Evidence-based strategies for interdental cleaning: A practical decision tree and review of the literature

Objective : Although several studies have investigated the effectiveness of various interdental cleaning devices, there is a need for an evidence-based synopsis for clinicians to customize interdental hygiene instructions and provide specific devices for each patient. This literature review aims to establish an evidence-based decision-making tree recommending individualized approaches to interdental cleaning based on embrasure size and patient-specific conditions. Data sources: Specific keywords related to interdental cleaning were used to search and identify the existing literature in PubMed and the Cochrane Library. Through a series of review processes, qualifying studies were identified and assessed with respect to the inclusion criteria to establish the decision tree. Results: A total of 27 studies were included to support a decision tree. Traditional dental floss continues to remain the first choice for individuals of high motivation and good manual dexterity with type I closed embrasures. For individuals with closed embrasures, but lack of motivation and/or dexterity, the use of easy flossers, soft picks, oral irrigation, and small (0.6 to 0.7 mm) interdental brushes are alternatives. For individuals with type II and type III open embrasure spaces, an interdental brush has the highest evidence for its effectiveness to remove interdental plaque. However, two studies showed that residual plaque could be found over lingual embrasures and thus lingual approach of the interdental brush is sometimes needed. The use of gum stimulators and/or woodsticks continues to be supported when significant gingival inflammation is present. Conclusion: Each patient should be individually assessed and given tailored oral hygiene home care instructions for the most effective outcomes. The proposed decision tree provides clinicians with an evidence-based guideline to help customize the use of interdental cleaning devices for each patient.