ORIGINAL Torkzaban ARTICLE et al
The Efficacy of Brushing and Flossing Sequence on Control of Plaque and Gingival Inflammation Parviz Torkzabana/Seyed Reza Arabib/Sepideh Seyedzadeh Sabounchib/ Ghodratollah Roshanaeic Purpose: To evaluate the efficacy of brushing and flossing order on control of plaque and gingival inflammation. Materials and Methods: This cross-over clinical trial was conducted on 35 students recruited from the dental school at Hamadan University of Medical Sciences. The subjects were asked to use dental floss and then brush for a 2-week period (FB), followed by brushing and then using dental floss for another 2-week period (BF). For a 7-day washout interval between the two phases, the subjects practiced dental hygiene according to their habitual method. The participants received dental prophylaxis at the beginning and plaque control record (PCR), plaque index (PI) and bleeding point index (BPI) were measured at baseline and the end of both phases. The differences of indices between two phases were analysed with the Wilcoxon signed rank test; to assess the influence of sex and sequence on PCR, PI and BPI, analysis of covariance (ANCOVA) was used after adjustment of initial values. Results: The PCR and PI indices in the FB method were significantly lower than with the BF method (P < 0.05). The PI and PCR index differences between the two phases were significant in men but nonsignificant in women. The effect of gender on PI and BPI and the interaction effect of sex and sequence of brushing and flossing on BPI were significant (P < 0.05). Conclusions: Flossing followed by brushing provides more statistically significant improvements over brushing followed by flossing with respect to plaque control. Key words: dental brush, dental floss, dental hygiene, dental plaque, gingival bleeding Oral Health Prev Dent 2015;13:267-273 doi: 10.3290/j.ohpd.a32678
P
eriodontal disease is the disease of the supporting dental tissues and the most common form is plaque-induced gingivitis (Newman et al, 2010). Dental plaque is one of the common factors responsible for gingival inflammation; its removal from the tooth surface is the most essential action for preventing and treating periodontal disease (Löe, 2000; Marsh, 2006; Kuramitsu et al, 2007; Periasamy and Kolenbrander 2009; Hujoel et al, a
Associate Professor, Member of Hamadan Dental Research Center, Department of Periodontology, Faculty of Dentistry, Hamadan University of Medical Sciences, Hamadan, Iran.
b
Assistant Professor, Department of Periodontology, Faculty of Dentistry, Hamadan University of Medical Sciences, Hamadan, Iran.
c
Assistant Professor, Department of Biostatistics and Epidemiology, School of Public Health, Hamadan University of Medical Sciences, Hamadan, Iran.
Correspondence: Dr. Sepideh Seyedzadeh Sabounchi, Department of Periodontology, Faculty of Dentistry, Hamadan University of Medical Sciences, Hamadan, Iran. Tel: +98-811-838-1081, Fax: +98811-838-1085. Email: [email protected]
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Submitted for publication: 17.03.13; accepted for publication: 17.07.13
2012; Ravald and Johansson 2012). Mechanical methods for plaque removal along with oral hygiene instructions are regarded as the first step in periodontal treatment (Christou et al, 1998; Needleman et al, 2005; Berchier et al, 2008). Toothbrush and toothpaste are still the most reliable means of dental plaque control, provided cleaning is sufficiently thorough and performed at regular intervals (Caves et al, 1993; Sjögren et al, 2004; Van Der Veijden and Slot 2011). Nevertheless, this means of plaque control is not adequate due to the limited ability of the toothbrush to reach the interdental areas (Asadoorian and Locker 2006; Berchier et al, 2008). These areas are the sites where plaque and inflammation are most pronounced (Lindhe et al, 2008) and regular interdental cleaning can result in better oral hygiene outcomes regarding dental plaque and gingivitis (Crocombe et al, 2012). Various products have been designed for accessing these sites, such as dental flosses, interdental brushes and wooden dental sticks (Slot et al, 2008). Of these,
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the most effective tool has been reported to be dental floss (Sambunjak et al, 2012). Bleeding on probing (BOP) and gingival indices are used for clinically describing the amount of gingival inflammation (Caves et al, 1993). BOP, one of the most commonly used diagnostic parameters, can be a sign of the local inflammatory response alterations related to destructive periodontitis (Ge et al, 2011). Dental brushes significantly reduce the dental plaque and BOP in all dental areas (Berchier et al, 2008). However, according to a systematic review, flossing in addition to toothbrushing is better able to reduce gingivitis compared to only toothbrushing and is associated with slightly greater reduction in plaque level (Sambunjak et al, 2011). It is possible that the sequence of using a toothbrush and dental floss may influence the removal of dental plaque and consequently the BPI. The purpose of this study was to investigate the sequence of brushing and flossing and its efficacy on controlling plaque and gingival inflammation.
MATERIALS AND METHODS This study was approved by the Institutional Review Board of Hamadan University of Medical Sciences. The study population consisted of dental students in their final year at Hamadan University of Medical Sciences’ dental school. Participants who had systemic diseases, gingivitis or periodontitis were excluded from the study. Other exclusion criteria were the use of antibiotics in the past 3 months, pregnancy, diabetes mellitus and smoking. After obtaining written consent forms, participants underwent dental prophylaxis treatment; in the next visit, baseline plaque index (PI), plaque control record (O’Leary et al, 1972) and bleeding on probing (bleeding point index, BPI; Lenox et al, 1973) were measured. Additionally, the Bass method of brushing and the appropriate method of flossing were taught to the participants during this baseline appointment. To ensure standardisation, identical toothbrushes (Oral-B; Kildare, Ireland), dental floss (Oral-B) and toothpaste (Crest, Procter and Gamble; Weybridge, Surrey, UK) were distributed. In order to compare the participants with themselves (cross-over design), they were studied in two phases with a 1-week wash-out interval. In the first phase of the study, the participants were asked to floss first and brush afterwards for two weeks (method FB). In the second phase, the participants were asked to do the opposite, i.e. floss after
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brushing, for another two weeks (method BF). In the interval period, the participants were asked to brush and floss according to their usual routine. Dental prophylaxis was repeated at the beginning of the second phase in order to create the same baseline conditions as at the start of the first phase and study indices were measured again. For measuring the plaque control record (PCR) (O’Leary index), disclosing tablets were given to the participants and the index was calculated as: number of surfaces with plaque × 100 total number of surfaces In order to measure plaque index (PI), plaque deposits on tooth surfaces were scored according to the Silness and Löe classification. The total plaque index was determined by dividing the sum of the scores by total tooth surfaces. • 0 = absence of plaque deposits • 1 = plaque detectable by running the periodontal probe along the gingival margin • 2 = visible plaque • 3 = abundant plaque Bleeding on probing was determined at the buccal, lingual and proximal surfaces using the BPI (Lenox et al, 1973). This was performed by inserting a periodontal probe 1 mm into the sulcus at the distal aspect of the tooth and moving it across the length of the sulcus to the mesial on the facial and lingual surfaces. Bleeding surfaces after 20–30 s were recorded. The percentage of the number of bleeding surfaces was calculated by dividing the sum of the number of bleeding surfaces by the total number of dental surfaces and multiplying by 100. At the end of each phase, the study parameters were measured again. The data were analysed with SPSS v.16 statistical software. The study indices were described using means and standard deviations (SD) and the differences of indices between two phases were analysed using the Wilcoxon signed-rank test. To assess the effect of gender and order of brushing and flossing on study indices after 2 weeks, analysis of covariance (ANCOVA) was used. The significance level was considered 0.05.
RESULTS Thirty-five participants were included in the study, 21 (60%) female and 14 (40%) male students. All (100%) of the participants remained until the end of the study.
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Table 1 Comparison of PI, PCR and BPI baseline scores between two hygiene methods Mean ± SD BF
FB
P-value
Total
0.88 ± 0.22
0.85 ± 0.64
0.18
Men
0.96 ± 0.28
0.87 ± 0.90
0.07
Women
0.81 ± 0.15
0.83 ± 0.25
0.88
Study Indices PI
PCR
BPI
Total
10.35 ± 7.38
10.40 ± 9.78
0.58
Men
11.98 ± 6.33
15.88 ± 8.95
0.10
Women
9.46 ± 8.03
6.02 ± 8.39
0.25
Total
18.01 ± 2.94
26.01 ± 24.94
0.11
Men
21.43 ± 1.99
32.59 ± 27.02
0.07
Women
15.47 ± 3.57
20.23 ± 22.93
0.30
SD: standard deviation.
Table 2 Comparison of PI, PCR and BPI scores after 2 weeks between two hygiene methods Mean ± SD Study indices
Frequency
BF
FB
P-value
PI
35
1.74 ± 0.49
1.61 ± 0.45
*0.01
PCR
35
45.4 ± 8.6
41.6 ± 7.6
*0.007
BPI
35
18.8 ± 18.6
16.7 ± 14.8
0.33
SD: standard deviation; * statistically significant.
Table 3 Comparison of PI, PCR and BPI scores after 2 weeks between two hygiene methods in males Mean ± SD Study indices
Frequency
BF
FB
P-value
PI
14
1.61 ± 0.74
1.39 ± 0.60
*0.007
PCR
14
49.2 ± 7.9
42.1 ± 7.8
*0.005
BPI
14
22.2 ± 21.3
22.4 ± 22.3
0.6
SD: standard deviation; * statistically significant.
Table 4 Comparison of PI, PCR and BPI scores after 2 weeks between two hygiene methods in females Mean ± SD Study indices
Frequency
BF
FB
P-value
PI
21
1.82 ± 0.21
1.76 ± 0.22
0.3
PCR
21
42.8 ± 8.2
41.3 ± 7.6
0.34
BPI
21
16.5 ± 16.9
12.9 ± 3.4
0.44
SD: standard deviation.
The means and standard deviations of the baseline study parameters are shown in Table 1. None of the baseline parameters differed significantly (P > 0.05) (Table 1). The PI and PCR indices with the FB method were significantly lower than with the BF method (P < 0.05). However, mean BPI was not significantly different between two methods
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(P > 0.05) (Table 2). Statistically significant differences among male participants for PI and PCR indices between two methods were observed (P < 0.05), but the BPI did not show a significant difference. In contrast, none of the indices exhibited significant differences between the two methods among female participants (Tables 3 and 4).
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Table 5 Comparison of BPI scores at baseline and after 2 weeks scores Mean ± SD Baseline
Hygiene methods BF
FB
After 2 weeks
P-value
Total
18.01 ± 2.94
18.8 ± 18.6
0.59
Men
21.43 ± 1.99
22.2 ± 21.3
0.75
Women
15.47 ± 3.57
16.5 ± 16.9
0.77
Total
26.01 ± 24.94
16.7 ± 14.8
0.08
Men
32.59 ± 27.02
22.4 ± 22.3
0.14
Women
20.23 ± 22.93
12.9 ± 3.4
0.21
SD: standard deviation.
Table 6 Evaluation of affected factors on study indices after 2 weeks according to ANCOVA Study indices
Factor
df
PI
Sequence Gender Sequence x sex (interaction effect)
PCR
BOP
P-value
MS
F
1
240.1
3.8
0.06
1
594.4
9.5
0.00*
1
32.3
0.5
0.48
Sequence
1
18.2
0.5
0.49
Gender
1
64.1
1.7
0.20
Sequence x sex (interaction effect)
1
4.4
0.1
0.74
Sequence
1
161.5
1.8
0.19
Gender
1
496.8
5.5
0.03*
Sequence x sex (interaction effect)
1
750.4
8.4
0.01*
df: degrees of freedom; MS: mean score; F: test statistic for ANCOVA. *Statistically significant.
The differences between baseline and 2-week BPI scores (total, men and women) of the two methods were not significant (P > 0.05) (Table 5). According to the results of ANCOVA, the order of brushing and flossing did not have a significant effect on periodontal indices after 2 weeks but the effect of sex on PI and BPI was significant (P < 0.05). The interaction effect of sex and order of brushing and flossing on BPI was significant, but it was not significant on other periodontal indices (Table 6 and Fig 1).
DISCUSSION The aim of this cross-over clinical trial was to determine the effect of the sequence of brushing and flossing on the control of plaque and gingival inflammation. The differences in the level of study indices between the two methods only reflected the relative efficacy of brushing and flossing sequence within the same individual. To eliminate the effects of phase one on study participants and therefore the results, a 1-week wash-out interval was held before starting phase 2.
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There was significant difference between the two phases regarding plaque index and plaque control record. The mean plaque index in the BF method after 2 weeks was 1.74 ± 0.49, with a range of 1.25 to 2.23. The mean plaque index in the FB method was 1.61 ± 0.45, with a range of 1.16 to 2.06. The mean plaque control record in the BF method after 2 weeks was 45.4% ± 8.6%, ranging from 36.8% to 54%. The mean plaque control record in the FB method was 41.6% ± 7.6%, ranging from 34% to 49.2%. Several studies have reported that flossing improves periodontal indices. Flossing first could be more effective in plaque control, because subsequent brushing can remove loosened plaque deposits. In the study done by Hague and Carr (2007), the efficacy of the use of an automated flossing device was evaluated in different areas of the mouth. Their results showed that the combined use of toothbrush and flossing yielded a greater reduction in the amount of plaque compared to the use of a toothbrush alone. However, the combined use of toothbrush and dental floss did not show a signifi cant difference in terms of gingivitis.
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Estimated Marginal Means of PI
sex male female
55
50
45
Estimated Marginal Means of PC
44
60
sex male female
42
40
38
36 FB
BF
FB
Sequence
BF Sequence
Estimated Marginal Means of BOP
Fig 1 Interaction effect between gender and sequence on study indices after 2 weeks. 22
sex male female
20 18 16 14
FB
BF Sequence
A study conducted by Jared et al (2005) compared different interdental toothbrushes. According to their results, the use of dental floss for 4 weeks reduced the plaque index more significantly than the use of the interdental brush alone. No signifi cant differences related to gingival parameters were found. The mean BPI between the two methods in this study did not differ significantly. In the BF method, the BPI after 2 weeks was 18.8% ± 18.6%, ranging from 0.2% to 37.4%. The mean BPI in the FB method was 16.7% ± 14.8% (range: 1.9% to 31.5%). In the study performed by Schiff et al (2006), three different plaque control protocols for treating gingivitis were compared. The results showed that there were no significant differences between the use of a toothbrush alone and combining it with dental floss in terms of reducing gingivitis. Zimmer et al (2006) compared the use of different oral hygiene devices/aids. The results showed there were no significant difference in plaque index or gingival bleeding index between using toothbrush alone and combined use of it with dental floss.
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In the present study, because dental prophylaxis was performed at the beginning of each phase, the result that PI and PCR scores were higher after 2 weeks vs baseline was expected. However, the bleeding on probing parameter does not change shortly after dental prophylaxis, and the comparison of baseline and 2-week results showed that the BPI score changed variously in the two phases. There was a nonsignificant increase in BPI scores (total, men and women) in the BF phase and nearly constant scores in the FB phase after 2 weeks (Table 5). The decrease of BPI in the FB phase could be the result of introducing the participants to oral hygiene instructions for the first time. The results of this study showed a statistically significant difference among male participants in PI and PCR indices between two methods (P < 0.05). The PI and PCR were significantly higher with the BF method, but the BPI showed no significant difference. Among female participants, none of the indices differed significantly between the two methods (Tables 2 and 3). More favourable oral health behaviours in females have been shown by several authors (Tinsley et al, 1995; Ostberg et al, 1999).
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Women are better informed about oral health and are more willing to seek dental help. This may suggest that they would implement oral health behaviours more conscientiously regardless of the sequence of measures performed. In contrast, the interaction of sex and sequence of brushing/flossing had a significant effect on BPI. The BPI with the BF method decreased in men but increased in women. The interaction effect was not significant for other study indices (Table 4 and Fig 1). The increased BPI in women using the BF method could be the result of a greater reduction in the amount of toothpaste in the saliva due to rinsing the mouth twice (once after brushing and once after flossing). Gingival inflammation may be influenced by certain ingredients in toothpaste; Shearer et al (2005) found that toothpaste can significantly reduce gingival inflammation and gingival bleeding as a result of the toothpaste’s ingredients. In this regard, Nordström and Birkhed (2009) demonstrated that rinsing the mouth after brushing causes a signifi cant reduction in the amount of toothpaste in both saliva and dental plaque. Further, Sjögren et al (1996) found that the clearance rate of toothpaste from the oral cavity is related to the duration of rinsing the mouth. The longer rinsing is performed, the more the toothpaste concentration in the oral cavity is reduced. This may provide a further possible explanation for our finding that brushing before flossing could sometimes cause less reduction in BPI compared to brushing after flossing. In contrast to women, the reduction of BPI with the BF method in men could be attributed to the fact that they usually tend to be less stringent in the performance of oral health behaviours. This may imply that, while participating in the study, the BF method increased the attention they paid to the brushing action prior to flossing, resulting in more BPI reduction. This study found that the effect of gender was significant on PI and BPI (P < 0.05), with males having significantly lower PI and higher BPI values than females. However, this disagrees with the results of Furata et al (2011), which showed that BPI and dental plaque levels were significantly lower in women than in men. The present finding that men had significantly lower PI and higher BPI scores than did women could be explained by the behavioural differences between the sexes. As females are known to be constistent in their oral hygiene habits, the male could have performed their oral hygiene measurements better just before the exam-
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ination than they would have routinely. This may explain the lower plaque indices and higher BPI scores observed.
CONCLUSION Flossing followed by brushing provides statistically significantly greater improvement over brushing followed by flossing with respect to plaque control only in males.
REFERENCES 1. Asadoorian J, Locker D. The impact of quality assurance programming: a comparison of two Canadian dental hygienist programs. J Dent Education 2006;70:965–971. 2. Berchier CE, Slot DE, Haps S, Van der Weijden GA. The efficacy of dental floss in addition to a toothbrush on plaque and parameters of gingival inflammation: a systematic review. Int J Dent Hygiene 2008;6:265–279. 3. Caves ES, Woo RC, Jones AA, Newbold DA, Manwell MA, Kornman KS. Relationship of bleeding on probing and gingival index bleeding as clinical parameters of gingival inflammation. J Clin Periodontol 1993;20:139–143. 4. Christou V, Timmerman MF, Van der Velden U, Van der Weijden GA. Comparison of different approaches of interdental oral hygiene: interdental brushes versus dental floss. J Periodontol 1998;69:759–764. 5. Crocombe LA, Brennan DS, Slade GD, Loc DO. Is self interdental cleaning associated with dental plaque levels, dental calculus, gingivitis and periodontal disease. J Periodont Res 2012;47:188–197. 6. Furata M, Ekuni D, Irie K, Azuma T, Tomofuji T, Ogura T, Morita M. Sex differences in gingivitis relate to interaction of oral health behaviors in young people. J Periodontol 2011;82:558–565. 7. Ge Z, Liu K-Z, Xiang X, Yang Q, Hui J, Kohlenberg E, Sowa MG. Assessment of local hemodynamics in periodontal inflammation using optical spectroscopy. J Periodontol 2011;82:1161–1168. 8. Hague AL, Carr MP. Efficacy of an automated flossing device in different regions of the mouth. J Periodontol 2007;78:1529–1537. 9. Hujoel P, Zina LG, Cunha-Cruz J, Lopez R. Historical perspectives on theories of periodontal disease etiology. Periodontol 2000 2012;58:153–160. 10. Jared H, Zhong Y, Rowe M, Ebisutani K, Tanaka T, Takase N. Clinical trial of a novel interdental brush cleaning system. J Clin Dent 2005;16:47–52. 11. Kuramitsu HK, He X, Lux R, Anderson MH, Shi W. Interspecies interactions within oral microbial communities. Microbiol Molecular Biol Rev 2007;71:653–670. 12. Lenox JA, Kopczyk RA. A clinical system for scoring a patient’s oral hygiene performance. J Am Dent Assoc 1973;86:849-852. 13. Lindhe J, Karring T, Lang NP. Clinical Periodontology and Implant Dentistry, ed 5. London: Blackwell, 2008: 705–733. 14. Löe H. oral hygiene in the prevention of caries and periodontal disease. Int Dent J 2000;50:129–139.
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Torkzaban et al 15. Marsh PD. Dental plaque as a biofilm and a microbial community – implications for health and disease. BMC Oral Health 2006;6(suppl 1):14. 16. Needleman I, Suvan J, Moles DR, Pimlott J. A systematic review of professional mechanical plaque removal for prevention of periodontal diseases. J Clin Periodontol 2005;32(suppl 6):229–282. 17. Newman MG, Takei HH, Klokkevold PR, Carranza FA. Clinical Periodontology, ed 11. St. Louis, MO: Elsevier/Saunders, 2010:34–54. 18. Nordström A, Birkhed D. Fluoride retention in proximal plaque and saliva using two NaF dentifrices containing 5,000 and 1,450 ppm F with and without water rinsing. Caries Res 2009;43:64–69. 19. O’Leary TJ, Drake RB, Naylor JE. The plaque control record. J Periodontol 1972;43:38-42. 20. Ostberg AL, Halling A, Lindblad U. Gender differences in knowledge, attitude, behavior and perceived oral health among adolescents. Acta Odontol Scand 1999;57:231– 236. 21. Periasamy S, Kolenbrander PE. Mutualistic biofilm communities develop with Porphyromonas gingivalis and initial, early, and late colonizers of enamel. J Bacteriol 2009;191:6804–6811. 22. Ravald N, Johansson CS. Tooth loss in periodontally treated patients. A long-term study of periodontal disease and root caries. J Clin Periodontol 2012;39:73–79. 23. Sambunjak D, Nickerson JW, Poklepovic T, Johnson TM, Imai P, Tugwell P, Worthington HV. Flossing for the management of periodontal disease and dental caries in adults. Cochrane database of systematic reviews 2011;12: Art.NO.: CD008829. DOI: 10.1002/14651858. CD008829.pub2.
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24. Schiff T, Proskin HM, Zhang YP, Petrone M, De Vizio W. A clinical investigation of the efficacy of three different treatment regimens for the control of plaque and gingivitis. J Clin Dent 2006;17:138–144. 25. Shearer B, Hall P, Clarke P, Marshall G, Kinane DF. Reducing variability and choosing ideal subjects for experimental gingivitis studies. J Clin Periodontol 2005;32:784–788. 26. Sjögren K, Birkhed D, Rangmar S, Reinhold AC. Fluoride in the interdental area after two different post-brushing water rinsing procedures. Caries Res 1996;30:194–199. 27. Sjögren K, Lundberg A, Birkhed D, Dudgedon DJ, Johnson MR. Interproximal plaque mass and fluoride retention after brushing and flossing – a comparative study of powered toothbrushing, manual toothbrushing and flossing. Oral Health Prev Dent 2004;69:759–764. 28. Slot DE, Dorfer CE, Van der Weijden GA. The efficacy of interdental brushes on plaque and parameters of periodontal inflammation: a systematic review. Int J Dent Hygiene 2008;6:253–264. 29. Tinsley BJ, Holtgrave DR, Reise SP, Erdley C, Cupp RG. Developmental status, gender,age and self-reported decision making influences on student’s risky and preventive health behaviors. Health Educ Q 1995;22:244–259. 30. Van Der Veijden F, Slot DE. oral hygiene in the prevention of periodontal diseases: the evidence. Periodontology 2000 2011;55:104–123. 31. Zimmer S, Kolbe C, Kaiser G, Krage T, Ommerborn M, Barthel C. Clinical efficacy of flossing versus use of antimicrobial rinses. J Periodontol 2006;77:1380–1385.
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The Efficacy of Brushing and Flossing Sequence on Control of Plaque and Gingival Inflammation Parviz Torkzabana/Seyed Reza Arabib/Sepideh Seyedzadeh Sabounchib/ Ghodratollah Roshanaeic Purpose: To evaluate the efficacy of brushing and flossing order on control of plaque and gingival inflammation. Materials and Methods: This cross-over clinical trial was conducted on 35 students recruited from the dental school at Hamadan University of Medical Sciences. The subjects were asked to use dental floss and then brush for a 2-week period (FB), followed by brushing and then using dental floss for another 2-week period (BF). For a 7-day washout interval between the two phases, the subjects practiced dental hygiene according to their habitual method. The participants received dental prophylaxis at the beginning and plaque control record (PCR), plaque index (PI) and bleeding point index (BPI) were measured at baseline and the end of both phases. The differences of indices between two phases were analysed with the Wilcoxon signed rank test; to assess the influence of sex and sequence on PCR, PI and BPI, analysis of covariance (ANCOVA) was used after adjustment of initial values. Results: The PCR and PI indices in the FB method were significantly lower than with the BF method (P < 0.05). The PI and PCR index differences between the two phases were significant in men but nonsignificant in women. The effect of gender on PI and BPI and the interaction effect of sex and sequence of brushing and flossing on BPI were significant (P < 0.05). Conclusions: Flossing followed by brushing provides more statistically significant improvements over brushing followed by flossing with respect to plaque control. Key words: dental brush, dental floss, dental hygiene, dental plaque, gingival bleeding Oral Health Prev Dent 2015;13:267-273 doi: 10.3290/j.ohpd.a32678
P
eriodontal disease is the disease of the supporting dental tissues and the most common form is plaque-induced gingivitis (Newman et al, 2010). Dental plaque is one of the common factors responsible for gingival inflammation; its removal from the tooth surface is the most essential action for preventing and treating periodontal disease (Löe, 2000; Marsh, 2006; Kuramitsu et al, 2007; Periasamy and Kolenbrander 2009; Hujoel et al, a
Associate Professor, Member of Hamadan Dental Research Center, Department of Periodontology, Faculty of Dentistry, Hamadan University of Medical Sciences, Hamadan, Iran.
b
Assistant Professor, Department of Periodontology, Faculty of Dentistry, Hamadan University of Medical Sciences, Hamadan, Iran.
c
Assistant Professor, Department of Biostatistics and Epidemiology, School of Public Health, Hamadan University of Medical Sciences, Hamadan, Iran.
Correspondence: Dr. Sepideh Seyedzadeh Sabounchi, Department of Periodontology, Faculty of Dentistry, Hamadan University of Medical Sciences, Hamadan, Iran. Tel: +98-811-838-1081, Fax: +98811-838-1085. Email: [email protected]
Vol 13, No 3, 2015
Submitted for publication: 17.03.13; accepted for publication: 17.07.13
2012; Ravald and Johansson 2012). Mechanical methods for plaque removal along with oral hygiene instructions are regarded as the first step in periodontal treatment (Christou et al, 1998; Needleman et al, 2005; Berchier et al, 2008). Toothbrush and toothpaste are still the most reliable means of dental plaque control, provided cleaning is sufficiently thorough and performed at regular intervals (Caves et al, 1993; Sjögren et al, 2004; Van Der Veijden and Slot 2011). Nevertheless, this means of plaque control is not adequate due to the limited ability of the toothbrush to reach the interdental areas (Asadoorian and Locker 2006; Berchier et al, 2008). These areas are the sites where plaque and inflammation are most pronounced (Lindhe et al, 2008) and regular interdental cleaning can result in better oral hygiene outcomes regarding dental plaque and gingivitis (Crocombe et al, 2012). Various products have been designed for accessing these sites, such as dental flosses, interdental brushes and wooden dental sticks (Slot et al, 2008). Of these,
267
Torkzaban et al
the most effective tool has been reported to be dental floss (Sambunjak et al, 2012). Bleeding on probing (BOP) and gingival indices are used for clinically describing the amount of gingival inflammation (Caves et al, 1993). BOP, one of the most commonly used diagnostic parameters, can be a sign of the local inflammatory response alterations related to destructive periodontitis (Ge et al, 2011). Dental brushes significantly reduce the dental plaque and BOP in all dental areas (Berchier et al, 2008). However, according to a systematic review, flossing in addition to toothbrushing is better able to reduce gingivitis compared to only toothbrushing and is associated with slightly greater reduction in plaque level (Sambunjak et al, 2011). It is possible that the sequence of using a toothbrush and dental floss may influence the removal of dental plaque and consequently the BPI. The purpose of this study was to investigate the sequence of brushing and flossing and its efficacy on controlling plaque and gingival inflammation.
MATERIALS AND METHODS This study was approved by the Institutional Review Board of Hamadan University of Medical Sciences. The study population consisted of dental students in their final year at Hamadan University of Medical Sciences’ dental school. Participants who had systemic diseases, gingivitis or periodontitis were excluded from the study. Other exclusion criteria were the use of antibiotics in the past 3 months, pregnancy, diabetes mellitus and smoking. After obtaining written consent forms, participants underwent dental prophylaxis treatment; in the next visit, baseline plaque index (PI), plaque control record (O’Leary et al, 1972) and bleeding on probing (bleeding point index, BPI; Lenox et al, 1973) were measured. Additionally, the Bass method of brushing and the appropriate method of flossing were taught to the participants during this baseline appointment. To ensure standardisation, identical toothbrushes (Oral-B; Kildare, Ireland), dental floss (Oral-B) and toothpaste (Crest, Procter and Gamble; Weybridge, Surrey, UK) were distributed. In order to compare the participants with themselves (cross-over design), they were studied in two phases with a 1-week wash-out interval. In the first phase of the study, the participants were asked to floss first and brush afterwards for two weeks (method FB). In the second phase, the participants were asked to do the opposite, i.e. floss after
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brushing, for another two weeks (method BF). In the interval period, the participants were asked to brush and floss according to their usual routine. Dental prophylaxis was repeated at the beginning of the second phase in order to create the same baseline conditions as at the start of the first phase and study indices were measured again. For measuring the plaque control record (PCR) (O’Leary index), disclosing tablets were given to the participants and the index was calculated as: number of surfaces with plaque × 100 total number of surfaces In order to measure plaque index (PI), plaque deposits on tooth surfaces were scored according to the Silness and Löe classification. The total plaque index was determined by dividing the sum of the scores by total tooth surfaces. • 0 = absence of plaque deposits • 1 = plaque detectable by running the periodontal probe along the gingival margin • 2 = visible plaque • 3 = abundant plaque Bleeding on probing was determined at the buccal, lingual and proximal surfaces using the BPI (Lenox et al, 1973). This was performed by inserting a periodontal probe 1 mm into the sulcus at the distal aspect of the tooth and moving it across the length of the sulcus to the mesial on the facial and lingual surfaces. Bleeding surfaces after 20–30 s were recorded. The percentage of the number of bleeding surfaces was calculated by dividing the sum of the number of bleeding surfaces by the total number of dental surfaces and multiplying by 100. At the end of each phase, the study parameters were measured again. The data were analysed with SPSS v.16 statistical software. The study indices were described using means and standard deviations (SD) and the differences of indices between two phases were analysed using the Wilcoxon signed-rank test. To assess the effect of gender and order of brushing and flossing on study indices after 2 weeks, analysis of covariance (ANCOVA) was used. The significance level was considered 0.05.
RESULTS Thirty-five participants were included in the study, 21 (60%) female and 14 (40%) male students. All (100%) of the participants remained until the end of the study.
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Table 1 Comparison of PI, PCR and BPI baseline scores between two hygiene methods Mean ± SD BF
FB
P-value
Total
0.88 ± 0.22
0.85 ± 0.64
0.18
Men
0.96 ± 0.28
0.87 ± 0.90
0.07
Women
0.81 ± 0.15
0.83 ± 0.25
0.88
Study Indices PI
PCR
BPI
Total
10.35 ± 7.38
10.40 ± 9.78
0.58
Men
11.98 ± 6.33
15.88 ± 8.95
0.10
Women
9.46 ± 8.03
6.02 ± 8.39
0.25
Total
18.01 ± 2.94
26.01 ± 24.94
0.11
Men
21.43 ± 1.99
32.59 ± 27.02
0.07
Women
15.47 ± 3.57
20.23 ± 22.93
0.30
SD: standard deviation.
Table 2 Comparison of PI, PCR and BPI scores after 2 weeks between two hygiene methods Mean ± SD Study indices
Frequency
BF
FB
P-value
PI
35
1.74 ± 0.49
1.61 ± 0.45
*0.01
PCR
35
45.4 ± 8.6
41.6 ± 7.6
*0.007
BPI
35
18.8 ± 18.6
16.7 ± 14.8
0.33
SD: standard deviation; * statistically significant.
Table 3 Comparison of PI, PCR and BPI scores after 2 weeks between two hygiene methods in males Mean ± SD Study indices
Frequency
BF
FB
P-value
PI
14
1.61 ± 0.74
1.39 ± 0.60
*0.007
PCR
14
49.2 ± 7.9
42.1 ± 7.8
*0.005
BPI
14
22.2 ± 21.3
22.4 ± 22.3
0.6
SD: standard deviation; * statistically significant.
Table 4 Comparison of PI, PCR and BPI scores after 2 weeks between two hygiene methods in females Mean ± SD Study indices
Frequency
BF
FB
P-value
PI
21
1.82 ± 0.21
1.76 ± 0.22
0.3
PCR
21
42.8 ± 8.2
41.3 ± 7.6
0.34
BPI
21
16.5 ± 16.9
12.9 ± 3.4
0.44
SD: standard deviation.
The means and standard deviations of the baseline study parameters are shown in Table 1. None of the baseline parameters differed significantly (P > 0.05) (Table 1). The PI and PCR indices with the FB method were significantly lower than with the BF method (P < 0.05). However, mean BPI was not significantly different between two methods
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(P > 0.05) (Table 2). Statistically significant differences among male participants for PI and PCR indices between two methods were observed (P < 0.05), but the BPI did not show a significant difference. In contrast, none of the indices exhibited significant differences between the two methods among female participants (Tables 3 and 4).
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Table 5 Comparison of BPI scores at baseline and after 2 weeks scores Mean ± SD Baseline
Hygiene methods BF
FB
After 2 weeks
P-value
Total
18.01 ± 2.94
18.8 ± 18.6
0.59
Men
21.43 ± 1.99
22.2 ± 21.3
0.75
Women
15.47 ± 3.57
16.5 ± 16.9
0.77
Total
26.01 ± 24.94
16.7 ± 14.8
0.08
Men
32.59 ± 27.02
22.4 ± 22.3
0.14
Women
20.23 ± 22.93
12.9 ± 3.4
0.21
SD: standard deviation.
Table 6 Evaluation of affected factors on study indices after 2 weeks according to ANCOVA Study indices
Factor
df
PI
Sequence Gender Sequence x sex (interaction effect)
PCR
BOP
P-value
MS
F
1
240.1
3.8
0.06
1
594.4
9.5
0.00*
1
32.3
0.5
0.48
Sequence
1
18.2
0.5
0.49
Gender
1
64.1
1.7
0.20
Sequence x sex (interaction effect)
1
4.4
0.1
0.74
Sequence
1
161.5
1.8
0.19
Gender
1
496.8
5.5
0.03*
Sequence x sex (interaction effect)
1
750.4
8.4
0.01*
df: degrees of freedom; MS: mean score; F: test statistic for ANCOVA. *Statistically significant.
The differences between baseline and 2-week BPI scores (total, men and women) of the two methods were not significant (P > 0.05) (Table 5). According to the results of ANCOVA, the order of brushing and flossing did not have a significant effect on periodontal indices after 2 weeks but the effect of sex on PI and BPI was significant (P < 0.05). The interaction effect of sex and order of brushing and flossing on BPI was significant, but it was not significant on other periodontal indices (Table 6 and Fig 1).
DISCUSSION The aim of this cross-over clinical trial was to determine the effect of the sequence of brushing and flossing on the control of plaque and gingival inflammation. The differences in the level of study indices between the two methods only reflected the relative efficacy of brushing and flossing sequence within the same individual. To eliminate the effects of phase one on study participants and therefore the results, a 1-week wash-out interval was held before starting phase 2.
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There was significant difference between the two phases regarding plaque index and plaque control record. The mean plaque index in the BF method after 2 weeks was 1.74 ± 0.49, with a range of 1.25 to 2.23. The mean plaque index in the FB method was 1.61 ± 0.45, with a range of 1.16 to 2.06. The mean plaque control record in the BF method after 2 weeks was 45.4% ± 8.6%, ranging from 36.8% to 54%. The mean plaque control record in the FB method was 41.6% ± 7.6%, ranging from 34% to 49.2%. Several studies have reported that flossing improves periodontal indices. Flossing first could be more effective in plaque control, because subsequent brushing can remove loosened plaque deposits. In the study done by Hague and Carr (2007), the efficacy of the use of an automated flossing device was evaluated in different areas of the mouth. Their results showed that the combined use of toothbrush and flossing yielded a greater reduction in the amount of plaque compared to the use of a toothbrush alone. However, the combined use of toothbrush and dental floss did not show a signifi cant difference in terms of gingivitis.
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Estimated Marginal Means of PI
sex male female
55
50
45
Estimated Marginal Means of PC
44
60
sex male female
42
40
38
36 FB
BF
FB
Sequence
BF Sequence
Estimated Marginal Means of BOP
Fig 1 Interaction effect between gender and sequence on study indices after 2 weeks. 22
sex male female
20 18 16 14
FB
BF Sequence
A study conducted by Jared et al (2005) compared different interdental toothbrushes. According to their results, the use of dental floss for 4 weeks reduced the plaque index more significantly than the use of the interdental brush alone. No signifi cant differences related to gingival parameters were found. The mean BPI between the two methods in this study did not differ significantly. In the BF method, the BPI after 2 weeks was 18.8% ± 18.6%, ranging from 0.2% to 37.4%. The mean BPI in the FB method was 16.7% ± 14.8% (range: 1.9% to 31.5%). In the study performed by Schiff et al (2006), three different plaque control protocols for treating gingivitis were compared. The results showed that there were no significant differences between the use of a toothbrush alone and combining it with dental floss in terms of reducing gingivitis. Zimmer et al (2006) compared the use of different oral hygiene devices/aids. The results showed there were no significant difference in plaque index or gingival bleeding index between using toothbrush alone and combined use of it with dental floss.
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In the present study, because dental prophylaxis was performed at the beginning of each phase, the result that PI and PCR scores were higher after 2 weeks vs baseline was expected. However, the bleeding on probing parameter does not change shortly after dental prophylaxis, and the comparison of baseline and 2-week results showed that the BPI score changed variously in the two phases. There was a nonsignificant increase in BPI scores (total, men and women) in the BF phase and nearly constant scores in the FB phase after 2 weeks (Table 5). The decrease of BPI in the FB phase could be the result of introducing the participants to oral hygiene instructions for the first time. The results of this study showed a statistically significant difference among male participants in PI and PCR indices between two methods (P < 0.05). The PI and PCR were significantly higher with the BF method, but the BPI showed no significant difference. Among female participants, none of the indices differed significantly between the two methods (Tables 2 and 3). More favourable oral health behaviours in females have been shown by several authors (Tinsley et al, 1995; Ostberg et al, 1999).
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Women are better informed about oral health and are more willing to seek dental help. This may suggest that they would implement oral health behaviours more conscientiously regardless of the sequence of measures performed. In contrast, the interaction of sex and sequence of brushing/flossing had a significant effect on BPI. The BPI with the BF method decreased in men but increased in women. The interaction effect was not significant for other study indices (Table 4 and Fig 1). The increased BPI in women using the BF method could be the result of a greater reduction in the amount of toothpaste in the saliva due to rinsing the mouth twice (once after brushing and once after flossing). Gingival inflammation may be influenced by certain ingredients in toothpaste; Shearer et al (2005) found that toothpaste can significantly reduce gingival inflammation and gingival bleeding as a result of the toothpaste’s ingredients. In this regard, Nordström and Birkhed (2009) demonstrated that rinsing the mouth after brushing causes a signifi cant reduction in the amount of toothpaste in both saliva and dental plaque. Further, Sjögren et al (1996) found that the clearance rate of toothpaste from the oral cavity is related to the duration of rinsing the mouth. The longer rinsing is performed, the more the toothpaste concentration in the oral cavity is reduced. This may provide a further possible explanation for our finding that brushing before flossing could sometimes cause less reduction in BPI compared to brushing after flossing. In contrast to women, the reduction of BPI with the BF method in men could be attributed to the fact that they usually tend to be less stringent in the performance of oral health behaviours. This may imply that, while participating in the study, the BF method increased the attention they paid to the brushing action prior to flossing, resulting in more BPI reduction. This study found that the effect of gender was significant on PI and BPI (P < 0.05), with males having significantly lower PI and higher BPI values than females. However, this disagrees with the results of Furata et al (2011), which showed that BPI and dental plaque levels were significantly lower in women than in men. The present finding that men had significantly lower PI and higher BPI scores than did women could be explained by the behavioural differences between the sexes. As females are known to be constistent in their oral hygiene habits, the male could have performed their oral hygiene measurements better just before the exam-
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ination than they would have routinely. This may explain the lower plaque indices and higher BPI scores observed.
CONCLUSION Flossing followed by brushing provides statistically significantly greater improvement over brushing followed by flossing with respect to plaque control only in males.
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