrush
Training: participants received a toothbrush and a fluoride-containing dentifrice and were
requested to brush their teeth twice a day, in the morning and in the evening. Participants
received either the BrushPicks or Glide floss to be used after each toothbrushing. No
specific instructions were given for any of the products distributed. Participants were not
allowed to use any other tooth-cleaning products or devices during the study
Baseline cleaning: not reported
“Figure 1. The BrushPicks dental cleaning aid (length-65 mm, width at center-2.5 mm,
width at bristle-end tip-0.6 mm)”
Outcomes Measurements: at baseline, 2 weeks, 4 weeks

Plaque measured by the Turesky criteria on the facial and lingual sites of the Ramfjord
teeth that were not crowned or clasp-bearing
Periodontal disease-gingivitis measured by the Eastman Interdental Bleeding Index at
the mesial and distal gingival margins of all natural teeth anterior to the third molar
Periodontal disease - gingivitis evaluated by the Lobene at al modification of the gingival
index
Compliance assessment: not assessed
Adverse effects: none reported or observed
Notes Smoking not specified
Random sequence generation (selection Unclear risk Quote: “Sixty three subjects from the
bias) Philadelphia, Pennsylvania area were ran-
domly assigned to either the ADA-Ac-
cepted Glide floss or the BrushPicks group”
No further description given on the
method used to generate the random se-
quence
Blinding (performance bias and detection Low risk Quote: “The objective of this double-blind
bias) Researcher-assessed outcomes clinical study...”
No further explanation about blinding was
given but blinding of outcome examiner
assumed
Yankell 2002 (Continued)
Incomplete outcome data (attrition bias) Low risk Attrition 1 out of 63, adequately reported
All outcomes and explained - unlikely that it could affect
the results
Selective reporting (reporting bias) Low risk No protocol available. All primary out-
comes in the ’Methods’ section were ad-
dressed in the ’Results’
Other bias Unclear risk Compliance was not assessed

Intra-examiner reliability was not reported
Financial support not declared
Industry provided oral hygiene devices.
BrushPicks TM: Dental Concepts, Para-
mus NJ, USA. Glide floss: W.L. Gore As-
sociates, Inc., Flagstaff, AZ, USA. Tooth-
brush: Oral-B P35. Oral-B Laboratories,
Belmont, CA, USA)
Yost 2006

Attrition: 8 participants lost from the study

Completed: n = 120
Age range: 18 to 63
Oral health status: not reported
Inclusion criteria: at least 5 interproximal sites that can accommodate the interdental
brush with adjacent teeth being natural dentition; mean plaque score of at least 1.5;
mean gingival score of at least 1.0; ability to floss but not a current floss user
Exclusion criteria: use of antibiotics, anticoagulants, steroids or other anti-inflammatory
products (except acetaminophen and 81 mg daily aspirin); diabetes; rheumatic fever;
hepatic or renal disease; gross caries or other hard tissue pathology; transmissible diseases;
heavy calculus; orthodontics; prosthodontics; piercing; allergy to red food dye
Location: USA
Interventions Comparison: interdental brushing (GUM, Go-Betweens) versus dental flossing (Crest
Glide)
Other intervention groups: Flosser (Butler), interdental cleaner (GUM Soft-Picks)
Participants were provided Crest Regular toothpaste and GUM soft toothbrushes
Training: participants were given product use and diary instructions. Product use by the
participants was supervised to ensure that product was used correctly
Baseline cleaning: participants were given a prophylaxis to remove all supragingival cal-
culus and plaque
“Although all four treatments are intended for cleaning of the interproximal spaces,
Yost 2006 (Continued)
the products are of different sizes and fit into different size interdental spaces. For any
qualified subject to use any of the four treatments, an interproximal site in a subject’s
mouth was identified for treatment if the site could accommodate the interdental brush”
Outcomes Measurements: at baseline and 6 weeks (before product use and again after the use of
the assigned product)
Plaque measured by the Benson modification of the Quigley-Hein index
Periodontal disease - gingivitis; bleeding measured by the Eastman Interdental Bleeding
Index
Periodontal disease - gingivitis measured by the Löe and Silness Gingival Index
Compliance assessment: at 3 weeks participants returned for diary and compliance review
Source of funding Industry: Sunstar Americas Inc. supported the study
Notes 12 smokers included in the study
Random sequence generation (selection Unclear risk Quote: “Subjects were given a prophylaxis
bias) to remove all supragingival plaque, ran-
domly assigned to one of the four test prod-
ucts...”
Comment: no further information given
on the sequence generation
Blinding (performance bias and detection Low risk Quote: “The subjects used their assigned
bias) Researcher-assessed outcomes product in a separate area to maintain ex-
aminer blinding.” No further explanation
given on the blinding of the assessor
Incomplete outcome data (attrition bias) Low risk Attrition 8 out of 128. Although reasons
All outcomes and breakdown by study arms were not pro-
vided, we judged attrition as unlikely to af-
fect the results
Selective reporting (reporting bias) High risk Standard deviations missing
Other bias Unclear risk Diary and compliance review mentioned in

’Methods’, but not reported in ’Results’
Intra-examiner reliability not reported
Study supported by the product manufac-
turer, first author employed by the manu-
facturer
ABI: angulated bleeding index; BOP: bleeding on probing; DF: dental flossing; EIBI: Eastman Interdental Bleeding Index; GI: gingival
index; IDB: interdental brushing; PD: probing depth; PI: plaque index; PPBI: periodontal pocket bleeding index; RCT: randomised
controlled trial
Characteristics of excluded studies [ordered by study ID]
Study Reason for exclusion
Bassiouny 1981 Cross-over study without sufficient washout period
Bergenholtz 1984 Intervention period less than 4 weeks
Caton 1993 No interdental brush among treatment groups; participants used wooden cleaner
Cronin 1996 Interdental brushing not included as an intervention; interdental cleaning device compared in the study is Oral-
B Interclean (ID2)
Cronin 1997 Interdental brushing not included as an intervention; interdental cleaning device compared in the study is Oral-
B Interclean (ID2)
Emling 1984 Abstract - not enough information. Intervention period less than 4 weeks
Gjermo 1970 Intervention period less than 4 weeks
Gordon 1996 Interdental brushing not included as an intervention; interdental cleaning device compared in the study is Oral-
B Interclean (ID2)
Isaacs 1999 Interdental brushing not included as an intervention; interdental cleaning device compared in the study is Oral-
B Interclean (ID2)
Kiger 1991 Cross-over study without sufficient washout period
Oppermann 1997 Abstract - not enough information. Intervention period less than 4 weeks
Rösing 2006 Intervention period less than 4 weeks
Schiffner 2007 Group 1 used a special brush (a short-head, multi-tufted toothbrush) as well as the interdental brush whereas
the participants in group 4 only used the toothbrush that they usually used
Smith 1988 Results presented as graphs without standard errors, or as ’same’, ’better than’ or ’worse than’, which could not
be used in the review
Van Swol 1977 Intervention period less than 4 weeks
Walsh 1989 Abstract - not enough information. Intervention period less than 4 weeks
Wolfe 1976 Intervention period less than 4 weeks
DATA AND ANALYSES
Comparison 1. Interdental brushing versus flossing
No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size
1 Gingivitis at 1 month 7 Std. Mean Difference (Random, 95% CI) -0.53 [-0.81, -0.24]
1.1 Trained interdental 6 Std. Mean Difference (Random, 95% CI) -0.52 [-0.83, -0.21]
brushing
1.2 Untrained interdental 1 Std. Mean Difference (Random, 95% CI) -0.62 [-1.13, -0.11]
brushing
2 Gingivitis at 3 months 2 Std. Mean Difference (Random, 95% CI) -1.98 [-5.42, 1.47]
3 Plaque at 1 month 7 Std. Mean Difference (Random, 95% CI) 0.10 [-0.13, 0.33]
3.1 Trained interdental 6 Std. Mean Difference (Random, 95% CI) 0.13 [-0.12, 0.38]
brushing
3.2 Untrained interdental 1 Std. Mean Difference (Random, 95% CI) -0.14 [-0.63, 0.36]
brushing
4 Plaque at 3 months 2 Std. Mean Difference (Random, 95% CI) -2.14 [-5.25, 0.97]
Analysis 1.1. Comparison 1 Interdental brushing versus flossing, Outcome 1 Gingivitis at 1 month.
Review: Interdental brushing for the prevention and control of periodontal diseases and dental caries in adults
Comparison: 1 Interdental brushing versus flossing
Outcome: 1 Gingivitis at 1 month
Std. Mean Std. Std.

Difference Mean Mean
Study or subgroup (SE) Difference Weight Difference
IV,Random,95% CI IV,Random,95% CI
1 Trained interdental brushing

Christou 1998 -0.18107 (0.052348) 19.9 % -0.18 [ -0.28, -0.08 ]
Imai 2011 -1.6742 (0.308) 10.6 % -1.67 [ -2.28, -1.07 ]
Ishak 2007 -0.50742 (0.189071) 15.1 % -0.51 [ -0.88, -0.14 ]
Jackson 2006 -0.47 (0.232) 13.4 % -0.47 [ -0.92, -0.02 ]
Jared 2005 -0.4 (0.262) 12.2 % -0.40 [ -0.91, 0.11 ]
Yost 2006 -0.3 (0.153) 16.6 % -0.30 [ -0.60, 0.00 ]
Subtotal (95% CI) 87.7 % -0.52 [ -0.83, -0.21 ]
-2 -1 0 1 2
Favours interdental brush Favours flossing
(Continued . . . )
(. . . Continued)
Std. Mean Std. Std.
Heterogeneity: Tau2 = 0.11; Chi2 = 26.24, df = 5 (P = 0.00008); I2 =81%
Test for overall effect: Z = 3.27 (P = 0.0011)
2 Untrained interdental brushing
Yankell 2002 -0.62 (0.26) 12.3 % -0.62 [ -1.13, -0.11 ]
Subtotal (95% CI) 12.3 % -0.62 [ -1.13, -0.11 ]

Heterogeneity: not applicable
Total (95% CI) 100.0 % -0.53 [ -0.81, -0.24 ]
Test for subgroup differences: Chi2 = 0.11, df = 1 (P = 0.74), I2 =0.0%
-2 -1 0 1 2
Analysis 1.2. Comparison 1 Interdental brushing versus flossing, Outcome 2 Gingivitis at 3 months.
Outcome: 2 Gingivitis at 3 months
Std. Mean Std. Std.

Imai 2011 -3.795 (0.6936) 48.3 % -3.80 [ -5.15, -2.44 ]
Jackson 2006 -0.28 (0.23) 51.7 % -0.28 [ -0.73, 0.17 ]
Total (95% CI) 100.0 % -1.98 [ -5.42, 1.47 ]

Heterogeneity: Tau2 = 5.91; Chi2 = 23.14, df = 1 (P<0.00001); I2 =96%
Test for subgroup differences: Not applicable
-4 -2 0 2 4
Analysis 1.3. Comparison 1 Interdental brushing versus flossing, Outcome 3 Plaque at 1 month.
Outcome: 3 Plaque at 1 month
Std. Mean Std. Std.

1 Trained interdental brushing

Christou 1998 -0.34509 (0.077844) 18.9 % -0.35 [ -0.50, -0.19 ]
Imai 2011 0 (0.034483) 20.3 % 0.0 [ -0.07, 0.07 ]
Ishak 2007 0.149866 (0.110662) 17.4 % 0.15 [ -0.07, 0.37 ]
Jackson 2006 0.98 (0.2423) 10.9 % 0.98 [ 0.51, 1.45 ]
Jared 2005 0.26 (0.262) 10.1 % 0.26 [ -0.25, 0.77 ]
Yost 2006 0.18 (0.22) 11.9 % 0.18 [ -0.25, 0.61 ]
Subtotal (95% CI) 89.5 % 0.13 [ -0.12, 0.38 ]

2 Untrained interdental brushing
Yankell 2002 -0.1386 (0.2523) 10.5 % -0.14 [ -0.63, 0.36 ]
Subtotal (95% CI) 10.5 % -0.14 [ -0.63, 0.36 ]

Heterogeneity: not applicable
Total (95% CI) 100.0 % 0.10 [ -0.13, 0.33 ]
Test for subgroup differences: Chi2 = 0.92, df = 1 (P = 0.34), I2 =0.0%
-1 -0.5 0 0.5 1
Analysis 1.4. Comparison 1 Interdental brushing versus flossing, Outcome 4 Plaque at 3 months.
Outcome: 4 Plaque at 3 months
Std. Mean Std. Std.

Imai 2011 -3.795 (0.6936) 47.9 % -3.80 [ -5.15, -2.44 ]
Jackson 2006 -0.62 (0.2321) 52.1 % -0.62 [ -1.07, -0.17 ]
Total (95% CI) 100.0 % -2.14 [ -5.25, 0.97 ]

Test for subgroup differences: Not applicable
-4 -2 0 2 4
ADDITIONAL TABLES
Table 1. Means and standard deviations (SD); gingivitis
Study Time Interdental brushing Floss
n Mean SD n Mean SD
Christou 6 weeks 26 0.83 0.18 26 0.86 0.15

1998*
Imai 2011* 6 weeks 29 0.11 0.03 29 0.17 0.04
12 weeks 30 0.08 0.02 30 0.2 0.04
Ishak 2007* 4 weeks 10 0.056 0.0479 10 0.081 0.0506
Jackson 2006 6 weeks 39 0.14 0.15 38 0.23 0.22
12 weeks 39 0.1 0.11 38 0.16 0.17
Jared 2005 4 weeks 30 1.03 0.57 29 1.29 0.7
Yankell 2002 4 weeks 31 1.21 0.27 31 1.41 0.39
Yost 2006 6 weeks 31 0.78 0.83** 31 0.95 0.83*
Table 1. Means and standard deviations (SD); gingivitis (Continued)
28 0.91 0.79*
*Split-mouth studies.
**The standard deviations in the Yost 2006 study were calculated from standard errors reported within graphs in the study report.
Table 2. Means and standard deviations (SD); plaque
Study Time Interdental brushing Floss
n Mean SD n Mean SD
Christou 6 weeks 26 2.15 0.99 26 2.47 0.86

1998*
Imai 2011* 6 weeks 29 1.23 0.18 29 1.23 0.18
12 weeks 30 1.26 0.24 30 1.28 0.22
Ishak 2007* 4 weeks 10 0.057 0.0221 10 0.053 0.0306
Jackson 2006 6 weeks 39 0.68 0.28 38 1 0.36
12 weeks 39 0.72 0.37 38 0.96 0.4
Jared 2005 4 weeks 30 2.02 0.77 29 2.23 0.83
Yankell 2002 4 weeks 31 1.67 0.29 31 1.71 0.28
Yost 2006 6 weeks 31 1.84 1.1** 31 2.06 1.1*
28 1.98 1.05*
*Split-mouth studies.
**The standard deviations in the Yost 2006 study were calculated from standard errors reported within graphs in the study report.
APPENDICES
Appendix 1. MEDLINE via OVID search strategy
1. exp Dental Devices, Home Care/
2. Toothbrushing/
3. ((interdental adj3 brush$) or (inter-dental adj3 brush$) or (interspace adj3 brush$) or (inter-space adj3 brush$)).mp.
4. ((interdental adj3 clean$) or (inter-dental adj3 clean$) or (interspace adj3 clean$) or (inter-space adj3 clean$)).mp.
5. ((interproximal adj3 clean$) or (inter-proximal adj3 clean$)).mp.
6. ((interdental adj3 aid$) or (inter-dental adj3 aid$)).mp.
7. (toothbrush$ or tooth-brush$ or “tooth brush$”).mp.
8. (floss$ or “dental tape$”).mp.
9. or/1-8
10. exp TOOTH DEMINERALIZATION/
11. (caries or carious).mp.
12. (teeth adj5 (cavit$ or caries$ or carious or decay$ or lesion$ or deminerali$ or reminerali$)).mp.
13. (tooth adj5 (cavit$ or caries$ or carious or decay$ or lesion$ or deminerali$ or reminerali$)).mp.
14. (dental adj5 (cavit$ or caries$ or carious or decay$ or lesion$ or deminerali$ or reminerali$)).mp.
15. (enamel adj5 (cavit$ or caries$ or carious or decay$ or lesion$ or deminerali$ or reminerali$)).mp.
16. (dentin$ adj5 (cavit$ or caries$ or carious or decay$ or lesion$ or deminerali$ or reminerali$)).mp.
17. (root$ adj5 (cavit$ or caries$ or carious or decay$ or lesion$ or deminerali$ or reminerali$)).mp.
18. Dental plaque/
19. ((teeth or tooth or dental or enamel or dentin) and plaque).mp.
20. exp DENTAL HEALTH SURVEYS/
21. (“DMF Index” or “Dental Plaque Index” or “Periodontal Index” or “Papillary Bleeding Index”).mp.
22. exp Periodontal Diseases/
23. periodont$.mp.
24. (gingiva$ adj3 pocket$).mp.
25. (periodontal adj3 pocket$).mp.
26. ((blood or bleed$) adj4 prob$).mp.
27. (gingival$ and (blood$ or bleed$ or inflamm$)).mp.
28. or/10-27
29. 9 and 28
The above search strategy was linked with the Cochrane Highly Sensitive Search Strategy (CHSSS) for identifying randomised trials in
MEDLINE: sensitivity-maximising version (2008 revision) as referenced in Chapter 6.4.11.1 and detailed in box 6.4.c of theCochrane
Handbook for Systematic Reviews of Interventions, version 5.1.0 (updated March 2011) (Higgins 2011):
1. randomized controlled trial.pt.
2. controlled clinical trial.pt.
3. randomized.ab.
4. placebo.ab.
5. drug therapy.fs.
6. randomly.ab.
7. trial.ab.
8. groups.ab.
9. or/1-8
10. exp animals/ not humans.sh.
11. 9 not 10
Appendix 2. EMBASE via OVID search strategy
1. exp Dental Device/
2. ((interdental adj3 clean$) or (inter-dental adj3 clean$)).mp.
3. ((interproximal adj3 clean$) or (inter-proximal adj3 clean$)).mp.
4. ((interdental adj3 aid$) or (inter-dental adj3 aid$)).mp.
5. ((interdental adj3 brush$) or (inter-dental adj3 brush$) or (interspace adj3 brush$) or (inter-space adj3 brush$)).mp.
6. (toothbrush$ or “tooth brush$” or tooth-brush$).mp.
7. (floss$ or “dental tape$”).mp.
8. (1 or 2 or 3 or 4 or 5) and (6 or 7)
9. Dental caries/
10. (caries or carious).mp.
11. (teeth adj5 (cavit$ or caries$ or carious or decay$ or lesion$ or deminerali$ or reminerali$)).mp.
12. (tooth adj5 (cavit$ or caries$ or carious or decay$ or lesion$ or deminerali$ or reminerali$)).mp.
13. (dental adj5 (cavit$ or caries$ or carious or decay$ or lesion$ or deminerali$ or reminerali$)).mp.
14. (enamel adj5 (cavit$ or caries$ or carious or decay$ or lesion$ or deminerali$ or reminerali$)).mp.
15. (dentin$ adj5 (cavit$ or caries$ or carious or decay$ or lesion$ or deminerali$ or reminerali$)).mp.
16. (root$ adj5 (cavit$ or caries$ or carious or decay$ or lesion$ or deminerali$ or reminerali$)).mp.
17. Tooth plaque/
18. ((teeth or tooth or dental or enamel or dentin) and plaque).mp.
19. (“DMF Index” or “Dental Plaque Index” or “Periodontal Index” or “Papillary Bleeding Index”).mp.
20. exp Periodontal Disease/
21. periodont$.mp.
22. (gingiva$ adj3 pocket$).mp.
23. (periodontal adj3 pocket$).mp.
24. ((blood or bleed$) adj4 prob$).mp.
25. (gingival$ and (blood$ or bleed$ or inflamm$)).mp.
26. or/9-25
27. 8 and 26
The above subject search was linked to the Cochrane Oral Health Group filter for EMBASE via OVID:
1. random$.ti,ab.
2. factorial$.ti,ab.
3. (crossover$ or cross over$ or cross-over$).ti,ab.
4. placebo$.ti,ab.
5. (doubl$ adj blind$).ti,ab.
6. (singl$ adj blind$).ti,ab.
7. assign$.ti,ab.
8. allocat$.ti,ab.
9. volunteer$.ti,ab.
10. CROSSOVER PROCEDURE.sh.
11. DOUBLE-BLIND PROCEDURE.sh.
12. RANDOMIZED CONTROLLED TRIAL.sh.
13. SINGLE BLIND PROCEDURE.sh.
14. or/1-13
15. (exp animal/ or animal.hw. or nonhuman/) not (exp human/ or human cell/ or (human or humans).ti.)
16. 14 NOT 15
Appendix 3. CINAHL via EBSCO search strategy
S1 MH “Dental Devices, Home Care+”
S2 MH Toothbrushing+
S3 ((interdental N3 brush*) or (inter-dental N3 brush*) or (interspace N3 brush*) or (inter-space N3 brush*))
S4 ((interdental N3 clean*) or (inter-dental N3 clean*))
S5 ((interproximal N3 clean*) or (inter-proximal N3 clean*))
S6 ((interdental N3 aid*) or (inter-dental N3 aid*))
S7 (toothbrush* or tooth-brush* or “tooth brush*”)
S8 (floss* or “dental tape*”)
S9 ((S1 or S3 or S4 or S5 or S6) and (S2 or S7 or S8))
S10 MH “Tooth demineralization+”
S11 (caries or carious)
S12 ((teeth N5 cavit*) or (teeth N5 caries) or (teeth N5 carious) or (teeth N5 decay*) or (teeth N5 lesion*) or (teeth N5 deminerali*)
or (teeth N5 reminerali*))
S13 ((tooth N5 cavit*) or (tooth N5 caries) or (tooth N5 carious) or (tooth N5 decay*) or (tooth N5 lesion*) or (tooth N5 deminerali*)
or (tooth N5 reminerali*))
S14 ((dental N5 cavit*) or (dental N5 caries) or (dental N5 carious) or (dental N5 decay*) or (dental N5 lesion*) or (dental N5
deminerali*) or (dental N5 reminerali*))
S15 ((enamel N5 cavit*) or (enamel N5 caries) or (enamel N5 carious) or (enamel N5 decay*) or (enamel N5 lesion*) or (enamel N5
deminerali*) or (enamel N5 reminerali*))
S16 ((dentin* N5 cavit*) or (dentin* N5 caries) or (dentin* N5 carious) or (dentin* N5 decay*) or (dentin* N5 lesion*) or (dentin*
N5 deminerali*) or (dentin* N5 reminerali*))
S17 ((root* N5 cavit*) or (root* N5 caries) or (root* N5 carious) or (root* N5 decay*) or (root* N5 lesion*) or (root* N5 deminerali*)
or (root* N5 reminerali*))
S18 MH “Dental plaque”
S19 ((teeth or tooth or dental or enamel or dentin*) and plaque)
S20 (“DMF Index” or “Dental Plaque Index” or “Periodontal Index” or “Papillary Bleeding Index”)
S21 MH “Periodontal diseases+”
S22 periodont*
S23 (gingiva* N3 pocket*)
S24 (periodontal N3 pocket*)
S25 (gingiva* and (blood* or bleed* or inflamm*))
S26 S10 or S11 or S12 or S13 or S14 or S15 or S16 or S17 or S18 or S19 or S20 or S21 or S22 or S23 or S24 or S25
S27 S9 and S26
The above subject search was linked to the Oral Health Group filter for CINAHL via EBSCO:
S1 MH Random Assignment or MH Single-blind Studies or MH Double-blind Studies or MH Triple-blind Studies or MH Crossover
design or MH Factorial Design
S2 TI (“multicentre study” or “multicenter study” or “multi-centre study” or “multi-center study”) or AB (“multicentre study” or
“multicenter study” or “multi-centre study” or “multi-center study”) or SU (“multicentre study” or “multicenter study” or “multi-
centre study” or “multi-center study”)
S3 TI random* or AB random*
S4 AB “latin square” or TI “latin square”
S5 TI (crossover or cross-over) or AB (crossover or cross-over) or SU (crossover or cross-over)
S6 MH Placebos
S7 AB (singl* or doubl* or trebl* or tripl*) or TI (singl* or doubl* or trebl* or tripl*)
S8 TI blind* or AB mask* or AB blind* or TI mask*
S9 S7 and S8
S10 TI Placebo* or AB Placebo* or SU Placebo*
S11 MH Clinical Trials
S12 TI (Clinical AND Trial) or AB (Clinical AND Trial) or SU (Clinical AND Trial)
S13 S1 or S2 or S3 or S4 or S5 or S6 or S9 or S10 or S11 or S12
Appendix 4. LILACS via BIREME search strategy
((interdental or inter-dental or interproximal or inter-proximal) AND (brush$ or cepillado or cepillo or escovacao or escova)) [Words]
or (Mh Dental devices, home care or Mh Dispositivos para el autocuidado bucal or Mh dispositivos para o cuidado bucal domiciliar)
[Words]
The above subject search was linked to the Brazilian Cochrane Centre filter:
(Pt randomized controlled trial OR Pt controlled clinical trial OR Mh randomized controlled trials OR Mh random allocation OR
Mh double-blind method OR Mh single-blind method OR Pt clinical trial OR Ex E05.318.760.535$ OR (Tw clin$ AND (Tw trial$
OR Tw ensa$ OR Tw estud$ OR Tw experim$ OR Tw investiga$)) OR ((Tw singl$ OR Tw simple$ OR Tw doubl$ OR Tw doble$
OR Tw duplo$ OR Tw trebl$ OR Tw trip$) AND (Tw blind$ OR Tw cego$ OR Tw ciego$ OR Tw mask$ OR Tw mascar$)) OR Mh
placebos OR Tw placebo$ OR Tw random$ OR Tw randon$ OR Tw casual$ OR Tw acaso$ OR Tw azar OR Tw aleator$ OR Mh
research design or Ct comparative study OR Ex E05.337$ OR Mh follow-up studies OR Mh prospective studies OR Tw control$ OR
Tw prospectiv$ OR Tw volunt$ OR Tw volunteer$) AND NOT (Ct animal AND NOT (Ct human and Ct animal)) [Words]
Appendix 5. Cochrane Oral Health Group’s Trials Register search strategy

An updated search of the Oral Health Group Trials Register was conducted in March 2013 using the Cochrane Register of Studies and
the search strategy below:
#1 ((interdental or “inter dental” or inter-dental or interproximal or “inter proximal” or inter-proximal or interspace or “inter space”
or inter-space)) AND (INREGISTER)
#2 ((floss* or “dental tape*” or brush* or toothbrush* or tooth-brush*)) AND (INREGISTER)
#3 ((caries or carious or cavit* or decay* or lesion* or deminerali* or reminerali* or plaque or periodont* or gingiva*)) AND (INREG-
ISTER)
#4 (#1 AND #2 AND #3) AND (INREGISTER)
Previous searches of the Oral Health Group’s Trials Register were undertaken in February 2011, December 2011 and October 2012
using the ProCite software and the search strategy below:
((interdental or “inter dental” or inter-dental or interproximal or “inter proximal” or inter-proximal or interspace or “inter space” or
inter-space) AND (floss* or “dental tape*” or brush* or toothbrush* or tooth-brush*) AND (caries or carious or cavit* or decay* or
lesion* or deminerali* or reminerali* or plaque or periodont* or gingiva*))
Appendix 6. Cochrane Central Register of Controlled Trials (CENTRAL) search strategy

#1 MeSH descriptor Dental devices, home care explode all trees
#2 MeSH descriptor Toothbrushing this term only
#3 ((interdental in All Text near/3 brush* in All Text) or (inter-dental in All
Text near/3 brush* in All Text) or (interspacein All Text near/3 brush* in All Text) or (inter-space in All Text near/3 brush* in All Text))
#4 ((interdental in All Text near/3 clean* in All Text) or (inter-dental in All Text near/3 clean* in All Text))
#5 ((interproximal in All Text near/3 clean* in All Text) or (inter-proximal in All Text near/3 clean* in All Text))
#6 ((interdental in All Text near/3 aid* in All Text) or (inter-dental in All Text near/3 aid* in All Text))
#7 (toothbrush* in All Text or tooth-brush* in All Text or “tooth brush*” in All Text)
#8 (floss* in All Text or “dental tape*” in All Text)
#9 ((#1 or #3 or #4 or #5 or #6) and (#2 or #7 or #8))
#10 MeSH descriptor Tooth demineralization explode all trees
#11 (caries in All Text or carious in All Text)
#12 ((teeth in All Text near/5 cavit* in All Text) or (teeth in All Text near/5 caries in All Text) or (teeth in All Text near/5 carious in
All Text) or (teeth in All Text near/5 decay* in All Text) or (teeth in All Text near/5 lesion* in All Text) or (teeth in All Text near/5
deminerali* in All Text) or (teeth in All Text near/5 reminerali* in All Text))
#13 ((tooth in All Text near/5 cavit* in All Text) or (tooth in All Text near/5 caries in All Text) or (tooth in All Text near/5 carious in
All Text) or (tooth in All Text near/5 decay* in All Text) or (tooth in All Text near/5 lesion* in All Text) or (tooth in All Text near/5
deminerali* in All Text) or (tooth in All Text near/5 reminerali* in All Text))
#14 ((dental in All Text near/5 cavit* in All Text) or (dental in All Text near/5 caries in All Text) or (dental in All Text near/5 carious in
All Text) or (dental in All Text near/5 decay* in All Text) or (dental in All Text near/5 lesion* in All Text) or (dental in All Text near/5
deminerali* in All Text) or (dental in All Text near/5 reminerali* in All Text))
#15 ((enamel in All Text near/5 cavit* in All Text) or (enamel in All Text near/5 caries in All Text) or (enamel in All Text near/5 carious
in All Text) or (enamel in All Text near/5 decay* in All Text) or (enamel in All Text near/5 lesion* in All Text) or (enamel in All Text
near/5 deminerali* in All Text) or (enamel in All Text near/5 reminerali* in All Text))
#16 ((dentin* in All Text near/5 cavit* in All Text) or (dentin* in All Text near/5 caries in All Text) or (dentin* in All Text near/5
carious in All Text) or (dentin* in All Text near/5 decay* in All Text) or (dentin* in All Text near/5 lesion* in All Text) or (dentin* in
All Text near/5 deminerali* in All Text) or (dentin* in All Text near/5 reminerali* in All Text))
#17 ((root* in All Text near/5 cavit* in All Text) or (root* in All Text near/5 caries in All Text) or (root* in All Text near/5 carious in
All Text) or (root* in All Text near/5 decay* in All Text) or (root* in All Text near/5 lesion* in All Text) or (root* in All Text near/5
deminerali* in All Text) or (root* in All Text near/5 reminerali* in All Text))
#18 MeSH descriptor Dental plaque this term only
#19 ((teeth in All Text or tooth in All Text or dental in All Text or enamel in All Text or dentin in All Text) and plaque in All Text)
#20 MeSH descriptor Dental Health Surveys explode all trees
#21 (“DMF Index” in All Text or “Dental Plaque Index” in All Text or “Periodontal Index” in All Text or “Papillary Bleeding Index”
in All Text)
#22 MeSH descriptor Periodontal diseases explode all trees
#23 periodont* in All Text
#24 (gingiva* in All Text near/3 pocket* in All Text)
#25 (periodontal in All Text near/3 pocket* in All Text)
#26 (gingiva* in All Text and (blood* in All Text or bleed* in All Text or inflamm* in All Text))
#27 (#10 or #11 or #12 or #13 or #14 or #15 or #16 or #17 or #18 or #19 or #20 or #21 or #22 or #23 or #24 or #25 or #26)
#28 (#9 and #27)
Appendix 7. ZETOC Conference Proceedings search strategy

“interdental brush*”
“inter-dental brush*”
“inter dental brush*”
“Interproximal brush*”
“inter-proximal brush*”
“inter proximal brush*”
“interspace brush*”
“inter-space brush*”
Appendix 8. Web of Science Conference Proceedings search strategy

# 1 TS=(“interdental brush*” or “inter-dental brush*”)
# 2 TS=(“interspace brush*” or “inter-space brush*”)
# 3 TS=(“interdental clean*” or “inter-dental clean*”)
# 4 TS=(“interdental aid*” or “inter-dental aid*”)
# 5 TS=(“interproximal clean*” or “inter-proximal clean*”)
# 6 TS=(interdental or inter-dental)
# 7 TS=(toothbrush or “tooth brush” or tooth-brush)
# 8 #6 and #7
# 9 #1 or #2 or #3 or #4 or #5 or #8
Appendix 9. US National Institutes of Health Trials Register (ClinicalTrials.gov) search strategy
interdental or inter-dental or “inter dental” or interproximal or inter-proximal or “inter proximal” or interspace or inter-space or “inter-
space”
Appendix 10. metaRegister of Controlled Trials search strategy

(brush* and (interdental or inter-dental or “inter dental” or interspace or inter-space or “inter space”))
CONTRIBUTIONS OF AUTHORS
• Conceiving, designing and co-ordinating the review: Peter Tugwell (PT), Tina Poklepovic (TP), Dario Sambunjak (DS), Helen
Worthington (HW).
• Designing search strategies and undertaking searches: DS, TP, Trevor Johnson (TJ).
• Screening search results and retrieved papers against inclusion criteria: DS, TP.
• Appraising quality of papers: DS, TP, HW, TJ.
• Extracting data from papers: HW, TP, TJ.
• Writing to authors of papers for additional information: TP, Pauline Imai (PI), TJ.
• Data management for the review and entering data into RevMan: TP, TJ, HW, DS.
• Analysis and interpretation of data: HW, TP, TJ.
• Providing a clinical perspective: TP, PI, TJ, Jan Clarkson (JC).
• Writing the review: TP, TJ, PI, HW.
• Providing general advice on the review: PT, HW, JC.
• Performing previous work that was the foundation of the current review: HW, PT, JC.
DECLARATIONS OF INTEREST
Two review authors (Pauline Imai and Helen Worthington) were also authors of the included trials but they were not involved in the
risk of bias assessments of these trials. This review will be used by some of the authors as part of other research projects. None of the
authors has any other interests related to this review.
SOURCES OF SUPPORT
Internal sources
• The University of Manchester, UK.
• MAHSC, UK.
The Cochrane Oral Health Group is supported by the Manchester Academic Health Sciences Centre (MAHSC) and the NIHR
Manchester Biomedical Research Centre.
External sources
• National Institute for Health Research (NIHR), UK.
CRG funding acknowledgement:
The NIHR is the largest single funder of the Cochrane Oral Health Group.
Disclaimer:
The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR, NHS or the
Department of Health.
• Cochrane Oral Health Group Global Alliance, UK.
All reviews in the Cochrane Oral Health Group are supported by Global Alliance member organisations (British Association of Oral
Surgeons, UK; British Orthodontic Society, UK; British Society of Paediatric Dentistry, UK; British Society of Periodontology, UK;
Canadian Dental Hygienists Association, Canada; National Center for Dental Hygiene Research & Practice, USA; Mayo Clinic,
USA; New York University College of Dentistry, USA; and Royal College of Surgeons of Edinburgh, UK) providing funding for the
editorial process (http://ohg.cochrane.org/).
DIFFERENCES BETWEEN PROTOCOL AND REVIEW

No major changes have been made to the methods used.
INDEX TERMS
Medical Subject Headings (MeSH)

Dental Caries [∗ prevention & control]; Dental Devices, Home Care [adverse effects]; Dental Plaque [prevention & control]; Gingivitis
[prevention & control]; Oral Hygiene [adverse effects; methods]; Periodontal Diseases [∗ prevention & control]; Randomized Controlled
Trials as Topic; Toothbrushing [adverse effects; instrumentation; ∗ methods]
MeSH check words

Adult; Humans

Interdental Brushing For The Prevention and Control of Periodontal Diseases and Dental Caries in Adults (Review)

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Interdental Brushing For The Prevention and Control of Periodontal Diseases and Dental Caries in Adults (Review)

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Cochrane Database of Systematic Reviews

Interdental brushing for the prevention and control of

Interdental brushing for the prevention and control of

Editorial group: Cochrane Oral Health Group.

PLAIN LANGUAGE SUMMARY

Interdental brushing for periodontal diseases and dental caries in adults

Patient or population: Adults, 16 years and older

Assumed risk Corresponding risk

the assigned interden-

GRADE Working Group grades of evidence

Introduction Periodontal diseases

Types of studies Types of interventions

Types of outcome measures Minor outcomes

Furthermore, we made a list of other outcomes found in the in-

Risk of bias Interpretation Within a study Across studies

of the control group.

Figure 1. Study selection flow diagram.

Study Time points Gingivitis index (scale) Plaque index (scale)

*One month includes four to six weeks data.

Adverse events Risk of bias in included studies

Incomplete outcome data

Periodontitis was not reported as an outcome in any included

All data concerning the means and standard deviations extracted

Patient or population: Adults, 16 years and older

Assumed risk Corresponding risk

GRADE Working Group grades of evidence

f unding was not declared.

Characteristics of included studies [ordered by study ID]

Methods Design: RCT, split-mouth, 2 interventions

Interventions Comparison: interdental brushing (IDB) versus dental flossing (DF)

Outcomes Measurements: at baseline, 6 weeks

Risk of bias Risk of bias

Bias Authors’ judgement Support for judgement

Allocation concealment (selection bias) Low risk Split-mouth study

Other bias Low risk Compliance was confirmed by a telephone

Methods Design: RCT, split-mouth, 2 interventions

Interventions Comparison: IDB versus DF

Outcomes Measurements: at baseline, 6 weeks and 12 weeks

Risk of bias Risk of bias

Bias Authors’ judgement Support for judgement

Allocation concealment (selection bias) Low risk Split-mouth study

Other bias Low risk Compliance assessed by self reported diary

but the EIBI was used, which is believed to

Methods Design: RCT, split-mouth, 2 arms

Interventions Comparison: IDB versus DF

Outcomes Measurements: at baseline and 1 month

Periodontal disease-gingivitis measured by the Bleeding on Probing Index

Source of funding Not reported

Notes Examiner was blinded to treatment randomisation

Risk of bias Risk of bias

Bias Authors’ judgement Support for judgement

Allocation concealment (selection bias) Low risk Split-mouth study

Other bias Low risk Compliance assessed by self reported diary

Methods Design: RCT, parallel, 2 arms

Interventions Comparison: IDB versus DF

Outcomes Measurements: at baseline, 6 weeks, 12 weeks

Source of funding Not reported

Risk of bias Risk of bias

Bias Authors’ judgement Support for judgement