Studies of powered interdental tools

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Discussion

Main result

Based on the findings of the synthesis of the individual studies, power interdental tools in conjunction with tooth brushing has a capability to increase oral health in a generally healthy population with gingivitis. The strongest argument for this conclusion is the power interdental tools ability to reduce gingival bleeding, a clinical sign of gingival inflammation. All of the studies (14/14) showed a significant lowering of bleeding scores for the power interdental tools at end of study. Three out of five studies comparing power interdental tools to tooth brushing alone found the power interdental tools to have an additional effect and ten out of ten studies found them to be as efficient or more efficient than tooth brush and floss at reducing bleeding.

Methodological discussion

A systematic review was chosen as the best method for gathering as much evidence as possible to answer the research question. A systematic review of scientific studies is an efficient method to gather evidence for a certain method or recommendation in the field of health-care where the demands for evidence based care is predominant (Rosén, 2012). A systematic review built on randomized controlled trials may provide strong evidence as the method of randomization is a well-accepted method to avoid the risk of systematic errors (Wallengren & Henricson, 2012). The strength of the design of a systematic literature review lies within the systematic search for, selection and quality assessment of relevant literature are performed systematically (SBU, 2016). This review has followed a protocol (PRISMA, 2009) to ensure a systematic approach. PRISMA is an evidence-based minimum set of items for reporting in systematic reviews and meta-analyses. PRISMA focuses on the reporting of reviews evaluating randomized trials, but can also be used as a basis for reporting systematic reviews or other types of research, particularly evaluations of interventions.
This literature study aimed at investigating the adjunctive effect of powered interdental tools on periodontal health. The databases searched (PubMed and Cochrane library) are two regularly used databases with a large number of studies in the field of medicine. Another relevant database to search would have been EMBASE, an Elsevier database including all of Medline plus over 2, 000 extra titles (including more EU journals). However, it was not included in the available databases of Jönköping university.
A strength of this study is that it builds on RCT’s only. RCT’s have the highest quality rating due to the randomization process being an important part of avoiding bias in a study (SBU, 2016). However, RCT’s can be of different quality and need to be assessed for risk of bias. This has been done following the SBU protocol for assessing bias in RCT studies (SBU, 2016). Although following a protocol for judging bias is a strength for this study the problem with the SBU protocol is that the total risk of each individual study is to be discussed and evaluated by two authors. The evaluation of bias in this study is done by the author alone and therefore not in accordance with the guidelines of the SBU.

Discussion of study results

Outcome measures in relation to research question
The research question aimed at investigating if power driven interdental tools could benefit the patient in better plaque removal and preventing gingivitis and by that improving oral health. As plaque is a cause of gingival inflammation (Lindhe et al., 2003) and gingival inflammation is clinically diagnosed by amongst other measures, bleeding (Lindhe et al., 2003), the three outcome measures – plaque, gingivitis and bleeding are relevant to investigating the research question.
Dental floss as control
Comparison was to be made with tooth brushing alone or tooth brushing with any non-power interdental tool. In the studies found, the only non-power interdental tool used as control was dental floss. As tooth brushing only has a marginal effect on interdental spaces, (Manson, 1986) any interdental tool is expected to give an additional effect. Dental floss has traditionally been the most recommended self-care product for patient’s regular oral hygiene routines (ADA, 2014). To use dental floss as the control suggests a wide acceptance that dental floss has an additional effect on plaque and gingivitis. A study of Sambunjak et al., (2011) supports this theory, even if evidence is deemed weak, however studies by Berchieret al. (2008) found this evidence unreliable. Studies have shown better efficacy by interdental brushes and tooth-picks (Sälzer et al., 2015).
The results from the miscellaneous group of “other power interdental tools” in this review show a reduction of plaque, gingivitis and bleeding at the same level as dental floss. As none of the studies have a control of tooth brushing only it is difficult to say if they have an additional effect on tooth-brushing alone. Therefore, there is an uncertainty of the relevance in comparing the power interdental tools to floss, to what extent being as efficient as dental floss is a proof of efficacy.
Efficacy of oral irrigators
Husseini (2008) didn’t find a benefit of using oral irrigators beyond tooth brushing on plaque build-up in a systematic review, but observed that the oral irrigators had an adjunctive effect on gingival index and bleeding scores. Out of the five studies on oral irrigation included in this review, only two (1, 5) reports a favourable plaque reducing score amongst the oral irrigators compared to tooth-brush alone, but all five reports a significant reduction of bleeding (1, 2, 3, 5, 9) and four a significant reduction of gingival inflammation (1, 3, 5, 9). This is consistent with the findings of Husseini (2008). In a study investigating oral irrigators with Chlorhexidine (Chaves et al., 1994) inflammation was significantly reduced which is in accordance with the studies by Lang & Räber (1981) and Newman et al., (1990). However, the study also reported the group using oral irrigation with water to improve gingivitis and bleeding scores without reducing plaque build-up. A study by Cutler et al (2000) supports the theory behind the phenomena, and suggests oral irrigation with water disrupts the cytokine levels in plaque and therefore has the ability to reduce gingivitis and bleeding without necessarily reducing amount of plaque. A study on implants (10) found the same effect around implants and suggests that the mechanisms behind oral irrigation on gingivitis may also be applied on mucositis.

Introduction
Plaque
Gingivitis
Bleeding
Plaque removal
Tooth-brushing
Interdental cleaning
Studies of powered interdental tools
Efficacy of oral irrigators
Objective and focused question
Materials & method
Design
Eligibility criteria
Information source
Search strategy
Data extraction & analysis
Ethical considerations
Results
Screening & selection
Presentation of study results
Study design & evaluation period
Study population
Reported outcome variables
Risk of bias within studies
Synthesis of the results
Results of individual studies
Discussion
Main result
Methodological discussion
Discussion of study results
Clinical relevance
Limitations and need for further research
Conclusion
References
GET THE COMPLETE PROJECT
The efficacy of power driven interdental tools as an addition to tooth-brushing on plaque removal and gingivitis in humans