Periodontology 2000, Vol.
55, 2011, 104–123
Printed in Singapore. All rights reserved
Oral hygiene in the prevention of
periodontal diseases:
the evidence
FRIDUS VAN DER WEIJDEN & DAGMAR ELSE SLOT
There is increasing public awareness of the value of
personal oral hygiene. People brush their teeth for a
number of reasons: to feel fresh and confident, to
have a nice smile, and to avoid bad breath and dis-
ease. Oral cleanliness is important for the preserva-
tion of oral health as it removes microbial plaque,
preventing it from accumulating on teeth and gingi-
vae (33). Maintenance of effective plaque control is
the cornerstone of any attempt to prevent and con-
trol periodontal disease. Supragingival plaque is
exposed to saliva and the natural self-cleansing
mechanisms that exist in the oral cavity. However,
although such mechanisms may eliminate food
debris, they do not adequately remove dental plaque.
Therefore, regular personal oral hygiene is required
for proper elimination of supragingival plaque (132).
The most widespread means of actively removing
plaque at home is toothbrushing. There is substantial
evidence showing that toothbrushing and other
mechanical cleansing procedures can reliably control
plaque, provided that cleaning is sufficiently thor-
ough and performed at appropriate intervals. Evi-
dence from large cohort studies has demonstrated
that high standards of oral hygiene will ensure the
stability of periodontal tissue support (9, 64).
Almost 50 years of experimental research and
clinical trials in various geographical and social set-
tings have confirmed that effective removal of dental
plaque is essential for dental and periodontal health
(84). Oral hygiene acts as a non-specific suppressor of
plaque mass. This therapeutic approach is based on
the rationale that any decrease in plaque mass bene-
fits the inflamed tissues adjacent to bacterial depos-
its. Diminishing plaque mass through good oral
hygiene will reduce the injurious load on these tis-
sues. The assumption that gingivitis is the precursor
of periodontitis and that maintenance of healthy
104
 2011 John Wiley & Sons A/S
PERIODONTOLOGY 2000
gingivae will prevent periodontitis is the basis on
which primary prevention of gingivitis is founded.
Consequently, preventing gingivitis could have a
major impact on periodontal care expenditure (13).
Primary prevention of periodontal disease includes
educational interventions for periodontal disease and
related risk factors, as well as regular, self-performed
plaque removal and professional mechanical removal
of plaque and calculus. As such, optimal oral hygiene
requires appropriate patient motivation, adequate
tools and professional oral hygiene instruction.
Oral hygiene instruction
Twice daily brushing with fluoride toothpaste is now
an integral part of most peopleÕs daily hygiene rou-
tine in Western societies. However, it appears that
most patients are unable to achieve total plaque
control at each cleaning. A systematic review (132)
was initiated to assess the effect of mechanical
plaque control. The review was refined to address the
effect of manual toothbrushing on plaque and
gingivitis parameters. The authors systematically
searched for papers that investigated the effect of
mechanical oral hygiene with respect to gingivitis
and plaque control in subjects with gingivitis in
studies of at least 6 months duration.
The US National Library of Medicine database
(MEDLINE-PubMed) was used to search for appro-
priate papers for review. The database was searched
up to and including September 2004. The search
strategy produced 3,223 citations, 33 of which were
identified as eligible for inclusion in this review. The
33 studies were randomized, controlled clinical
studies involving adults (‡18 years old) with plaque
and gingivitis. Table 1 shows the results of the
 Evidence-based oral hygiene methods

Table 1. Meta-analyses comparing baseline vs. end-of-trial data in studies of 6 months or more for manual tooth-
brushes in adults with gingivitis. Weighted mean differences (WMD) and 95% confidence intervals are provided.
A negative value favors oral hygiene instruction [Adapted from Van der Weijden & Hioe (132)]

Studies Index WMD 95% confidence Test for overall Test for heterogeneity
included (random) interval effect (P value) (P value and I2)
Lobene et al. (82) Plaque index; )0.1 )0.20, 0.01 0.06 0.00001 90.0%
Renvert & Silness & Löe
Birkhed (103) (119)
Stephen et al. (122)
Svatun et al. (124)
Svatun et al. (125)
Svatun et al. (126)
Svatun et al. (127)
Svatun et al. (128)
Stephen et al. (122) Percentage )5.84 )3.27, )8.41 0.00001 0.26 24.8%
Svatun et al. (124) bleeding
Svatun et al. (125) on probing
Svatun et al. (126)
Svatun et al. (127) Bleeding index; )9.77 )6.42, )13.13 0.00001 0.75 0%
Svatun et al. (128) Ainamo & Bay
(2)

meta-analysis in terms of plaque and gingivitis for the
manual toothbrush control groups in the eight trials
in which both professional oral hygiene instruction
and prophylaxis were provided at the start of the
study. The plaque data in Table 1 are based on the
index described by Silness & Löe (119) and the data
regarding occurrence of bleeding on probing and
gingival inflammation are based on the index de-
scribed by Ainamo & Bay (2). For the eight selected
studies, the mean baseline plaque index value varied
between 0.29 and 0.72, and the mean plaque index
value at the conclusion of the study ranged from 0.21
to 0.98. The plaque index weighted mean difference of
0.10 between baseline and the end of the trial was not
significant (P = 0.06). The level of gingivitis, assessed
as the proportion of bleeding sites at baseline, varied
between 23 and 31% and was reduced to 20–24% at
the conclusion of the study. The weighted mean dif-
ference of 5.84% between the values at baseline and
the end of the trial was significant (P < 0.00001). The
two studies that used the Ainamo & Bay index for
gingivitis showed a reduction from 25.6 to 29.8 at
baseline to 16.3–19.4 at the end of these studies. The
weighted mean difference of 9.77 indicated that these
results were statistically significant (P = 0.00001).
During the meta-analysis concerning plaque, an
obvious heterogeneity in the clinical outcomes of the
selected studies was found. In cases where hetero-
geneity is significant, readers should exercise caution
as the weighted mean difference may not provide an
exact measure of the results.
In the review by van der Weijden & Hioe (132),
the major challenge was determining what to
compare in these studies. For example, whether
manual toothbrushing should be compared with no
oral hygiene. Instead, the authors decided to sys-
tematically search the literature for controlled clin-
ical trials of 6 months or longer that assessed the
effects of various forms of plaque control in gingi-
vitis subjects. In these trials, the manual toothbrush
group provided data that could be analyzed
according to whether the baseline intervention was
professional oral hygiene instructions or prophy-
lactic measures. Data for baseline and the end of
the trial could then be compared with the effect of
mechanical oral hygiene (Table 1). It was expected
that, in most studies, the manual toothbrush group
with standard fluoride toothpaste would be the
control group, as it indeed turned out to be. There
were no negative control groups. It is therefore
impossible to rule out that part of the observed
effect was due to the Hawthorne effect, which is the
change in behavior of participants involved in a
study. Van der Weijden & Hioe (132) concluded
that, in adults with gingivitis, the quality of self-
performed mechanical plaque removal was not
sufficiently effective and should be improved. Based
on studies of 6 months or longer, it appears that a
single oral hygiene instruction describing correct
use of a mechanical toothbrush, in addition to a
single professional session of Ôoral prophylaxisÕ at
baseline, had a significant, albeit small, positive

105
van der Weijden & Slot
effect on the reduction of gingival inflammation in
adults with gingivitis (132).
Toothbrushes
Natural physiological forces that clean the oral cavity
are inefficient at removing dental plaque. Tongue
movement makes contact with the lingual aspects of
the posterior teeth, and, to a lesser extent, can also
clean their facial surfaces. The cheek covers the
buccal aspects of the posterior maxillary teeth and
can thereby help prevent the copious build-up of
dental plaque on these surfaces. Saliva flow has some
limited potential in cleaning debris from interproxi-
mal spaces and occlusal pits, but it is less effective in
removing and ⁄ or washing out plaque. These de-
fenses can best be classified as superficial actions to
control or mediate plaque build-up. Thus natural
cleaning of dentition is virtually non-existent. To be
controlled, plaque must be removed frequently by
active methods. Hence, the dental community con-
tinues to encourage proper oral hygiene and more
effective use of mechanical cleaning devices (28).
Maintenance of oral hygiene has been an objective
of man since the dawn of civilization. The exact
origin of mechanical devices for cleaning teeth is
unknown. In 1780, the Englishman William Addis
manufactured a toothbrush that had a bone handle
and holes for placement of natural hog bristles,
which were held in place by wire. In the early 1900s,
celluloid began to replace the bone handle, a change
that was hastened by World War I, when bone and
hog bristles were in short supply. Nylon filaments
were introduced in 1938. Nylon filaments made
toothbrushes inexpensive enough for nearly every
person to own one.
During the past 50 years, oral hygiene has im-
proved, and, in industrialized countries, 80–90% of
the population brushes their teeth once or twice a
day (108, 109). Today, numerous manual toothbrush
types are available. However, there is still insufficient
evidence that one specific toothbrush design is
superior to another. Modern toothbrushes have
bristle patterns that are designed to enhance plaque
removal from hard-to-reach areas of the dentition,
particularly proximal areas. The handle size is
appropriate for the hand size of the prospective user,
and much emphasis has been placed on new ergo-
nomic designs (76, 85).
There is no consensus as to the optimal frequency
of toothbrushing. How often and how much plaque
needs to be removed to prevent development of
106
dental disease is not known. From a practical view-
point, it is generally recommended that patients
brush their teeth at least twice daily, not only to re-
move plaque but also to apply fluoride through the
use of dentifrice to prevent caries. This advice is also
provided based on reasons of practicality and feelings
of oral freshness. Despite the fact that most individ-
uals claim to brush their teeth at least twice a day, it
is clear from both epidemiological and clinical stud-
ies that mechanical oral hygiene procedures, as per-
formed by most subjects, are insufficient to control
supragingival plaque formation and prevent gingivitis
and more severe forms of periodontal disease (117).
Recently, a systematic review was initiated by
Wiggelinkhuizen et al. (unpublished results) to assess
the effect of a single brushing exercise using a man-
ual toothbrush. The MEDLINE and Cochrane Central
register of Controlled Trials (CENTRAL) databases
were searched up to December 2008 to identify
appropriate studies. The variable ÔplaqueÕ was
selected as an outcome parameter. Independent
screening of titles and abstracts of 1,949 MEDLINE–
Pubmed and 867 Cochrane papers resulted in iden-
tification of 50 publications that met the eligibility
criteria. These papers described 167 experiments
with 8,236 subjects. Based on the baseline and end
scores, a plaque reduction percentage was calculated
for each of the eligible experiments taken from the
selected studies. Using these data, the weighted
mean difference was calculated to be 43%, with a
range of 28–53%. This weighted mean is an approx-
imation of the mean plaque reduction resulting from
a single brushing. However, one cannot rule out the
Hawthorne effect. This could potentially improve the
outcome and result in an overestimation of the actual
mean effect. The results of this review indicate that,
on average, people are not effective brushers, and
probably live with constant, large amounts of plaque
on their teeth even though they brush once a day.
Electric toothbrushes
Maintaining nearly plaque-free teeth is not easy. The
electric toothbrush represents an advance that has
the potential to enhance both plaque removal and
patient motivation. Electric toothbrushes were
introduced to the market more than 50 years ago.
The first toothbrush powered by electricity was
developed by Bemann & Woog in Switzerland, and
was introduced in the United States in 1960 as the
Broxodent. In 1961, a cordless rechargeable model
was introduced by General Electric (36). Studies of

Fig. 1. Conventional electric toothbrush moving back and
forth and sideways, resulting in an elliptical movement.
the use of these early electric toothbrushes showed
that there was no difference in plaque removal when
compared with a manual toothbrush; they also had
mixed effects on gingivitis. In 1986, an international
workshop on oral hygiene concluded that, up to that
time, neither powered nor manual toothbrushes had
been found to remove more plaque, regardless of the
brushing method (86). The first generation of electric
toothbrushes had a brush head designed as a manual
toothbrush that made a (combined) horizontal and
vertical motion (see Fig. 1). Because of the lack of
clear superiority and many mechanical problems,
powered toothbrushes fell out of favor. During the
late 1960s, these toothbrushes gradually disappeared
from the market.
Since the 1980s, tremendous advances have been
made in electrically powered toothbrush technology.
A variety of electric toothbrushes have been devel-
oped to improve the efficiency of plaque removal.
These toothbrushes use increased filament velocity
and brush stroke frequency and various filament
patterns and motions. At the 1996 World Workshop in
Table 2. Summary of the number of studies that provide comparisons between power-driven and manual tooth-
brushes in reduction of gingival bleeding or inflammation [Adapted from Sicilia et al. (118)]
Mode of action of the Electric toothbrush No difference
electric toothbrush more effective
Oscillating ⁄ rotating 4 1
Counter-rotational 4 1
Sonic 0 2
Ultrasonic 0 1
Others 2 3
Evidence-based oral hygiene methods
Periodontics, it was carefully concluded that the
limited evidence suggested that electric brushes
provide additional benefit compared to manual
brushes (56).
At the 4th European Workshop on Periodontology
in 2001, Sicilia et al. (118) reviewed the available lit-
erature to evaluate the effectiveness of power-driven
toothbrushes compared with manual toothbrushes in
terms of gingival bleeding or inflammation resolution
in the treatment of patients with gingivitis or chronic
periodontitis. A search was made of the MEDLINE
and Cochrane Oral Health Group Specialised
Trials Register databases up to July 2001. The search
resulted in 343 titles and abstracts, and 21 studies
were finally selected. Unfortunately, data heteroge-
neity prevented quantitative analysis. Table 2 shows
a descriptive analysis of the studies, from which it
was concluded that limited evidence exists for the
higher efficacy of electric toothbrushes relative to
manual brushes in reducing gingival bleeding or
inflammation. This advantage appears to be related
to the ability of the electric toothbrushes to remove
dental plaque.
More recently, a systematic review compared
manual and powered toothbrushes in everyday use,
principally in relation to plaque removal and gingival
health. This review was performed in collaboration
with the Cochrane Oral Health Group (38). Five
electronic databases were searched (up to the middle
of 2002) to identify randomized controlled trials
comparing powered and manual toothbrushes. Trials
with a duration of at least 28 days were included. The
initial search identified 354 studies, and 29 trials
fulfilled the inclusion criteria and provided results
that could be entered into a meta-analysis. At 1–
3 months, the standardized mean differences for
plaque and gingivitis were )0.44 (95% confidence
interval )0.66, )0.21) and )0.45 (95% confidence
interval )0.76, )0.15), respectively. These data rep-
resented an 11% reduction using the Quigley & Hein
Manual toothbrush Results are difficult to
more effective interpret
0 0
0 1
1 0
0 1
0 0
107
van der Weijden & Slot
Fig. 2. Oscillating ⁄ rotating toothbrush.
plaque index (100) and a 6% reduction using the Löe
& Silness gingival index (87) in favor of the powered
toothbrush. After 3 months, the standardized mean
differences for plaque and gingivitis were )1.15 (95%
confidence interval )2.02, )0.29) and )0.51 (95%
confidence interval )0.76, )0.25), respectively. These
values represented a 7% reduction using the Quigley
& Hein plaque index and a 17% reduction using the
Ainamo & Bay index (2) in favor of the powered
toothbrush. Sensitivity analyses revealed that the re-
sults were robust when selecting trials of high quality.
The authors concluded that, in general, there was no
evidence of a statistically significant difference be-
tween powered and manual brushes (38). However,
rotation ⁄ oscillation-powered brushes (see Fig. 2)
significantly reduced both short- and long-term
plaque and gingivitis.
Dentifrices
The use of a toothbrush is usually combined with a
dentifrice in order to facilitate plaque removal and
apply agents to the tooth surfaces for therapeutic or
preventive reasons. The term dentifrice is derived
from dens (tooth) and fricare (to rub). A simple,
contemporary definition of dentifrice is a mixture
used on the tooth in conjunction with a toothbrush.
Dentifrices are marketed as toothpowders, tooth-
pastes and gels. The traditional role of dentifrice is
primarily cosmetic, aiding the cleaning of teeth, and
producing fresh breath. Dentifrices also make the
procedure more pleasant.
Conflicting reports have been published concern-
ing the added value of using dentifrice for plaque
removal. Eid & Talic (41) compared the effectiveness
108
of toothbrushing with a dentifrice or toothbrushing
with water after a 2-day period of plaque accumula-
tion. They reported an overall reduction in plaque of
67% for manual toothbrushing with a dentifrice and
an overall reduction of 59% for toothbrushing with
water. Binney et al. (24) examined the effectiveness of
rinsing before brushing on plaque removal. Water
served as a negative control and was used as a both a
pre-brushing rinse and while toothbrushing. rinsing
with water and then brushing with water removed
more plaque than any other combination of pre-
brushing mouth rinse and dentifrice. In conclusion,
the function of dentifrice in the ÔinstantÕ removal of
plaque is questionable (that is the immediate effect of
brushing as opposed to a prolonged effect beyond the
brushing exercise) (98).
Traditionally, it is believed that dentifrices should
contain an abrasive. The addition of abrasives facili-
tates plaque and stain removal without producing
gingival recession ⁄ tooth abrasion or requiring alter-
ation of the remaining components of the dentifrice
(146). For many decades, abrasive systems such as
calcium carbonate, alumina and dicalcium phos-
phate have been used. Today, most dentifrices con-
tain silica. Although more expensive, silica can be
combined with fluoride salts and is very versatile. It
has also been shown to increase the abrasivity of
dentifrices, resulting in even more plaque removal
(69). The results of obtained by Paraskevas et al. (98)
questioned this traditional supposition. These au-
thors found that an increase in dentifrice abrasive-
ness did not result in increased plaque removal. This
result is in supported by a report from the American
Dental Association Division of Science (4), which
accepts that Ôplaque removal is associated minimally
with abrasives, which is another action attributed to
the toothbrushÕ.
Another factor that may be involved in the process
of plaque removal is the detergent (or surfactant)
contained in the dentifrice formulation. Detergents
are surface-active compounds that are added to the
formulation because of their foaming properties. This
foaming effect may be beneficial in clearing the
loosened plaque from the teeth and also provide the
pleasant feeling of cleanness. However, insufficient
evidence exists on the role of detergent in the plaque-
removing effectiveness of dentifrices.
Today, dentifrice formulations contain ingredients
that may also help improve oral health. Fluoride
is almost omnipresent in commercially available
toothpastes. Dentifrices are effective fluoride carriers.
Dentifrices deliver fluoride as sodium fluoride,
sodium monofluorophosphate, amine fluoride or

stannous fluoride. The contribution of fluoride to the
prevention of caries is well established. However,
fluoride has not exhibited consistent efficacy in
controlling gingival inflammation. For this reason,
addition of chemical factors with anti-plaque and ⁄ or
anti-inflammatory properties has been proposed
to deal with the inefficiencies of mechanical self-
performed plaque removal. As the most commonly
used oral hygiene device is a toothbrush, it is rea-
sonable to consider dentifrice as a possible delivery
system for antimicrobials. With some imagination,
this may indicate a paradigm shift toward use of an
Ôoral-care creamÕ instead of an abrasive dentifrice.
However, with few exceptions, chemical agents with
antibacterial properties have not been successfully
formulated into dentifrices. Problems with dentifrice
formulation have involved finding compatible con-
stituents to combine with the active ingredients in
the dentifrice formula.
There has been increased research interest in
agents such as bisbiguanide, triclosan, sanguinarine,
quaternary ammonium chloride compounds and
metal salts. Tin combined with fluoride (stannous
fluoride, SnF2) is a well-known agent that has been
used in dentifrice formulations since the beginning of
the 1940s. Several formulations, including dentifrices,
gels and mouth rinses have been tested throughout
the years. Although most studies agree that SnF2
products have a plaque-reducing effect, there is dis-
agreement with regard to the effects of SnF2 formu-
lations on the parameters of gingivitis. A systematic
review by Paraskevas & Van der Weijden (97) sear-
ched for papers that investigated the effect of SnF2 on
parameters of gingival inflammation. Table 3 shows a
summary of the meta-analysis. For dentifrice ⁄ gel
formulations, there was a significant reduction in
Table 3. Meta-analyses between stannous fluoride and sodium fluoride dentifrices in subject with gingivitis.
Weighted mean differences (WMD) and 95% confidence intervals are provided. Negative values favor stannous
fluoride [Adapted from Paraskevas & Van der Weijden (97)]
Studies included Index WMD
(random)
Mankodi et al. (88) Plaque index; Base )0.02
Mankodi et al. (89) Quigley &
End )0.31
McClanahan et al. (91) Hein (100)
Williams et al. (144)
Beiswanger et al. (19) Gingival index; Base )0.01
Mankodi et al. (89) Löe & Silness
End )0.15
McClanahan et al. (91) (87)
Shapira et al. (116)
Sgan-Cohen et al. (115)
Williams et al. (144)
Evidence-based oral hygiene methods
gingivitis and plaque for SnF2-containing dentifrice
compared to a conventional (NaF) dentifrice.
The bisbiguanide compounds, including chlor-
hexidine gluconate and alexidine, are the most
effective agents currently in use. Chlorhexidine is
most commonly used in mouthwash form, and has
been shown to be an effective inhibitor of plaque
when used alone as well as in conjunction with other
mechanical cleaning procedures. Although very
effective when used as a mouth rinse, chlorhexidine
has demonstrated limited efficacy when included in
dentifrices, as it can be inactivated by flavor and
detergent (1, 15, 68). Even when a formulation has
shown clinical efficacy, its side effects, such as
development of stains on teeth and tongue, limit the
use of chlorhexidine to specific indications and for
short periods of time (107).
Triclosan [5-chloro-2-(2,4-dichlorophenoxy) phe-
nol] is a commonly used antimicrobial agent found in
products such as acne creams, deodorants and hand
soaps. Triclosan is used in many oral care products
because it exhibits antibacterial as well as antifungal
and antiviral properties. As triclosan is non-ionic, it is
compatible with dentifrice formulations and has
reasonable substantivity. It can be detected on the
oral mucosa and in dental plaque at least 3 and 8 h,
respectively, after use (59). It is a broad-spectrum
antimicrobial agent, active against all major plaque
bacteria. Triclosan alone has moderate anti-plaque
properties (49), and has shown anti-inflammatory
effects on gingival tissues (50). Daily use of a triclo-
san ⁄ copolymer dentifrice may have some effect on
periodontitis progression (102), and the use of tri-
closan-containing products has been associated with
very few adverse side effects. Hioe & Van der Weijden
(59) performed a systematic review to assess the
95% Test for overall Test for heterogeneity
confidence effect (P value) (P value and I2)
interval
)0.14, 0.10 >0.05 0.05 62.7%
)0.54, )0.07 0.01 <0.0001 91.7%
)0.03, 0.01 >0.05 0.67 0%
)0.20, )0.11 <0.00001 <0.00001 91.1%
109
van der Weijden & Slot
effectiveness of self-performed mechanical plaque
control with a triclosan-containing dentifrice in
gingivitis subjects. The data show that both triclo-
san ⁄ zinc citrate and triclosan ⁄ copolymer have sig-
nificant, albeit small, positive effects on plaque
reduction and gingivitis (Table 4).
Dentifrices with claims of reducing supragingival
calculus formation are also available. Currently
available calculus-controlling dentifrices contain ei-
ther a pyrophosphate or zinc system. Their aim is to
inhibit the nucleation and crystal growth of calcium
phosphate minerals, which, in turn, should lessen the
amount of calculus deposited on the teeth. In this
way, the mineralization of plaque is delayed, and the
plaque becomes more susceptible to mechanical re-
moval. These dentifrices do not have an effect on
existing calculus.
Some substances in dentifrices may induce local or
systemic side effects. Chlorhexidine in dentifrices
may result in tooth staining (147). Pyrophosphates,
flavorings and detergents, especially sodium lauryl
sulfate, which are present in most commercially
available dentifrices, have been implicated as causa-
tive factors in certain oral hypersensitive reactions
such as aphthous ulcers, stomatitis, cheilitis (39, 105),
burning sensations (75) and oral mucosal desqua-
mation (57). In these cases, the dental professional
should be identify these conditions and advise the
patient to discontinue use of the suspected dentifrice.
Interdental devices
The interdental gingiva fills the embrasure between
two teeth apical to their contact point. This is a
ÔshelteredÕ area that is difficult to access when teeth
are in their normal positions. In populations that use
toothbrushes, the interproximal surfaces of the mo-
lars and premolars are the predominant sites of
residual plaque. Removal of plaque from these sur-
faces remains a valid objective because, in patients
susceptible to periodontal disease, gingivitis and
periodontitis are usually more pronounced in this
interdental area than on oral or facial aspects (83).
Dental caries also occurs more frequently in the
interdental region than on oral or facial smooth
surfaces. A fundamental principle of prevention is
that the effect is greatest where the risk of disease is
greatest. Toothbrushing alone does not reach the
interproximal areas of teeth, resulting in parts of the
teeth that remain unclean. Good interdental oral
hygiene requires a device that can penetrate between
adjacent teeth.
110
Many different marketed products are designed to
achieve this goal, including floss, woodsticks, rubber-
tip simulators, interdental brushes, single-tufted
brushes and recently introduced electrically powered
cleaning aids (i.e. oral irrigators). Flossing is the most
commonly advocated method as it can be performed
in nearly all circumstances. While picking oneÕs teeth
may be one of humanityÕs oldest habits (51), not all
interdental cleaning devices suit all patients or all
types of dentition. Factors such as the contour and
consistency of gingival tissues, the size and form of
the interproximal embrasure, tooth position and
alignment, and patient ability and motivation should
be taken into consideration when recommending an
interdental cleaning method. The most appropriate
interdental hygiene aid(s) must be selected for each
individual patient. The selection is most dependent
on the size and shape of the interdental space as well
as the morphology of the proximal tooth surface. The
level of dexterity and ability of the patient to use a
particular hygiene aid should also be taken into ac-
count (36), even for evidence-based decisions. Prac-
tical efficacy is also influenced by the acceptability
of the method to patients and therefore their
compliance (7, 11, 141).
Dental floss
Suggestions regarding the benefits of flossing date
back to the early 19th century, when it was believed
that irritating matter between teeth was the source of
dental disease (63, 99). Over the years, it has become
generally accepted that dental floss has a positive
effect on removing plaque (9, 36, 134, 143). The
American Dental Association reports that up to 80%
of plaque may be removed by this method (5). As
dental plaque is naturally pathogenic and dental floss
disrupts and removes some interproximal plaque
(134), it was thought that flossing should reduce
gingival inflammation, and flossing as the sole form
of oral hygiene has been shown to be effective in
preventing the development of gingival inflammation
and reducing the level of plaque (14).
Berchier et al. (20) performed a systematic review
of the scientific literature to determine the effective-
ness of dental floss in combination with tooth-
brushing on plaque and clinical inflammatory
symptoms of adults with periodontal disease. Eligible
studies provided a test group that used dental floss as
an adjunct to toothbrushing and a control group that
used toothbrushing only. The MEDLINE and CEN-
TRAL databases were searched up to December 2007
to identify appropriate studies. Plaque and gingivitis
 Table 4. Meta-analyses between triclosan and control dentifrices in subject with gingivitis. Weighted mean differences (WMD) and 95% confidence intervals are
provided. A negative value favor triclosan [Adapted from Hioe & Van der Weijden (59)]

Comparison Studies included Index WMD 95% Test for overall Test for heterogeneity
(random) confidence effect (P value) (P value and I2)
interval
Triclosan ⁄ zinc citrate Renvert & Birkhed (103) Plaque index; Silness & Base )0.00 )0.04, 0.03 0.85 1.00 0%
Stephen et al. (122) Löe (119)
Svatun et al. (124) End )0.07 )0.10, )0.05 <0.00001 0.53 0%
Svatun et al. (125)
Svatun et al. (126)
Svatun et al. (128)
Triclosan ⁄ zinc citrate Stephen et al. (122) Percentage bleeding on Base )0.83 )1.37, 3.03 0.46 0.98 0%
Svatun et al. (124) probing
Svatun et al. (125) End )10.81 )12.69, )8.93 <0.00001 0.48 0%
Svatun et al. (126)
Triclosan ⁄ copolymer Allen et al. (3) Plaque index; Quigley & Base )0.01 )0.03, 0.05 0.72 0.98 0%
Bolden et al. (25) Hein (100)
Deasy et al. (37) End )0.48 )0.73, )0.24 <0.0001 <0.00001 97.2%
Denepitiya et al. (40)
Garcia-Godoy et al. (52)
Kanchanakamol et al. (73)
Mankody et al. (90)
McClanahan et al. (91)
Tritana et al. (131)
Triclosan ⁄ copolymer Allen et al. (3) Gingival index; Base )0.01 )0.03, 0.01 0.30 1.00 0%
Bolden et al. (25) Löe & Silness (87)
Deasy et al. (37) End )0.24 )0.35, )0.13 <0.0001 <0.00001 98.30%
Denepitiya et al. (40)
Garcia-Godoy et al. (52)
Kanchanakamol et al. (73)
Mankody et al. (90)
McClanahan et al. (91)
Tritana et al. (131)
Evidence-based oral hygiene methods

111
van der Weijden & Slot

Table 5. Descriptive overview of the results of the baseline scores were not statistically different. Com-
dental floss and toothbrush group compared to the paring brushing and flossing against brushing only,
toothbrush only group. [Adapted from Berchier et al. the plaque index weighted mean difference was )0.04
(20)]
(95% confidence interval )0.12, 0.04; P = 0.39) and
Reference Plaque Gingival Bleeding the gingival index weighted mean difference was
score score score )0.08 (95% confidence interval )0.16, 0.00; P = 0.06).
Finkelstein et al. (45) 0 0 0 The end scores also showed no significant differences
between groups for plaque (weighted mean differ-
Gjermo et al. (53) + x x
ence )0.24, 95% confidence interval )0.53, 0.04;
Hague & Carr. (54) ? 0 x P = 0.09) or gingivitis (weighted mean difference
Hague et al. (55) 0 0 x )0.04, 95% confidence interval )0.08, 0.00; P = 0.06).
Hill et al. (58) 0 0 x
The heterogeneity observed at the end point for the
plaque scores (I2 = 76.4%) indicates that the weigh-
Jared et al. (67) + 0 0 ted mean difference should not be used as an exact
Kiger et al. (74) + 0 x measure of the results. Based on the individual
Schiff et al. (110) 0 0 x papers in this review, a trend that indicated a bene-
ficial adjunctive effect of floss on plaque levels was
Vogel et al. (133) 0 0 x
observed. However, this could only be substantiated
Walsh et al. (137) 0 x + as a non-significant trend in the meta-analysis.
Zimmer et al. (149) 0 x 0 Dental professionals should therefore determine, on
an individual patient basis, whether high-quality
+, significant difference in favor of toothbrush plus floss group; 0, no signifi-
cant difference; x, no data available; ?, unknown. flossing is an achievable goal. If this is likely to be the
case, daily flossing may be introduced as the oral
were selected as outcome variables. Independent hygiene tool for interdental cleaning. However, a
screening of titles and abstracts of 1,166 MEDLINE– routine recommendation to use floss is not
Pubmed and 187 Cochrane papers resulted in iden- supported by scientific evidence as established by
tification of 11 publications that met the eligibility Berchier et al. (20) in their comprehensive literature
criteria. search and critical analysis.
The majority of these studies showed that there One may ask why the review by Berchier et al. (20)
was no benefit of flossing on plaque or clinical does not show dental floss as a co-operative adjunct
parameters of gingivitis (see Table 5 for description). to toothbrushing. Advocacy of floss as an interdental
From the collective data of the studies, it was possible cleaning device hinges, in large part, on common
to perform a meta-analysis of plaque and gingival sense. However, common sense arguments are the
index scores. Table 6 provides a summary of the lowest level of scientific evidence (104). A possible
outcomes of the meta-analysis. In both instances, explanation is that previous narrative reviews were

Table 6. Meta-analyses between floss as an adjunct to toothbrushing and toothbrushing only. Weighted mean dif-
ferences (WMD) and 95% confidence intervals are provided. Negative values favor floss [Adapted from Berchier et al.
(20)]

Studies Index WMD 95% Test for Test for heterogeneity

included (random) confidence overall effect (P value and I2)
interval (P value)
Jared et al. (67) Plaque index; Base )0.04 )0.12, 0.04 0.39 0.85 0%
Hague & Carr (54) Quigley &
End )0.24 )0.53, 0.04 0.09 0.005 76%
Hague et al. (55) Hein (100)
Schiff et al. (110)
Hague & Carr (54) Gingival index; Base )0.08 )0.16, 0.00 0.06 0.11 43.3%
Hague et al. (55) Löe & Silness
End )0.04 )0.08, 0.00 0.06 0.89 0%
Hill et al. (58) (waxed) (87)
Hill et al. (58)
(unwaxed)
Kiger et al. (74)
Schiff et al. (110)

112

not performed systematically. These reviews also lack
meta-analysis or descriptive analysis based on ex-
tracted data.
The fact that dental floss has no additional effect
on toothbrushing is apparent from more than one
review. Hujoel et al. (63) found that flossing was only
effective in reducing the risk of interproximal caries
when applied professionally. High-quality profes-
sional flossing performed in first-grade children on
school days reduced the risk of caries by 40%. In
contrast, self-performed flossing failed to show a
beneficial effect. The lack of an effect on caries and
the absence of an effect on gingivitis in the review by
Berchier et al. (20) are most likely the consequence of
plaque not being removed efficiently, as was also
established by Berchier et al. (20).
Research also shows that few individuals floss
correctly (78). The inability to floss correctly may
cause a lack of motivation (129). Historically, com-
pliance with regular flossing has been far less than
ideal. The routine use of dental floss has consistently
been shown to be dramatically low (e.g. approxi-
mately 7% of the Dutch population flosses on a
regular basis). The reasons for this lack of compliance
apparently relate to two issues: lack of patient ability
(132) and lack of motivation (31). Studies are incon-
sistent in their ability to demonstrate that educa-
tional attempts to influence floss frequency can be
successful (7). However, it has also been shown that
flossing is like any other skill in that it can be taught,
and those who are given appropriate instruction will
increase their flossing frequency (7, 113, 123).
Sniehotta et al. (121) provided evidence for the
effects of a concise intervention on oral self-care
behavior. Other studies have shown that educational
attempts to modify client behavior were not suc-
cessful in improving flossing frequency (7, 79). The
difficulty in flossing probably makes application of
this technique less than universal.
Woodsticks
Toothpicks are one of the earliest and most persistent
tools used to pick teeth. The toothpick may date back
to the days of the cave people, who probably used
sticks to pick food from between their teeth. Origi-
nally, dental woodsticks were advocated by dental
professionals as Ôgum massagersÕ, which were used to
massage inflamed gingival tissue in the interdental
areas to reduce inflammation and encourage kerati-
nization of the gingival tissue (51).
Woodsticks are designed to allow the mechanical
removal of plaque from interdental surfaces. They
Evidence-based oral hygiene methods
are fabricated from soft wood to improve adaptation
into the interdental space and to prevent injury to
the gingiva. They should not be confused with
toothpicks, which are meant simply for removing
food debris after a meal (141). Round toothpicks are
too thick and too blunt to reach the lingual half of
the tooth when trying to angle them, while the
curved surface of the toothpick provides only point
contact with the tooth surface. Rectangular wood-
sticks are also designed inappropriately for inter-
dental cleaning as they are too pliable to be able to
clean lingually (21). However, triangular woodsticks
seem to have the correct shape to fit the interdental
space (135).
A tapered form of triangular woodstick makes it
possible for the patient to angle the device
interdentally and even clean the lingually localized
interdental surfaces (93). Based on the results of
Bergenholtz et al. (21), it may be concluded that tri-
angular woodsticks with low surface hardness and
high strength values are preferred for interdental
cleaning. Based on studies performed in vivo and
from autopsy material, it was shown that a triangular
pointed woodstick inserted interdentally can main-
tain a subgingival plaque-free region of 2–3 mm (93).
The resilience of the gingival papilla allows cleaning
apical to the subgingival margins of fillings (risk
surfaces for recurrent caries). For open interdental
spaces, common among adults, woodsticks appear
most appropriate (76). In periodontitis patients, the
woodstick will depress the papilla, which may help in
re-contouring the interdental tissues and conse-
quently preclude the need for periodontal surgery
(18). Woodsticks can only be used effectively where
sufficient interdental space is available. Woodsticks
have the advantage of being easy to use and can be
used throughout the day without the need for a
bathroom or mirror (51).
How effective is the woodstick in maintaining oral
health? Does it offer any particular advantage over
flossing or interdental brushes? Hoenderdos et al.
(60) performed a systematic review to evaluate and
summarize the available evidence on the effective-
ness of using triangular woodsticks in combination
with toothbrushing to reduce both plaque and clini-
cal inflammatory symptoms of gingival inflamma-
tion. The MEDLINE and CENTRAL databases were
searched up to February 2008 to identify appropriate
studies. Plaque and gingivitis were selected as out-
come variables. Independent screening of the titles
and abstracts of 181 MEDLINE and 65 CENTRAL
papers yielded seven publications with eight clinical
experiments that met the eligibility criteria.
113
van der Weijden & Slot
Table 7. Descriptive overview of the results for woodsticks compared to other interventions [Adapted from
Hoenderdos et al. (60)]
Reference Plaque score
Barton (16)
Bassiouny & Grant (17)
Caton et al. (30)
Finkelstein & Grossman (44)
Gjermo & Flötra (53) (part 1)
Bergenholtz & Brithon (22)
Finkelstein & Grossman (44)
Gjermo & Flötra (53) (part 1)
Gjermo & Flötra (53) (part 3)
Wolffe (145)
Bassiouny & Grant (17)
Gjermo & Flötra (53) (part 3)
+, significant difference in favor of the test group; 0, no significant difference; x, no data available; ?, unknown.
The heterogeneity of the data prevented quantita-
tive analysis. However, Table 7 summarizes the dif-
ferences between woodsticks and other devices in the
form of a descriptive analysis. In seven studies, use of
triangular woodsticks resulted in a significant incre-
mental improvement in gingival health. None of
the studies that scored visible interdental plaque
demonstrated any significant advantage of using
woodsticks as opposed to alternative methods
(toothbrushing only, dental floss or interdental
brushes) in patients with gingivitis.
A series of histological investigations in patients
with periodontitis has shown that the papillary area
with the greatest inflammation corresponds to the
middle of the interdental tissue. It is difficult to
clinically assess the mid-interdental area, as it is
usually not available for direct visualization (137).
When used on healthy dentition, woodsticks depress
the gingivae by up to 2 mm and therefore clean part
of the subgingival area. Thus, woodsticks may spe-
cifically remove subgingivally located interdental
plaque that is not visible and therefore not evaluated
by the plaque index. This physical action of wood-
sticks in the interdental area may produce a clear
beneficial effect on interdental gingival inflammation
(45).
The included studies from the review by Hoend-
erdos et al. (60) show that changes in gingival
inflammation, as assessed by the gingival index, are
not as obvious as bleeding as an indicator of dis-
ease. Numerous studies have shown that sulcular
114
Bleeding score Gingival score Comparison
x + x Toothbrush only
0 x x Toothbrush only
x + x Toothbrush only
0 + 0 Toothbrush only
0 x x Toothbrush only
x x x Dental floss
0 ? 0 Dental floss
0 x x Dental floss
0 x x Dental floss
0 x x Dental floss
? x x Interdental brush
x x x Interdental brush
bleeding is a very sensitive indicator of early gingival
inflammation. Bleeding following the use of wood-
sticks can also be used to increase patient motiva-
tion and awareness of their gingival health. Several
studies have shown the clinical effectiveness of
gingival self-assessment (71, 72, 139). The presence
of bleeding provides immediate feedback on the
level of gingival health. The dentist or dental
hygienist can also easily demonstrate the gingival
condition to the patient by using the interdental
bleeding index for this obvious clinical manifesta-
tion. Such monitoring may encourage patients to
include woodsticks as part of their own oral hygiene
regimen (22).
Interdental brushes
Interdental brushes are frequently recommended by
dental professionals to patients with sufficient space
between their teeth. Interdental brushes are small,
specially designed brushes for cleaning between the
teeth. They have soft nylon filaments twisted into a
fine stainless steel wire. They may be conical or
cylindrical in shape and are available in different
widths to match the interdental space, ranging from
1.9–14 mm in diameter. Upon examination of ex-
tracted teeth from individuals who habitually used
interdental brushes, Waerhaug (136) showed that the
supragingival proximal surfaces (the central part of
the interdental space and the embrasures) were free
of plaque, and that some subgingival deposits were
 Evidence-based oral hygiene methods

removed up to a depth of 2–2.5 mm below the gin-
gival margin.
Slot et al. (120) systematically reviewed the litera-
ture to determine the effectiveness of interdental
brushes used as adjuncts to toothbrushes in terms of
the presence of plaque and clinical parameters of
periodontal inflammation in patients with gingivitis
or periodontitis. This situation was compared to
toothbrushing alone or toothbrushing in combina-
tion with floss or woodsticks. The MEDLINE–Pub-
Med and CENTRAL databases were searched up to
November 2007 to identify appropriate studies.
Clinical parameters of periodontal inflammation
such as plaque, gingivitis, bleeding and pocket depth
were selected as outcome variables. Independent
screening of the titles and abstracts of 218 MEDLINE–
PubMed and 116 Cochrane papers resulted in iden-
tification of nine publications that met the eligibility
criteria.
Table 8 summarizes differences between inter-
dental brushes and various intervention strategies. All
three studies that compared interdental brushes as
an adjunct to brushing showed a significant differ-
ence in favor of the use of interdental brushes for
plaque removal. The majority of the studies showed a
positive significant difference on the plaque index
when using interdental brushes compared with floss.
No differences were found for the gingival or bleeding
indices. Two of three studies showed that interdental
brushes, when compared with floss, had a significant
positive effect on pocket reduction in patients with
periodontitis. One of the two comparative studies
showed that interdental brushes remove more dental
plaque than woodsticks.
From the collective data it appeared to be possible
to perform a meta-analysis for the comparison of
interdental brushes or floss as adjuncts to tooth-
brushing. Table 9 provides a summary of the outcome
of the meta-analysis. In all instances, baseline scores
were not statistically different. End scores only
showed a significant effect for the Silness & Löe
plaque index in favor of the interdental brush
group relative to the floss group (weighted mean dif-
ference )0.48, 95% confidence interval )0.65, )0.32;
P < 0.00001). Comparisons using the other indices
(Quigley & Hein plaque index, bleeding on probing
and pocket depth) were not statistically significant.
The heterogeneity observed with the Silness & Löe
index (P = 0.001, I2 = 85.4%) reflects the different
behaviors of the study populations to the study
product, differences in study design and other factors
that may influence outcome. Again, readers should
therefore exercise caution when using this weighted
mean difference as an exact measure of the outcomes.
Within the limitations of the search and selection
strategy of the review, Slot et al. (120) concluded that,
as an adjunct to toothbrushing, interdental brushes
remove more dental plaque than flossing.
In young individuals in whom the papillae fill out
the interdental spaces, dental floss is the only tool

Table 8. Descriptive overview of the results for interdental brushes and other interventions [Adapted from Slot et al.
(120)]

Reference Plaque score Gingival score Bleeding score Pocket depth Comparison
Bassiouny & Grant (17) ? x x x Toothbrush only
Jared et al. (67) + + 0 x Toothbrush only
Kiger et al. (74) + 0 x x Toothbrush only
Christou et al. (32) + x 0 + Dental floss
Gjermo & Flötra (53) + x x x Dental floss
Ishak & Watts (65) 0 x 0 0 Dental floss
Jackson et al. (66) + x 0 + Dental floss
Jared et al. (67) 0 0 0 x Dental floss
Kiger et al. (74) + 0 x x Dental floss
Rösing et al. (101) + x x x Dental floss
Yost et al. (148) 0 0 0 x Dental floss
Bassiouny & Grant (17) ? x x x Woodstick
Gjermo & Flötra (53) + x x x Woodstick

+, significant difference in favor of the test group; 0, no significant difference; x, no data available; ?, unknown.

115
van der Weijden & Slot

Table 9. Meta-analyses between interdental brushes and floss. Weighted mean differences (WMD) and 95% confi-
dence intervals are provided. A negative value favors interdental brushes [Adapted from Slot et al. (120)]

Studies Index WMD 95% Test for Test for heterogeneity

included (random) confidence overall effect (P value and I2)
interval (P value)
Jackson et al. (66) Plaque index; Base )0.01 )0.08, 0.06 0.84 0.97 0%
Rösing et al. (101) Silness & Löe (119)
End )0.48 )0.65, )0.32 <0.00001 0.001 85.40%
Christou et al. (32) Plaque index; Base )0.01 )0.28, 0.26 0.94 1.0 0%
Jared et al. (67) Quigley &
End )0.25 )0.57, 0.06 0.12 0.74 0%
Hein (100)
Christou et al. (32) Bleeding on Base 0.01 )0.04, 0.06 0.62 0.86 0%
Ishak & Watts (65) probing
End )0.04 )0.10, 0.02 0.17 0.74 0%
Jackson et al. (66)
Christou et al. (32) Pocket depth Base 0.14 )0.19, 0.47 0.39 0.28 22.00%
Ishak & Watts (65)
End )0.04 )0.28, 0.21 0.77 0.77 0%
Jackson et al. (66)

that can reach into this area. This space only in-
creases when the interdental papilla recedes. The size
of the interdental brush should fit snugly in this
interdental space. Therefore, patients require inter-
dental brushes of various sizes. Schmage et al. (111)
assessed the relationship between the interdental
space and the position of teeth. Most interproximal
spaces in anterior teeth were small, and their size was
most suited to the use of floss. Premolars and molars
have larger interproximal spaces and are accessible
by interdental brushes. Most studies did not discuss
the different interdental brush sizes, nor did they
indicate whether the interdental brushes were used at
all available approximal sites. This need to account
for different sizes of interdental spaces makes a ÔtrueÕ
random assignment of interdental brushes in clinical
trials difficult.
Two out of the three studies that assessed probing
pocket depth (32, 66) showed that reduction was
more pronounced with interdental brushes than with
floss. Only Ishak & Watts (65) could not support this
finding. A possible reason why the meta-analysis
does not support this advantage is the large differ-
ence between the interdental brush and floss groups
in these studies at baseline. To overcome this
imbalance, an elegant approach would be to use the
difference between baseline and end scores as a
measure of effect. Only one study (32) provides this
information. Jackson et al. (66) proposed that the
reduced pocket depth may have been related to the
reduction in swelling with concomitant recession.
However, given the lack of effect on signs of gingival
inflammation (see meta-analysis, Table 7), the effect
on pocket depth cannot readily be explained by a
reduction in the level of gingival inflammation. As an
explanation for the observed effect, the proposition
by Badersten et al. (12) seems plausible. They sug-
gested that mechanical depression of the interdental
papilla is induced by interdental brushes, which in
turn causes recession of the marginal gingival. This,
together with good plaque removal, could be the
reason for the reduction in pocket depth.
Patient acceptance is a major issue to be consid-
ered when it comes to the long-term use of inter-
dental cleaning devices (141). Patient preferences
were evaluated in three studies (32, 65, 74). Com-
paring interdental brushes and dental floss, patients
preferred the interdental brushes. The interdental
brushes were considered to be simpler to use, despite
their tendency to bend, buckle and distort (65), which
made the procedure somewhat complicated at times.
Interdental brushes were considered to be less time-
consuming and more efficacious than floss for
interdental plaque removal (32), which is consistent
with previous work (23).
Oral irrigators
Additional oral hygiene aids have been developed in
an attempt to augment the effect of toothbrushing on
reducing interdental plaque (141). The oral irrigator
was introduced in 1962. This device has been dem-
onstrated to be safe (34, 80) and probably provides a
particular benefit with regard to gingival health for
the large proportion of the general public who does
not clean interproximal spaces on a regular basis
(48). Oral irrigators are designed to remove plaque
and soft debris through the mechanical action of a

116

stream of water. Oral irrigator devices can also be
used with antimicrobial agents (77). Patients report
that oral irrigators facilitate the removal of food
debris in posterior areas, especially in cases of fixed
bridges or orthodontic appliances, when the proper
use of interdental cleaning devices is difficult (27).
Since its introduction, the oral irrigator has at times
been a popular device (95). However, there has been
considerable controversy regarding the appropriate
use and efficacy of this instrument (8, 95). Studies
using an oral irrigator have reported both positive
(43, 62, 81, 130) and negative results (10, 138) in
terms of periodontal inflammation and plaque. This
inconsistency causes confusion about the efficacy of
the oral irrigator.
Husseini et al. (64) performed a systematic review
of the existing literature to evaluate the effectiveness
of oral water irrigation as an adjunct to toothbrushing
on plaque and clinical parameters of periodontal
inflammation relative to toothbrushing alone or reg-
ular oral hygiene. Papers in the MEDLINE-PubMed
and CENTRAL databases up to January 2008 were
searched to identify appropriate studies. Clinical
parameters of periodontal inflammation such as
plaque, bleeding, gingivitis and pocket depth were
selected as outcome variables. Independent screen-
ing of the titles and abstracts of 809 PubMed and 105
Cochrane papers resulted in identification of seven
publications that met the eligibility criteria.
The heterogeneity of the data prevented quantita-
tive analysis. Table 10 shows a descriptive analysis of
the selected studies. None of the selected studies
showed a significant difference between tooth-
brushing plus use of an oral irrigator and tooth-
brushing alone. When use of the oral irrigator was
compared to regular oral hygiene, there were some
significant differences for the clinical parameters of
Table 10. Descriptive overview of the results of the toothbrush and oral irrigation group relative to the toothbrush
only or regular oral hygiene only group [Adapted from Husseini et al. (64)]
Reference Plaque score Bleeding score
Frascella et al. (48) 0 0
Hoover et al. (61) ? x
Walsh et al. (138) 0 0
Flemmig et al. (46) 0 +
Flemmig et al. (47) 0 +
Meklas et al. (92) 0 x
Newman et al. (95) 0 +
+, significant difference in favor of the test group; 0, no significant difference; x, no data available; ?, unknown.
Evidence-based oral hygiene methods
periodontitis. With respect to plaque, no significant
differences were observed. All three studies that
presented data on bleeding scores showed significant
reductions in the oral irrigator group compared to
the regular oral hygiene group (46, 47, 95). When
observing visual signs of gingival inflammation, three
out of four studies (46, 47, 95) found a significant
effect with use of an oral irrigator as an adjunct to
regular oral hygiene. Two of the four studies (46, 95)
showed a significant reduction in probing depth as a
result of using an oral irrigator as an adjunct to reg-
ular oral hygiene.
Plaque reduction is a prerequisite for an oral hy-
giene device to be considered valuable (95). The se-
lected papers for this review reported no statistically
significant reduction in plaque with use of an oral
irrigator. Despite a lack of effect on the plaque index,
studies did find a significant effect on the bleeding
index. The mechanisms underlying these clinical
changes in the absence of a clear effect on plaque are
not understood. Various hypotheses have been put
forward by the authors to explain the results. One of
the hypotheses is that, when patients with gingivitis
perform supragingival irrigation on a daily basis, the
population of key pathogens (and their associated
pathogenic effects) may be altered, reducing gingival
inflammation (46). There is also the possibility that
water pulsations may alter the specific host–microbe
interaction in the subgingival environment and that
inflammation is reduced independent of plaque re-
moval (31). Another possibility is that the beneficial
activity of the oral irrigator is at least partly due to
removal of food deposits and other debris, flushing
away of loosely adherent plaque, removal of bacterial
cells, interference with plaque maturation and stim-
ulation of immune responses (48). Other explana-
tions include mechanical stimulation of the gingiva
Gingival score Pocket depth Comparison
0 x Toothbrush only
? x Toothbrush only
0 ? Toothbrush only
+ + Regular oral hygiene
+ 0 Regular oral hygiene
0 x Regular oral hygiene
+ + Regular oral hygiene
117
van der Weijden & Slot
or a combination of previously reported factors (47,
48). Irrigation may reduce plaque thickness, which
may not be easily detected using two-dimensional
scoring systems (70). This may be the reason for an
absence of an effect on plaque but a positive effect on
gingival inflammation (Table 10).
Irrigation devices may increase the delivery of fluid
beneath the gingival margin (47). Greater penetration
of a solution into periodontal pockets is achieved by
patient-applied supragingival irrigation compared
with mouth rinsing (46). Studies that evaluated the
ability of supragingival irrigation to project an aque-
ous solution (H2O or medicinal fluids) subgingivally
determined that supragingival irrigation with a stan-
dard irrigation tip was capable of delivering H2O or a
medicinal fluid 3 mm subgingivally or to approxi-
mately half the probing depth in a 6 mm pocket (41,
82). Two studies demonstrated that H2O irrigation
had little effect on the composition of the subgingival
flora in sites with pocket probing depths of 4 mm or
less (106, 142). An accessory for an oral irrigator de-
vice, the Pik Pocket subgingival irrigation tip
(WaterPik Technologies, Fort Collins, CO), facilitates
subgingival penetration of irrigants to 90% of the
depth of 6 mm pockets when placed 1 mm subgin-
givally (26). Supragingival irrigation applies consid-
erable force to the gingival tissues. Irrigation was
shown to have the potential to induce bacteremia
relative to brushing (112, 114), flossing (29, 140),
scaling and root planing (42), and chewing (35).
Given the collective evidence, it appears that irriga-
tion is safe for healthy patients.
Husseini et al. (64) concluded that use of an oral
irrigator as an adjunct to toothbrushing does not
have a beneficial effect on reducing plaque scores.
However, there is evidence that suggests a positive
tendency toward improved gingival health when
using an oral irrigator as an adjunct to toothbrushing
as opposed to regular oral hygiene (i.e. self-
performed oral hygiene without any specific
instruction).
Discussion and conclusions
This paper summarizes the highest level of evidence
that is currently available with respect to various as-
pects of oral hygiene. The systematic reviews
included here attempted to collate all empirical evi-
dence that fitted pre-specified eligibility criteria to
answer a specific research question. They used ex-
plicit, systematic methods that are selected to mini-
mize bias, providing more reliable findings from
118
which conclusions can be drawn and decisions can
be made (6, 96). These methods include hypothesis
formulation, literature searches, critical appraisal,
trial planning, ethical review, trial conduct, trial
reporting, systematic reviews and meta-analyses.
Systematic reviews of randomized controlled trials
are seen as the gold standard for assessing the
effectiveness of healthcare interventions. The method
of collecting information from a systematic review
provides a solid basis for clinical decision-making
(94). The Cochrane Collaboration declares in the
Cochrane Handbook for Systematic Reviews (http://
www.cochrane-handbook.org) that reviews are
needed to help ensure that healthcare decisions
throughout the world can be based on informed,
high-quality, timely research evidence. Using meta-
analyses, systematic reviews can provide a quantita-
tive distillation of apparently conflicting clinical data
or identify a trend that might not be evident in a
narrative review. As valuable as systematic reviews
can be, their usefulness depends on the focus and
quality of the previously published studies.
According to the American Dental Association,
evidence-based dentistry is an approach to oral
health care that requires judicious integration of
systematic assessments of clinically relevant scien-
tific evidence, integrating the patientÕs oral and
medical condition and history with the dentistÕs
clinical expertise and the patientÕs treatment needs
and preferences (http://ebd.ada.org/about.aspx). For
example, the results established following the sys-
tematic review on use of floss disappointed many
dental professionals and believers in the use of floss.
The fact that floss does not appear to be effective in
the hands of the general public does not preclude its
use. For instance, in interdental situations that only
allow the penetration of a string of dental floss, this
would be the best available tool. Although floss
should not be the first tool recommended for
cleaning open interdental spaces, if the patient does
not like any other tool, flossing could still be part of
oral hygiene instruction. However, dental profes-
sionals should realize that proper instruction, suffi-
cient motivation of the patient and a high level of
dexterity are necessary to make the flossing effort
worthwhile.
Based on the available literature, it can be con-
cluded that a single oral hygiene instruction has a
small positive effect that will last 6 months or more.
Further research should establish the effect of re-
peated oral hygiene instructions. Toothbrushing
using a manual toothbrush is effective to the extent
that it results in reduction of the plaque scores by

approximately half. Using an oscillating ⁄ rotating
toothbrush, additional efficacy can be obtained. In
studies ‡3 months in duration, a 7% increase in
plaque reduction and a 17% increase in gingivitis
reduction were observed for electric toothbrushing
relative to manual toothbrushing. With respect to
interdental cleaning, the best available data suggest
the use of interdental brushes. These brushes should
therefore be the first choice in patients with open
interdental spaces. Meta-analysis showed superiority
of the interdental brush to floss with respect to
plaque removal. A dentifrice is usually used in
combination with toothbrushing. To enhance the
mechanical action of the toothbrush, abrasive ingre-
dients have been added to dentifrices. Research has
shown that these do not contribute to the instant
cleaning effect. However, data on stannous fluoride
and triclosan support use of these products in the
prevention of gingival inflammation.
In light of the results of this comprehensive liter-
ature review and critical analysis, it is evident that
mechanical oral hygiene plays an important part in
the prevention and treatment of periodontal disease.
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