Periodontology 2000, Vol.
62, 2013, 243255
Printed in Singapore. All rights reserved
Periodontal self-care:
evidence-based support
C O N N I E L. D R I S K O
The focus of this volume of Periodontology 2000 is
Learned and Unlearned Concepts in Periodontology.
The editor has challenged the author to re-examine
the current literature regarding periodontal self-care.
The desired outcome of the literature review is to
provide a well-documented report, including evi-
dence-based recommendations for clinicians on how
best to help their patients prevent achieve good
periodontal health with unsupervised home care.
Periodontal self-care usually includes toothbrush-
ing with a dentifrice and perhaps the use of adjunc-
tive aids such as dental floss, interdental cleaning
devices, mouthrinses, irrigation devices and other
less common approaches. The concept that self-care
is essential to periodontal health has generally been
endorsed by healthcare providers, but how achiev-
able is it by the average person? Isnt compliance with
daily oral cleanliness as important in managing
chronic periodontitis as diet and exercise are to
managing other chronic conditions such as diabetes
and obesity? Is it really the most predictable way to
prevent further attachment loss caused by chronic
periodontitis? How efficient are patients at achieving
maximum plaque control with personal hygiene
activities commonly used at home? To answer these
questions, this author reviewed a series of systematic
reviews and meta-analyses where available. Select
randomized controlled trials were included when
systematic reviews or meta-analyses were not avail-
able on certain topics. Current epidemiologic data
were also included from a list of 36 studies reported
between 2008 and July 2012 that address changes in
reported periodontal status of populations around
the world and the potential role of periodontal self-
care on the prevalence of periodontitis.
Systematic reviews were chosen as the main re-
source for this paper because they have been used in
evidence-based literature to provide a detailed sum-
mary of the individual and combined results of
studies published on a topic that has met stringent
guidelines for eligibility before inclusion in the
 2013 John Wiley & Sons A/S
PERIODONTOLOGY 2000
analysis (35). A caution to the reader is that the
strength of systematic reviews relies on the quality of
previously published articles and of the original re-
search. Systematic reviews may fail to provide strong
guidance on the topic explored, and are sometimes
biased or contain an insufficient number of pub-
lished articles to provide a clear understanding of the
topic under review.
However, there are some topics that have not been
subjected to systematic reviews, or the number of
qualified papers selected for systematic reviews were
so few that the conclusions were often based on only
a few papers out of hundreds, making them less
generalizable and useful to the clinician in guiding
their decisions. Therefore, the author has included
comments for guidance to the reader based on the
best available systematic reviews on each of the
topics included in the current periodontal self-care
literature.
In 2005, Worthington & Needleman (54) addressed
important questions regarding the prevention and
treatment of periodontal diseases while serving as
guest editors of a series of articles published in a pre-
vious volume of Periodontology 2000 (Vol. 37, 2005).
Based on systematic reviews between 1966 and March
2004, they concluded that there was no evidence from
randomized controlled trials to support the pre-
sumption that personal oral-hygiene measures, such
as toothbrushing, prevent the initiation or progression
of chronic periodontitis. They reported that the
majority of studies examining health-education
interventions demonstrated short-term reductions in
plaque and gingival bleeding. However, they
questioned the overall significance and magnitude of
the clinical and public health effects of personal oral
hygiene because the changes were generally quite
small.
Now, 7 years later, we take a similar approach to
see if the evidence has grown in support of personal
oral hygiene as a valuable tool for preventing and or
controlling periodontal disease. The focus of this
243
Drisko
review on periodontal self-care will be based
primarily on the results of systematic reviews and
meta-analyses. As noted before, this approach is not
without its issues because after the rigorous process
of the systematic review has been followed, including
a critical quality-assessment of the studies, it is
known that often only a rather small number of
articles qualify for inclusion in the analysis. To date,
despite these disadvantages, systematic reviews and
meta-analyses appear to remain the most desirable
long-term benchmarks for evidence-based practice
and will therefore drive the discussion and conclu-
sions presented in this paper. Some, but not all,
systematic reviews are homogenous enough to merit
pooling studies and a meta-analysis, thus providing
the highest level of evidence in the literature.
Therefore, inclusion of meta-analyses is also impor-
tant in this review on periodontal self-care.
To determine if any significant changes had occurred
in the evidence to support personal oral hygiene since
the 2005 (Vol. 37) edition of Periodontology 2000, a
current search of the PubMed database from 1965 to
June 2012 was conducted; this yielded 18,713 articles
on oral hygiene and 110 articles on subgingival irriga-
tion and interdental devices. These were further re-
duced to English-language systematic reviews and
meta-analyses. One-hundred and nine systematic re-
views and or meta-analyses were reviewed under the
general topic of oral hygiene and included randomized
controlled clinical trials on the use of manual and
power-driven toothbrushes, dental floss and inter-
proximal brushes, dentifrices, mouthrinses and
subgingival irrigation in patients with gingivitis and
periodontitis. A portion of these 109 systematic reviews
formed the majority of the literature base for this paper.
Mechanical plaque removal in
adults: toothbrushing with and
without professional plaque
control
Manual toothbrushing
Once- or twice-daily brushing with a fluoridated
dentifrice is very much a part of the daily oral-hy-
giene routine of people in western society and in
many other developed countries of the world. The
most recent systematic review on this topic, carried
out by van der Weijden & Hioe (51), yielded 3,223
titles and abstracts, producing a pool of 33, 6-month
studies for analysis of adults with gingivitis. The
purpose of the analysis was to determine the
244
effectiveness of plaque control in gingivitis subjects.
The authors reported that self-performed oral hy-
giene (toothbrushing) after one session of profes-
sional instruction, combined with a professional oral
prophylaxis, resulted in small, but significant, de-
creases in gingivitis (51). Meta-analysis performed on
nine of the 33 studies extracted from their review
resulted in small, but statistically significant, reduc-
tions of 0.28 in the Turesky modification of the
Quigley & Hein plaque index and of 0.21 in the
Talbott modification of the Loe and Silness gingival
index (32, 49, 51).
In a 30-year prospective study by Axelsson et al.
(9), subjects with surfaces that were more than 80%
plaque-free obtained and sustained better periodon-
tal health than did those with detectable plaque on
more than 20% of the surfaces. People who consis-
tently brush more than once a day, floss and seek
regular dental care, are more likely to retain more
teeth over time (31, 51). During their 26-year longi-
tudinal study, Kressin et al. (31) observed that con-
sistent brushing more than once a day produced a
49% reduction of the risk of tooth loss compared with
those subjects who did not consistently practice good
oral-hygiene habits.
Clearly, the most successful approach to main-
taining good periodontal health is to keep plaque
accumulation consistently to < 20%, a feat that is
not easy for most. The 30-year longitudinal study of
Axelsson et al. corroborated that finding, and Ax-
elsson et al. (9) showed that surfaces which were
more than 80% plaque-free correspond with long-
term, stable periodontal health. Realistically, the vast
majority of people do not have access to regular
oral-hygiene instructions and monthly professional
plaque removal, so generalizing the results of the
study of Axelsson et al. to the global population is
not appropriate. However, the study does show,
without a doubt, that daily effective plaque removal
in select populations does lead to better periodontal
health.
Professional mechanical plaque removal
Interestingly, another systematic review showed only
weak to moderate evidence that professional
mechanical plaque removal is effective in maintain-
ing periodontal health in the absence of oral-hygiene
instructions, and that there was little difference in the
benefits or adverse effects between different methods
of professional mechanical plaque removal (34).
Professionally delivered mechanical plaque removal,
as defined in this systematic review, included scaling

and or polishing, supragingival or subgingival
scaling, with or without oral-hygiene instructions.
The frequency of professional mechanical plaque re-
moval did seem to positively influence the markers of
health, including dental plaque (four studies), bleed-
ing inflammation (three studies), probing depth
(only one study), and attachment levels (three stu-
dies), and professional mechanical plaque removal
plus oral-hygiene instructions was superior to no
treatment (three studies). The strength of the
evidence was diminished because of small sample
sizes, lack of appropriate statistics, and inconsistent
and possibly increased risk of bias in the 32 studies
evaluated out of the 132 full-text articles extracted
from 2,179 titles and abstracts. Professional
mechanical plaque removal vs. no treatment favored
reduction of plaque and bleeding, but showed no
differences for probing depth or attachment levels.
Overall, the evidence was weak in the authors opin-
ion, and inconsistencies may have led to a risk of bias.
When comparing professional mechanical plaque
removal with oral-hygiene instructions, there was no
difference between professional mechanical plaque
removal and no treatment for plaque and bleed-
ing inflammation.
One of the studies included in the meta-analysis of
Weaks et al. (53) reported statistically significant in-
creases in bleeding with air polishing vs. prophylaxis
during the procedure, but there were no statistically
significant differences between the groups 12 days
after treatment.
When Needleman et al. (34) looked at variable
frequency vs. fixed frequency of professional
mechanical plaque removal (recall appointments)
from randomized controlled clinical trials, they found
no evidence of a difference between the two methods
of scheduling. Again, weak evidence, risk of bias and
loss to follow-up in the studies failed to differentiate
clearly the benefits between various frequencies of
recall appointments.
Summary
Practical implications of the systematic review of
Needleman et al. (34), of professional plaque removal
for the prevention of periodontal diseases, include
the following.
Little value in providing professional mechanical
plaque removal in the absence of oral-hygiene
instructions.
The possibility of additional gains for some
patients having professional mechanical plaque
removal, including better patient satisfaction.
Periodontal self-care: evidence-based support
Little difference in adverse effects or risk using
prophy cups or air-polishing devices relative to
endocarditis, as both cause bacteremia.
Greater health gain with more frequent profes-
sional mechanical plaque removal, but little
guidance gleaned as to the optimal frequency of
professional mechanical plaque removal from
these analyses.
Weak to moderate evidence to support oral
hygiene instructions, with or without professional
plaque removal.
Risk of study bias, inconsistent results, lack of
appropriate analytical statistical analyses and
small sample sizes.
Authors comments
Indeed, it appears that there is work to be done in this
area to conduct better-designed trials that provide
appropriate data, good follow-up protocols, fewer
inconsistencies and less risk of bias. The assumption
that more frequent recall is beneficial was suggested
in these analyses; however, the weakness of the data
examined in this systematic review, as stated earlier,
may have skewed the outcomes to a less positive one
in support of regular professional intervention. Watt
& Marinho (52) have suggested that periodontal dis-
ease prevention should not be studied in isolation,
but within the context of general health promotion.
Perhaps this is one explanation of why the systematic
reviews discussed so far are so weak in support of
periodontal self-care.
Manual toothbrushes vs. powered
toothbrushes
What about the efficacy of manual toothbrushes vs.
powered toothbrushes on periodontal health? The
introduction of powered toothbrushes has had a
minimal, yet positive, influence on the ability of pa-
tients to remove supragingival, but not necessarily
interproximal, plaque. Powered toothbrushes were
introduced commercially in the 1960s. Several articles
and systematic reviews comparing manual tooth-
brushes with powered toothbrushes have been pub-
lished or updated over the last 8 years, including that
of Deery et al. in 2004 (20) and, most recently, the
Cochrane Collaboration review by Deacon et al. in
2010 (19), that compared different rotational types of
powered toothbushes and their effect on plaque and
gingivitis. The objectives of the 2004 Cochrane review
by Deery et al. (20) were to compare the effectiveness
of manual and powered toothbrushes in daily use and
245
Drisko
their effects on stain and calculus removal, their
dependability, any adverse effects and cost. Of 354
studies, 215 full articles were obtained, with only 29
trials fulfilling the criteria for inclusion in the meta-
analysis. Of these, 26 studies reported plaque scores
and gingivitis scores for 16 short-term trials (defined
as 13 months) and for 10 long-term trials (defined as
>3 months). The powered toothbrushes were placed
into six groups depending on their mode of action,
including: side to side; counter oscillation; rotation
oscillation; circular powered; ultrasonic powered; and
unknown action which indicated a brush action that
the reviewers were unable to determine from the
reported publication or the manufacturers descrip-
tion (20). Comparisons were made at 3 and 6 months.
The primary outcomes were that reduction of pla-
que and gingivitis with powered toothbrushes was at
least as effective as that with manual toothbrushes in
both short-term and long-term studies. This repre-
sented a reduction of about 11% in the Quigley-Hine
plaque index and a reduction of 6% in the Loe and
Silness gingival index (32). Deacon et al. (19) con-
cluded that there was no evidence for a statistically
significant difference between powered and manual
toothbrushes; however, the rotation oscillation-pow-
ered toothbrushes did reduce plaque and gingivitis
significantly in the short- and long-term. They point
out that the differences were rather small and that the
clinical significance of these results is not known. They
conclude that greater standardization of trial design
and observation of methodological guidelines would
be beneficial for future trials and meta-analyses.
Seven years later, a new Cochrane Collaboration
Systematic review was conducted and reported by
Deacon et al. in 2011 (19), to directly compare the
different modes of powered toothbrushes and their
effect on plaque reduction and gingival health. The
earlier, 2004, review on powered toothbrushes only
compared powered toothbrushes with manual
toothbrushes, and did not perform a comparison,
based on the mode of rotation, of powered tooth-
brushes with each other (19). In the 2010 study, pla-
que reduction and gingival health, as well as calculus
and stain removal, cost, dependability and adverse
effects, were also assessed, similarly to the 2004 study
(20). The review included data from 17 studies and a
total of 1,369 subjects. Seven trials conducted over a
time-period of up to 3 months-time showed that
rotation oscillation toothbrushes reduce plaque and
gingivitis significantly more than do side-to-side
toothbrushes. However, because of the small number
of trials, there was an unclear or a high risk of bias in
these studies. No other conclusions could be made.
246
Only minor, short-lived adverse side effects were re-
ported that did not appear to be clinically relevant.
Cost and dependability were not reported so they
could not be evaluated, leaving much yet to be
learned about the efficacy, efficiency and possible
advantages or disadvantages of powered tooth-
brushes in periodontal self-care. The major finding
that toothbrushes with rotational oscillation appear
to be superior to side-to-side brushes, gives some
guidance to the dental professional in recommending
powered toothbrushes to patients.
Niederman summarized the systematic review of
Deacon et al. 2010 (19) by observing that 87% of
studies published on the topic did not qualify for the
review (36). Niederman concludes in his article that
there continues to be poor trial design or poor
reporting despite the fact that oral health in the USA
is a multibillion-dollar industry and that millions of
industry dollars are spent on these trials. He observed
that many trials still do not adhere to Consolidated
Standards of Reporting Trials (CONSORT), a set of
guidelines that was developed by a group of leading
international scientists and editors in the 1990s who
were concerned about the quality of evidence being
reported (37).
Summary
A summary of systematic reviews on mechanical
plaque removal found the following.
The clinical importance of statistically significant
but small changes in plaque and gingivitis scores
from mechanical plaque removal was unclear.
It was also unclear as to whether patient or pro-
fessionally performed plaque control (or a com-
bination of the two) is important for primary or
secondary prevention of periodontal diseases.
More trials of good quality are required to provide
a fair assessment of the superiority of different
modes of action for powered toothbrushes on
prevention of periodontal diseases.
Authors comments
Despite the lack of strong evidence-based conclu-
sions, as reported by the authors of the systematic
reviews discussed above, it would appear that use of a
powered toothbrush is at least as effective as hand
brushing in plaque removal and reduction of
gingivitis and that certain types of rotational oscilla-
tion-powered toothbushes may have some slight
advantages over other types. The reviews do not
indicate that powered toothbrushes are detrimental

to oral health. As the use of powered or hand tooth-
brushes has been reported to have positive effects on
plaque and gingivitis reduction in many randomized
controlled trials (3, 10, 24, 38, 40, 50), recommending
their use to patients is supported by the evidence,
although this evidence is weak, according to the au-
thors of the systematic reviews.
Flossing in addition to
toothbrushing
Periodontitis and gingivitis are predominately ob-
served in the interproximal sites and are associated
with residual biofilms not usually removed by
toothbrushing alone. As the primary means of plaque
control is mechanical, it is important, in terms of
patient compliance and efficacy, to have evidence on
which interdental cleaning method is preferred by
the patient. As discussed previously, systematic reviews
can be used for evidence as part of the decision
process. They provide especially important informa-
tion that helps guide the development of treatment
plans and therapy. Many different products are
marketed for interdental cleaning; therefore, a report
of the systematic reviews comparing different types
of interdental devices is warranted.
Dental floss was introduced as a measure of
cleaning for preventing disease, together with a
dentifrice and toothbrush, by Levi Spear Parmly in
1819 (41). It has long been accepted that good oral
hygiene is very important to oral health and that the
addition of flossing to toothbrushing is desirable to
achieve better interproximal health and to prevent
periodontal disease and dental caries. Flossing has
some disadvantages, in that it is an additional
expense and is time consuming, thus negatively
influencing the ability or desire of many patients to
participate in this activity. This may especially be true
globally, in developing and economically disadvan-
taged countries, where access to a toothbrush or
chewing stick is limited and additional oral-hygiene
devices are either unavailable or unaffordable.
Patient compliance with dental flossing is low (8),
but dental flossing has long been assumed to be an
effective way to clean interproximally to remove bio-
film and prevent interproximal periodontal disease
and dental caries. However, a 2008 systematic review
by Berchier et al. (11) concluded that dental floss in
conjunction with toothbrushing provided no addi-
tional benefit compared with toothbrushing alone.
A very recent Cochrane Collaboration review
published in 2011 came to the opposite conclusion
Periodontal self-care: evidence-based support
(41). The authors researched the literature on the
effects of flossing and toothbrushing compared with
toothbrushing alone (41) on periodontal disease and
caries and found that flossing plus toothbrushing
showed a statistically significant benefit compared
with toothbrushing alone in reducing gingivitis at the
three study time points. Some, but not all, studies re-
viewed in 2008 by Berchier et al. (11), 3 years earlier,
were included in this more recent 2011 review (41). In
the 2011 study (41), 12 trials qualified for inclusion,
totaling 582 participants who performed flossing and
brushing (intervention group) and 501 participants
who performed brushing only (control group). All of
the trials had outcomes of plaque and gingivitis at the
time points studied (1, 3 and 6 months). Of the 12 trials
included, seven were assessed as at unclear risk of bias
and five were at high risk of bias (41). The reasons for
the increased risk of bias in these studies ranged from
conflicts of interest reported by the authors of the
papers, incompleteness of outcome data (as a result of
attrition of study participants), self-reported data on
adverse events by the participants rather than direct
observation by the examiners and the heterogeneity of
the studies. Starting with a different pool of studies for
evaluation may partially explain the differences in
conclusions because the two reviews were conducted
on similar, but different, groups of publications.
Although there was a statistically significant
reduction in gingivitis, the magnitude of improve-
ment in the Loe and Silness gingivitis index (32) was
minimal. The results showed a 0.13-point (22) re-
duction on a 0-3 point scale at 1 month, and 0.20 and
0.09-point reductions at 3 and 6 months respectively.
The authors conclude that there is weak, very unre-
liable, evidence from 10 studies that flossing plus
toothbrushing may be associated with a small reduc-
tion in plaque at 1 and 3 months. No studies included
reported the effectiveness of flossing plus tooth-
brushing for preventing dental caries as none was of
sufficient length to assess caries formation.
Summary
The results of two systematic reviews of flossing and
toothbrushing compared with toothbrushing alone
(11, 41) are summarized as follows.
One systematic review in 2008 concluded that
there was no additional benefit of flossing in
conjunction with toothbrushing (11).
A more recent systematic review conducted in
2011 (41) concluded that there was a statistically
significant benefit associated with flossing plus
toothbrushing, compared with toothbrushing
247
Drisko
alone, in reducing gingivitis, although the mag-
nitude of change was minimal and the authors
state that the data may not be clinically relevant.
Weak, very unreliable, evidence to support floss-
ing plus toothbrushing may be associated with a
small reduction in plaque at 1 and 3 months.
However, overall the authors concluded that there
was not enough evidence to support or refute a
clear benefit for flossing in reducing plaque at 1, 3
or 6 months (41).
None of the studies reported the effectiveness of
flossing plus toothbrushing for preventing dental
caries because the studies were of short duration
(11, 41).
The desirable benefits of flossing in reducing
gingivitis are not negatively impacted by pro-
longed damage or adverse effects produced by
improper flossing techniques because most sub-
jects self-correct when flossing is causing tem-
porary harm to the soft tissues.
Authors comments
Although the systematic reviews did not strongly
support flossing as a useful periodontal self-care
adjunct, there was positive support for the use of
dental floss for plaque and gingivitis reduction, with
the possible exception of occasional floss cuts fol-
lowing improper use. It would appear that until fu-
ture systematic reviews are published to contradict
the use of floss for interproximal cleaning, that daily
flossing for interdental plaque control is still sup-
ported by the literature. Flossing, however, may be
more effective at cleaning the interproximal tooth
tooth contact surfaces for the prevention of inter-
proximal caries than for the prevention of periodon-
tal disease. The studies reported in the meta-analyses
discussed above were not of long enough duration to
test the caries-reduction hypothesis. Interproximal
plaque removal was found to be marginally effective
in the prevention of periodontal diseases according
to these systematic reviews, but may be accom-
plished more effectively with other cleaning devices,
as discussed in the following section.
Interdental brushes: effect on
plaque and periodontal
inflammation
The evidence available by systematic review on inter-
dental cleaning focuses primarily on interdental bru-
shes compared with toothbrushing and or flossing.
248
An earlier attempt at a systematic review addressed
the question of whether interdental brushes could be
beneficial for orthodontic patients. However, no
eligible studies were identified in that review process
to support the use of interdental brushes in addition
to toothbrushing in orthodontic patients. Since then,
another systematic review on interdental brushes has
been conducted. The aim was to evaluate the
adjunctive use of an interdental brush in the general
adult population and establish how effective inter-
dental brushes are in terms of plaque and inflam-
mation reduction compared with toothbrushing
alone or toothbrushing in combination with floss or
woodsticks (46). Independent screening of 218 titles
and abstracts in MEDLINE PubMed and 116 Coch-
rane papers yielded nine publications that met the
eligibility criteria. The authors concluded that as an
adjunct to brushing, the interdental brushes remove
more interproximal dental plaque than does brushing
alone. They also showed a significantly positive effect
on plaque scores in all but one study. Using the Loe
and Silness gingival index, two of three of the studies
compared within-groups comparisons showed a sig-
nificant reduction in bleeding in two of three of the
studies and no change in the third study. Two of the
nine studies showed a significant reduction in prob-
ing pocket depth. Most studies in the review also
reported significant, positive differences in the pla-
que index, favoring interdental brushes over floss.
End scores showed a significant, positive effect using
the Loe and Silness plaque index (44).
Summary
The use of interdental brushes with toothbrushing
compared with toothbrushing alone, or floss and
woodsticks (26, 46) can be summarized as follows.
Interdental brushes remove more plaque than
does toothbrushing alone.
Interdental brushes remove more plaque than do
dental floss and woodsticks.
Inconclusive evidence is available on the effect of
interdental brushes on inflammation.
There is no difference in the effect of interdental
brushes on parameters of gingival inflammation
as compared with floss.
Authors comments
Based on the systematic reviews discussed above, it
would appear that if the patient or the clinician pre-
fers to limit the number of interdental cleaning de-
vices, interproximal brushes would be the first choice

of use because they are superior to floss in inter-
proximal plaque removal. When systematic reviews
are inconclusive, and because no harm was noted
from the use of interproximal brushes, the clinician
must use their clinical judgment on whether to rec-
ommend various interproximal cleaning devices to
their patients. Despite the weak support from these
systematic reviews for reducing inflammation with
interproximal brushes, it seems logical to assume that
reduction of interproximal plaque would lead to
reduction of interproximal gingival inflammation. As
stated previously, more well-designed trials are nee-
ded to test the effectiveness of interdental brushes on
the reduction of gingival inflammation.
Dentifrices
If asked, most individuals claim to brush their teeth at
least once or twice a day, yet epidemiological studies
have shown that the prevalence of gingivitis and
chronic periodontitis remains high in most popula-
tions [Albandar (4), Sheiham & Netuveli (43)]. The
maintenance of an effective level of plaque control is
thought to be mandatory for preventing periodontal
disease and maintaining periodontal health following
treatment. However, achieving and sustaining a high
level of plaque-free sites is clearly difficult using
conventional mechanical procedures and dentifrices.
From a global perspective, it appears that other ap-
proaches, including chemotherapeutic adjuncts, are
needed for improving and maintaining the peri-
odontal health of large communities and populations.
The efficacy of oral-hygiene products has been
extensively reviewed in other papers but in general
the findings show that dentifrices may not have
significant additive effects on plaque removal or
reduction of gingival inflammation over and above
toothbrushing, according to several authors (1, 2,
18, 33). Popular dentifrices currently commercially
available contain amine fluoride stannous fluoride,
stannous fluoride sodium hexametaphosphate, tri-
closan (2-hydroxy-2,4,4-trichlorodiphenyl ether),
alcohol or nonalcohol-based essential oils, sodium
bicarbonate, quaternary ammonium compounds
(such as cetylpyridinium chloride), zinc citrate or
zinc chloride (1, 16, 17, 33).
Two sets of guidelines exist for acceptance of a
chemotherapeutic product for the control of supra-
gingival dental plaque and gingivitis (55, 56). The
first, published in 1986 by the American Association,
Council on Dental Therapeutics, outlines the criteria
used by the Council in evaluating chemotherapeutic
Periodontal self-care: evidence-based support
products (55). The other is guidance on the assess-
ment of the efficacy of toothpastes, which was pub-
lished by the US Food and Drug Administration
Commission in 1999 (56). Suprisingly, there are few
systematic reviews on the efficacy of dentifrices on
the prevention or treatment of gingivitis or peri-
odontitis.
Davies et al. (18) compared the effectiveness of
triclosan copolymer and fluoride dentifrices in
improving plaque control and gingival health in trials
lasting at least 6 months. Sixteen trials provided data
for a meta-analysis. The triclosan copolymer denti-
frice significantly improved plaque control compared
with a fluoride dentifrice, as measured using the
Quigley-Hein index for plaque severity, the Loe and
Silness plaque index and the gingivitis severity index.
The 16 studies in this review were from seven coun-
tries around the world and contained data from
adults using the dentifrices unsupervised. The
reviewers surmise that because they were able to find
little, if any, publication bias, and because the par-
ticipants were using the dentifrices unsupervised,
that the finding of greater gingival health in subjects
using the triclosan copolymer dentifrice can be
generalizable to other populations around the world.
Another systematic review, by Hioe & van der We-
ijden (25), produced similar results when comparing
self-performed mechanical plaque control with tri-
closan-containing dentifrices (triclosan zinc citrate)
in clinical trials of at least 6 months duration. In their
literature search of 105 titles and abstracts, 18 trials
were found to be suitable for extraction of clinical
data. They reported a significant, albeit small, positive
effect of triclosan-containing dentifrice on plaque
reduction and gingivitis compared with the control.
The efficacy of stannous fluoride-containing den-
tifrice on reducing gingivitis was also evaluated by
Paraskevas & van der Weijden (39). A literature
search, yielding 542 papers, resulted in 36 publica-
tions, of which 15 were used that fulfilled the criteria
of eligibility. For stannous fluoride-containing
dentifrices, a statistically significant reduction in
gingivitis was noted in comparison with the control.
Plaque reduction yielded inconsistent results, and no
differences were found. Because of a lack of data, a
meta-analysis for stannous fluoride dentifrice
mouthrinse formulations could not be performed.
The authors concluded that the use of stannous
fluoride-containing dentrifice results in the reduction
of gingivitis and plaque when compared with a con-
ventional dentifrice; however, the exact magnitude of
the effect was difficult to assess because of study
outcomes with a high level of heterogeneity.
249
Drisko
Gunsolley (23) reviewed the literature and extracted
45 articles, which met the criteria for inclusion, from
four published and one unpublished study on the
effect of stannous fluoride-containing dentifrice on
gingivitis. The results showed a statistically significant
reduction in plaque, although the difference
was small and was not considered important because
the studies were homogenous. For the triclosan
copolymer-containing dentifrice, the reported
anti-plaque effect was greater than that of stannous
fluoride. The author evaluated other formulations of
triclosan, and concluded that only the copolymer
formulation resulted in plaque reduction.
Regarding gingivitis reduction, Gunsolley reported
that the antigingivitis results for the stannous fluo-
ride-containing dentifrice were statistically, as well as
clinically, significant. This was an interesting finding
because the antiplaque effect for the stannous fluo-
ride-containing dentifrice was neither statistically
significant because of the homogeneity, nor was it
clinically significant.
Both triclosan co polymer- and stannous fluoride-
containing dentifrices appear to have a positive effect
on plaque reduction and gingivitis control to varying
degrees, depending on the systematic reviews in-
cluded in this paper. Practitioners can use these re-
sults to help decide which dentifrice to recommend
to their patients when reduction of plaque and gin-
givitis are the primary goals.
Summary
Summary of the systematic reviews of Davies et al.
(18), Paraskevas & van der Weijden (39) and Gun-
solley (23) showed the following.
Dentifrice containing triclosan copolymer was
more effective in reducing gingivitis and plaque
than was a fluoride dentifrice control (18).
Dentifrice containing stannous fluoride reduced
gingivitis compared with sodium fluoride-con-
taining dentifrice, but the magnitude of the effect
on gingivitis and plaque reduction could not be
determined because of the heterogeneity of the
studies (39).
Dentifrice containing stannous fluoride was less
effective as an antiplaque agent as well as an
antigingivitis agent when compared with triclo-
san copolymer-containing dentifrice (23).
Authors comments
Since these systematic reviews were published, new
studies have provided disturbing information that the
250
systemic effects of triclosan copolymer may be
detrimental to overall health (5, 6). Triclosan is a
microbicide and is found in various household and
personal hygiene products. It has been reported to be
detected in urine, breast milk and plasma in a large
segment of different populations around the world.
Allmyr et al. (6), in a short-term study, reported that
exposure to triclosan in dentifrice does not change
CYP3A4 activity or the plasma concentrations of
thyroid hormones. However, based on a study of the
Australian environment, bioaccumulation of triclo-
san in wastewater and soil affects microbial processes
and may shift the balance of certain ecosystems (30).
Some important antibiotics and disinfectants may
exhibit co-resistance or cross-resistance with triclo-
san as well as with some of the quaternary ammo-
nium compounds, which could be detrimental to
their long-term use in dentifrice and mouthrinses
(57).
Mouthrinses and their effect on
plaque and gingivitis
Gunsolley (23) also reported on the efficacy of
mouthrinses. The results of his review showed that 21
studies supported the efficacy of mouthrinses with
essential oils whereas a smaller number of seven
studies favored a strong antiplaque and antigingivitis
effect of mouthrinses containing 0.12% chlorhexi-
dine. The efficacy of cetylpyridinium chloride
mouthrinse varied substantially, depending on the
formulation of the product.
The analysis showed moderately consistent results
with regard to the antigingivitis effects of mouthrin-
ses containing essential oils and of stannous fluoride-
containing dentifrices; the results of one-half of the
studies were statistically significant for each agent,
but all of the studies demonstrated antigingivitis
effects.
When comparing mouthrinses and dentifrices as
antiplaque and antigingivitis agents, Gunsolley (23)
concluded that the results showed statistically sig-
nificant antiplaque effects for both agents in all four
studies included. Greater antiplaque effects were
found in all cases where 0.12% chlorhexidine exhib-
ited larger changes than did mouthrinses containing
essential oils. The results were similar for gingivitis.
The four studies showed a statistically significant
advantage for the active agents over the control
agents. Mouthrinses containing essential oils had
about 60% of the antigingivitis effect of 0.12%
chlorhexidine; however, the difference in antigingi-

vitis effects of the agents was close to, but failed to
reach, statistical significance (P = 0.068). There were
not enough other studies that directly compared
other active agents (two or fewer) to be included in
the evaluation.
Stoeken et al. (48) reviewed 566 papers, resulting in
11 publications that met the criteria of eligibility for
systematic review. In all the studies, essential oil
mouthrinses were used as an adjunct to regular daily
toothbrushing. The primary outcome measure was
gingivitis. The results showed a statistically signifi-
cant reduction in plaque and gingivitis with the use of
essential oil mouthrinses compared with the control.
Separate analyses of the interproximal sites showed
that essential oil provided significantly more gingi-
vitis reduction than the control and that the degree of
gingivitis reduction was equal to that achieved with
the use of dental floss (48).
Upon completing the reviews of antiplaque and
antigingivitis agents, there appears to be strong
evidence to support the benefit of augmenting
mechanical methods of brushing and flossing in
adults with chemotherapeutic agents to control pla-
que and gingivitis (23). Mouthrinses containing
0.12% chlorhexidine or essential oils, and dentifrices
containing triclosan with 2.0% Gantrez copolymer or
stannous fluoride, reduce the level of gingival
inflammation (23). Use of essential oil mouthrinses
has been shown to be effective in the interproximal
areas in reducing plaque and gingivitis (48).
Summary
Summary on the use of antimicrobial mouthrinse to
control plaque and gingivitis.
0.2% chlorhexidine-containing mouthrinse is effec-
tive in reducing plaque and gingival inflammation.
Essential oils in mouthrinse are effective in
reducing plaque and gingivitis, and this occurs at
about 60% of the magnitude of chlorhexidine.
Essential oils-containing mouthrinse is effective in
reducing plaque and gingivitis in interproximal
areas, and is as effective as floss in reducing
interproximal plaque and gingivitis.
Subgingival irrigation
Subgingival irrigation has been used as an adjunct for
personal oral hygiene for many years, yet the litera-
ture to support its use is rather small. In 2005,
Greenstein (22) performed an extensive review of the
irrigation literature for the Research, Science and
Periodontal self-care: evidence-based support
Therapy Committee of the American Academy of
Periodontology (22). Although it was not a systematic
review or a meta-analysis, the analysis was extremely
thorough and included all relevant papers up to 2004
on supragingival and subgingival irrigation, as ap-
plied by the patient or the dental professional. His
findings were as follows.
Supragingival and marginal irrigation will con-
tinue to play a role in the treatment of gingivitis
and the maintenance of periodontal patients.
There is a paucity of data to support the conten-
tion that a single episode of subgingival irrigation
increases the immediate impact on root-planing
efficacy.
There is limited information to suggest that mul-
tiple in-office irrigation appointments provide a
substantial benefit beyond that of root planing.
Some preliminary data suggest that irrigation with
a high concentration of substantive drugs may
enhance the efficacy of root debridement.
Additional research is needed to verify the utility
of this treatment modification.
Conceptually, irrigation therapy may be of in-
creased value when root planing is less than ideal
because of anatomy or other factors.
It appears that the greatest shortcoming of irri-
gation therapy is the quick elimination of sub-
gingivally placed drugs.
Later, in 2008, Husseini et al. (29) screened 809
PubMed and 105 Cochrane papers and identified
seven publications that met the eligibility criteria for
systematic review. Their findings are as follows.
As an adjunct to brushing, oral irrigation does not
visibly reduce plaque.
Oral irrigation trends toward improving gingival
health relative to gingival index, bleeding scores
and pocket depth over regular oral hygiene or
toothbrushing alone.
The periodontal index of the toothbrush-only
group deteriorated over time, whereas that of the
oral irrigation group did not.
Authors comments
It would appear that subgingival irrigation has some
positive effect on reducing inflammation and has
some evidence to support its use by patients as an
adjunct to brushing and interdental cleaning.
Discussion
Based on the evidence gleaned from systematic re-
views, it is notable that most authors of these reviews
251
Drisko
commented on the relatively small number of trials
that could pass the quality assessment inclusion in
the systematic review. Hujoel et al. (28) conducted a
similar search of the literature on the effect of per-
sonal oral hygiene and chronic periodontitis and
found only three randomized controlled clinical trials
that qualified for the systematic review out of a pool
of 24 identified in MEDLINE and 99 potentially rel-
evant ones in CENTRAL. Of those, 35 were retrieved
and 32 were subsequently excluded because they did
not measure periodontal outcome and or were not
of 9 months duration or lacked a control group.
Hujoel et al. (28) concluded, from the three studies
that met the criteria, that none of the trials provided
evidence to support that improved personal oral hy-
giene prevents or controls chronic periodontitis. They
offer several explanations for their findings: (i) there
may be no association between personal oral hygiene
and chronic periodontitis; (ii) improved plaque con-
trol may not be related to a decreased risk for chronic
periodontitis; (iii) microbiological research on path-
ogenic mechanisms has suggested that plaque leads
to gingivitis and possibly to periodontitis, yet no
randomized controlled trials or epidemiological
study supports the nonspecific plaque hypothesis;
and (iv) biases in clinical studies have masked a po-
sitive association between plaque and chronic peri-
odontitis. As controversial as these thoughts may be,
they do beg the question of how important is daily
periodontal self-care in the overall scheme of things?
Hujoel et al. (28) suggested, like many of the other
authors of systematic reviews of the various plaque-
removal procedures, that better evidence is needed in
human trials to support the efficacy of self-care in
preventing periodontitis.
The epidemiological data from two longitudinal
studies in Sweden and Norway indicate that in some
parts of the world, the prevalence of periodontal
disease may have declined in the last three decades
(27, 45). In the epidemiologic report of Hugoson
et al. (27) commonly referred to as the Swedish
Jonkoping study, the data from their 30-year longi- health score, the lower is the decayed, missing or
tudinal study indicate a possible trend of a lower
prevalence of periodontitis. They reported a general
increase in retained number of molars in all age
groups between 20 and 80 years, and a decrease in
mean plaque scores among all age groups over time,
with the largest decrease in the 19932003 time per-
iod. In addition, there was a general decrease in the
mean gingivitis scores in the 19731983 period, as
well as in the 19932003 period, for all age groups. A
similar European study the Oslo study was meta-analyses reported here. Interproximal devices,
published in 2007 by Skudutyte et al. (45) and con-
252
cluded that periodontal health and oral hygiene had
been improving in 35-year-old subjects over the last
30 years, similarly to that of the Jonkoping study
(15). There are too few reports to generalize the
findings of these two studies; however, they show
that periodontal health can significantly improve
over time at a population level and they may be used
to reach more general conclusions. The direct role of
periodontal self-care cannot be determined from
these two studies, but the scores of randomized
controlled trials and systematic reviews discussed in
this paper would suggest that periodontal self-care
with a variety of aids can positively influence the
degree of success that patients can have in control-
ling plaque and gingival inflammation.
A systematic review by Broadbent et al. (15) has
indicated that poor dental-plaque control and
smoking have a detrimental and synergistic effect on
oral health in the first 32 years of life. They state that
all populations experience plaque-related dental
diseases, and the development of these chronic dis-
orders across time most likely would be similar
among various populations, indicating that plaque
control is central to periodontal disease status. Other
authors of systematic reviews and meta-analyses
have indicated that low educational attainment (13),
smoking (12) and socio-economic status (14, 42) are
related to adverse periodontal health outcomes.
Additionally, Dumitrescu et al. (21) showed that
variations in self-esteem, self-confidence and per-
fectionism were associated with oral health status
and oral health behaviors. They conclude that better
understanding of the psychological factors associated
with oral hygiene can help in further developing
strategies to help patients improve their oral hygiene
in addition to helping professionals to design better
programs on prevention and education.
Other authors have concluded that health beliefs
about toothbrushing are significantly correlated with
certain oral health-care practices and oral health
status, showing that the better the self-rated oral
filled teeth score, and that increased toothbrushing
frequency is related to better oral health status (7).
Conclusions
Toothbrushing or flossing alone does not appear to
be highly effective in controlling dental plaque and
gingivitis according to the systematic reviews and
namely interproximal brushes, are more effective at

reduction of interproximal plaque and gingivitis than
are flossing or brushing alone. Some added benefit
may be attributed to the use of rotational oscillation
powered toothbrushes over manual toothbrushes.
Recommendations by the dentist and dental
hygienist to add one or more chemotherapeutic
agents to the typical oral-hygiene regimen has been
shown, in systematic reviews and meta-analyses, to
reduce the level of plaque and gingival inflammation
in these patients. Two dentifrices and two oral
mouthrinses were identified as having some adjunc-
tive affect in addition to toothbrushing. Similarly, oral
irrigation does not seem to reduce visible plaque but
does tend to reduce inflammation, as measured by
bleeding, gingival index and probing depths.
The most likely benefit for continuing to have pa-
tients perform self-care, perhaps with the addition of
interproximal brushes, antimicrobial dentifrices and
or antimicrobial mouthrinses, is the prevention
and or reduction of periodontal disease. However,
in most studies the authors questioned the clinical
significance of the very small changes that were
found, despite the fact that they were statistically
significant.
Further studies are needed to confirm that regular
daily self-care and use of these adjunctive agents will
result in a lower prevalence and severity of peri-
odontal disease. It is likely that the addition of che-
motherapeutic agents to mechanical plaque removal
will enhance the ability of the patient to obtain and
maintain better periodontal health. Slots (47) has
discussed a variety of applications of povidone-io-
dine and dilute bleach through patient-applied irri-
gation protocols as being effective alternative addi-
tional self-care practices for reducing gingival
inflammation and maintaining lower gingivitis scores
and subgingival bacterial counts. New ideas like these
should be explored in randomized controlled trials
and subjected to systematic reviews to help guide the
clinician in promoting low-cost oral-hygiene alter-
natives to their patients. These types of studies would
be particularly useful in the global forum, where ac-
cess to more expensive oral-hygiene products, such
as chlorhexidine mouthrinses, may be unaffordable
and thus unattainable.
Patients are not very compliant with their own
personal self-care, nor do they consistently attend
regular recall appointments for professional care.
Therefore, it would be useful for the clinician to have
a strong evidence base upon which to recommend
the minimal tools tasks they require of their patients
to achieve the shared goal of better periodontal
health. To date, high-quality evidence is either lack-
Periodontal self-care: evidence-based support
ing or weak in some areas regarding the efficacy of
self-care and periodontal disease.
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