While floss is the most widely recommended and used interdental cleaning aid,90 it can be difficult to use properly and adherence may be low.95,96 In patients for whom flossing results in inadequate plaque removal or those who cannot adhere to a flossing regimen, additional interdental cleaning aids are beneficial.96
Interdental brushes remove more plaque interproximally when compared to floss and have demonstrated similar reductions in interproximal probing depths and gingival bleeding in numerous studies.97-99 Interdental brushes can be particularly helpful in areas of concavities and root anamalies, such as the mesial of the maxillary first premolars. In patients who have received previous periodontal care interdental brushes have been shown to be more effective than floss overall.89,100 This is most likely due to less papillary fill in the embrasure spaces and additional access for interdental brushes. A comprehensive systematic review demonstrating the efficacy of interdental brushes demonstrated that in adult patients with adequate interdental space to utilize interdental brushes, plaque removal was greater with toothbrushing and adjunctive use of interdental brushes than toothbrushing alone, toothbrushing with floss, and toothbrushing with interdental wood sticks.101 Furthermore, patients have been shown to prefer the use of interdental brushes over flossing.99-101 Nevertheless, they may not be correct for all sites as they require more interdental space, and less papillary fill, than floss does for their comfortable use.96
Triangular wooden tips inserted in interproximal areas, while better accepted by patients than flossing, demonstrate no overall reduction in plaque or gingival index, but do demonstrate a reduction in BOP that is similar to that seen with flossing.102
Powered flossers, have been shown to result in a reduction in interdental plaque deposits and gingival bleeding when compared to toothbrushing alone.89,100,103 The magnitude of this reduction is variable and dependent upon the type and design of powered flosser.89 It has also been noted that in patients with dental implants, given differences in cross-section and emergence profile these sites when compared to natural teeth, may benefit from the use of a powered flosser.104 Additionally, in patients who lack the dexterity to perform other forms of interdental cleaning or who have not demonstrated adherence with an interdental cleaning regimen in the past, powered flossers may provide motivation and benefit for improved interdental cleaning.89
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