**1. Introduction**

Beyond dispute, dental plaque accumulation is the primary etiological factor of the diseases that are shown in the oral cavity, as caries, gingivitis, and periodontitis [1]. Dental plaque is a biofilm structure and consists of complex microbial communities. This structure resides on both hard tissues and soft tissues of the oral cavity and not easily or sufficiently removed from the surfaces by natural cleaning process (natural physiologic forces, tongue, or saliva). There are two main strategies to control or damage the biofilm structure. The first one is removing the matrixenclosed microbial microcolonies by using shear forces that cope with the adhesion forces without damaging the cleaning material surface, meaning the mechanical biofilm removal from the surface. The second is using chemicals to kill the bacteria

and thus, later needs to clean residuals by mechanical forces. The most effective way to control the growth of biofilm is the mechanical removal of the biofilm [2].

Bacterial products of dental plaque biofilm are known to initiate host defense mechanisms, resulting hard and soft tissue destruction. Mechanical control of the dental plaque biofilm is prerequisite for the prevention and control of dental caries and periodontal diseases [3]. Regularly performed optimal oral hygiene measures alter the composition of the pocket microbiota by lowering the amount of periodontopathogens. Therefore, to obtain oral health or to control disease progression, mechanical plaque control measures must be undertaken not only in adult population or patients with periodontal disease but also in younger generation which should be educated about the prevention strategies profoundly. Long-term success of the periodontal therapy is closely related with the plaque removal efficacy of the patients [4]. Longitudinal studies reveal that sites with inadequate plaque removal present deeper probing depths and attachment loss after periodontal therapy [4, 5].

The historical background of mechanical plaque control stands the dates of ancient Egyptians who made brushes by thin wooden sticks called miswak. Today still the most widely known self-performed mechanical plaque biofilm removal/ control method at home is toothbrushing. The buccal, palatinal or lingual, and occlusal surfaces of the teeth are easy to clean well with toothbrushes but do not reach the interdental region of teeth efficiently [6]. Toothbrushing when applied with a proper technique can clean only 65% of the total tooth surface. Due to limitations of the toothbrushes in the penetration of the proximal areas, interdental cleaning gains attention as a separate title. Interdental plaque biofilm control measures should be used as adjunctive to toothbrushing to complement the mechanical cleaning [7–9]. For the maintenance of the periodontal health and caries prevention, toothbrushing should be combined with interdental cleaning once every 24 hours [10, 11].

#### **2. Interdental cleaning products**

Numerous devices and methods have been introduced over the counter for interdental cleaning with different levels of efficacy. Interdental cleaning device selection should be primarily based on the contour of the papilla, size of the embrasures, tooth alignment, and patients' attitude toward oral health. When evaluating the existing products, ease of use, plaque removal efficacy, and possible tissue trauma should be considered before prescription. Since patients have different types of dentitions and interdental spaces, dental professionals should recommend the suitable devices to each individual patient and guide them according to their needs [9].

The remaining of this chapter will focus on the interdental cleaning products currently available over the counter.

#### **2.1 Dental floss**

At the beginning of the nineteenth century, Levi Spear Parmly, a dentist from New Orleans, first introduced the idea of tooth flossing with a piece of silk thread. Within years, commercial production of unwaxed silk floss enabled the home use, and in 1898, dental floss was patented by the Johnson & Johnson Company of Brunswick, New Jersey. During the 1940s, nylon replaced silk as the material for dental floss due to its consistent texture and resistance to shredding. Nylon usage also yielded the development of dental tape, broader type of dental floss, in the 1950s [12].

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*Role of the Mechanical Interdental Plaque Control in the Management of Periodontal Health…*

Today several types of flosses are available. While waxed floss is generally recommended to individuals with tight interproximal contacts, unwaxed floss is suitable for the normal tooth contacts since it slides through the contact area easily. Different materials and floss designs also make it possible to clean around braces and fixed partial dentures. The American Dental Association (ADA) reported that up to 80% of plaque can be removed by flossing [13]. However, most of the people find flossing difficult and time-consuming. To make flossing easier, disposable floss holders or powered flossing devices have been introduced. Comparing the use of powered devices with manual flossing, no significant differences were detected in

In individuals with intact papilla which only allows the penetration of dental floss, flossing is the best option for interdental cleaning [9]. However, dental professional should spend time to motivate and properly instruct the patient about the flossing since the effectiveness is technique sensitive. Studies mainly attributed the lack of efficacy of flossing to manual complexity of the technique and/or to the lack of patients' compliance [15]. On the other hand, in a recent study which conducted in young subjects without interdental attachment loss, toothbrushing in combination with flossing was reported to be capable of both plaque and gingival inflamma-

Berchier et al. [17] conducted a meta-analysis including 11 randomized clinical trials (RCTs) comparing toothbrushing and flossing (test) to toothbrushing alone (control). Results of this meta-analysis revealed no significant differences between test and control groups in terms of plaque and gingival indices. In 2011, Sambunjak et al. [18] investigated the added benefit of flossing to toothbrushing with a systematic review. This review included 12 RCTs with a total of 582 participants. As a result, authors concluded that toothbrushing combined with flossing reduced gingivitis compared to toothbrushing alone. Regarding to plaque reduction, weak and inconsistent statements were associated with toothbrushing and flossing combination at 1- and 3-month periods. No information was available in terms of dental caries prevention because of the short trial periods and difficulties of the

Current literature unfortunately does not support dental floss usage on a routine basis. However, absence of an evidence does not mean absence of an effect [19]. The presence of a weak evidence regarding to the use of dental floss in combination with toothbrushing is mainly related to study designs and small sample size of the studies. Long-term RCTs with higher sample size populations and retrospective studies

The use of dental woodsticks is usually advised by dental professionals to massage the inflamed gingiva, to reduce the inflammation of interdental area, and to increase the keratinization. Woodsticks, made of soft wood, have a wedge-like triangular design suitable for the interdental anatomy. When inserted, the base of the triangle should rest on the gingival side, whereas the tip should point occlusally or incisally [21, 22]. Triangular-shaped woodsticks with low surface hardness and high strength values were shown to be more suitable for interdental cleaning than rounded toothpicks [23]. Previous in vitro studies revealed that triangular-shaped woodsticks which are inserted interdentally could maintain 2–3 mm subgingival plaque-free zone. The resilience of the gingival papilla allows cleaning of the subgingival margins of the restorations which also reduces the risk of the recurrent

*DOI: http://dx.doi.org/10.5772/intechopen.81082*

terms of plaque and gingivitis reduction [14].

tion reduction [16].

early-stage caries detection.

caries development [21, 23].

**2.2 Woodsticks**

are needed to increase the strength of data [20].

#### *Role of the Mechanical Interdental Plaque Control in the Management of Periodontal Health… DOI: http://dx.doi.org/10.5772/intechopen.81082*

Today several types of flosses are available. While waxed floss is generally recommended to individuals with tight interproximal contacts, unwaxed floss is suitable for the normal tooth contacts since it slides through the contact area easily. Different materials and floss designs also make it possible to clean around braces and fixed partial dentures. The American Dental Association (ADA) reported that up to 80% of plaque can be removed by flossing [13]. However, most of the people find flossing difficult and time-consuming. To make flossing easier, disposable floss holders or powered flossing devices have been introduced. Comparing the use of powered devices with manual flossing, no significant differences were detected in terms of plaque and gingivitis reduction [14].

In individuals with intact papilla which only allows the penetration of dental floss, flossing is the best option for interdental cleaning [9]. However, dental professional should spend time to motivate and properly instruct the patient about the flossing since the effectiveness is technique sensitive. Studies mainly attributed the lack of efficacy of flossing to manual complexity of the technique and/or to the lack of patients' compliance [15]. On the other hand, in a recent study which conducted in young subjects without interdental attachment loss, toothbrushing in combination with flossing was reported to be capable of both plaque and gingival inflammation reduction [16].

Berchier et al. [17] conducted a meta-analysis including 11 randomized clinical trials (RCTs) comparing toothbrushing and flossing (test) to toothbrushing alone (control). Results of this meta-analysis revealed no significant differences between test and control groups in terms of plaque and gingival indices. In 2011, Sambunjak et al. [18] investigated the added benefit of flossing to toothbrushing with a systematic review. This review included 12 RCTs with a total of 582 participants. As a result, authors concluded that toothbrushing combined with flossing reduced gingivitis compared to toothbrushing alone. Regarding to plaque reduction, weak and inconsistent statements were associated with toothbrushing and flossing combination at 1- and 3-month periods. No information was available in terms of dental caries prevention because of the short trial periods and difficulties of the early-stage caries detection.

Current literature unfortunately does not support dental floss usage on a routine basis. However, absence of an evidence does not mean absence of an effect [19]. The presence of a weak evidence regarding to the use of dental floss in combination with toothbrushing is mainly related to study designs and small sample size of the studies. Long-term RCTs with higher sample size populations and retrospective studies are needed to increase the strength of data [20].
