Flossing for the management of periodontal diseases and dental caries in adults

Dario Sambunjak; Jason W Nickerson; Tina Poklepovic; Trevor M Johnson; Pauline Imai; Peter Tugwell; Helen V Worthington

doi:10.1002/14651858.CD008829.pub2

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Figure 1

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Figure 3

Study selection flow diagram

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Analysis 1.1

Comparison 1 Toothbrushing plus flossing vs toothbrushing alone at 1 month, Outcome 1 Gingival Index (lower better).

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Analysis 1.2

Comparison 1 Toothbrushing plus flossing vs toothbrushing alone at 1 month, Outcome 2 Plaque (lower better).

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Analysis 2.1

Comparison 2 Toothbrushing plus flossing vs toothbrushing alone at 3 months, Outcome 1 Gingival index (0‐3 scale, lower better).

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Analysis 2.2

Comparison 2 Toothbrushing plus flossing vs toothbrushing alone at 3 months, Outcome 2 Plaque (0‐5 scale, lower better).

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Analysis 3.1

Comparison 3 Toothbrushing plus flossing vs toothbrushing alone at 6 months, Outcome 1 Gingival index (0‐3 scale, lower better).

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Analysis 3.2

Comparison 3 Toothbrushing plus flossing vs toothbrushing alone at 6 months, Outcome 2 Plaque (0‐5 scale, lower better).

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Summary of findings for the main comparison. Flossing plus toothbrushing for periodontal disease and dental caries

Flossing plus toothbrushing for periodontal disease and dental caries
Patient or population: Settings: everyday self‐care Intervention: flossing plus toothbrushing
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Control	Flossing plus toothbrushing
Gingivitis Scale from: 0 to 3 Follow‐up: mean 1 month	The mean gingivitis in the control groups was 0.67 points	The mean gingivitis in the intervention groups was 0.13 lower (0.02 to 0.23 lower)¹		489 (7 studies)	⊕⊝⊝⊝ very low^2,3,4,5	The estimate is for the 1‐month time point. Results are consistent in other observed time points (3‐ and 6‐month)
Interproximal caries			Not estimable	0 (0)	See comment	No included study assessed caries as an outcome
Harms and adverse effects			Not estimable	(5 studies)	See comment	Adverse effects were assessed in five studies, but they used different outcome measures, so meta‐analysis was not appropriate
Plaque Scale from: 0 to 5 Follow‐up: mean 29 days	The mean plaque in the control groups was 2.97 points	The mean plaque in the intervention groups was 0.19 lower (0.42 lower to ‐0.05 lower)⁶		416 (5 studies)	⊕⊝⊝⊝ very low^2,5,7,8	The estimate is for the 1‐month time point. Results consistent with 6‐month outcome. 3‐month outcome was statistically significant
Calculus			Not estimable	0 (0)	See comment	No included study assessed calculus as an outcome
Clinical attachment loss			Not estimable	0 (0)	See comment	No included study assessed calculus as an outcome
Quality of life			Not estimable	0 (0)	See comment	No included study assessed quality of life as an outcome
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹ Re‐expressed from SMD into the Loe‐Sillness Gingival Index score. Result should be interpreted with caution since back‐translation of the effect size is based on the results of only one study (Hague 2007). The estimate is for the 1‐month time point, results show similar effect for 3 months and larger effect for 6 months with SMDs of ‐0.36 (1 month), ‐0.41 (3 months) and ‐0.72 (6 months). ² Sensitivity analysis excluding a high risk of bias study (Vogel 1975) did not show a significant change in results. ³ I² = 60% ⁴ Only one study had more than 40 subjects in a study arm and one study had less than 10 subjects per study arm. ⁵ Most of the included studies were small, industry‐sponsored studies. A few had inadequately reported outcomes. ⁶ Re‐expressed from the SMD into the Turesky‐modification of the Quigley‐Hein Plaque Index score. Result should be interpreted with caution since back‐translation of the effect size is based on the results of only one study (Jared 2005). ⁷ I² = 51% ⁸ Only one study had more than 40 subjects in a study arm.

Summary of findings for the main comparison. Flossing plus toothbrushing for periodontal disease and dental caries

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Comparison 1. Toothbrushing plus flossing vs toothbrushing alone at 1 month

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Gingival Index (lower better) Show forest plot	7	489	Std. Mean Difference (IV, Random, 95% CI)	‐0.36 [‐0.66, ‐0.05]

1.1 Manual flossing	6	383	Std. Mean Difference (IV, Random, 95% CI)	‐0.42 [‐0.78, ‐0.07]
1.2 Automated flossing	2	106	Std. Mean Difference (IV, Random, 95% CI)	‐0.16 [‐0.80, 0.47]
2 Plaque (lower better) Show forest plot	5	416	Std. Mean Difference (IV, Random, 95% CI)	‐0.23 [‐0.52, 0.06]

2.1 Manual flossing	4	310	Std. Mean Difference (IV, Random, 95% CI)	‐0.28 [‐0.70, 0.14]
2.2 Automated flossing	2	106	Std. Mean Difference (IV, Random, 95% CI)	‐0.12 [‐0.51, 0.27]

Comparison 1. Toothbrushing plus flossing vs toothbrushing alone at 1 month

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Comparison 2. Toothbrushing plus flossing vs toothbrushing alone at 3 months

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Gingival index (0‐3 scale, lower better) Show forest plot	6	656	Std. Mean Difference (IV, Random, 95% CI)	‐0.41 [‐0.68, ‐0.14]

2 Plaque (0‐5 scale, lower better) Show forest plot	5	594	Std. Mean Difference (IV, Random, 95% CI)	‐0.20 [‐0.36, ‐0.04]

Comparison 2. Toothbrushing plus flossing vs toothbrushing alone at 3 months

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Comparison 3. Toothbrushing plus flossing vs toothbrushing alone at 6 months

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Gingival index (0‐3 scale, lower better) Show forest plot	4	564	Std. Mean Difference (IV, Random, 95% CI)	‐0.72 [‐1.09, ‐0.35]

2 Plaque (0‐5 scale, lower better) Show forest plot	3	487	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.06 [‐0.23, 0.12]

Comparison 3. Toothbrushing plus flossing vs toothbrushing alone at 6 months

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