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The Journal of Clinical Dentistry ® THE INTERNATIONAL JOURNAL OF APPLIED DENTAL RESEARCH www.JClinDent.com Volume XVII 2006 Number 3 SENIOR EDITOR Robert C. Emling, EdD EDITORIAL BOARD Martin Addy, BDS, MSc, PhD, FDSRCS Jolán Bánóczy, MD, PhD, DSc Caren M. Barnes, RDH, MS Augusto R. Elias Boneta, DMD, MSD Annerose Borutta, Prof.Dr.med.habil. Robert L. Boyd, DDS, MEd Kenneth H. Burrell, DDS, MS Mark E. Cohen, PhD William Michael Edgar, PhD, DDSc, FDSRCS Denise Estafan, DDS, MS John D.B. Featherstone, MSc, PhD Ralph P. Feller, DMD, MS, MPH Stuart L. Fischman, DMD Rosa Helena Miranda Grande, DDS, PhD John J. Hefferren, PhD Elliot V. Hersh, DMD, PhD Mark E. Jensen, DDS, PhD Carl J. Kleber, MSD, PhD Israel Kleinberg, DDS, PhD, DSc Karl F. Leinfelder, DDS, MS John H. Manhold, MA, DMD Jonathan Mann, DMD, MSc Milton V. Marshall, PhD, DABT Pier Francesco Porciani, MD, MScD Howard M. Proskin, PhD Mark S. Putt, MSD, PhD Bruce R. Schemehorn, MS Warren Scherer, DDS Thomas Schiff, DMD Charles M. Schoenfeld, DDS, PhD Pramod M. Soparkar, BDS, DMD, MS Jon B. Suzuki, DDS, PhD, MBA Jason M. Tanzer, DMD, PhD Wei-Ming Tay, BDS, FDS, PhD Norman Tinanoff, DDS, MS Henry O. Trowbridge, DDS, PhD Richard I. Vogel, DMD James S. Wefel, PhD Wayne T. Wozniak, PhD Stefan Zimmer, Priv.-Doz. Dr. med. dent. Samuel L. Yankell, MS, PhD, RDH (Chair) PUBLISHER Stephen M. Siegel The Journal of?Clinical Dentistry (ISSN 0895-8831) is published by Professional Audience Communications, Inc., P.O. Box 243, Yardley, PA 19067. POSTMASTER; Send address changes to P. O. Box 8, Moorestown, NJ 08057. Copyright © 2006 by the YES Group, Inc. All rights reserved. No part of this publication may be reproduced without written permission from the publisher. Reprint Interproximal Gingivitis and Plaque Reduction by Four Interdental Products Kevin G. Yost, PhD Sunstar Americas, Inc. Chicago, IL, USA Mark E. Mallatt, DDS, MSD Indiana State Department of Health Indianapolis, IN, USA Joanne Liebman, RDH, MEd Hill Top Research West Palm Beach, FL, USA

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Page 1: The Journal of Clinical Dentistry - Ortho Technology · 80 The Journal of Clinical Dentistry Vol. XVII, No. 3 tips (all Sunstar Americas, Inc., Chicago, IL, USA). Flossers consist

The

Journal ofClinical Dentistry®

THE INTERNATIONAL JOURNAL OF APPLIED DENTAL RESEARCHwww.JClinDent.com

Volume XVII 2006 Number 3

SENIOR EDITORRobert C. Emling, EdD

EDITORIAL BOARDMartin Addy, BDS, MSc, PhD, FDSRCSJolán Bánóczy, MD, PhD, DScCaren M. Barnes, RDH, MSAugusto R. Elias Boneta, DMD, MSDAnnerose Borutta, Prof.Dr.med.habil.Robert L. Boyd, DDS, MEdKenneth H. Burrell, DDS, MSMark E. Cohen, PhDWilliam Michael Edgar, PhD, DDSc,FDSRCSDenise Estafan, DDS, MSJohn D.B. Featherstone, MSc, PhDRalph P. Feller, DMD, MS, MPHStuart L. Fischman, DMDRosa Helena Miranda Grande, DDS, PhDJohn J. Hefferren, PhDElliot V. Hersh, DMD, PhDMark E. Jensen, DDS, PhDCarl J. Kleber, MSD, PhDIsrael Kleinberg, DDS, PhD, DScKarl F. Leinfelder, DDS, MSJohn H. Manhold, MA, DMDJonathan Mann, DMD, MScMilton V. Marshall, PhD, DABTPier Francesco Porciani, MD, MScDHoward M. Proskin, PhDMark S. Putt, MSD, PhDBruce R. Schemehorn, MSWarren Scherer, DDSThomas Schiff, DMDCharles M. Schoenfeld, DDS, PhDPramod M. Soparkar, BDS, DMD, MSJon B. Suzuki, DDS, PhD, MBAJason M. Tanzer, DMD, PhDWei-Ming Tay, BDS, FDS, PhDNorman Tinanoff, DDS, MSHenry O. Trowbridge, DDS, PhDRichard I. Vogel, DMDJames S. Wefel, PhDWayne T. Wozniak, PhDStefan Zimmer, Priv.-Doz. Dr. med. dent.Samuel L. Yankell, MS, PhD, RDH (Chair)

PUBLISHERStephen M. Siegel

The Journal of?Clinical Dentistry (ISSN 0895-8831) is published by Professional Audience Communications, Inc., P.O. Box 243, Yardley, PA 19067.POSTMASTER; Send address changes to P. O. Box 8, Moorestown, NJ 08057.Copyright © 2006 by the YES Group, Inc. All rights reserved. No part of this publication may be reproduced without written permission from the publisher.

Reprint

Interproximal Gingivitis and Plaque Reductionby Four Interdental Products

Kevin G. Yost, PhD

Sunstar Americas, Inc.Chicago, IL, USA

Mark E. Mallatt, DDS, MSD

Indiana State Department of HealthIndianapolis, IN, USA

Joanne Liebman, RDH, MEd

Hill Top ResearchWest Palm Beach, FL, USA

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Abstract• Objective: The study was conducted to compare the performance of three interdental products to dental floss in the control and

removal of plaque, and in the reduction of gingivitis.• Methodology: One-hundred and twenty subjects were screened for the presence of interproximal sites of a size suitable for a GUM®

Go-Betweens® cleaner, and for being in compliance with inclusion and exclusion criteria. They were then assessed with thePlaque, Gingivitis, and Eastman Interdental Bleeding Indices (EIBI) at baseline, given a prophylaxis, randomly assigned to one offour products (Glide® dental floss, Butler® flossers, GUM® Go-Betweens® cleaners, and GUM® Soft-Picks® cleaners), and givenproduct use instructions. Subjects returned at three weeks for a compliance review and at six weeks for a final visit. Plaque wasassessed at the final visit before and after using the assigned products. Plaque, gingivitis, and bleeding scores were evaluated byanalysis of covariance using the baseline measurements as the covariate.

• Results: All four interdental products significantly reduced interdental plaque from baseline to before-use at the final visit (aftersix weeks) employing baseline plaque as a covariate. Reductions were 16% to 24%. Similarly, use of the products at the final visitresulted in 26% to 31% reductions in plaque with the before-use plaque as a covariate. Interdental gingivitis scores showed a reductionboth lingually and buccally, with reductions ranging from 27% to 36% for the former and 34% to 53% for the latter (baseline wasthe covariate). No statistical differences were found between the products on the lingual interdental sites. The Go-Betweens clean-ers showed a statistically greater reduction in the Gingival Index score buccally than the other three products. No differences werenoted among the products for the EIBI.

• Conclusion: In this study, dental floss, the recognized “gold standard” for gingivitis reduction, was matched in performance byflossers and an interdental cleaner with small elastomeric fingers, and surpassed by an interdental brush. All products performedcomparably for plaque reduction and removal.

(J Clin Dent 17:79–83, 2006)

79

IntroductionToothbrushes are the primary and most frequently used tool

for maintaining good oral hygiene. About 98% of Americansuse a toothbrush to clean their teeth. However, tooth brushing isnot enough. With a good design and careful technique a tooth-brush can clean into the embrasure, the open and easily accessi-ble area between teeth. Toothbrush bristles cannot properly pen-etrate under the contact and thoroughly clean interproximalspaces.1

It has long been known the most severe gingivitis occurs inter-proximally.2 Mechanical cleaning has even been found to per-form better than chemical treatment in reducing gingivitis.1 TheAmerican Dental Association recommends the use of dentalfloss for complete between-teeth cleaning. By disturbing andremoving plaque, flossing has become the standard of care sinceit reaches the area where gingivitis starts and is often missedwhen brushing. Traditional dental floss is not easy to use, how-ever, presenting a barrier to achieving good oral care to those withreduced dexterity or an inability or unwillingness to devote timeto the flossing procedure.

Alternatives to traditional floss include single-use flossers andinterdental brushes. Previous studies have examined the plaqueremoval capabilities of interdental brushes to floss with varyingresults.3-7 In particular, Yamamoto, et al.4 found the addition offlossing to brushing resulted in an increase in plaque removal, andthe use of an interdental brush with regular brushing removedeven more plaque. This study compared the plaque removal andgingivitis reduction capabilities of a flosser, a fine, small-diame-ter, interdental brush, and an interdental cleaner with small syn-thetic rubber fingers, to those of traditional dental floss.

Materials and MethodsStudy Population

Study participants were chosen from an urban and suburbanpopulation in Florida. A total of 154 subjects were screened andsigned the consent form, with 128 meeting all the study criteriato be enrolled and randomized. An additional eight subjectswere dropped after randomization with the remaining 120subjects completing the study. A summary of the demographicsappears in Table I.

Interproximal Gingivitis and Plaque Reduction by Four Interdental ProductsKevin G. Yost, PhD

Sunstar Americas, Inc.Chicago, IL, USA

Mark E. Mallatt, DDS, MSD

Indiana State Department of HealthIndianapolis, IN, USA

Joanne Liebman, RDH, MEd

Hill Top ResearchWest Palm Beach, FL, USA

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80 The Journal of Clinical Dentistry Vol. XVII, No. 3

tips (all Sunstar Americas, Inc., Chicago, IL, USA). Flossersconsist of a short piece of floss held between tines of a device forsingle-use flossing. The Go-Betweens Cleaners interdentalbrushes have a handle molded around the twisted wire of a smallcylindrical brush. The Soft-Picks interdental cleaners resemblethe brushes, but do not have metal or fiber bristles. Instead, theyhave small elastomeric fingers protruding perpendicularly froma plastic core. Subjects were also provided Crest® Regular tooth-paste (Procter & Gamble, Cincinnati, OH, USA) and GUM®

430 soft toothbrushes (Sunstar Americas, Inc., Chicago, IL, USA).There was no negative control.

Statistical analysis was performed using JMP 3.2 (SAS Insti-tute Inc., Cary, NC, USA) software.

ResultsNot all sites in the subjects’ mouths were considered suitable

for the study since the interproximal areas needed to be acces-sible to all of the types of products tested. Figure 1 shows the fre-quency of sites meeting this criterion in the maxilla andmandible. As would be expected, sufficiently accessible siteswere more frequently found toward the back of the mouth, al-though missing teeth reduced the number of posterior sites.

For plaque, the within-treatment analyses were conducted uti-lizing Student’s t-test for paired data to evaluate the changes frombaseline to before-use at the final visit. The same method wasused to compare the before-use plaque levels at the final visit tothe after-use levels at the final visit (Table II, Figure 2). Those re-sults indicated statistically significant changes for all productstested.

The between-treatment analyses were conducted with ananalysis of covariance, using the baseline plaque level as the co-variate for the analysis of mean change from baseline, and theplaque level at the final visit before-use as the covariate for thechange at the final visit from before- to after-use. The results ofthose analyses indicated no significant differences between treat-ments (Table III).

Within-treatment analyses of gingivitis changes from baselineto the final visit using the Student’s t-test for paired data are pre-sented in Table IV and Figures 3a and 3b. Means for the wholemouth, and separate analyses of the changes for the lingual andbuccal aspects are shown. All products showed statistically sig-

Although all four treatments are intended for cleaning of theinterproximal spaces, the products are of different sizes and fitinto different size interdental spaces. For any qualified subject touse any of the four treatments, an interproximal site in a subject’smouth was identified for treatment if the site could accommodatethe interdental brush. To be included in the study, subjects wererequired to have at least five interproximal sites of this size withadjacent teeth being natural dentition, as well as having a meanplaque score of at least 1.5 and a mean gingival score of at least1.0. The subjects needed to have the ability to floss, though werenot to be current floss users.

Subjects were excluded if they were on antibiotic or anti-coagulant therapy, steroids, or other anti-inflammatory productswithin the previous month (acetaminophen and 81 mg dailyaspirin were not considered anti-inflammatory). Diabetes,rheumatic fever, hepatic or renal disease, gross caries or otherhard tissue pathology, other transmissible diseases, heavy cal-culus, orthodontics, prosthodontics, piercings, and allergy to redfood dye were each also a basis for exclusion.

Study ProceduresAt the baseline visit, subjects presented having refrained from

oral hygiene procedures for the previous 12–18 hours. Exami-nations were performed in the order of oral soft tissue, gingivi-tis (Löe and Silness Gingival Index5), plaque level (Benson mod-ification of the Quigley-Hein Index6), and interdental bleeding(Eastman Interdental Bleeding Index,7 EIBI). Subjects weregiven a prophylaxis to remove all supragingival calculus andplaque, randomly assigned one of the four test products, andgiven product use and diary instructions. Product use by thesubjects was supervised at this visit to ensure the product wasused correctly. The subject was informed of the designated in-terdental sites to be treated with the assigned product once daily.

Subjects returned at three weeks for a medical/dental historyupdate, diary and compliance review, and additional product asneeded.

At six weeks, subjects again presented at the site having re-frained from oral hygiene for 12–18 hours. An oral soft tissueexam was followed by gingivitis and plaque examinations of thedesignated sites. The subjects used their assigned product in aseparate area to maintain examiner blinding, followed by a re-peated plaque exam and an EIBI assessment.

Products TestedThe four test products were Crest® Glide® original dental

floss (Procter & Gamble, Cincinnati, OH, USA) as the positivecontrol, Butler® Flossers, GUM® Go-Betweens® Cleaners, avery small interdental brush, and GUM® Soft-Picks® interden-tal cleaners, plastic cleaners with elastomeric (synthetic rubber)

Table I Study Demographics

Females: 83 Age mean and range: 39.6; 18–63Males: 37 Age mean and range: 35.1; 19–57

Caucasian: 71 Smokers: 12African American: 19 Non-Smokers: 108

Hispanic: 27Other: 3

Figure 1. Total number of sites found at each arch location across all subjects.

0

10

20

30

40

50

60

70

80

90

100

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Tooth Number

Nu

mb

er o

f S

ites

Maxilla

Mandible

Right Side Left Side

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Vol. XVII, No. 3 The Journal of Clinical Dentistry 81

nificant reductions in gingivitis, both lingually and buccally.For gingivitis, the between-treatment analyses were conducted

separately of the mean change from baseline for the lingual andbuccal sites, utilizing analysis of covariance with the baseline

gingivitis level as the covariate. The results of those analyses in-dicated no significant differences between treatments for the lin-gual sites, but a significant difference between the treatments atthe buccal sites favoring the gingivitis reduction achieved bythe Go-Betweens Cleaners (Table V).

With a statistically significant result for the analysis of co-variance for the buccal sites, the four treatments were compared

Table VAnalysis of Covariance of Gingivitis Level Changes fromBaseline to Final Visit for the Lingual and Buccal Sites

Gingivitis—Between-treatment AnalysesLingual Sites

Least Squares Means (Changes from Baseline)

Flossers Glide Floss Go-Betweens Soft-Picks0.390 0.397 0.533 0.445

Analysis of Covariance p-value: Significant Comparisons:0.3016 No significant differences between products

Buccal SitesLeast Squares Means (Changes from Baseline)

Flossers Glide Floss Go-Betweens Soft-Picks0.475 0.417 0.647 0.450

Analysis of Covariance p-value: Significant Comparisons:0.0208 Go-Betweens vs. other three products

Table IIIBetween-treatment Analysis of Covariance of Plaque LevelChanges from Baseline to Final Visit Before-use, and of the

Plaque Removed at the Final Visit During Use

Plaque—Between-treatment AnalysesLeast Squares Means Changes: Baseline to Final Visit Before-use

Flossers Glide Floss Go-Betweens Soft-Picks0.577 0.395 0.491 0.410

Analysis of Covariance p-value: Significant Comparisons:0.3375 No significant differences between products

Least Squares Means Changes: Final Visit from Before to After Use

Flossers Glide Floss Go-Betweens Soft-Picks0.619 0.540 0.558 0.506

Analysis of Covariance p-value: Significant Comparisons:0.2623 No significant differences between products

Figure 2. Whole mouth plaque levels (as Plaque Index) at baseline, at the finalvisit before product use, and at the final visit after product use. Error bars arestandard errors.

Plaque Levels

0

0.5

1

1.5

2

2.5

3

Flossers Glide Go-Betw eens Soft-Picks

Baseline

Final Before

Final After

Table IIAnalysis of Changes from Baseline Plaque

Utilizing Student’s t-test for Paired Data

Plaque Index

Mean t-test %Evaluation n Mean Change* p-value Change

Baseline 2.60 — — —Flossers Before Use at Final Visit 28 1.98 0.62 < 0.0001 24%

After Use at Final Visit 1.36 0.62 < 0.0001 31%

Baseline 2.46 — — —Glide Floss Before Use at Final Visit 31 2.06 0.40 < 0.001 16%

After Use at Final Visit 1.51 0.55 < 0.0001 27%

Baseline 2.30 — — —Go-Betweens Before Use at Final Visit 31 1.84 0.47 < 0.001 20%

After Use at Final Visit 1.29 0.55 < 0.001 30%

Baseline 2.34 — — —Soft-Picks Before Use at Final Visit 30 1.95 0.39 < 0.001 17%

After Use at Final Visit 1.44 0.51 < 0.0001 26%

*Indicates change from baseline to before-use at final visit and change frombefore-use at final visit to after-use at final visit.

Table IVAnalysis of Changes from Baseline Gingivitis

Utilizing Student’s t-test for Paired Data

Gingivitis Index

Whole Lingual Lingual Buccal BuccalMouth Lingual Mean t-test % Buccal Mean t-test %

Evaluation n Mean Mean Change p-value Change Mean Change p-value Change

Baseline 1.35 1.47 1.23Flossers

Final Visit28

0.91 1.070.39 < 0.0001 27%

0.760.48 < 0.0001 39%

Baseline 1.36 1.49 1.23Glide Floss

Final Visit31

0.95 1.090.40 < 0.0001 27%

0.810.42 < 0.0001 34%

Baseline 1.38 1.49 1.27Go-Betweens

Final Visit31

0.78 0.960.54 < 0.0001 36%

0.610.66 < 0.0001 53%

Baseline 1.31 1.46 1.17Soft-Picks

Final Visit30

0.88 1.020.44 < 0.0001 32%

0.740.43 < 0.0001 37%

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82 The Journal of Clinical Dentistry Vol. XVII, No. 3

directly. As shown in Table VI, the Go-Betweens Cleaners werefound to have achieved a statistically significantly greater re-duction than the other three products. No difference was foundamong these other three products.

Interdental bleeding was measured using the EIBI. Thechanges from baseline to the final visit for each group are shownin Table VII. Each product achieved a significant reduction in theEIBI over the six-week trial. The between-treatment analyseswere conducted utilizing analysis of covariance, with the base-line EIBI level utilized as the covariate for the analysis of meanchange from baseline. The results of the analysis indicated no sig-nificant differences between treatments (Table VIII).

Although the EIBI change for Go-Betweens was greatest, itwas not statistically significant. Of the 120 subjects, four hadEIBI scores of 0 at baseline, two in each of the Glide and Go-Betweens groups. Among these, three had scores greater than 0at the final visit. Yet, at the end of the study, 47 subjects had EIBIscores of 0, as shown in Table IX.

DiscussionA primary means of personal oral hygiene is the removal, or

at least the disturbance, of dental plaque. The result of suchtreatment can reduce gingivitis. This study has sought to assessthe effects of three less well known tools in the prevention andtreatment of gingivitis in comparison to dental floss, the standardfor interproximal gingival care.

Flossers can be considered more acceptable for use by thosewho cannot hold traditional floss, or who prefer to floss with justone hand while “on the go.” Interdental brushes have been pro-posed as superior devices for cleaning larger interproximal spacessince the brush can conform to the space. Recently introducedonto the market, GUM Soft-Picks are interdental cleaners simi-lar to an interdental brush, but without wire and having smallelastomeric fingers rather than typical fiber bristles.

In this study, all four of the tested products were shown to re-move plaque when used in conjunction with normal tooth brush-ing, as shown at the final visit when plaque levels on the teethwere assessed before and after use of the designated product.Each product also effected a reduction in plaque levels in con-junction with tooth brushing, as shown by the reduction frombaseline to the six-week visit. Since there was not a cell of toothbrushing alone without any other interdental cleaning regimen,

Table VIComparison of Mean Changes in Gingivitis Levelfrom Baseline to Final Assessment Between theFour Treatments Evaluated with a t-test for theSignificance of the Magnitude of the Difference

Glide Go-Betweens Soft-Pickst-test t-test t-test

Diff. p-value Diff. p-value Diff. p-value

Flossers 0.058 0.4731 –0.172 0.0349 0.025 0.7611Glide –0.229 0.0041 –0.033 0.6774Go-Betweens 0.196 0.0152

Table VIIIAnalysis of Covariance of EIBI Level Changes

from Baseline to Final Visit

EIBI—Between-treatment AnalysesLeast Squares Means of Changes from Baseline

Flossers Glide Floss Go-Betweens Soft-Picks0.370 0.442 0.535 0.445

Analysis of Covariance p-value: Significant Comparisons:0.1985 No significant differences between products

Table VIIChanges from Baseline of EIBI Evaluated

with Student’s t-test for Paired Data

Eastman Interdental Bleeding Index

EIBIEIBI Mean t-test %

Evaluation n Mean Change p-value Change

Baseline 0.73Flossers

Final Visit 28 0.41 < 0.0001 56%

Baseline 0.58Glide Floss

Final Visit 31 0.23 0.36 < 0.0001 62%

Baseline 0.64Go-Betweens

Final Visit 31 0.14 0.50 < 0.0001 78%

Baseline 0.79Soft-Picks

Final Visit 30 0.26 0.53 < 0.0001 67%

Table IXNumber of Subjects with EIBI Scoresof 0 or Greater than 0 at Final Visit*

Flossers Glide Floss Go-Betweens Soft-Picks

> 0 19 21 15 18= 0 9 10 16 12

*A Chi-square test shows this is not significant, p = 0.3613.

Figure 3a and 3b. Lingual (a) and buccal (b) gingivitis levels (as GingivitisIndex) at baseline and at the final visit. Error bars are standard errors.

Lingual Gingivitis

0

0.4

0.8

1.2

1.6

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Flossers Glide Floss Go-Betweens Soft-Picks

Gin

giv

itis

In

dex (

GI)

Baseline

Final Visit

Buccal Gingivitis

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Flossers Glide Floss Go-Betweens Soft-Picks

Gin

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GI)

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Final Visit

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Vol. XVII, No. 3 The Journal of Clinical Dentistry 83

this reduction over the six weeks cannot be attributed to thecleaners alone. All four of the cleaners achieved the same levelof plaque reduction as determined through an analysis of co-variance of the data.

The four products were also assessed for their effect on gin-givitis as measured by the Gingival Index, and all four achieveda reduction in inflammation. Although a slight difference inmean values was observed on lingual gingiva, there was no sta-tistical difference. The improvement achieved on the buccal gin-giva was seen to be statistically different among the products. Inthe least squared means found in the analysis of covariance of thereduction in the Gingival Index, the Go-Betweens cleanersshowed a significantly greater reduction than the other threeproducts on the buccal aspect, and achieved a 55% greater re-duction than the Glide dental floss ([0.647–0.417]/0.417 = 55%).No difference was noted between the flossers and the dentalfloss, although the two products differ in material and construc-tion. The floss was a polytetrafluoroethylene monofilament andvery slippery with little texture. The floss in the flosser, a multi-filament strand of polyester, provided greater texture and frictionagainst the tooth. The elastomeric fingers of the Soft-Picks inter-dental cleaners appeared to provide good clinical performance,as it both removed plaque and reduced gingivitis at levels indis-tinguishable from the dental floss standard.

Traditional floss and flossers can access and clean the smallspaces inaccessible to other interdental cleaners, and is preferredin those locations. Still, using traditional dental floss can be dif-ficult or inconvenient. There are a number of alternative devicesavailable for cleaning many interproximal spaces, and in thisstudy three alternative products were all able to remove plaquefrom the selected embrasures comparably to dental floss in

conjunction with tooth brushing, although no differences werefound. Their effects upon plaque accumulation over the sixweeks of the study also did not differ. In assessing gingivitis, thethree alternative products were able to achieve large reductionsin inflammation comparable to the standard for interdental care,dental floss. On the buccal surfaces, the greatest reduction in dis-ease was achieved with the Go-Betweens Cleaners interdentalbrush.

Acknowledgment: This article was written with special thanks and inmemoriam to Philip Mallatt, DDS. The authors wish to thank James P. Bowman,MS of Hill Top Research for his critical assistance in reviewing the statisticalanalysis, and Diana Gold, BA, CCRC for her diligence in conducting the study.This study was supported by Sunstar Americas, Inc.

For further correspondence with the author(s) of this paper,contact Richard Demke—[email protected].

References1. Caton JG, Blieden TM, Lowenguth RA, Frantz BJ, Wagener CJ, Doblin JM,

Stein SH, Proskin HM: Comparison between mechanical cleaning and an anti-microbial rinse for the treatment and prevention of interdental gingivitis. J ClinPeriodontol 20:172–178, 1993.

2. Linde J, Koch G: The effect of supervised oral hygiene on the gingiva of chil-dren. J Periodont Res 2:215–220, 1967.

3. Gjermo P, Flotra L: The effect of different methods of interdental cleaning.J Periodont Res 5:230–236, 1970.

4. Yamamoto N, Hasegawa K, Sueda T, Kinoshita S: The effects of interdentalbrush and dental floss in the reduction of interdental plaque. Nippon ShishubyoGakkai Kaishi 17:258–264, 1975.

5. Löe H, Silness J: Periodontal disease in pregnancy. I. Prevalence and sever-ity. Acta Odontol Scand 21:533–551, 1963.

6. Benson B, Henyon G, Grossman E: Clinical plaque removal efficacy of threetoothbrushes. J Clin Dent 4:21–25, 1993.

7. Caton JG, Polson AM. The interdental bleeding index: A simplified procedurefor monitoring gingival health. Compend Cont Educ Dent 6:88, 90–92, 1985.