Knowledge, Awareness and Practice of Interdental Aids among Dentists in Bangalore City - A Questionnaire Based Study

Introduction

Dental plaque plays a vital role in the progression of periodontitis. Mechanical control is the gold standard in prevention of periodontitis. Brushing teeth is the prevalent method for mechanically removing plaque; however it is inadequate in the interdental areas. It has also been demonstrated that periodontitis occurs frequently in the interproximal areas and often in severe form. Therefore, interdental toothbrushes, toothpicks, floss, etc, must be used regularly.¹

Dental floss is used widely to clean tight spaces between teeth, making it a common interdental tool, while interdental brushes are used in wider interdental spaces. The disadvantage in the usage of floss is that it is not very effective in removing plaque from the concave sides of the tooth. Flossing also requires manual dexterity.¹

The effectiveness of interdental brushes in minimizing inter-proximal plaque varies based on their size and shape. Thinner interdental brushes would be more effective in individuals with healthy gums and smaller gaps between their teeth. These brushes are particularly helpful for individuals with limited hand coordination or large hands.¹ When utilized appropriately, interdental brushes are typically effective for about a week before needing replacement, depending on the quality of the brush and the technique used. Once the bristles wear out or the wire weakens or bends, it is necessary to dispose the brush and start using a new one.²

The oral irrigator helps to reduce the levels of biofilm and debris around crowns, bridges, orthodontic appliances and implants, and in interdental areas.³

Wood sticks may not be the first choice for recommendation, but many older individuals may opt to use them instead of floss.³ Wooden interdental aids appear to offer no significant advantage over brushing with respect to plaque removal. They may, however, reduce gingival bleeding.⁴

Periodontal treatment is effective only if thorough, regular plaque removal is maintained.⁵ Studies have shown that oral prophylaxis will reduce gingival and periodontal inflammation by removing the subgingival bacterial population, rendering the environment significantly less pathogenic. However, the microflora gradually shifts back to a pathogenic supportive environment over three months.⁶

Dental health is highly an individualized concept. The attitude of people toward their own teeth and attitudes of dentists who provide dental care, play an important role in determining the oral health conditions of the population. The attitude and behaviour of dentists toward their oral health care reflect their understanding of the importance of dental procedures and improving the oral health of their patients.⁷

Effective removal of plaque by personal oral hygiene control is the most effective mode towards the prevention of dental caries and periodontal diseases. Periodontitis progresses faster interdentally, and plaque control in these areas is ardous.⁸ Furthermore, reducing plaque overall can enhance long-term health by reducing the bacterial count in the mouth, which in turn lowers the risk of systemic infections and related complications.

Many studies have examined the oral health behaviours of dental professionals, but relatively little attention has been paid to the awareness and practice of interdental aids. Therefore, this study was undertaken with the objective of assessing the knowledge and practice of interdental aids among dentists.

Materials and Methods

This was a questionnaire-based survey conducted among one hundred subjects. Ethical clearance for the study was obtained from the Institutional review board of Sri Rajiv Gandhi College of Dental Sciences and Hospital, Bangalore. An online questionnaire consisting 15 questions - five on knowledge, five on attitude, and the remaining five on participants’ practices, was prepared and distributed to all the participants via Google forms.

The objective of the questionnaire was to assess the understanding and knowledge regarding interdental aids and their use in daily oral hygiene practices among the dentists. The questionnaires were sent to the dentists practicing in Bangalore city and the responses were collected.

Statistical analysis

Statistical Package for Social Sciences (IBM SPSS version 23; Chicago Inc., USA), was used to perform the statistical analyses. Descriptive analysis of the informative and outcome parameters was performed using mean and standard deviation for quantitative variables, frequency and proportions for categorical variables. The Chi Square Goodness of Fit test was employed to analyse the variation in responses to the study questionnaire among the participants.

Independent sample t test was used to compare the responses for the study questionnaire based on the gender and other important socio-demographic characteristics of the study participants.

The significance level was established at P-value below 0.05.

Results

The study involved a total of one hundred participants, among which 24 were male dentists and 76 were female dentists practicing in Bangalore. The distribution accounts for 24% male and 76% female representation in the sample (Figure 1).

The majority of population (96%) demonstrated awareness of interdental aids. Only a small fraction (2%) believed that interdental aids are ineffective for maintaining optimal gingival health and preventing oral diseases. Similarly, a significant majority of 94 participants showed proficiency in flossing techniques. Furthermore, 88% of respondents expressed confidence in the effectiveness of combining tooth brushing with interdental aids compared to tooth brushing alone. Conversely, a minimal proportion, only 6% of participants, lacked awareness regarding the selection of interdental aids based on interdental area size and shape (Table 1). Analysis of knowledge-based responses revealed statistically significant findings among the study participants.

Nearly 96% of study participants recognized the importance of interdental cleaning aids in the maintenance of oral health. However, only 65 subjects reported using interdental aids daily. A small percentage (6%) were unaware that using dental floss without guidance can lead to gingival injury. When asked about recommending nylon interdental brushes for patients with dental implants, only 43% agreed. Additionally, 59% believed that patients are compliant with the use of interdental aids (Table 2). The analysis of attitude-based responses uncovered statistically significant findings among the study participants.

Approximately 88% of the participants inquire about the oral care habits of their patients before suggesting interdental aids. A mere 7% refrain from recommending interdental aids altogether. Additionally, only 56% of respondents suggest flossing prior to brushing. Moreover, 58% of the participants concur that water flossers are suitable for both healthy individuals and those with periodontal conditions. Only 52% of dentists advocate floss holders for patients with physical challenges (Table 3). Statistically significant findings were observed when comparing the practice of interdental aid usage between male and female dental practitioners, with both groups demonstrating commendable adherence to such practices.

The average knowledge scores for male and female dentists were 4.83±0.483 and 4.51±0.931, respectively. Upon comparing the groups, no statistically significant difference was observed. In terms of attitude scores, male dentists had a mean score of 4.08±1.1, while female dentists had a mean score of 3.29±1.198. The difference in attitude towards interdental cleaning aids was statistically significant (P =0.005) between the two groups. Regarding practice scores, male dentists had a mean score of 3.667±1.3726, and female dentists had a mean score of 3.355±1.4. No statistically significant difference was found on comparison between the groups (Table 4).

Discussion

A recent study by Mahtani AA et al., conducted amongst 100 randomly selected patients from the general population revealed that use of dental flossing and interdental brushes effectively eliminated interdental plaque, and suggested that clinicians must collaborate with patients to determine the best oral hygiene methods as per the patient's preference and skill level.¹

The removal of inter-proximal plaque is contemplated to be crucial for the preservation of gingival health, prevention of periodontal diseases and reduction of caries. Regrettably, toothbrushes are not productive in removing plaque between teeth. Therefore, patients must rely on extra homecare techniques such as interdental aids.¹ Interdental aids are available in a variety of forms, including dental floss, interdental brushes, rubber tips, wooden tooth picks, water jets, and oral irrigators.⁹

In our study, the majority of participants were already familiar with interdental aids, given that it was conducted among dentists. This is in contrast to the findings of Madan et al. (2014), where the knowledge and practice of interdental aids among dentists themselves were found to be very low.10

A latest investigation revealed dental floss to be superior to toothpicks in reducing interdental plaque, as evidenced by improvements in gingival and plaque indices.¹¹ Frequent mechanical plaque removal within 24 hours may help prevent an increase in the severity of gingival inflammation over a period of 30 days in patients with no history of periodontitis.¹²

In an analysis evaluating interdental brushes (IDBs) in combination with brushing alone, two out of three studies demonstrated a decrease in plaque scores for the groups using IDBs. Additionally, one out of three studies indicated a reduction in the gingival index among the outpatient population.¹³

In the current study, most of the respondents demonstrated a fair level of knowledge regarding the awareness of interproximal devices in daily oral hygiene, despite lack of knowledge in certain specific areas. This aligns with the findings of a study conducted by Bennadi et al., conducted among a group of dental professionals in Tumkur, where similar results were reported.⁶

A study conducted in Australia among general population showed that more than two thirds of women (67.5%) reported brushing twice a day along with the practice of using other oral hygiene products, such as mouthwashes (40.7%), dental floss (42.7%). It can be said that use of aids other than a toothbrush is more common in western countries. It could be attributed to frequent and regular dental checkups done among western population during which they receive information and awareness regarding various interdental cleaning methods.¹⁴ In our study, an overwhelming 96% of the participants acknowledged the significance of interdental cleaning aids in maintaining overall oral health.

Recommending flossing and interdental brushing in dental practices represents an approach to the prevention of gingivitis and consequently periodontitis.¹⁵ Dental and medical students must be encouraged to be role models in practicing as well as promoting oral health for their patients, families, friends and ultimately the society. Moreover, the subjects' oral health is directly related to their physical well-being.¹⁶ Limitations of this study would be the sample size. A larger sample size could result in a more accurate outcome.

Conclusion

The study on oral hygiene aids among dentists revealed that their understanding and application of interdental aids were generally good, although some areas showed knowledge gaps. Improvements are needed in the practice of using interdental aids. Dentists are encouraged to adopt recommended oral self-care habits and set an example for their patients. This will contribute to averting dental problems and thus helps in maintaining the oral health of patients.

Source(s) of support

Nil

Conflict of Interest

Nil