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Interdental Cleaning
A Peer-Reviewed Publication
Written by Patty Bonasso Byrd, RDH, BS
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Educational Objectives
Introduction
Upon completion of this course, the clinician will be able to
do the following:
1. Discuss the current status of caries, gingivitis, and
periodontal disease in the United States
2. List the dental implications associated with inadequate/ineffective interdental plaque control
3. Recognize the clinical signs of infrequent interdental
plaque control and identify patients who are at a high
risk for periodontal diseases
4. Recommend appropriate interdental cleaning methods
and devices for specific patient needs, and explain the
necessity of interdental plaque control as part of the
patient’s complete self-care program
Interdental plaque control is an essential part of every
patient’s self-care program. Toothbrushing alone cannot remove plaque between tooth surfaces and adjacent gingiva,4
and many patients are noncompliant. Dental conditions
resulting from infrequent or ineffective interdental cleaning
include caries, gingivitis and periodontal diseases.
Abstract
Interdental plaque control is essential to every patient’s
self-care program. Bacteria have a causal relationship in
the etiology of caries and periodontal disease. Excellent
oral hygiene is necessary to remove dental plaque to prevent oral disease, and clinical examination should include
an assessment of plaque levels interdentally as well as a
review of diet, risk factors and medical history. It has
been shown that toothbrushes are relatively ineffective
interdentally, and it is also known that periodontal disease
typically begins interstitially. Toothbrushing alone cannot remove plaque between tooth surfaces and adjacent
gingiva. It is also known that only a minority of patients
are compliant flossers.1 In one survey, more than half of
respondants indicated that the majority of their patients
(70 percent to 80 percent) did not floss daily.2 Amongst
implant patients—a patient population for whom flossing has been particularly stressed—few floss.3 Several
dental conditions result from infrequent or ineffective
interdental cleaning, including caries and periodontal
diseases. These two, in combination, suggest a need for
effective interdental cleaning. Ongoing patient education
is also an integral part of patient compliance.While most
patients brush at least for a short period of time, fewer use
interdental devices. Adjunctive aids, including interdental brushes, floss, and mechanical devices, are available to
remove interdental plaque. Clinical studies have shown
that manual interdental brushes are particularly effective
at reducing plaque and gingivitis. Selecting with the patient the sizes and types of interdental device(s) that are
best for him or her includes an assessment of the interdental space; contact points; retentive areas; gingival shape,
position, and pockets; and patient demonstration to help
motivate them and increase the likelihood of effective
interdental cleaning. Ultimately, the goal of patient care
is to prevent, arrest or control periodontal disease and/
or caries. The patient’s ability to remove plaque effectively and thoroughly is essential to every patient’s selfcare program.
2
Prevalence of Caries, Gingivitis,
and Periodontal Disease
Caries
The National Health and Nutrition Examination Survey
(NHANES) documents improvements in the oral health of
the U.S. civilian population. The decline in the prevalence
and severity of dental caries in permanent teeth, reported
in previous national surveys, continued from 1988 to 1994
and 1999 to 2002. Declines in dental caries were seen in both
crowns and roots, and an overall decline in dental caries
was seen in the U.S. population irrespective of age, gender,
ethnicity, poverty status, education level, or smoking status.
While the overall decline is a positive trend, it has been
estimated that 68 percent of people experience caries before
the age of 20, and by the age of 59 approximately 95 percent
have experienced some decay.5 Despite the decrease in caries prevalence and severity in the permanent dentition and
the increase in the proportion of children and adolescents
who benefit from dental sealants, disparities remain. Ethnic
minorities and those with lower income or lower education
level, and current smokers across all age groups have larger
unmet needs compared with their counterparts. There are
currently around 36 million baby boomers, and this number
is anticipated to increase over the next four decades to reach
around 80 million baby boomers by 2050.6 Concomitantly,
more people are keeping all of their natural teeth or retaining more teeth. As the U.S. population ages, preventive
interventions will be needed for these age groups at the
individual, clinical, and community level to help prevent
coronal, root, and recurring caries.
Gingivitis
Gingivitis is first found in early childhood and increases in
both prevalence and severity in adolescence before leveling
off in older age groups.7 In the United States, the prevalence
of gingivitis among schoolchildren has been found in a
number of surveys to range from 40 percent to 60 percent.
In adults, 50 percent were found to have gingivitis around at
least three or four teeth.8
Periodontal Disease
Moderate periodontal disease is found in the majority of
the adult population. However, it is only in a minority of
people that this progresses to generalized periodontitis.
Data from the National Center for Health Statistics and
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the National Institute of Dental and Craniofacial Research
indicates that only 5 to 15 percent of any population suffers from generalized periodontitis.9
Ideally, gingivitis and/or periodontal disease should be
prevented through excellent oral hygiene. Factors related to
the attainment of good oral hygiene include the individual
oral anatomy, age, gender, socioeconomic status, motivation
and dexterity.
While advancing age may cause a decrease in a patient’s
dexterity and, consequently, difficulty in performing oral
hygiene procedures, and while with increasing age there is a
greater likelihood of systemic conditions that may influence
the intraoral environment and of intraoral conditions having
had more time to progress, in and of itself age is not considered
a risk factor for periodontal disease. Tooth retention, good
oral hygiene, and periodontal health are closely associated, regardless of age. With respect to gender, national surveys have
consistently shown that oral hygiene is poorer in males than
in females, measured in terms of either soft plaque deposits
or calculus. A further indication of this in the absence of other
influencing factors is the higher level of clinical attachment
loss (CAL) found in males than females.10
Socioeconomic status (SES) can influence the level of
oral hygiene and the presence of gingivitis in individuals.
Generally, people who are better educated, wealthier and
live in more desirable circumstances enjoy better systemic
and oral health than people who are less educated and financially disadvantaged.11 While gingivitis is clearly correlated
to SES, there is no clear-cut correlation between SES and the
prevalence of periodontitis.12
Bacteria are the causal agents in the onset of gingivitis
and periodontal disease, but the presence of bacteria does
not determine periodontal disease progression. Factors influencing the development of inflammation and the progression of periodontal disease may include genetics, hormonal
changes, stress, and systemic diseases such as diabetes.
A genetic role was first identified in periodontal disease in
1997.13 The proinflammatory cytokine IL-1 is a key regulator
of the host response to microbial infection14 and is tied to the
genetic makeup of the individual, but is unlikely to be the
only gene involved.15 More research will be necessary before
the genetic contribution to periodontitis can be determined.
In women, hormonal issues (puberty, pregnancy and
birth control pills) may cause an exaggerated response
to bacterial plaque, and can result in gingivitis and
possibly periodontitis.
Stress has been studied from the perspective of the
mind-body connection and disease and assessed in terms
of adverse life events, clinical depression, and coping skills.
High levels of stress seem to be associated with progressive
periodontitis as well as a number of systemic diseases.16
Diabetes lowers resistance to infections and delays
healing. Periodontal infections can affect glycemic control,
which ultimately can be life threatening. Conversely, poorly
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controlled diabetics are at increased risk for periodontal infections. Diabetics respond abnormally to inflammation and
infection, demonstrating differences in gingival crevicular
fluid and vascular abnormalities. A thorough understanding
of the relationship between diabetes, periodontal disease,
and professional and personal dental care is imperative in
the care of diabetic patients.17
Strong risk factors for periodontal disease include smoking and tobacco use. Smoking has been shown to increase the
risk of both periodontitis and refractory periodontitis. It is
estimated that 90 percent of refractory chronic periodontitis
cases are smokers,18 and healing following mechanical treatment is slower in smokers than in nonsmokers. Smoking
inhibits the growth and attachment of fibroblasts associated
with healing in periodontal ligaments, and is associated with
changes to the vascularization of the local area. This results
in a slower reduction in the number of blood cells, including
neutrophils, following periodontal therapy.19 It is this poor
vascularization (rather than less or less severe gingivitis and
periodontal disease) that results in lower bleeding upon
probing levels found in smokers with deep pockets.20
Recent research also suggests that heavy drinking is a risk
factor, and that excessive alcohol consumption is associated
with poorer oral hygiene.
Plaque and Pocket Formation
Microbial plaque is the primary etiologic factor in the
development of gingival and periodontal diseases.21 As
bacterial plaque accumulates on the tooth surface adjacent
to the gingival margin, an inflammatory response begins
within two to four days. Initially the plaque is supragingival
and consists mainly of gram-positive bacteria, especially A.
actinomycetemcomitans and Streptococcal species.22,23 This
changes after day three, when filamentous bacteria begin to
be seen on the surface of the plaque and later penetrate it.
Over the next seven to 14 days, bacterial plaque becomes
thicker. The connective tissue becomes infiltrated with
fluid, lymphocytes, neutrophils, and plasma cells. Collagen
fibers begin to break down, epithelium proliferates, and
epithelial extensions are formed. Clinically, slight gingival
enlargement occurs and gingival pockets (“pseudopockets”)
are formed. Gingivitis at this stage can be reversed if plaque
is controlled and inflammation reduced. If undisturbed, the
disease process continues and clinically marginal redness,
bleeding upon probing, and spongy marginal gingiva are apparent. While not all gingivitis leads to periodontal disease,
plaque removal while the gingivitis is reversible will prevent
the development of destructive periodontal disease.
Bacteria from supragingival plaque enter the gingival
sulcus as subgingival plaque develops. Mature subgingival plaque consists mainly of gram-negative anaerobes,
and between the third and 12th week after supragingival
plaque forms, the subgingival plaque is well-differentiated
and organized.24
3
The bacteria in plaque release biological irritants. The
host response includes the release of antibodies, lymphocytes, and white blood cells. As periodontitis develops in response to the bacterial invasion and inflammation, soft- and
hard-tissue destruction occurs with the release of cytokines,
prostaglandins, and MMPs (associated with the destruction
of hard tissue, or alveolar bone).
Pockets can be divided into gingival and true periodontal
pockets, depending upon the degree of anatomic involvement (Table 1).
Anatomy
A healthy sulcus should measure from 0.5mm to 1.8mm in
depth and should have no evidence of infection.25 The interdental gingiva is located between two adjacent teeth and
may be flat or saddle-shaped (spaces between teeth), tapered
or narrow (overlapping or crowded), pointed or pyramidal
(anterior), or flat with two papillae (facial and lingual) connected by a col on posterior teeth. Most periodontal infections begin in the col area.26
While gram-negative organisms in the periodontal crevice are closely associated with periodontitis, an important
finding is that supragingival plaque can serve as a natural
reservoir for them.27
When the bacterial insult is strong enough to overwhelm
the host defense, bacteria in supragingival plaque migrate
subgingivally to form a subgingival biofilm.28
Since most periodontal infections begin in the col area,
it is critical that all interdental plaque be removed.29 Toothbrushing alone has been proven to be ineffective at removing
interdental plaque; it is necessary to use interdental cleaning
aids. Frequent professional supragingival cleaning and good
personal oral hygiene have been shown to have a beneficial
effect on subgingival microbiota in moderately deep pockets. The benefits of scaling and root planing combined with
personal plaque control in the treatment of chronic periodontitis have been clinically proven.30
Devices Used for Removing
Interdental Plaque
Vibratory and sulcular toothbrushing techniques are useful
for removing interdental plaque (Charter’s, Stillman and
Bass methods), and are successful to some degree in removing bacterial plaque near the line angles of the facial and lingual embrasures.31 However, for complete plaque removal
interdentally, other devices are needed (Table 2).
Interdental devices include the use of interdental
brushes, tips, and floss. These have all been found to be
effective, depending upon the targeted area of the interdental space.
Interdental brushes offer the advantage of being available
in wider and new thinner versions, such as Go-Betweens®
(Sunstar Butler), to accommodate the various dimensions
of the interdental spaces. Patients who have dexterity issues often find interdental brushes easier to use. Effective
at removing interdental plaque, brushes have the added
advantage of serving as vehicles for the local application
of antibacterial agents such as 0.12 percent chlorhexidine
gluconate or desensitizing agents to exposed sensitive root
areas. Interdental brushes are available with both coated
and uncoated wire, and some include antibacterial agents
(chlorhexidine) on the bristles.
Table 1. Gingival and Periodontal Pockets
Pockets
Gingival Pocket
Periodontal Pocket
Definition
Formed by gingival enlargement without
apical migration of junctional epithelium
Formed as a result of disease or degeneration that
causes the junctional epithelium to migrate apically
along the cementum
Structures involved
Margin of gingiva has moved toward incisal or occlusal without deeper periodontal
structures becoming involved
Cementum, periodontal ligament, bone
Tooth wall
Enamel
Cementum or cementum/enamel
Base
Base of sulcus near CEJ
Base of pocket on cementum at level of
attached periodontal tissue
Suprabony
Suprabony: Base of pocket is coronal to crest of
alveolar bone
Intrabony: Base of pocket is below or apical to the
crest of aveolar bone
Type
Actinomyces actinomycetemcomitans (Aa), Bacteroides forsythus (Bf ) (now Tannerella forsythensis),
Porphyromonas gingivalis (Pg), Prevotella intermedia
(Pi), Treponema denticola 8
Broad gram-negative pathogens
Clinical signs and symptoms
Slight gingival enlargement/sponginess,
marginal redness, bleeding upon probing
Edema, erythema, bleeding upon probing and/or suppuration, tooth mobility, furcation involvement
Adapted from Wilkins, Clinical Practice of the Dental Hygienist. 8 th ed. p. 227.
4
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Table 2.
Mechanical Device
Indications for Use
Interdental brushes
Proximal tooth surfaces adjacent to open embrasures, orthodontic appliances, fixed prostheses, dental
implants, periodontal splints, space maintainers, concave proximal surfaces, exposed Class IV furcations; applications of fluorides for prevention of decay, particularly root surface caries and for surfaces adjunct to any
prosthesis; antibacterial agents for control of plaque and gingivitis; desensitizing agents
Interdental tips
Plaque forming on tooth surface or just below gingival margin
Floss
Proximal surface of each tooth and line angles
Tufted dental floss
Wide embrasures; mesial and distal abutments of fixed partial dentures; under pontics;
orthodontic appliance
Gauze strips
Proximal surfaces of widely spaced teeth; distal and mesial surfaces of abutment teeth; distal portions of
dentures supported by implants
Toothpicks in holders
Plaque forming at or below gingival margin; interdental cleaning; concave proximal tooth surfaces; exposed
furcation areas; orthodontic appliances
Wooden dental cleaners
Exposed proximal tooth surfaces
Adapted from Wilkins, Clinical Practice of the Dental Hygienist. 8 th ed. Ch. 24.
Adjuncts.
Chemotherapeutic
Irrigation
Floss is able to reach into narrow interdental spaces
where use of an interdental brush may be difficult and will
also remove plaque at the interproximal contact. Preference,
availability, interdental anatomy, and dexterity all play roles
in the selection of an interdental device.
In addition to these interdental devices, there are a
number of mechanical and chemotherapeutic adjuncts that
may be useful in reducing and removing interdental plaque.
Recent research on a novel electric interdental cleaning aid
(Hummingbird™, Oral B) compared patients using either
the cleaning aid with floss or manual floss interdentally over
a period of 30 days. Manual floss was equally effective in
reducing plaque and gingivitis, and, while safe and effective,
the mechanical device offered no advantage.32
A study of another mechanical interdental device
(Interclean) in a German population revealed significantly less plaque reduction than with manual interdental
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Indications for Use
Irrigation
Reduce gingivitis; reduce or alter
microbial flora; penetration onto pocket;
delivery of antimicrobial agents; periodontal maintenance
Mouthrinse
Preprocedural rinse, dental caries prevention; after nonsurgical periodontal
therapy
Dentifrice
Control dental caries; remineralization;
gingival health, calculus prevention;
desensitization
Adapted from Wilkins, Clinical Practice of the Dental Hygienist. 8 th ed. Ch. 24.
brushes. In this study, it was found that only 5 percent of
interdental plaque remained following patient use of manual
interdental brushes.33 In two other studies, the same device
was compared to the use of dental floss, and the device and
manual dental floss were found to be equally effective in
reducing plaque.34,35
Based upon the results of these clinical studies, while
there may be a subjective perception of improved interdental cleaning with mechanical devices, from a clinical
perspective manual interdental brushes are superior
and floss is equally effective in reducing and removing
plaque interdentally.
Irrigators help remove plaque and debris interdentally
and may also be used in conjunction with an antimicrobial agent. Irrigation can also be achieved through the use
of blunt-ended cannulae to syringe antimicrobial agents
into shallow to moderate periodontal pockets. The use of
a chlorhexidine gluconate rinse has been shown to reduce
plaque by 64.9 percent.36 Other adjuncts include the use of
essential oil mouthrinses, zinc nitrate, CPC, and triclosan
copolymer dentifrice.
5
Conclusion
Clinical judgment, clinical skills, patient-related factors,
and the patient’s current dental status affect oral health.
Bacteria have a causal relationship in the etiology of caries
and periodontal disease. Excellent oral hygiene is necessary
to remove dental plaque to prevent oral disease, and clinical
examination should include an assessment of plaque levels
aproximally and interdentally as well as a review of diet, risk
factors, and medical history.
While most patients brush for at least a short period
of time, fewer use interdental devices in addition to toothbrushes. It has been shown that toothbrushes are relatively
ineffective interdentally, and it is also known that periodontal disease typically begins interstitially. Adjunctive aids,
including interdental brushes, floss, and mechanical devices,
are available to remove interdental plaque. Clinical studies
have shown that manual interdental brushes are particularly
effective at reducing plaque and gingivitis. Selecting the
sizes and types of interdental devices that are best for the
patient in conjunction with him or her should include an
assessment of the interdental space, contact points, retentive areas, gingival shape and position, and pockets. Patient
demonstration can provide additional motivation and increase the likelihood of proper interdental cleaning.
Ultimately, the goal of patient care is to prevent, arrest,
and control periodontal disease and caries. The patient’s
ability to remove plaque from all areas, including interproximal areas, is an essential part of every patient’s selfcare program.
References
1. Ciancio S. Improving oral health: current considerations. J Clin Periodontol. 2003; 30
Suppl 5:4–6.
2. www.docere.com/Hygienetown/Article. Accessed June 2006.
3. Clarizio, L.F. Peri-implant infections. Oral and Maxillofacial Infections 2000;8(1):35–54.
4. Wilkins Esther M. Clinical Practice of the Dental Hygienist. 8th ed. Philadelphia: Lippincott,
Williams and Wilkins; 1999:371.
5. Center for Disease Control;accessed June 2006
6. Available
at: “www.census.gov/population/www/projections/natsum-T3.html
(accessed May, 2006.)
7. Stamm JW. Epidemiology of gingivitis. J Clin Periodontal 1986; 13:360–370.
8. Oliver RC, Brown LJ, Loe H. Periodontal diseases in the United States population. J
Periodontal 1998;69:269–278.
9. U.S. Public Health Service, National Institute of Dental Research. Oral Health of United
States Adults; National Findings. Bethesda, MD: National Institue of dental research;
1987. NIH Publication number 87–2868.
10. American Academy of Periodontology Research, Science and Therapy Committee Position
Paper: Epidemiology of periodontal diseases
11. Ibid.
12. U.S. Public Health Service, National Institute of Dental Research. Oral Health of United
States Adults; National Findings. Bethesda, MD: National Institue of dental research;
1987. NIH Publication number 87–2868.
13. Kornman KS, Crane A, Wang HY, et al. The interleukin-1 genotype as a severity factor in
adult periodontal disease. J. Clinical Periodontal 1997; 24:72–77.
14. McDevitt MJ, Wang HY, Knobleman C. et al. Interleukin-1 genetic association with
periodontitis in clinical practice. J Periodontal 2000; 71: 156–163.
15. Mark LL, Haffejee AD, Socransky SS, et al. Effect of the interleukin-1 genotype on
monocyte IL-1beta expression in subjects with adult periodontitis. J Periodontal Res
2000;35: 172–177.
16. American Academy of Periodontology Research, Science and Therapy Committee Position
6
Paper: Epidemiology of periodontal diseases p 1412.
17. Wilkins Esther M. Clinical Practice of the Dental Hygienist. 8th ed. Philadelphia: Lippincott,
Williams and Wilkins; 1999.
18. American Academy of Periodontology Research, Science and Therapy Committee Position
Paper: Epidemiology of periodontal diseases
19. Ibid.
20. Ibid.
21. Wilkins Esther M. Clinical Practice of the Dental Hygienist. 8th ed. Philadelphia: Lippincott,
Williams and Wilkins; 1999.
22. Lovegrove, J.M. Dental plaque revisited: bacteria associated with periodontal disease. J
NZ Soc Periodontol 2004;87:7–21.
23. Li J, Helmerhorst EJ, Leone CW, Troxler RF, Yaskell T, Haffajee AD, Socransky SS, Oppenheim
FG. Identification of early microbial colonizers in human dental biofilm. J Appl Microbiol.
2004;97(6):1311–8.
24. Lovegrove, J.M. Dental plaque revisited: bacteria associated with periodontal disease. J
NZ Soc Periodontol 2004;87:7–21.
25. Wilkins Esther M. Clinical Practice of the Dental Hygienist. 8th ed. Philadelphia: Lippincott,
Williams and Wilkins; 1999.
26. Ibid.
27. American Academy of Periodontology Research, Science and Therapy Committee Position
Paper: Epidemiology of periodontal diseases
28. Page RC, Offenbacher S, Schroeder HE, Seymour GJ, Kornman KS. Advances in the
pathogenesis of periodontitis: Summary of developments, clinical implications and
future directions. Periodontal 2000 1997; 14:216–248.
29. Wilkins Esther M. Clinical Practice of the Dental Hygienist. 8th ed. Philadelphia: Lippincott,
Williams and Wilkins; 1999:372.
30. American Academy of Periodontology Research, Science and Therapy Committee Position
Paper: Treatment of Plaque-Induced Gingivitis, Chronic Periodontitis, and Other Clinical
Conditions
31. Wilkins Esther M. Clinical Practice of the Dental Hygienist. 8th ed. Philadelphia: Lippincott,
Williams and Wilkins; 1999.
32. Cronin MJ, Dembling WZ, Cugini M, Thompson MC, Warren PR. A 30-day clinical
comparison of a novel interdental cleaning device and dental floss in the reduction of
plaque and gingivitis. J Clin Dent. 2005;16(2):33–7.
33. Schmage P, Platzer U, Nergiz I. Comparison between manual and mechanical methods of
interproximal hygiene. Quintessence Int. 1999 Aug;30(8):535–9.
34. Isaacs RL, Beiswanger BB, Crawford JL, Mau MS, Proskin H, Warren PR. Assessing the
efficacy and safety of an electric interdental cleaning device. J Am Dent Assoc. 1999
Jan;130(1):104–8.
35. Gordon JM, Frascella JA, Reardon RC. A clinical study of the safety and efficacy of a novel
electric interdental cleaning device. J Clin Dent. 1996;7(3 Spec No):70–3.
36. Brightman LJ, Terazhalmy GT, Greenwell H, Jacobs M, Enlow DH. The effects of 0.12
percent chlorhexidine gluconate mouthrinse on orthodontic patients aged 11 through
17 with established gingivitis. Am J Orthod Dentofac Orthop 1991;100:324–329.
Author Profile
Patty Bonasso Byrd, RDH, BS, is a graduate of the University of Louisville (1978) Dental Hygiene Program. She
lectures nationwide on a variety of topics related to dental
hygiene and is adjunct clinical faculty at UL and an author.
She has been actively involved in the Kentucky State Dental
Hygiene Association, serving as president (1998–99) and
delegate to the ADHA.
Disclaimer
The author of this course has no commercial ties with the
sponsors or the providers of the unrestricted educational
grant for this course.
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Questions
1. Ineffective or infrequent interdental
cleaning may result in:
a. Caries
b. Gingivitis
c. Periodontitis
d. All of the above
2. National surveys have consistently
shown that oral hygiene is:
a. Poorer in females than males
b. Poorer in males than females
c. Equal in males and females
d. Poorer in elderly males and females
3. Despite the decrease in caries
prevalence and severity in the
permanent dentition and the
increase in proper prevention
treatments, disparities remain.
a. True
b. False
4. Factors related to the attainment of
good oral hygiene are:
a. Oral anatomy
b. Motivation
c. Dexterity
d. All of the above
5. Gingivitis is clearly correlated
to SES and the prevalence
of periodontitis.
a. True
b. False
6. Age is not considered a risk factor
for periodontal disease.
a. True
b. False
7. Statement 1: Bacteria are the causal
agents in the onset of gingivitis and
periodontal disease.
Statement 2: The presence of bacteria does not determine periodontal
disease progression.
a. Statement #1 is true. Statement #2 is true.
b. Statement #1 is true. Statement #2 is false.
c. Statement #1 is false. Statement #2 is true.
d. Statement #1 is false. Statement #2 is false.
8. ______ seem(s) to be associated with
progressive periodontitis as well as a
number of systemic diseases.
a. Hormonal status
b. Gender
c. Stress
d. Socioeconomic status
9. Risk factors for periodontal
disease include:
a. Smoking and tobacco use
b. Diabetes
c. Poor oral hygiene
d. All of the above
10. Poor vascularization results in
lower bleeding upon probing levels
found in smokers with deep pockets.
a. True
b. False
11. As bacterial plaque accumulates
on the tooth surface adjacent to the
gingival margin, an inflammatory
response begins within:
a. Twenty-four hours
b. Two to four days
c. Five to seven days
d. Seven to 14 days
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12. The structures involved in a
periodontal pocket include:
a. Bone
b. Cementum
c. Periodontal ligament
d. All of the above
13. Bacteria from supragingival plaque
can enter the sulcus and be a source
for subgingival plaque development.
a. True
b. False
14. As periodontitis develops in
response to bacterial invasion
and inflammation, soft- and hardtissue destruction occurs with the
release of:
a. MMPs
b. Prostaglandins
c. Cytokines
d. All of the above
15. Depending upon the degree of
anatomic involvement, pockets can
be divided into:
a. Gingival and subgingival
b. Gingival and true periodontal
c. Periodontal and microbial
d. Gram-negative and pseudopockets
16. The interdental gingiva is located
between two adjacent teeth and
may be:
a. Pointed or pyramidal
b. Flat or saddle-shaped
c. Tapered or narrow
d. All of the above
17. When the bacterial insult is strong
enough to overwhelm the host defense, bacteria in the supragingival
plaque will:
a. Stay in the supragingival plaque
b. Migrate subgingivally to form a
subgingival biofilm
c. Die within a couple of days
d. Not cause inflammation
18. It is critical that all interdental
plaque is removed, since most
periodontal infections begin in:
a. The col
b. The pseudopocket
c. The gingival pocket
d. The base
19. Devices used to remove plaque
interdentally include:
a. Wooden dental cleaners
b. Tufted dental floss
c. Interdental brushes
d. All of the above
22. Which of the following plays
a role in the selection of an
interdental device?
a. Preference
b. Availability
c. Dexterity
d. All of the above
23. In addition to floss and interdental
brushes, there are a number of mechanical adjuncts that may be useful
in reducing interdental plaque.
a. True
b. False
24. The indications for use of
dentifrice include:
a. Reduction of gingivitis
b. Delivery of antimicrobial agents
c. Calculus prevention
d. All of the above
25. Irrigation can be achieved through
the use of:
a. A syringe with blunt-ended cannula
b. A syringe with cartridge
c. Essential oil mouthrinses
d. Diet
26. The use of a chlorhexidine
gluconate rinse has been shown
to reduce plaque by:
a. 46.9 percent
b. 64.9 percent
c. 94.6 percent
d. A factor of 10
27. While most patients brush for at
least a short period of time:
a. They use interdental devices as much
as toothbrushes
b. They also use interdental devices more
than toothbrushes
c. Fewer use interdental devices in addition
to toothbrushes
d. Fewer use adjunctive chemotherapeutics
with interdental devices in addition to
toothbrushes
28. It has been shown that
toothbrushes are relatively
ineffective interdentally.
a. True
b. False
20. What toothbrushing
techniques are useful for
removing interdental plaque?
29. Ultimately, the goal of patient care
is to:
21. What type of device offers the
advantage of being available in
wider and new thinner versions?
30. The patient’s ability to remove
plaque effectively and thoroughly
is not essential to every patient’s
self-care program.
a. Stillman and Bass methods
b. Vibratory
c. Sulcular
d. All of the above
a. Floss
b. Interdental brushes
c. Toothpicks
d. Tips
a. Arrest periodontal disease and caries
b. Control periodontal disease and caries
c. Prevent periodontal disease and caries
d. All of the above
a. True
b. False
7
ANSWER SHEET
Interdental Cleaning
Name:
Title:
Address:
E-mail:
City:
State:
Telephone: Home (
)
Office (
Specialty:
ZIP:
)
Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all
information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn
you 4 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp.
Mail completed answer sheet to
Educational Objectives
Academy of Dental Therapeutics and Stomatology,
1. Discuss the current status of caries, gingivitis, and periodontal disease in the United States
A Division of PennWell Corp.
P.O. Box 116, Chesterland, OH 44026
or fax to: (440) 845-3447
2. List the dental implications associated with inadequate/ineffective interdental plaque control
3. Recognize the clinical signs of infrequent interdental plaque control and identify patients who are at a high risk for
periodontal diseases
4. Recommend appropriate interdental cleaning methods and devices for specific patient needs, and explain the necessity of
interdental plaque control as part of the patient’s complete self-care program
For immediate results, go to www.ineedce.com
and click on the button “Take Tests Online.” Answer
sheets can be faxed with credit card payment to
(440) 845-3447, (216) 398-7922, or (216) 255-6619.
P ayment of $59.00 is enclosed.
(Checks and credit cards are accepted.)
Course Evaluation
Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0.
If paying by credit card, please complete the
following:
MC
Visa
AmEx
Discover
1. Were the individual course objectives met?Objective #1: Yes No
Objective #3: Yes No
Acct. Number: _______________________________
Objective #2: Yes No
Objective #4: Yes No
Exp. Date: _____________________
2. To what extent were the course objectives accomplished overall?
5
4
3
2
1
0
3. Please rate your personal mastery of the course objectives.
5
4
3
2
1
0
4. How would you rate the objectives and educational methods?
5
4
3
2
1
0
5. How do you rate the author’s grasp of the topic?
5
4
3
2
1
0
6. Please rate the instructor’s effectiveness.
5
4
3
2
1
0
7. Was the overall administration of the course effective?
5
4
3
2
1
0
8. Do you feel that the references were adequate?
Yes
No
9. Would you participate in a similar program on a different topic?
Yes
No
Charges on your statement will show up as PennWell
10. If any of the continuing education questions were unclear or ambiguous, please list them.
___________________________________________________________________
11. Was there any subject matter you found confusing? Please describe.
___________________________________________________________________
___________________________________________________________________
12. What additional continuing dental education topics would you like to see?
___________________________________________________________________
___________________________________________________________________
AGD Code 490
PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.
AUTHOR DISCLAIMER
The author of this course has no commercial ties with the sponsors or the providers of
the unrestricted educational grant for this course.
SPONSOR/PROVIDER
This course was made possible through an unrestricted educational grant. No
manufacturer or third party has had any input into the development of course content.
All content has been derived from references listed, and or the opinions of clinicians.
Please direct all questions pertaining to PennWell or the administration of this course to
Machele Galloway, 1421 S. Sheridan Rd., Tulsa, OK 74112 or [email protected].
COURSE EVALUATION and PARTICIPANT FEEDBACK
We encourage participant feedback pertaining to all courses. Please be sure to complete the
survey included with the course. Please e-mail all questions to: [email protected].
8
INSTRUCTIONS
All questions should have only one answer. Grading of this examination is done
manually. Participants will receive confirmation of passing by receipt of a verification
form. Verification forms will be mailed within two weeks after taking an examination.
EDUCATIONAL DISCLAIMER
The opinions of efficacy or perceived value of any products or companies mentioned
in this course and expressed herein are those of the author(s) of the course and do not
necessarily reflect those of PennWell.
Completing a single continuing education course does not provide enough information
to give the participant the feeling that s/he is an expert in the field related to the course
topic. It is a combination of many educational courses and clinical experience that
allows the participant to develop skills and expertise.
COURSE CREDITS/COST
All participants scoring at least 70% (answering 21 or more questions correctly) on the
examination will receive a verification form verifying 4 CE credits. The formal continuing
education program of this sponsor is accepted by the AGD for Fellowship/Mastership
credit. Please contact PennWell for current term of acceptance. Participants are urged to
contact their state dental boards for continuing education requirements. PennWell is a
California Provider. The California Provider number is 3274. The cost for courses ranges
from $49.00 to $110.00.
Many PennWell self-study courses have been approved by the Dental Assisting National
Board, Inc. (DANB) and can be used by dental assistants who are DANB Certified to meet
DANB’s annual continuing education requirements. To find out if this course or any other
PennWell course has been approved by DANB, please contact DANB’s Recertification
Department at 1-800-FOR-DANB, ext. 445.
RECORD KEEPING
PennWell maintains records of your successful completion of any exam. Please contact our
offices for a copy of your continuing education credits report. This report, which will list
all credits earned to date, will be generated and mailed to you within five business days
of receipt.
CANCELLATION/REFUND POLICY
Any participant who is not 100% satisfied with this course can request a full refund by
contacting PennWell in writing.
© 2008 by the Academy of Dental Therapeutics and Stomatology, a division
of PennWell
www.ineedce.com