Treating an intramuscular abscess following toothpick injury in a diabetic patient: A case report and literature review (CARE Complaint).

RATIONALE: Toothpick puncture (TPP) is a penetrating injury that can result in bringing pathogens to the deep space. Such penetrating wounds are typically of pinpoint size with initial symptoms appearing subtle. Consequently, the injury itself is often neglected by patients, or is not detected during physical examinations by medical doctors. Reported complications from such injuries include osteomyelitis and septic arthritis, mostly due to delayed treatment. PATIENT CONCERNS: A diabetic patient aged 83-year-old presented a 2-day history of skin redness, swelling, and tenderness over his forearm following a TPP a week earlier. Laboratory investigations showed leukocytosis with neutrophilic predominance and a high level of C-reactive protein. Before his operation, cultures of aspirated fluid from the injured site revealed the presence of Streptococcus anginosus, Streptococci viridans, Prevotella intermedia, and Pavimonas (Peptostreptococcus) micra. DIAGNOSIS: Intramuscular abscess associated with toothpick injury. INTERVENTIONS: Surgical irrigation with debridement and adjunctive antibiotics of ceftriaxone and clindamycin were given with a satisfactory response. Cultures of debrided tissue showed the presence of P intermedia and P (Peptostreptococcus) micra. OUTCOMES: A split-thickness skin graft was done. Patient was discharged on the 30th postoperative day. LESSONS: Toothpick injury, initial symptoms of which are subtle, can in some cases, lead to serious complications especially when managements are delayed. In such situations (including the present case), surgical irrigation and debridement are administrated for the eradication of infections, removal of potentially retained toothpick, and tissue cultures analyzed. Adjunctive antibiotics is recommended to combat both the aerobic and anaerobic microorganisms of the gastrointestinal tract, skin surface, and oral cavity.

The use of an interdental brush mitigates periodontal health inequalities: the Korean National Health and nutrition examination survey (KNHANES).

BACKGROUND: The purpose of this study was to evaluate the mitigating effect of the use of interdental brushes on periodontal health inequality. METHODS: This study was based on the data acquired in the Sixth Korea National Health and Nutrition Examination Survey (KNHANES VI; 2013-2015). A total of 17,583 participants (7,633 males and 9,950 females)) aged 19 years or older completed the KNHANES VI between 2013 and 2015. Multivariable logistic regression analysis was performed using socioeconomic characteristics (sex, age, level of education, individual income), personal health practice (smoking, toothbrushing, dental flossing, interdental brushing, dental clinic visiting), systematic medical factors (diabetes mellitus, hypercholesterolemia, hypertension, obesity) and the community periodontal index. We confirmed differences in the prevalence of periodontal disease with the use of an interdental brushes stratified according to individual income. RESULTS: Three logistic regression models adjusted for covariates hierarchically. In all models, individuals who used an interdental brush were not significantly different from individuals who did not use an interdental brush. The adjusted odds ratio (OR) for interdental brushing was 0.918 with a 95% confidence intervals (CIs) of 0.797-1.057. When periodontal disease was the outcome of the model, the lowest income group had 1.266 (95% CIs 1.066 to 1.502) times the odds of having periodontal disease than the highest income group. In interdental brush nonusers, the lowest income group had 1.276 (95% CI 1.061-1.533) times the odds of having periodontal diseases than the highest income group. However, in the interdental brush users, there were no significant differences in periodontal disease prevalence among income groups. CONCLUSIONS: The results suggest that the use of interdental brushes could alleviate periodontal health inequality.

Laparoscopic Treatment of a Pyogenic Hepatic Abscess Caused by Transmural Duodenal Perforation of a Toothpick.

The development of pyogenic hepatic abscess resulting from perforation of the gastrointestinal tract is a rare pathologic finding. It is a condition that can be fatal making early detection and subsequent removal of the inciting foreign body critical to avoid more deleterious sequela. Yet, its initial presentation tends to be nonspecific and typically is only discovered once surgical investigation into the cause of persisting abscess formation is performed. In this study, laparoscopic treatment of a 52-year-old male with a non-resolving hepatic abscess due to transmural gastrointestinal perforation of a toothpick is presented. Although a rare finding, reports of foreign body induced hepatic abscess have recently increased in the world literature, allowing some preliminary efforts in proposing diagnostic characterization. Yet, more case studies will be required to permit validation of these findings making continued reporting of this pathologic process critical.

ED approach to electrical toothbrush associated hand injury, a unique case of non-oropharyngeal injury.

Puncture wounds are common injuries treated in the emergency department (ED). Prior studies have shown that toothbrushes are common reservoirs for oral flora, especially in regions near the head of the toothbrush near the bristles. ED providers must be aware of the danger associated with bacterial contamination of the associated wound and should be familiar with different pathogens and options for treatment. We present a unique case of a 30-year-old male with non-intraoral injury who presented to the ED after puncturing his left palm with the metal post of an electric toothbrush.

Successful treatment of generalized refractory chronic periodontitis through discontinuation of waxed or coated dental floss use: A report of 4 cases.

BACKGROUND AND OVERVIEW: Generalized refractory chronic periodontitis is a periodontal condition that is resistant to conventional therapy. Management of this condition often is frustrating to both the patient and the clinician. CASE DESCRIPTIONS: The authors present 4 cases of generalized refractory chronic periodontitis characterized by an inflammatory gingival response and progressive bone loss that did not respond to extensive periodontal treatments and regular periodontal care. Histologic examination of affected gingival tissue revealed an abundance of plasma cells, a feature seen in certain oral contact hypersensitivity reactions. The authors suspected that waxed or coated dental floss was the offending contactant, and its removal from the patients' oral hygiene regimens resulted in a dramatic improvement of the periodontal characteristics. CONCLUSIONS AND PRACTICAL IMPLICATIONS: In cases of periodontal disease as described in this report, dental practitioners should consider the possibility of a contact hypersensitivity reaction to waxed or coated dental floss, whereby the floss exacerbates the condition instead of assisting in its resolution.

Is Implant Flossing a Risk-Free Procedure? A Case Report with a 6-year Follow-up.

This study reports a case of peri-implantitis correlated with floss fibers trapped by the implant-prosthetic macrostructure. Discrepancy between the radiographic feature and probing depth was the starting point for a correct evaluation. The minimally invasive removal of the trapped material with the aid of a periodontal endoscope resulted in a complete resolution of the peri-implantitis with a stable long-term result (6 years). This case report argues for some reconsiderations in hygienic, diagnostic, and therapeutic approaches in oral implantology.

Dental floss as a possible risk for the development of peri-implant disease: an observational study of 10 cases.

AIM: To report on a possible relationship between the use of dental floss or superfloss and the development of peri-implantitis. MATERIALS AND METHODS: Ten patients with progressive peri-implantitis with an intensive oral hygiene protocol, which consisted of extensive professional supra- and submucosal cleaning, and not responding to this therapy were scheduled for examination. Plaque and bleeding indices and probing depth measurements were assessed, and radiographic examination was performed every two years. RESULTS: In all ten cases, remnants of dental floss were found around the neck and coronal part of a dental implant. After careful removal of these floss remnants and implant cleansing, a significant improvement in the peri-implant conditions in nine of ten cases was noted. In one case, peri-implant probing depth decreased substantially. However, bleeding on probing was still present. In vitro testing yielded that the application of various types of dental floss on the exposed rough implant surfaces may easily lead to tearing of floss fibers. This may result in the deposition of floss remnants on rough implant surfaces, which, in turn, may lead to the development of plaque-related peri-implant inflammation and, subsequently, bone loss. CONCLUSION: In case of exposed rough surfaces of the dental implant, the peri-implant conditions may be jeopardized by the application of dental floss, and hence, the utilization of interproximal brushes or toothpicks may be preferred for daily home care practices.

Diamino fluoreto de prata - uma nova proposta para o tratamento não operatório de lesões proximais em molares decíduos: estudo clínico randomizado / Silver diamine fluoride - a new proposal for the non-operative treatment for approximal caries lesions in primary molars: randomized clinical trial

Este ensaio clínico randomizado, cego e controlado com placebo teve como objetivo principal avaliar a eficácia do diamino fluoreto de prata (DFP) a 30% no tratamento não operatório de lesões de cárie em superfícies proximais de molares decíduos e compará-la a eficácia do infiltrante resinoso e a do controle do biofilme interproximal pelo uso do fio dental. Além disso, também avaliou a custo-eficácia e o desconforto dos tratamentos e a satisfação dos participantes quanto ao tratamento recebido. Para isso, foram selecionadas 141 crianças entre 3 e 10 anos de idade, que apresentavam pelo menos uma superfície proximal com lesão de cárie clinicamente em esmalte. A alocação dos participantes foi aleatória, de acordo com o tratamento: DFP a 30%, infiltrante resinoso de cárie e orientação para o uso diário do fio dental (controle). Todos os participantes receberam o tratamento ativo para os quais foram alocados e também o placebo dos tratamentos realizados nos outros grupos. Os custos dos materiais utilizados nos tratamentos foram registrados. Ao final da consulta de tratamento, foi aplicada aos participantes a Escala Facial de Wong-Baker para avaliação do desconforto. Os responsáveis pelos participantes, que concluíram o seguimento da pesquisa, responderam a um questionário de satisfação sobre o tratamento recebido. As crianças foram examinadas após 1 mês para avaliação de higiene bucal e também de presença de biofilme nas superfícies tratadas

Análises de regressão foram realizadas para verificar se os grupos de tratamento influenciaram os desfechos testados após 12 e 24 meses de seguimento (análise por protocolo - Poisson multinível e análise de sobrevida). Valores pontuais de custo-eficácia dos tratamentos foram calculados e, para comparar a custo-eficácia da implementação do uso do DFP em relação às outras opções testadas foi utilizada a razão de custo-eficácia incremental. Análises de regressão de Poisson foram utilizadas para verificar a associação entre o desconforto e variáveis explicativas. A satisfação dos participantes e seus responsáveis foi explorada descritivamente. Um total de 316 superfícies proximais foram incluídas, sendo a maioria classificada como escore 2 do ICDAS (Sistema Internacional de Detecção e Avaliação de Cárie) associadas à ausência de imagem radiográfica (46,8%). As perdas de seguimento foram de 15% e 24% aos 12 e 24 meses, respectivamente. Não houve associação entre o grupo de tratamento e a progressão das lesões aos 12 e 24 meses, tanta pela análise por protocolo como pela análise de sobrevida. A taxa de progressão clínica das lesões para cavidade em dentina foi de 2,5% aos 12 meses e de 5,6% aos 24 meses

This randomized, blinded and placebo-controlled clinical trial aimed to evaluate the efficacy of 30% silver diamine fluoride (SDF) as a non-operative treatment of the approximal surfaces of primary molars and to compare it with the efficacy of resin infiltration and the mechanical control of the interproximal biofilm by flossing. We also evaluated the cost-efficacy and the discomfort of the treatments as well as the parent's satisfaction regarding treatments. One hundred forty-one, 3-to-10-year-old, children were included. They must present at least one caries lesion clinically into enamel sited on an approximal surface of primary molar. Participants were randomly allocated to the following groups according to active treatment to be received: 30% SDF, caries resin infiltration, flossing orientation (control). All participants received the active treatment, in which they were allocated and they also received the placebo treatment corresponding to the other groups. Costs of materials used in the treatment were registered. In the end of treatment session, the Wong-Baker faces scale was applied to evaluate participants' reported discomfort. Children were examined after 1 month to evaluation of the oral hygiene and the presence of the biofilm on the treated surfaces. After 6, 12 and 24 months, visual and tactile examinations were performed to verify the lesions progression. Radiography was taken at 12- and 24-month follow-ups. To evaluate the efficacy of non-operative treatments, two outcomes were considered: (I) any clinical progression and (II) progression to cavity into dentine

The radiographic progression was used as a secondary outcome and to evaluate with clinical standard of lesions progression. Regression analyses were used to verify if the treatment influenced on these outcomes after 12 and 24 months (per-protocol analyses - multilevel Poisson and survival analysis). Cost-efficacy ratios were calculated for the treatments. To compare the cost-efficacy of implementing the use of DFP versus other options tested, the incremental cost-efficacy ratio was used. Poisson regression analyses were used to verify the association between discomfort and explanatory variables. The parents' satisfaction about the treatments were explored descriptively. A total of 316 approximal surfaces were included. The majority of them were classified as ICDAS (International Caries Detection and Assessment System) score 2 associated with absence of radiographic image. The dropout in the study was 15% and 24% at 12-month and 24-month follow-up, respectively. There was no association between treatment groups and lesions progression at 12 and 24 months, both for the per-protocol analysis and by survival analysis. The rate of clinical lesions progression to cavity into dentine was 2.5% at 12 months and 5.6% at 24 months. Lesions without initial radiographic image did not progress into the middle of the dentine or more. Baseline clinical condition of caries lesions was associated with lesions progression in all analyses. The caries risk was also associated to caries progression in 24-month analyses and in the survival analyses

Streptococcus gordonii prosthetic joint infection in the setting of vigorous dental flossing.

A 65-year-old woman with osteoarthritis, who underwent knee replacement 5 years prior, developed sudden onset knee pain and swelling. She had voluntarily starting a vigorous dental flossing regimen prior to the onset of symptoms. The patient underwent right knee arthrotomy, irrigation and debridement of right total knee arthroplasty and exchange of polyethylene with retention of the prosthesis. Intraoperative cultures grew Streptococcus gordonii. She was treated with 6 weeks of ceftriaxone and was later placed on oral antibiotic suppression.

Toxicity of extracts from disposable chopsticks, toothpicks, and paper cups on L-929 cells.

OBJECTIVE: To evaluate the toxicity of extracts from disposable chopsticks, toothpicks, and paper cups on L-929 cells. METHODS: We followed national standards to prepare the extracts from disposable chopsticks, toothpicks, and paper cups used for the cell culture media, and the morphology of L-929 cells was observed with an optical microscope. The loss rate for adherent cells was evaluated with the trypan blue exclusion method, and cell proliferation was determined using the WST-1 assay. RESULTS: Compared with the control group, the cells cultured in media containing the extracts showed signs of apoptosis and necrosis after culturing for 4 or 7 days, and the loss rate for adherent cells was significantly increased (P < 0.05). An obvious decrease in cell viability was also observed (P < 0.05). CONCLUSION: The extracts from disposable chopsticks, toothpicks, and paper cups can affect the growth and proliferation of L-929 cells and are potentially toxic to humans.

Interdental cleaning and gingival injury potential of interdental toothbrushes.

The effective cleaning of interdental spaces using toothbrushes is a challenge. The aim of the present in vitro study was to evaluate on the one hand the interdental cleaning efficiency and on the other hand the gingival injury potential of an electric single-headed sonic toothbrush (Water-pik) and two single-tufted manual toothbrushes (Curaprox 1009; Lactona Interdental Brush). Brushes were evaluated using a brushing device. Test dental casts (maxillary sextants) consisting of black teeth coated with white paint were brushed using standardized horizontal movements. Thereafter, black (i.e. cleaned) areas were measured planimetrically. The soft tissue injury potential was evaluated using front segments of porcine mandibles. In the same brushing device, test brushes were moved over the gingiva. Before and after each treatment, the porcine mucosa was stained with a plaque disclosing agent to visualize injured areas, which could then be measured planimetrically as well. These evaluations were each made after 15, 30, 60, and 120 seconds of brushing. The statistical analysis was performed using non-parametric Mann-Whitney tests, and the level of significance was set at 5%. The best cleaning performance of 46% across all interdental spaces assessed was found with the electric sonic toothbrush (Waterpik), while the performances of the manual brushes from Lactona and Curaprox were 14.8% and 5%, respectively. At each point of evaluation, the gingiva was injured most markedly by the powered sonic toothbrush (Waterpik), followed by the manual Curaprox brush. The smallest damage of the porcine gingiva was produced by the manual Lactona brush. When comparing the manual toothbrushes, the Lactona product revealed a better cleaning performance combined with a smaller injury potential than the Curaprox brush. Thus, the prophylactic goal to achieve high degrees of cleaning while producing minimal damage is important and should have priority when evaluating and selecting toothbrushes.

Moderate quality evidence finds statistical benefit in oral health for powered over manual toothbrushes.

DATA SOURCES: The Cochrane Oral Health Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, CINAHL, National Institutes of Health Trials Register and the WHO Clinical Trials Registry Platform for ongoing trials. Reference lists of identified articles were also scanned for relevant papers. Identified manufacturers were contacted for additional information. STUDY SELECTION: Only randomised controlled trials comparing manual and powered toothbrushes were considered. Crossover trials were eligible for inclusion if the wash-out period length was more than two weeks. DATA EXTRACTION AND SYNTHESIS: Study assessment and data extraction were carried out independently by at least two reviewers. The primary outcome measures were quantified levels of plaque or gingivitis. Risk of bias assessment was undertaken. Standard Cochrane methodological approaches were taken. Random-effects models were used provided there were four or more studies included in the meta-analysis, otherwise fixed-effect models were used. Data were classed as short term (one to three months) and long term (greater than three months). RESULTS: Fifty-six trials were included with 51 (4624 patients) providing data for meta-analysis. The majority (46) were at unclear risk of bias, five at high risk of bias and five at low risk. There was moderate quality evidence that powered toothbrushes provide a statistically significant benefit compared with manual toothbrushes with regard to the reduction of plaque in both the short and long-term. This corresponds to an 11% reduction in plaque for the Quigley Hein index (Turesky) in the short term and a 21% reduction in the long term. There was a high degree of heterogeneity that was not explained by the different powered toothbrush type subgroups.There was also moderate quality evidence that powered toothbrushes again provide a statistically significant reduction in gingivitis when compared with manual toothbrushes both in the short and long term. This corresponds to a 6% and 11% reduction in gingivitis for the Löe and Silness indices respectively. Again there was a high degree of heterogeneity that was not explained by the different powered toothbrush type subgroups. The greatest body of evidence was for rotation oscillation brushes which demonstrated a statistically significant reduction in plaque and gingivitis at both time points. CONCLUSIONS: Powered toothbrushes reduce plaque and gingivitis more than manual toothbrushing in the short and long term. The clinical importance of these findings remains unclear. Observation of methodological guidelines and greater standardisation of design would benefit both future trials and meta-analyses. Cost, reliability and side effects were inconsistently reported. Any reported side effects were localised and only temporary.

Powered versus manual toothbrushing for oral health.

BACKGROUND: Removing dental plaque may play a key role maintaining oral health. There is conflicting evidence for the relative merits of manual and powered toothbrushing in achieving this. This is an update of a Cochrane review first published in 2003, and previously updated in 2005. OBJECTIVES: To compare manual and powered toothbrushes in everyday use, by people of any age, in relation to the removal of plaque, the health of the gingivae, staining and calculus, dependability, adverse effects and cost. SEARCH METHODS: We searched the following electronic databases: the Cochrane Oral Health Group's Trials Register (to 23 January 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2014, Issue 1), MEDLINE via OVID (1946 to 23 January 2014), EMBASE via OVID (1980 to 23 January 2014) and CINAHL via EBSCO (1980 to 23 January 2014). We searched the US National Institutes of Health Trials Register and the WHO Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. SELECTION CRITERIA: Randomised controlled trials of at least four weeks of unsupervised powered toothbrushing versus manual toothbrushing for oral health in children and adults. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by The Cochrane Collaboration. Random-effects models were used provided there were four or more studies included in the meta-analysis, otherwise fixed-effect models were used. Data were classed as short term (one to three months) and long term (greater than three months). MAIN RESULTS: Fifty-six trials met the inclusion criteria; 51 trials involving 4624 participants provided data for meta-analysis. Five trials were at low risk of bias, five at high and 46 at unclear risk of bias.There is moderate quality evidence that powered toothbrushes provide a statistically significant benefit compared with manual toothbrushes with regard to the reduction of plaque in both the short term (standardised mean difference (SMD) -0.50 (95% confidence interval (CI) -0.70 to -0.31); 40 trials, n = 2871) and long term (SMD -0.47 (95% CI -0.82 to -0.11; 14 trials, n = 978). These results correspond to an 11% reduction in plaque for the Quigley Hein index (Turesky) in the short term and 21% reduction long term. Both meta-analyses showed high levels of heterogeneity (I(2) = 83% and 86% respectively) that was not explained by the different powered toothbrush type subgroups.With regard to gingivitis, there is moderate quality evidence that powered toothbrushes again provide a statistically significant benefit when compared with manual toothbrushes both in the short term (SMD -0.43 (95% CI -0.60 to -0.25); 44 trials, n = 3345) and long term (SMD -0.21 (95% CI -0.31 to -0.12); 16 trials, n = 1645). This corresponds to a 6% and 11% reduction in gingivitis for the Löe and Silness index respectively. Both meta-analyses showed high levels of heterogeneity (I(2) = 82% and 51% respectively) that was not explained by the different powered toothbrush type subgroups.The number of trials for each type of powered toothbrush varied: side to side (10 trials), counter oscillation (five trials), rotation oscillation (27 trials), circular (two trials), ultrasonic (seven trials), ionic (four trials) and unknown (five trials). The greatest body of evidence was for rotation oscillation brushes which demonstrated a statistically significant reduction in plaque and gingivitis at both time points. AUTHORS' CONCLUSIONS: Powered toothbrushes reduce plaque and gingivitis more than manual toothbrushing in the short and long term. The clinical importance of these findings remains unclear. Observation of methodological guidelines and greater standardisation of design would benefit both future trials and meta-analyses.Cost, reliability and side effects were inconsistently reported. Any reported side effects were localised and only temporary.

Interdental brushing for the prevention and control of periodontal diseases and dental caries in adults.

BACKGROUND: Effective oral hygiene is a crucial factor in maintaining good oral health, which is associated with overall health and health-related quality of life. Dental floss has been used for many years in conjunction with toothbrushing for removing dental plaque in between teeth, however, interdental brushes have been developed which many people find easier to use than floss, providing there is sufficient space between the teeth. OBJECTIVES: To evaluate the effects of interdental brushing in addition to toothbrushing, as compared with toothbrushing alone or toothbrushing and flossing for the prevention and control of periodontal diseases, dental plaque and dental caries. SEARCH METHODS: We searched the following electronic databases: the Cochrane Oral Health Group's Trials Register (to 7 March 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 2), MEDLINE via OVID (1946 to 7 March 2013), EMBASE via OVID (1980 to 7 March 2013), CINAHL via EBSCO (1980 to 7 March 2013), LILACS via BIREME (1982 to 7 March 2013), ZETOC Conference Proceedings (1980 to 7 March 2013) and Web of Science Conference Proceedings (1990 to 7 March 2013). We searched the US National Institutes of Health Trials Register (http://clinicaltrials.gov) and the metaRegister of Controlled Trials (http://www.controlled-trials.com/mrct/) for ongoing trials to 7 March 2013. No restrictions were placed on the language or date of publication when searching the electronic databases. SELECTION CRITERIA: We included randomised controlled trials (including split-mouth design, cross-over and cluster-randomised trials) of dentate adult patients. The interventions were a combination of toothbrushing and any interdental brushing procedure compared with toothbrushing only or toothbrushing and flossing. DATA COLLECTION AND ANALYSIS: At least two review authors assessed each of the included studies to confirm eligibility, assessed risk of bias and extracted data using a piloted data extraction form. We calculated standardised mean difference (SMD) and 95% confidence interval (CI) for continuous outcomes where different scales were used to assess an outcome. We attempted to extract data on adverse effects of interventions. Where data were missing or unclear we attempted to contact study authors to obtain further information. MAIN RESULTS: There were seven studies (total 354 participants analysed) included in this review. We assessed one study as being low, three studies as being high and three studies as being at unclear risk of bias. Studies only reported the clinical outcome gingivitis and plaque data, with no studies providing data on many of the outcomes: periodontitis, caries, halitosis and quality of life. Three studies reported that no adverse events were observed or reported during the study. Two other studies provided some data on adverse events but we were unable to pool the data due to lack of detail. Two studies did not report whether adverse events occurred. Interdental brushing in addition to toothbrushing, as compared with toothbrushing alone Only one high risk of bias study (62 participants in analysis) looked at this comparison and there was very low-quality evidence for a reduction in gingivitis (0 to 4 scale, mean in control): mean difference (MD) 0.53 (95% CI 0.23 to 0.83) and plaque (0 to 5 scale): MD 0.95 (95% CI 0.56 to 1.34) at one month, favouring of use of interdental brushes. This represents a 34% reduction in gingivitis and a 32% reduction in plaque. Interdental brushing in addition to toothbrushing, as compared with toothbrushing and flossing Seven studies provided data showing a reduction in gingivitis in favour of interdental brushing at one month: SMD -0.53 (95% CI -0.81 to -0.24, seven studies, 326 participants, low-quality evidence). This translates to a 52% reduction in gingivitis (Eastman Bleeding Index). Although a high effect size in the same direction was observed at three months (SMD -1.98, 95% CI -5.42 to 1.47, two studies, 107 participants, very low quality), the confidence interval was wide and did not exclude the possibility of no difference. There was insufficient evidence to claim a benefit for either interdental brushing or flossing for reducing plaque (SMD at one month 0.10, 95% CI -0.13 to 0.33, seven studies, 326 participants, low-quality evidence) and insufficient evidence at three months (SMD -2.14, 95% CI -5.25 to 0.97, two studies, 107 participants very low-quality evidence). AUTHORS' CONCLUSIONS: Only one study looked at whether toothbrushing with interdental brushing was better than toothbrushing alone, and there was very low-quality evidence for a reduction in gingivitis and plaque at one month. There is also low-quality evidence from seven studies that interdental brushing reduces gingivitis when compared with flossing, but these results were only found at one month. There was insufficient evidence to determine whether interdental brushing reduced or increased levels of plaque when compared to flossing.

Incidence and magnitude of bacteraemia caused by flossing and by scaling and root planing.

AIM: (1) Investigate incidence, magnitude and bacterial diversity of bacteraemia due to flossing compared with scaling and root planing (SRP) and (2) Identify any associations with clinical parameters. MATERIALS AND METHODS: Full-mouth flossing and single quadrant SRP were performed at separate visits for 30 patients with chronic periodontitis. Baseline blood samples and at 30 s and 10 min. after completion of flossing, 5 min. after initiation of SRP and 30 s and 10 min. after completion of SRP were obtained. Total bacteraemia and viridans streptococcal bacteraemia (VSB) were investigated. RESULTS: Total bacteraemia incidence was 30% for flossing and 43.3% for SRP (no significant difference; p = 0.21). Flossing and SRP caused the same incidence of VSB (26.7%). Flossing caused a higher mean magnitude of total bacteraemia than SRP (7.4 ± 16.2 CFU/ml versus 2 ± 3.4 CFU/ml), but the difference was not significant (p = 0.2). Flossing caused a higher mean magnitude of VSB than SRP (1.2 ± 1.6 CFU/ml versus 0.4 ± 0.2 CFU/ml), but the difference was not significant (p = 0.09). Viridans streptococci comprised 11.4% of flossing bacteraemia isolates and 7.6% in SRP. No correlations were found between clinical parameters and incidence or magnitude of bacteraemia following flossing. Gingival inflammation was significantly associated with incidence of total bacteraemia (p = 0.01) and VSB (p = 0.001) following SRP. No correlations were found for any parameter and magnitude of total bacteraemia or VSB following SRP. CONCLUSIONS: No differences were found between flossing and SRP in the incidence or magnitude of total bacteraemia or VSB. This finding is important in the ongoing re-evaluation of antibiotic prophylaxis to prevent infective endocarditis.