Cochrane · intervention · CD012018
Home use of interdental cleaning devices, in addition to toothbrushing, for preventing and controlling periodontal diseases and dental caries
Worthington, HV, MacDonald, L, Poklepovic Pericic, T, et al. · Cochrane Database of Systematic Reviews · 2019 · Cochrane Library
Full textEvery question was extracted from the full review (methods and results), not only its Summary of Findings table.
Questions
60
current version
GRADE rated
29
No studies
18
Included studies
35
as reported
No studies 18 · 30%Ungraded 13 · 21.7%Very low 20 · 33.3%Low 9 · 15%Moderate 0 · 0%High 0 · 0%
Ungraded means an effect was reported without a GRADE rating; it is not a gap. No studies means the review found nothing to answer the question. The six categories are a display order, not a score.
Review question
| Element | Planned (methods) | Found (results) |
|---|---|---|
| Population | Dentate participants irrespective of age, race, sex, socioeconomic status, geographical location, background fluoride exposure, initial dental health status, setting or time of intervention. Excluded: majority with orthodontic appliances; participants selected on the basis of special health conditions; or majority with severe periodontal disease | 35 RCTs randomising 3929 adults (aged 18-78 years; mean ages 20-53 years); most studies included both sexes; most participants had slight to moderate periodontal disease (advanced disease excluded) and a low level of gingival inflammation at baseline; no studies in children |
| Intervention | Toothbrushing plus any home-use mechanical interdental cleaning device (floss; interdental brushes; wooden cleaning sticks; rubber/elastomeric cleaning sticks; oral irrigators) | Floss (n=15); Interdental brushes (n=2); Wooden cleaning sticks (n=2); Rubber/elastomeric cleaning sticks (n=2); Oral irrigators (n=5) |
| Comparison | Toothbrushing alone; Another mechanical interdental cleaning device | Toothbrushing alone (n=35); Flossing (comparator in head-to-head comparisons) |
| Outcomes | Primary: Gingivitis (gingival and bleeding indices); Periodontitis (clinical attachment loss, pocket probing depth); Interproximal caries (progression into enamel/dentine, D(M)FS change, radiographic); Plaque (scores/indices); Harms and adverse effects. Secondary: Halitosis; Patient satisfaction; Cost of intervention | Gingivitis (n=35); Plaque (n=33); Periodontitis (n=6, useable data in 1 comparison); Interproximal caries (n=0); Adverse effects (n=22); Halitosis (n=0); Patient satisfaction (n=0); Cost of intervention (n=0) |
| Study designs | Randomised controlled trials (including split-mouth, cross-over and cluster-randomised); minimum duration 4 weeks | Parallel-group, split-mouth and cross-over randomised controlled trials (first-period data only used from cross-over trials) |
| Timing | Minimum intervention duration 4 weeks for periodontal diseases and 24 weeks for dental caries | Outcomes measured at 1 month (short term) and 3 and 6 months (medium term); most measured at 4-6 weeks |
Search date: 2019-01-16. Databases: Cochrane Oral Health's Trials Register; Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE Ovid; Embase Ovid; CINAHL EBSCO
Questions and results
Current version onlyFlossing plus toothbrushing vs Toothbrushing alone
Population: Adults, 16 years and older (dentate)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Gingivitis (proportion of bleeding sites) 1 month | MD -0.03 [-0.14, 0.08] | 2 studies · 158 participants | Very low Downgraded: risk of bias, imprecision, inconsistency |
Harms and adverse effects | Adverse effects were assessed and reported in seven studies. Three reported no adverse events on the oral hard or soft tissues. Four reported sporadic adverse events with mild severity, with no evidence of a difference… | 7 studies | Ungraded |
Interproximal caries | No included study assessed caries as an outcome. | 0 studies | No studies |
Gingivitis (gingival index) 1 month | SMD -0.58 [-1.12, -0.04] | 8 studies · 585 participants | Low Downgraded: risk of bias, inconsistency |
Plaque 1 month | SMD -0.42 [-0.85, 0.02] | 7 studies · 542 participants | Very low Downgraded: risk of bias, imprecision, inconsistency |
Periodontitis (probing pocket depth) | One study measured probing pocket depth but no data were reported (Graziani 2017). | 1 study | Ungraded |
Interdental brushing plus toothbrushing vs Toothbrushing alone
Population: Adults, 16 years and older (dentate)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Plaque 1 month | SMD -1.07 [-1.51, -0.63] | 2 studies · 93 participants | Low Downgraded: risk of bias, imprecision |
Periodontitis (probing pocket depth) | One study measured probing pocket depth but no data were reported (Graziani 2017). | 1 study | Ungraded |
Interproximal caries | No included study assessed caries as an outcome. | 0 studies | No studies |
Gingivitis (gingival index) 1 month | MD -0.53 [-0.83, -0.23] | 1 study · 62 participants | Very low Downgraded: risk of bias, imprecision |
Gingivitis (proportion of bleeding sites) 1 month | MD -0.05 [-0.13, 0.03] | 1 study · 31 participants | Very low Downgraded: risk of bias, imprecision |
Harms and adverse effects | Harms and adverse outcomes (SoF): Neither study reported any information about adverse events. Jared 2005 assessed adverse events (participants issued a symptom diary) but did not report the findings; Graziani 2017 did… | 1 study | Ungraded |
Wooden cleaning stick plus toothbrushing vs Toothbrushing alone
Population: Adults, 16 years and older (dentate)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Plaque 3 months | MD -0.03 [-0.13, 0.07] | 1 study · 24 participants | Very low Downgraded: risk of bias, imprecision |
Interproximal caries | No included study assessed caries as an outcome. | 0 studies | No studies |
Gingivitis (gingival index) | Gingivitis measured by gingival index: Not measured. | 0 studies | No studies |
Gingivitis (proportion of bleeding sites) 3 months | MD -0.25 [-0.37, -0.13] | 1 study · 24 participants | Very low Downgraded: risk of bias, imprecision |
Harms and adverse effects | Harms and adverse outcomes: Not reported (neither study reported on adverse effects). | 0 studies | No studies |
Periodontitis (probing pocket depth) | No included study assessed periodontitis as an outcome. | 0 studies | No studies |
Rubber/elastomeric cleaning stick plus toothbrushing vs Toothbrushing alone
Population: Adults, 16 years and older (dentate)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Periodontitis (probing pocket depth) | One study measured probing pocket depth but no data were reported (Graziani 2017 mentioned PPD as outcome but no data). | 1 study | Ungraded |
Harms and adverse effects | Harms and adverse outcomes: Not reported (neither study reported on adverse effects). | 0 studies | No studies |
Gingivitis (proportion of bleeding sites) 1 month | MD -0.07 [-0.15, 0.01] | 1 study · 30 participants | Very low Downgraded: risk of bias, imprecision |
Plaque 1 month | MD -0.22 [-0.41, -0.03] | 1 study · 30 participants | Very low Downgraded: risk of bias, imprecision |
Interproximal caries | No included study assessed caries as an outcome. | 0 studies | No studies |
Gingivitis (gingival index) 1 month | MD -0.01 [-0.19, 0.21] | 1 study · 12 participants | Very low Downgraded: risk of bias, imprecision |
Oral irrigation plus toothbrushing vs Toothbrushing alone
Population: Adults, 16 years and older (dentate)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Periodontitis (probing pocket depth) | Periodontitis measured in one study but useable data not provided (Walsh 1989 reported proportion of sites with >4 mm pocket depth at 3 months but not mean PD; attachment loss measured but no data). | 1 study | Ungraded |
Plaque 1 month | SMD -0.16 [-0.41, 0.10] | 3 studies · 235 participants | Low Downgraded: risk of bias, imprecision |
Gingivitis (gingival index) 1 month | SMD -0.48 [-0.89, -0.06] | 4 studies · 380 participants | Very low Downgraded: risk of bias, imprecision, inconsistency |
Gingivitis (proportion of bleeding sites) 1 month | MD -0.00 [-0.07, 0.06] | 2 studies · 126 participants | Low Downgraded: risk of bias, inconsistency |
Harms and adverse effects | Three studies reported that there were no adverse events, one reported one incidence of aphthous ulcer in irrigator group, one reported oral lacerations but found no difference between the interventions, and one did… | 5 studies | Ungraded |
Interproximal caries | No included study assessed caries as an outcome. | 0 studies | No studies |
Interdental brushing plus toothbrushing vs Flossing plus toothbrushing
Population: Adults, 16 years and older (dentate)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Gingivitis (proportion of bleeding sites) 4 to 6 weeks | MD -0.06 [-0.08, -0.03] | 6 studies · 234 participants | Low Downgraded: risk of bias, inconsistency |
Gingivitis (gingival index) 4 to 6 weeks | SMD -0.40 [-0.70, -0.11] | 3 studies · 183 participants | Low Downgraded: risk of bias, imprecision |
Interproximal caries | No included study assessed caries as an outcome. | 0 studies | No studies |
Plaque 1 month (4 to 6 weeks) | SMD -0.47 [-0.84, -0.11] | 5 studies · 290 participants | Very low Downgraded: risk of bias, imprecision, inconsistency |
Periodontitis (probing pocket depth) 4 to 6 weeks | MD -0.06 [-0.27, 0.16] | 3 studies · 107 participants | Low Downgraded: risk of bias, imprecision |
Harms and adverse effects | Five studies reported there were no adverse events. Two studies reported on problems with the use of interdental brushes or floss, which sometimes caused soreness. (Six studies reported on adverse events; none… | 6 studies | Ungraded |
Wooden cleaning stick plus toothbrushing vs Flossing plus toothbrushing
Population: Adults, 16 years and older (dentate)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Gingivitis (gingival index) | Gingivitis measured by gingival index: Not measured. | 0 studies | No studies |
Periodontitis (probing pocket depth) | No included study assessed periodontitis. | 0 studies | No studies |
Plaque 3 months | MD 0.02 [-0.06, 0.10] | 1 study · 24 participants | Very low Downgraded: risk of bias, imprecision |
Harms and adverse effects | Harms and adverse outcomes: Not reported (neither study reported on adverse effects). | 0 studies | No studies |
Interproximal caries | No included study assessed caries as an outcome. | 0 studies | No studies |
Gingivitis (proportion of bleeding sites) 3 months | MD 0.01 [-0.12, 0.14] | 1 study · 24 participants | Very low Downgraded: risk of bias, imprecision |
Rubber/elastomeric cleaning stick plus toothbrushing vs Flossing plus toothbrushing
Population: Adults, 16 years and older (dentate)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Gingivitis (gingival index) 4 to 6 weeks | SMD -0.22 [-0.69, 0.24] | 6 studies · 256 participants | Very low Downgraded: risk of bias, imprecision, inconsistency |
Plaque 4 to 6 weeks | SMD -0.08 [-0.46, 0.29] | 6 studies · 273 participants | Very low Downgraded: risk of bias, imprecision, inconsistency |
Periodontitis (probing pocket depth) | One study measured periodontitis but the data were not usable (Smith 1988 measured PPD but data unusable). | 1 study | Ungraded |
Harms and adverse effects | Five studies assessed adverse events. One did not report findings, but the others reported either no adverse events or minor adverse events that did not significantly differ between interventions. | 5 studies | Ungraded |
Interproximal caries | No included study assessed caries as an outcome. | 0 studies | No studies |
Gingivitis (proportion of bleeding sites) 1 month | MD -0.03 [-0.08, 0.03] | 5 studies · 212 participants | Low Downgraded: risk of bias, inconsistency |
Oral irrigation plus toothbrushing vs Flossing plus toothbrushing
Population: Adults, 16 years and older (dentate)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Gingivitis (proportion of bleeding sites) 1 month | MD -0.12 [-0.19, -0.05] | 2 studies · 133 participants | Low Downgraded: risk of bias, imprecision |
Periodontitis (probing pocket depth) | No included study assessed periodontitis. | 0 studies | No studies |
Gingivitis (gingival index) 1 month | MD -0.06 [-0.12, 0.00] | 1 study · 63 participants | Very low Downgraded: risk of bias, imprecision |
Plaque 1 month | SMD 0.31 [-0.08, 0.70] | 2 studies · 133 participants | Very low Downgraded: risk of bias, imprecision |
Interproximal caries | No included study assessed caries as an outcome. | 0 studies | No studies |
Harms and adverse effects | Both studies reported that there were no adverse events in either study group. | 2 studies | Ungraded |
Rubber/elastomeric cleaning stick plus toothbrushing vs Interdental brushing plus toothbrushing
Population: Adults, 16 years and older (dentate)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Plaque 4 to 6 weeks | SMD 0.08 [-0.33, 0.49] | 2 studies · 92 participants | Very low Downgraded: risk of bias, imprecision |
Gingivitis (gingival index) 4 to 6 weeks | MD 0.10 [-0.32, 0.52] | 1 study · 61 participants | Very low Downgraded: risk of bias, imprecision |
Gingivitis (proportion of bleeding sites) 1 month | MD -0.02 [-0.10, 0.06] | 1 study · 31 participants | Very low Downgraded: risk of bias, imprecision |
Interproximal caries | No included study assessed caries as an outcome. | 0 studies | No studies |
Periodontitis (probing pocket depth) | Two studies measured periodontitis but data not presented or usable (Smith 1988 PPD unusable; Graziani 2017 measured PPD but no data). | 2 studies | Ungraded |
Harms and adverse effects | Harms and adverse outcomes (SoF): Not reported. Yost 2006 performed examinations of the oral soft tissue at the final visit but did not report the findings; Graziani 2017 and Smith 1988 did not measure adverse effects. | 1 study | Ungraded |
Flossing plus toothbrushing vs Toothbrushing alone
Population: Dentate participants (any age)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Outcome NR | no estimate extracted | NR | No studies |
Interdental brushing plus toothbrushing vs Toothbrushing alone
Population: Dentate participants (any age)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Outcome NR | no estimate extracted | NR | No studies |
Wooden cleaning stick plus toothbrushing vs Toothbrushing alone
Population: Dentate participants (any age)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Outcome NR | no estimate extracted | NR | No studies |
Rubber/elastomeric cleaning stick plus toothbrushing vs Toothbrushing alone
Population: Dentate participants (any age)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Outcome NR | no estimate extracted | NR | No studies |
Oral irrigation plus toothbrushing vs Toothbrushing alone
Population: Dentate participants (any age)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Outcome NR | no estimate extracted | NR | No studies |
Interdental brushing plus toothbrushing vs Flossing plus toothbrushing
Population: Dentate participants (any age)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Outcome NR | no estimate extracted | NR | No studies |
Wooden cleaning stick plus toothbrushing vs Flossing plus toothbrushing
Population: Dentate participants (any age)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Outcome NR | no estimate extracted | NR | No studies |
Rubber/elastomeric cleaning stick plus toothbrushing vs Flossing plus toothbrushing
Population: Dentate participants (any age)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Outcome NR | no estimate extracted | NR | No studies |
Oral irrigation plus toothbrushing vs Flossing plus toothbrushing
Population: Dentate participants (any age)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Outcome NR | no estimate extracted | NR | No studies |
Rubber/elastomeric cleaning stick plus toothbrushing vs Interdental brushing plus toothbrushing
Population: Dentate participants (any age)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Outcome NR | no estimate extracted | NR | No studies |