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Summary Review/Periodontology

The effectiveness of interproximal oral hygiene aids

Question: What is the comparative effectiveness of interproximal oral hygiene aids?


Data sources

Medline, Embase and Web of Science databases. This was supplemented with searches of the journals; Journal of Periodontology, Journal of Clinical Periodontology, The International Journal of Periodontics and Restorative Dentistry and International Journal of Dental Hygiene.

Study selection

Randomised controlled trials assessing interproximal oral hygiene (IOH) aids in physically competent patients reporting gingival inflammation, plaque or probing depth with at least two weeks follow-up were included.

Data extraction and synthesis

Study selection and data abstraction were carried out independently by two reviewers. Risk of bias was assessed using the Cochrane tool. The primary outcomes were gingival index (GI) and bleeding on probing (BOP), and a random effects network meta-analysis (NMA) was carried out for each outcome.


Twenty-two studies involving a total of 2,030 patients were included. Sample sizes of the studies ranged from ten to 110 patients with follow-up periods of between four to 24 weeks. One study was considered to have a high risk of bias, 17 an unclear risk and four a low risk. A range of interproximal oral hygiene aids were tested including flossing (FL), powered flossing (FL2), toothpicks (TP), toothpicks and intensive oral hygiene instructions (TO), water jet irrigation devices (WJ), interdental brushes (IB), gum massaging devices (MD), toothbrush only (Ctrl), powered, electric, sonic toothbrush (Powered Ctrl) and powered control and water jet (PW). NMA for bleeding on probing saw the greatest reduction with toothpick and intensive oral hygiene instruction (26.4% [95% CI: 7.50, 45.4]); waterjet had the next largest reduction with an average of 19.3% (95% CI: 16.2%, 22.4%) with relatively smaller reductions for floss. The interdental brush was seen to be more efficacious than the majority of the alternative oral hygiene aids with a mean effect of 0.34 reduction in GI as compared with control (95% CI: 0.12, 0.56).


In the absence of strong evidence about IOH aids differences in the impact on patients, practitioners should customise IOH aid recommendations and offer alternatives rather than insisting on instruction on the use of a universally recommended cleaning aid. Further well designed and appropriately powered clinical trials are warranted to provide more authoritative guidelines on IOH selection.

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  1. Sambunjak D, Nickerson JW, Poklepovic T, Johnson TM, Imai P, Tugwell P, et al. Flossing for the management of periodontal diseases and dental caries in adults. Cochrane Database Syst Rev 2011; 12: Art. No.: CD008829. DOI:10.1002/14651858.CD008829.pub2.

  2. Poklepovic T, Worthington HV . Johnson TM et al. Interdental brushing for the prevention and control of periodontal diseases and dental caries in adults. Cochrane Database Syst Rev 2013; 12: Art. No.: CD009857. DOI: 10.1002/14651858.CD009857.pub2.

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Authors and Affiliations


Additional information

Address for correspondence: Georgios A. Kotsakis, Department of Periodontics, University of Washington, 1959 NE Pacific St, Seattle, WA 98195, USA. E-mail:

Kotsakis GA, Lian Q, Ioannou AL, Michalowicz BS, John MT, Chu H. A network meta-analysis of interproximal oral hygiene methods in the reduction of clinical indices of inflammation. J Periodontol 2018; 89: 558–570. doi: 10.1002/JPER.17-0368. Review. PubMed PMID: 29520910; PubMed Central PMCID:PMC5984142.

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Richards, D. The effectiveness of interproximal oral hygiene aids. Evid Based Dent 19, 107–108 (2018).

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