Periodontal disease is a major public health problem, characterized by irreversible tooth loss, increase risk of adverse systemic conditions such as cardiovascular disease and preterm birth. Periodontitis presents itself in the form of gingivitis or periodontal pockets/periodontitis. Gingivitis always precedes the later, but the reverse may not be true. Furthermore, gingivitis does not progress to periodontitis which could be a major contributing factor of neglect by the patients. Authors have suggested that bacterial infection medicated by host response is the main etiology behind gingival and periodontal tissue inflammation. Daily removal of plaque can thus help to prevent the disease, though not completely. The daily use of oral irrigation has shown to reduce gingivitis and microbial growth but its economic feasibility in low socio-economic setup is questionable. Dental plaque is the primary etiology for chronic gingivitis that may develop within 10–21 days in the absence of total plaque control. Approximately 50% of the population over the age of 30 years has some form of gingivitis. Although mechanical plaque control can be an effective strategy for preventing the progression of periodontal diseases, most individuals do not adequately brush their teeth, and only 11%–51% of the population admits to using dental floss or some type of interdental cleaning device on a daily basis. The complete plaque control not only demands a very high motivation level but also needs to be supplemented with a good amount of manual dexterity and sticking to the oral hygiene regime recommended by the dentist. It is not only the hard tissue that serve as a platform for the plaque formation but also the oral mucosa and the tongue that are colonized by the plaque. The soft tissues in fact serve as a potent reservoir of bacteria that can recolonize in future on the teeth surfaces. Gingivitis and periodontitis are among one of the most prevalent infections affecting the oral cavity, making it essential for dental professionals to encompass risk assessment and disease management for their patients to insure a healthier outcome. Hence a regular cleaning is necessary, especially in the interdental areas for removal of plaque and to prevent gingivitis and periodontitis by means apart from the regular brushing. The most common and affordable ways of achieving this is through the use of dental floss. Although other interdental aids have been developed, flossing still remains a popular and affordable means for most of the population. The present study was thus carried out to evaluate the effect of flossing with an unwaxed dental floss apart from toothbrushing as an effective means to reduce gingival inflammation.
MATERIALS AND METHODS
Ethical clearance was obtained at the start of the study from the Ethical Committee of Azam Campus on 27/12/2017 (ethical approval letter no. NDC/IEC/271217/GINGIVITIS). The study was an open-labeled nonexperimental clinical study. A total of 60 adult patients between 20 and 50 years were selected from those reporting to the institution from January to March 2018; randomly assigned by lottery method to two groups – one Group A with only manual toothbrushing (Oral B) and the Group B with manual toothbrushing (Oral B) and flossing with an unwaxed dental floss (Colgate). The participants were free of any known systemic illness or substance abuse. A written informed consent was obtained from all the participants before the start of the study. All the participants were provided the same type of toothbrushes (soft bristle and flat surface) and the dental floss was also supplied to the Group B participants. The study was carried out for 28 days. The Group A participants were asked to brush twice daily using manual toothbrushing. Group B participants were instructed to use the unwaxed dental floss every night before bed, apart from brushing twice. The correct method of using the dental floss, i.e., wrapping the floss of 18 inches around the middle fingers, use of the index finger along with the thumb to guide the floss in an up and down movements in between the teeth was demonstrated to the patients, they were asked to perform it in front of the examiner and also were provided with a video of the same procedure. Every evening a reminder was given to the participants of Group B to floss after brushing. Both the groups were evaluated by a calibrated examiner at baseline, after 14 days (first follow-up) and after 28 days (second follow-up). The gingival index was recorded using the Loe and Sillness index while the gingival bleeding was scored using the Carter and Barnes Bleeding Index. The proximal/interdental plaque accumulation was recorded using the marginal/proximal plaque index. The data collected were subjected to statistical analysis using SPSS, IBM Analytics, New York, USA version 22.0. A paired t-test was carried out to compare the data at baseline, 14 days, and 28 days; and all the P < 0.05 was considered to be statistically significant.
The overall mean and the standard deviation of the two groups at baseline, 14 days, and 28 days of evaluation are shown in Table 1. There was a statistically significant reduction in the gingivitis, bleeding, and plaque accumulation in the Group B compared to Group A, at baseline and after 28 days of evaluation (P < 0.001). The percentage reduction in the bleeding index on the facial surface was greater in Group B (62.2) than Group A (42.3) at 14 days (P = 0.049). At 28 days, the Group B percentage reduction (60.2) was also significantly greater than that for Group A (40.6) at P = 0.0024. There was no significant reduction in the bleeding index for the lingual surfaces between the two groups. The percentage reduction in the gingival index for the two groups is shown in Table 2. After 21 days, the mean reduction in the plaque score for Group B was 8.1; which was significantly lesser than that of Group B (12.4) (P = 0.0109). The results thus showed that there was a significant reduction in the plaque accumulation and gingival bleeding for Group B compared to Group A.
The concept of interdental cleansing with a filamentous material was introduced for the first time by Parmly in 1819. It was a tool, along with a dentifrice and toothbrush, and served as a measure for preventing dental disease. Unwaxed silk floss was first produced in 1882 by Codman and Shurtleff, but Johnson and Johnson made silk floss widely available from 1887 as a by-product of sterile silk, which was leftover from the manufacturers of sterile sutures. Since dental floss is able to remove some interproximal plaque, it is assumed that frequent flossing will reduce the risk of interproximal caries and periodontal disease. It is recommended that daily toothbrushing should be accompanied with dental flossing for the prevention of caries and periodontal diseases. However, the patient compliance with daily dental flossing is extremely low. Patients attribute their lack of dental flossing compliance to lack of motivation and difficulties using the floss. A study of young cohort from 15 years of age, reported that significantly higher percentage of females believed that using dental floss was important than their male counterparts. However, even those who do floss are often not using the proper flossing technique, for example, they quickly pass the floss through the contact points and fail to sufficiently de-plaque the interdental surfaces. It is a fact that interproximal cleansing is essential for the control of gingival and periodontal disease. A lot of people find it difficult to achieve plaque control, especially in the interproximal areas, with a traditional dental floss. Lang and Ronis stated that only about 305 of the adults use dental floss as a cleansing aid and among them 22% of the people know the correct way of using the same. Another study stated that people prefer other alternatives over dental floss mainly due to the ease of utilization. In the present study, we observed that the addition of dental floss to manual toothbrushing provides significant benefits to oral health through greater reductions in bleeding and gingivitis over only brushing, notably with a significant increase in the percentage reduction in bleeding in Group B compared to Group A. Thus, flossing can serve as an adjunct to toothbrushing and in turn prevent the occurrence of gingivitis. In a study by Hague et al., the reduction in the mean gingival score was 0.13, which was lower than our study findings [Table 1]. Schiff reported a reduction in the gingival bleeding by 0.2 at 3 months and 0.09 at 6 months after utilization of automated floss. Since we used the manual flossing technique, a direct comparison between the two studies cannot be made. Jared 2005 reported of reduction in the plaque scores after the utilization of floss post 1 month along with toothbrushing, but the difference was not significant which is in contrast to the present study findings. Bauroth et al. in 2003, reported of plaque score of 2.46 (0.55) for floss group compared to only brushing group; 2.57 (0.48). They found a significant reduction on subsequent follow-up, similar to the findings of our study. Schiff, in 2006, reported that the mean of plaque score was higher in the control group (1.49) compared to the flossing group (1.47), but the difference was not statistically significant. Sharma et al. 2002, reported that there was a better reduction of the mean plaque scores with brushing and flossing than brushing alone (2.48 and 2.52, respectively). Rosema et al. in 2008, reported that there was no difference between the plaque reduction scores after 3 months of follow-up with usage of floss. Since we followed the patients only for 28 days, a direct comparison with the study findings cannot be made. A systematic review by Berchier et al. reported that no clinical evidence was present as to recommend the regular use of floss and in its ability to reduce interdental plaque accumulation. The authors suggest that the recommendation is purely based on the clinician's judgment. The reduction in the plaque accumulation that was observed could be attributed to novelty and Hawthorne effect. The Hawthorne effect is a reaction of subjects to the realization they are in a study and are being observed otherwise known as potential patient reporting bias. The novelty effect and Hawthorne effect can be considered as certain placebo effects. The impact of a placebo effect should not be underestimated. Feil et al. intentionally used the Hawthorne effect and showed improvement in oral health. The novelty effect is something that could have influenced participants even in this group. The results of the present study add to the existing data and clearly show a reduction in plaque and gingival inflammation from using an unwaxed dental floss. Further studies on a larger scale and for a longer duration need to be carried out for more clinical significance.
- Regular toothbrushing helped to improve the gingival health and reduce the amount of plaque accumulation
- Toothbrushing and flossing served better in achieving interdental plaque control and in reducing gingival bleeding
- Regular flossing, if the patient is trained appropriately, can minimize the amount of gingival bleeding and also reduce the risk of periodontitis arising due to plaque accumulation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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