Effectiveness of dental floss in the management of gingival health: A 6-month follow-up of a randomized controlled clinical trial.

OBJECTIVES: To evaluate, (i) if subjects submitted to a structured oral hygiene training program (OHt) maintain adopted habits over 180 days without professional guidance; and (ii) in perspective whether flossing provides additional benefits to toothbrushing on gingival health. MATERIALS AND METHODS: Seventy-five adult subjects showing approximately 40% proximal gingival bleeding were randomized to receive OHt (1 session weekly over 8 weeks) using toothbrush and dental floss or toothbrush alone. The subjects were then followed over 180 days without professional guidance. Primary outcomes were mean interproximal Gingival Index (GI) and GI = 2 (gingival bleeding). Mixed linear models were used for the comparison between groups (p < 0.05). RESULTS: 68 subjects received OHt, 48 subjects completed the 180-day follow-up. Subjects maintained adequate oral hygiene routines. Besides a reduction in gingival inflammation, no alterations in gingival status were observed among groups, subjects additionally instructed to use dental floss showing a mean interproximal GI = 2 of 12.8 ± 2.5 compared with 19.8 ± 2.2 for subjects limited to tooth brushing alone. CONCLUSIONS: OHt intensive training promotes gingival health and maintenance lasting at least 6 months without professional supervision reinforcing important principles: (i) dental health professionals should dedicate time training and motivating their patients to reach adequate self-performed plaque control; and (ii) the adjunctive use of dental floss appears essential to reduce interproximal gingival inflammation in subjects with intact interdental papillae. CLINICAL RELEVANCE: Dentists need to invest time in training/motivating/engage their patients to achieve adequate OH; adjunct flossing in subjects with papilla filling the interdental space appears essential to reach and maintain gingival health. CLINICALTRIALS: GOV : (53831716.5.0000.5346). TRIAL REGISTRATION: The protocol registration was filed May 9, 2018 (# 538,311,716.5.0000.5346) on ClinicalTrials.gov. An NCT number (NCT04909840) was generated upon completed registration.

Efficacy of dental floss in the management of gingival health: a randomized controlled clinical trial.

OBJECTIVES: This randomized controlled clinical trial evaluated the efficacy of dental floss as a supplement to toothbrushing in support of gingival health in adults. MATERIALS AND METHODS: Seventy-five systemically healthy subjects, non-smokers, without loss of interproximal periodontal attachment and with more than 15% of the interproximal sites presenting with gingival bleeding were randomized into two groups either performing toothbrushing supplemented by dental floss (TB + DF) or toothbrushing (TB) alone. Over a 60-day period, participating subjects weekly received oral hygiene instruction and supervised personal and professional plaque removal by applying the devices assigned for the group. Study subjects were instructed to perform toothbrushing twice daily (group TB + DF and TB) and use dental floss once daily (group TB + DF). Gingival Index (GI) and Plaque Index (PlI) were evaluated at baseline, and at 30 and 60 days. Linear mixed models were used to compare PlI and GI intra- and intergroup means. RESULTS: Interproximal gingival inflammation (GI = 2 and mean GI) was significantly reduced in both groups by day 30, reduction in inflammation being significantly greater in the TB + DF compared with the TB alone group. No further significant alterations were observed by day 60. Moreover, reduction in gingival inflammation (GI = 2) was greater in the anterior compared with the posterior dentition. CONCLUSIONS: Interproximal gingival inflammation may be significantly reduced by toothbrushing alone, the effect being significantly enhanced when toothbrushing is combined with dental floss. TRIAL REGISTRATION: The protocol registration was filed on May 9, 2018 (# 538,311,716.5.0000.5346) on ClinicalTrials.gov and after complete registration, a NCT number was generated (NCT04909840). Since the date in May 2018 when the protocol preregistration was filed, no change in methodology, primary outcome, and data analysis has occurred. CLINICAL RELEVANCE: Optimized personal oral hygiene routines in individuals without loss clinical attachment interproximal should include dental floss as a supplement to toothbrushing in support of gingival health.

Does flossing before or after brushing influence the reduction in the plaque index? A systematic review and meta-analysis.

OBJECTIVES: The purpose of this systematic review was to assess whether flossing before or after influences plaque index reduction. METHODS: This systematic review was conducted according to the guidelines of the preferred reporting items for systematic reviews and meta-analyses and registered with the International prospective register of systematic reviews under number CRD42019126239. The PICO question was, 'does flossing before or after brushing have any effect on reducing dental plaque?'. An electronic search was performed until April 2020 in the following databases: PubMed/MEDLINE, Scopus Web of Science and Cochrane Library. The initial database search resulted in 9679 references, and after detailed analysis of the titles and abstracts of the selected studies, the inclusion/exclusion criteria were applied, and 06 complete articles were downloaded and selected for further analysis. After the complete 02 articles were selected, 60 patients with a mean age of 23.1 years were studied and compared dental flossing before or after dental brushing. RESULTS: The results showed that there was no statistical difference between brush-floss and floss-brush in reducing plaque index (p = 0.91, RR: 0.01, 95% CI: -0.16, 0.18). CONCLUSIONS: Flossing before or after brushing has no significant effect on reducing dental plaque index. However, more clinical studies should be conducted.

Efficacy of an unwaxed dental floss impregnated with 2% chlorhexidine on control of supragingival biofilm: A randomized, clinical trial.

AIM: In the present study, we evaluated the antiplaque and antigingivitis efficacy of a dental floss impregnated with 2% chlorhexidine digluconate. METHODS: Thirty dental students were randomly divided into three groups (n=10): (a) negative control (NC) group, in which no interproximal cleaning was performed; (b) the positive control (PC) group, which used a standard unwaxed dental floss twice daily; and (c) and the test group, which used a unwaxed dental floss impregnated with 2% chlorhexidine twice daily. Six surfaces per tooth were evaluated by the Quigley-Hein plaque index (Turesky modification) at the last appointment (day 15), and testing for the presence of marginal bleeding was performed using the marginal bleeding index (MBI) at both the baseline and last appointments. RESULTS: At day 15, the test group had the lowest mean plaque index (1.04±0.67), showing a statistically-significant difference compared to the NC group (1.40±0.65, P<.001) and PC group (2.30±0.73, P<.001). The PC and test groups showed a mean reduction of 70.2% and 87.26%, respectively, with significant reduction compared to baseline (P<.05) for the MBI. No statistically-significant difference was found between the PC and test groups (P=.126). CONCLUSION: Unwaxed dental floss impregnated with 2% chlorhexidine showed additional reductions in supragingival interproximal biofilm compared with a conventional unwaxed dental floss, without additional improvement in marginal bleeding.

Why do children and adolescents neglect dental flossing?

AIM: To identify the variables and actual difficulties related to children and adolescents' non-compliance with dental flossing. METHODS: This cross-sectional study with 36 children and 59 adolescents were selected from dental clinics at the Dental School, University of São Paulo. The percentage of surfaces with disclosed biofilm was used to evaluate general oral hygiene. Participants answered questions concerning dental flossing (difficulties, self-reported motivation, and previous instruction). An examiner observed how the participants flossed their teeth and their possible faults. Univariate and multiple logistic regression analyses were performed and odds ratio values were calculated in order to verify the association between non-compliance (or difficulties) with flossing and possible reasons for that. RESULTS: Similar non-compliance with daily flossing was observed among children and adolescents (p = 0.95). Children's flossing negligence was strongly associated with self-reported laziness in flossing (p = 0.02), and negatively associated with their previous practice by some dentists (p = 0.009). Self-described difficulties in flossing also showed an association with laziness in flossing (p = 0.03). No association was found between negligence of flossing and all variables tested among adolescents (p ≥ 0.05). CONCLUSIONS: Low compliance and difficulties in flossing among children and adolescents seemed to be more related to lack of motivation, although problems concerning manual skills were also observed.

Levantamento transversal da relação do índice de placa com o grau de escolaridade, idade e frequência do uso do fio dental e escova em pacientes de 31 a 69 anos de idade / The relationship of plaque index, educational degree, age, and frequency of dental fl oss in patients from 31 to 69 years-old ­ a cross-sectional study

Objetivo: estudar o índice de placa e a sua correlação com a técnica de higiene empregada, com o grau de escolaridade, idade, frequência e o conhecimento sobre a higiene oral. Material e métodos: em uma amostra da população da cidadede Divinópolis/MG, foi aplicado um questionário específico sobre os hábitos de higiene oral. O exame clínico foi realizado com sonda milimetrada, e a placa evidenciada pelo corante. Todos os pacientes foram divididos em quatro faixas etárias e receberam reforço na higiene oral. As possíveis associações entre os critérios foram investigadas com o teste Qui-quadrado. Resultados: 216 pacientes (86 homens, 130 mulheres) foram incluídos. No total, 5.853 dentes e 23.412 faces foram analisados. O nível de placa variou de 54,29% (60-69 anos) a 60,10% (40-49 anos), e as faces interproximais foram as mais coradas (83,27%). Um total de 140 pacientes não tinha realizado tratamento periodontal prévio; dos 76 pacientes com tratamento prévio, 34 não haviam sido instruídos sobre a higiene oral. Metade dos pacientes relatou usar a escova dental três vezes ao dia; 1/3 dos pacientes usavam o fio dental duas vezes e estavam no ensino médio. Conclusão: 1) há necessidade de uma campanha maciça sobre a importância da escova dental e do fio dental, e como usá-los; 2) os menores índices de placa estão nos indivíduos de grau superior; 3) as faces proximais coradas confirmam a falta de uso do fio dental, principalmente nos pacientes que foram submetidos ao tratamento periodontal, por ausência de informação profissional.

Objective: to study the plaque index and possible correlations with oral hygiene, educational levels, age, and frequency of dental flossing. Material and methods: a patient sample from Divinopolis/MG received an appropriate questionnaire survey regarding their oral hygiene habits. The clinical exam was made with a periodontal probe and a disclosing agent. All patients were divided according to 4 age conditions and receive further oral instructions. Possible associations were investigated with the Chi-square method. Results: 216 patients (86 men, 130 women) were included. Overall, 5,852 teeth and 23,412 surfaces were examined. Plaque levels varied from 54.29% (60-69 years) to 60.10% (40-49 years), being most prevalent at the proximal surfaces (83.27%). 140 patients did not have previous periodontal treatment; from 76 patients under active periodontal treatment, 34 had no oral hygiene instructions. Half of the patients reported the use of toothbrushing 3 times a day; 1/3 of patients reported flossing twice a day. Conclusion: 1) a massive campaign is needed to underscore the importance of oral hygiene and dental floss, 2) the lowest plaque scores were observed in people with higher education, 3) the proximal surfaces confirmed the lack of dental floss, particularly in patients under periodontal treatment due to the lack of professional information.

Clinical Evaluation of Residual Tetrasodium Pyrophosphate Released from Two Different Anticalculus Flosses

The aim of this study was to compare the residual content of tetrasodium pyrophosphate released by two different anticalculus dental flosses (Reach PP(r) - entangled polypropylene floss and Reach NT(r) - texturized nylon) in the oral cavity. Ten healthy individuals (aged between 18 and 30 years) were enrolled in this randomized crossover clinical investigation. Participants received instructions on daily dental flossing and the interventions were randomly performed in 2 different groups (NT or PP) of five individuals each according to the dental flosses. Individuals were instructed to use each dental floss with a total of six slides on the two interproximal aspects of target teeth (3 slides on each interproximal aspect). A washout period of one week was used before start flossing interventions and after each type of dental floss to prevent any bias related to the exposure to any product that contained the active ingredient. Samples were collected by #35 sterilized absorbent paper points from interdental fluid after flossing and assessed by ion chromatography. The levels of residual tetrasodium pyrophosphate were evaluated by means of binomial generalized linear model proportions and canonical link function. Both dental flosses were effective in tetrasodium pyrophosphate release at therapeutic levels in the interdental gingival crevicular fluid for a period of up to 2 h after use. No significant differences were found between both groups (p>0.05). It may be concluded that both material composition and physical structure of the new dental floss did not affect the release or the maintenance of anticalculus agent at therapeutic levels for a period of up to 2 h after single use.

O objetivo deste estudo foi comparar o teor residual de pirofosfato de tetrasodio liberado por dois tipos diferentes de fio dental anti-cálculo (Reach PP(r) - polipropileno entrelaçado e Reach NT(r) - nylon texturizado) na cavidade oral. Dez indivíduos saudáveis (com idade entre 18 e 30 anos) foram selecionados para este estudo clínico em modelo crossover. Os participantes receberam instruções sobre como utilizarem os fios dentais e as intervenções foram randomicamente realizadas em 2 grupos de 5 participantes de acordo com o tipo de fio avaliado. O participantes foram instruídos a passarem cada fio dental em um total de 6 passadas ao redor dos 2 espaços interproximais dos dentes selecionados (3 passadas em cada face interproximal). Um período de washout de 1 semana foi utilizado antes do início do estudo e após cada intervenção com o objetivo de prevenir a ocorrência de viés relacionado à exposição de algum agente terapêutico. Amostras do fluido interdental após as intervenções foram avaliadas por meio de cromatografia de íons. A porcentagem residual de pirofosfato tetrassódico foi verificada empregando-se o método da cromatografia de íons, pela colheita do fluido interdental com cones de papel absorvente esterilizados. Os teores de pirofosfato tetrassódico residual foram comparados para cada fio dental e para cada tempo de colheita do fluido interdental. Não foram observadas diferenças significantes entre os grupos avaliados (p>0,05). Conclui-se que a composição do material e a estrutura física dos fios dentais não exerceram influência na liberação e na permanência do agente anti-tártaro, que permaneceu em níveis terapêuticos por um período de até 2 h após o uso único.

Fio dental: da dificuldade ao êxito na remoção do biofilme interproximal / Dental floss: from difficulty to success in the removal of interproximal biofilms

A higiene bucal é um importante meio de prevenção das doenças cárie e periodontal. Em relação às superfícies proximais, o fio dental é considerado um excelente instrumento para a remoção do biofilme localizado nesses locais. Verifica-se, entretanto, que a frequência de uso do fio dental ainda é baixa na população em geral. Desse modo, o presente estudo objetivou realizar uma revisão de literatura referente aos fatores relacionados à utilização do fio dental, a sua eficiência na redução do biofilme interproximal e as técnicas educativas utilizadas para orientar e motivar as pessoas quanto ao seu uso. Os estudos analisados sugerem que uma pequena parcela da população utiliza o fio dental. Verificou-se a presença de dificuldades na auto-remoção eficiente do biofilme interproximal. Quando as pessoas são estimuladas e orientadas de forma adequada, melhoram muito a qualidade de sua higiene bucal. Normalmente isso é conseguido através de técnicas educacionais específicas.(AU)

Oral hygiene is important in preventing caries and periodontal disease. Regarding interproximal surfaces, dental floss is considered an excellent instrument for the removal of plaque from these locations; however, it has been proven that its frequency of use is still quite low in the general population. As such, the present study aimed to carry out a literature review referent to the factors related to the use of dental floss, its efficiency in reducing interproximal plaque, and the educational techniques that can be used to advise and motivate patients. It was concluded that only a small percentage of the population actually uses dental floss. Moreover, difficulties also arise in the efficient self-removal of interproximal biofilms. However when patients are properly advised and motivated, the quality of their hygiene habits also increases proportionally. This is commonly achieved through specific educational techniques.(AU)

Valor comercial y eficacia de la cinta de politetrafluoretileno (PTFE) para la remoción de la biopelícula dental interproximal comparado con la seda dental de nylon en adolescentes y adultos jóvenes / Price and the efficacy of the polytetrafluoroethylene (PTFE) tape for the removal of the proximal dental biofilm compared to the common nylon dental floss in adolescents and young adults

Objetivo: Identificar el valor comercial y la eficacia de la cinta de politetrafluoretileno (PTFE) como método de higiene oral para la remoción de la biopelícula dental interproximal, comparado con la seda dental de nylon en adolescentes y adultos jóvenes. Métodos: Se utilizó la cinta de PTFE para remover la biopelícula dental interproximal. Por muestreo aleatorio simple el tamaño de la muestra fue de 87 (31 hombres y 56 mujeres) con un rango de edades entre 16 y 28 años. A los participantes se les suspendió toda clase de higiene oral durante un período de 12 horas, posteriormente se realizó una tinción con revelador de placa bacteriana y se llevó a cabo la remoción tanto con la cinta de PTFE como con la seda dental mediante la misma técnica y por el mismo operador. La recolección de datos se hizo con base en la división coronal (por tercios) del índice de higiene de Greene y Vermillion, pero se modificó para evaluar solamente las caras interproximales. Resultados: En el grupo de seda dental la presencia de la biopelícula dental interproximal fue 72.6% antes y 11.2% después de la remoción y en el grupo de PTFE fue 72.9% antes y 11% después; al comparar la remoción de la biopelícula con los dos métodos no hubo diferencias estadísticamente significativas (p>0.05). El valor comercial del PTFE es en promedio 2.7 veces más económico que el de la seda dental de nylon. Conclusiones: La similitud en la remoción de la bio-película interproximal de la cinta de PTFE frente a la seda dental fue significativa. Gracias a su buena bio-compatibilidad, tolerancia y bajo costo, la cinta de PTFE sirve como un método alternativo para retirar la bio-película interproximal. Los resultados de este estudio abren una puerta para investigar técnicas poco ortodoxas, pero eficaces, en el mantenimiento de la salud bucal con el único propósito de mejorar la calidad de vida en las poblaciones menos favorecidas.

Objective: To identify the price and the efficacy of the polytetrafluoroethylene PTFE tape as an oral hygiene method for the removal of the proximal dental biofilm, compared to the common nylon dental floss in adolescents and young adults. Methods: The polytetrafluoroethylene tape was used as a method for the removal of the proximal dental biofilm. By a randomized procedure the sample size was of 87 (31 men and 56 women) between 16 and 28 years old. The oral hygiene of the participants was suspended during a period of 12 hours. A suitable disclosing solution was used to paint the dental surfaces. The removal of the biofilm was made by the same operator who used the same technique with the two materials (polytetrafluoroethylene tape and nylon dental floss). The information was collected using the coronal division (in thirds) of the Greene and Vermillion Oral Hygiene Index. This index was modified to evaluate proximal surfaces only. Results: In the group of dental floss the presence of the proximal biofilm was 72.6% before and 11.2% after its removal. In the group of PTFE was 72.9% before and 11% after. After the comparison of the two methods the differences are not significant. PTFE price is 2.7 times lower than common nylon dental floss. Conclusions: The similarity in the removal of the proximal biofilm of the PTFE tape when compared to the nylon floss was significant. Thanks to its biocompatibility, tolerance and its low price, the PTFE tape is an alternative method for the removal of the biofilm in these proximal areas. Results of this study open a way for the investigation on non orthodox techniques, but effective, for the maintenance of the oral health with the only purpose of improving life quality of poor populations.