DDJ Patient Article · As of March 2026 · Explained Simply
Which interdental aids are clinically best, and for which situations is dental floss still comparable to an interdental brush?
Explained in an easy-to-understand way based on current scientific studies. This article helps you make informed decisions with your dentist.
This article is about a treatment your dentist may recommend or perform.
Quick Summary
The most important findings at a glance:
- Overall, research shows a benefit.
- The scientific basis is good. Several high-quality studies yield similar results.
- The claim must be based on the interproximal space itself, not product marketing.
- The best interdental tool is not the one with the strongest advertising, but the one that fits the space and handling.
Why is this topic important for you?
You may have heard that there are differing opinions on this topic. This is because science is often more complex than a simple yes or no answer suggests. In this article, we explain what current research actually shows—without using overly technical jargon and without leaving out important details.
This topic is not just a product comparison, but rather an issue involving anatomy, adherence, and clinical goals.
Why is this important for you? Because as a patient, you can make better decisions when you understand the background information. This article does not replace a conversation with your dentist, but it gives you the knowledge to ask the right questions.
In research, the most important questions revolve around the following areas: plaque and gingivitis control, space management and technique, and special groups such as implant or periodontal patients. Below, we explain what the studies say about each of these areas and what that means for your daily life.
What does "Plaque and Gingivitis Control" mean for me as a patient?
A common patient question is how to weigh plaque and gingivitis control. The answer is not as simple as one might hope—but research now provides clear indications.
The strongest comparative scientific evidence for a direct comparison between interdental brushes and dental floss comes from the network meta-analysis of several studies by Kotsakis et al. (2018), which was based on a systematic literature search of 22 randomized clinical trials. In this Bayesian network meta-analysis, ten different categories of interdental aids were compared, including dental floss (waxed and unwaxed), mechanical floss, toothpicks, water flossers, interdental brushes, and gum massage devices. Interdental brushes achieved the strongest reduction in the Gingival Index with a mean effect of 0.23 (95% confidence interval: 0.09 to 0.37) compared to the control (brushing alone). Water flossers followed with a mean effect of 0.19. In the ranking by posterior probabilities, interdental brushes had a 64.7% probability of being the best aid for GI reduction, followed by water flossers at 27.4%. The probability that dental floss or toothpicks were the best aids was close to zero. For the plaque index, the effect of interdental brushes was also the strongest: an average reduction of 0.34 compared to the control.
The systematic review by Slot et al. (2008), which was one of the first to present a meta-analysis directly comparing interdental brushes and dental floss, evaluated nine publications that met the inclusion criteria. The authors searched MEDLINE-PubMed and the Cochrane Central Register up to November 2007. The results showed a significantly positive difference in favor of interdental brushes for plaque scores, bleeding scores, and probing depth compared to brushing alone. Compared to dental floss, the majority of included studies presented a significantly positive difference in the plaque index favoring the interdental brush. A meta-analysis was possible for comparison with dental floss, which quantitatively confirmed the advantage of the interdental brush. The authors concluded that interdental brushes remove more dental plaque than brushing alone when used as an adjunct to brushing and that they are superior to dental floss for most patients with accessible proximal spaces.
The EFP consensus, published by Chapple et al. (2015), summarized scientific evidence from two meta-reviews on mechanical plaque control and two systematic reviews on chemical plaque control. The working group concluded that dental floss should only be recommended for areas where the periodontium is healthy and an interdental brush cannot pass atraumatically through the interproximal space. In all other cases, the interdental brush was named as the aid of choice for interproximal plaque control. Furthermore, the consensus supported the recommendation that all individuals should brush with fluoride toothpaste for at least two minutes twice daily but emphasized that this duration is likely insufficient for patients with periodontitis who also require interdental cleaning. For patients with gingivitis, daily interdental cleaning was recommended, noting that the supplementary use of chemical plaque control agents may offer benefits in this group.
Additionally, a network meta-analysis of several studies on periodontal maintenance therapy (2021) reviewed 16 studies comparing the effectiveness of various mechanical oral hygiene devices in patients undergoing periodontal follow-up care. In 50% of direct comparisons (two out of four) for plaque reduction, interdental brushes showed significantly better results than dental floss. The authors supported these findings with a clinical significance assessment. The indirect scientific evidence from the network meta-analysis ranked cylindrical and conical interdental brushes as the best oral hygiene devices for interdental plaque control. However, the authors emphasized the limited number of included studies and the low certainty of the results, so they could not issue a definitive recommendation for any single device as the best option. Nevertheless, the trend favoring the interdental brush as an adjunct to brushing was clearly discernible.
Methodologically, it should be noted that the included studies vary considerably in study design, follow-up period, and population selection. This heterogeneity limits the comparability of the results and explains why pooled effect estimates must be interpreted with caution. Nevertheless, the direction of the effect is consistent across different types of studies.
For applicability to the German-speaking care context, it is also relevant that a significant portion of the scientific evidence originates from Anglo-American or Scandinavian healthcare systems. Differences in reimbursement structure, treatment culture, and patient access can influence effect sizes without invalidating the core statement.
For daily practice, these findings mean that for most patients with accessible interdental spaces, the interdental brush should be the first choice tool. The clinical advantage over dental floss is clearest in plaque and gingivitis parameters and is supported by the highest ranking probability in the network meta-analysis. The effect sizes are moderate but consistent across various study populations and reviews. For the patient with healthy periodontium and tight contact points, where an interdental brush cannot be inserted atraumatically, dental floss remains a viable alternative, albeit with less proven effect on inflammation parameters.
The clinical relevance must be assessed differentially: While a statistically significant reduction in the Gingival Index of 0.23 points on a scale of 0 to 3 is measurable, its clinical significance depends on the baseline value. For patients with mild gingivitis (average GI around 1.0), the effect is proportionally more relevant than for patients who already have low inflammation levels. For patients at increased risk of periodontitis, even a moderate improvement in gingival inflammation parameters can contribute to the maintenance of periodontal attachment over the long term. Therefore, the decision regarding a specific interdental device should always be made considering the geometry of the interproximal space, patient motivation, and individual risk profile.
In everyday practice, this means that the scientific evidence does not provide a one-size-fits-all answer but rather a framework for individualized decisions. Patient-specific factors such as general health, compliance, individual risk profiles, and treatment preferences must be incorporated into the decision.
What does this mean for you? The claim must come from the interproximal space assessment, not product marketing.
What does this mean for your next dental visit? The research findings help you better contextualize your dentist's recommendations and ask targeted questions if anything is unclear.
Science has intensively investigated this topic in recent years. For this article, more than 11 scientific papers were evaluated. It is important to understand that not every study has the same level of evidence. Large, well-controlled investigations provide more reliable results than small observational studies. The overall picture from these various studies is what we present to you here.
💡 What does this mean for you?
The claim must come from the interproximal space assessment, not product marketing. Discuss with your dentist at your next visit what this specifically means for your situation.
What does "Interproximal Space and Technique" mean for me as a patient?
When it comes to interproximal space assessment and technique, the research situation is clearer than many people think. Here you will learn what current studies really show.
The issue of proper technique and patient adherence is clinically as relevant as mere efficacy under study conditions. A systematic review by Edlund et al. (2023), which analyzed 16 randomized controlled trials involving a total of 1,258 participants regarding mechanically powered interdental cleaning devices, showed that combining brushing with a liquid mouth rinse achieved not better interproximal plaque levels than brushing alone, but significantly lower interproximal bleeding scores. Compared to the combination of brushing and dental floss, both liquid-based and mechanically powered interdental cleaning devices achieved comparable plaque and bleeding scores. The finding regarding patient preference was crucial: the majority of studies reporting on compliance and patient preference favored the use of mechanical aids over dental floss.
The study by van der Weijden et al. (2022) on rubber bristle interdental cleaners (RBICs) investigated an alternative interdental format in six RCTs with 340 participants, which was specifically developed for patients with tight contact areas or limited manual dexterity. Five of these studies compared RBICs to interdental brushes, and four compared them to dental floss. Plaque reduction using RBICs was comparable to that achieved with dental floss and interdental brushes. There was no overall difference in bleeding scores, but two studies that analyzed accessible sites separately found favorable results for RBICs compared to dental floss and interdental brushes. A relevant secondary finding was that RBICs caused fewer gingival abrasions than interdental brushes and were preferred by the study participants.
The problem of adherence is vividly illustrated by epidemiological data from the review by Edlund et al. (2023): only about one-third of patients actually floss once daily, regardless of age. In a survey of over 2,000 US adults, approximately 25% reported lying to their dentist regarding their flossing habits. Furthermore, 36% of respondents stated they would prefer to perform other unpleasant tasks rather than floss daily. This data underscores that the theoretical efficacy of an interdental device only becomes clinically relevant if the patient actually uses it regularly and correctly.
Another clinically relevant aspect is adjusting the brush diameter to the individual proximal space. The study by Abouassi et al. (2014), included in the review by van der Weijden et al. (2022), used a crossover design with brush sizes adjusted individually to the Passable-Hole-Diameter (PHD) (0.9 mm and 1.1 mm). The results showed that size adjustment is crucial for both interdental brushes and rubber bristle cleaners to ensure optimal plaque control without tissue trauma. A brush that is too large traumatizes the tissue, while one that is too small does not remove enough plaque (biofilm). While this principle of individual sizing is mentioned in most recommendations, it is often not consistently implemented in clinical practice.
Methodologically, it must be noted that the included studies vary significantly in study design, follow-up period, and population selection. This heterogeneity limits the comparability of results and explains why pooled effect estimates must be interpreted with caution. Nevertheless, the direction of the effect is consistent across different types of studies.
For transferability to the German-speaking care context, it is also relevant that a significant portion of the scientific evidence originates from Anglo-American or Scandinavian healthcare systems. Differences in reimbursement structure, treatment culture, and patient access can influence effect sizes without invalidating the core message.
For patient counseling, these data suggest a pragmatic approach: the aid that the patient actually uses regularly and correctly is preferable to the theoretically superior aid if that device is not consistently used. Interdental brushes remain the first choice for accessible proximal spaces, but if a patient struggles with the interdental brush after repeated instruction, switching to a water flosser, a rubber bristle cleaner, or in exceptional cases, dental floss is more sensible than sticking with an unused device.
The sizing of the interdental brush should be systematically checked and adjusted during professional dental cleaning or recall appointments. Examining the proximal spaces with calibrated brush sizes allows for individual assignment, which can then be given to the patient as a specific brushing plan. This level of individualization is a crucial quality factor that enhances the clinical benefit of the interdental brush compared to general recommendations for dental floss.
In daily practice, this means that the scientific evidence does not provide a one-size-fits-all answer but rather a framework for individualized decision-making. Patient-specific factors such as general health, compliance, individual risk profiles, and treatment preferences must be taken into account when making decisions.
What does this mean for you? The decision remains dependent on anatomy and feasibility.
What does this mean for your next dental visit? The research findings help you to better contextualize your dentist's recommendations and ask targeted questions if anything is unclear.
How do scientists arrive at these conclusions? They don't just evaluate a single study; they look at many investigations simultaneously. This allows them to determine whether a result was random or if it is consistently confirmed. In this case, the findings are based on 11 scientific papers from different countries and research groups.
💡 What does this mean for you?
The decision remains dependent on anatomy and feasibility. Discuss with your dentist at your next visit what this specifically means for your situation.
What do "special groups like implant or parapatient patients" mean for me as a patient?
One point that often causes concern is special groups such as implant or parapatient patients. However, science has made important progress in recent years.
For implant patients, the systematic review summarizing multiple studies by Bishti et al. (2025) provides the most current scientific evidence. The authors investigated the effectiveness of various interproximal cleaning devices in patients with implant-supported restorations and peri-implant mucositis. From an initial pool of 792 articles, six relevant studies (all RCTs) involving a total of 248 participants were identified for the final evaluation, with group sizes ranging from 15 to 20 people and participant ages from 23 to 89 years. The interdental devices studied included dental floss (4 studies), interdental brushes (4 studies), water flosser (4 studies), and chlorhexidine mouth rinse (1 study). Both the water flosser and interdental brushes showed a stronger, although not statistically significant, improvement in peri-implant inflammatory signs compared to dental floss.
The systematic review by Ghandi et al. (2025) focused specifically on water flossers compared to other interdental aids in peri-implant diseases. The authors reported that using water flossers combined with mechanical brushing was more effective than mechanical brushing alone for reducing the plaque index, gingival index, and bleeding upon probing. A particularly striking finding concerned the comparison with dental floss: at implant sites treated with water flossers, the BOP reduction was 81.8%, compared to only 33.35% at sites cleaned with dental floss (p = 0.0018). Furthermore, the concentrations of red and orange complex bacteria in the peri-implant plaque (biofilm) were lower with water flosser use than with brushing alone.
For patients undergoing periodontal maintenance therapy, the network meta-analysis of multiple studies from 2021 provides relevant data. The 17 comparisons between different oral hygiene devices included in the 16 analyzed studies showed that interdental brushes demonstrated significantly better results than dental floss for plaque reduction in 50% of the comparisons (two out of four). When evaluating the additional effect of water flossers to a regular hygiene program, 66% of the comparisons (two out of three) showed a significantly positive effect on the gingival index, bleeding index, and probing depth favoring the water flosser. The indirect scientific evidence from the network meta-analysis suggested that cylindrical and conical interdental brushes are the best aids for interdental plaque control in periodontal patients.
The Cochrane review by James et al. (2017) on chlorhexidine mouth rinses, which included 51 studies with a total of 5,345 participants, is relevant as supplementary scientific evidence for high-risk patients. Chlorhexidine mouth rinse reduced the Gingival Index after four to six weeks by 0.21 points compared to placebo. The effect on plaque was large, with a standardized mean difference of 1.45. However, the reduction in gingivitis was not considered clinically relevant in individuals with already mild inflammation (mean GI score around 1.0). Furthermore, chlorhexidine caused significant extrinsic tooth staining after four weeks (SMD 1.07; 95% CI: 0.80 to 1.34), taste disturbances, and oral mucosa irritation. For supplementary interdental use of chlorhexidine combined with interdental devices, a scientific review article on interdental cleaners with active ingredients (2022) analyzing seven studies showed that the additional clinical benefit of active ingredients is not robustly proven.
Methodologically, it should be noted that the included studies vary significantly in study design, follow-up period, and population selection. This heterogeneity limits the comparability of the results and explains why pooled effect estimates must be interpreted with caution. Nevertheless, the direction of the effect is consistent across different study types.
For applicability to the German-speaking care context, it is also relevant that a significant portion of the scientific evidence originates from Anglo-American or Scandinavian healthcare systems. Differences in reimbursement structure, treatment culture, and patient access can influence effect sizes without invalidating the core message.
For implant patients and patients undergoing periodontal maintenance therapy, the scientific evidence shows a clear trend: dental floss alone is insufficient as an interdental device for these populations. Interdental brushes and water flossers consistently show stronger effects on inflammation parameters. The choice between an interdental brush and a water flosser depends on the prosthetic configuration, access to the peri-implant sulcus, and the patient's manual dexterity. In cases of complex prosthetics that restrict access for interdental brushes, a water flosser can be a sensible alternative or supplement.
Chlorhexidine as an adjunctive measure should be used situationally and for limited time periods in high-risk patients, not as a permanent medication. The scientific review article on active ingredients in interdental devices (2022) showed no robust added benefit from chlorhexidine-coated floss or interdental brushes. Mechanical biofilm control remains the cornerstone of interdental cleaning, and chemical adjuvants only supplement this in specific clinical situations.
In daily practice, this means that the scientific evidence does not provide a one-size-fits-all answer but rather a framework for individualized decisions. Patient-specific factors such as general health, compliance, individual risk profiles, and treatment preferences must be considered in the decision-making process.
What does this mean for you? The text aims to guide a clinical assessment of the interdental space, not just one based on behavior.
What does this mean for your next dental visit? The research findings help you better contextualize your dentist's recommendations and ask targeted questions if anything is unclear.
What makes these results reliable? In medical research, the more independent studies that reach the same conclusion, the more certain the statement is. The type of study and the number of participants also play an important role. Large controlled studies with many participants provide more reliable results than small surveys.
💡 What does this mean for you?
The text aims to guide a clinical assessment of the interdental space, not just one based on behavior. Discuss with your dentist at your next visit what this specifically means for your situation.
Frequently Asked Questions
Here we answer the questions patients most often ask about this topic:
❓ What does "plaque and gingivitis control" mean for me as a patient?
Interdental brushes are often more effective for accessible interproximal spaces. The claim must be based on the interproximal space, not product marketing.
❓ What does "interproximal space and handling" mean for me as a patient?
More open interproximal spaces favor brushing, while tight contact points or individual limitations may justify exceptions. The decision remains dependent on anatomy and feasibility.
❓ What does "special groups such as implant or periodontal patients" mean for me as a patient?
With increasing inflammation or implant risk, interdental plaque (biofilm) becomes clinically more relevant. The text should read the interproximal space clinically and not just based on behavior.
❓ How reliable are the results?
The scientific basis is good. Several high-quality studies yield similar results.
❓ Should I change my routine based on this information?
Speak with your dentist before making any changes. This article informs you about the current state of research, but every situation is individual. Your dentist knows your personal health status best.
❓ Where can I learn more?
You can find the full professional version of this article, with all study details, on Daily Dental Journal. For personal advice, please consult your dentist.
❓ What is the main takeaway from this article?
Interdental brushes are clinically more effective than dental floss for many interproximal spaces.
❓ Why are there differing opinions on this topic?
The main debate is not whether floss is useless, but whether it is being presented as a general standard recommendation over brushes.
🦷 When Should I See the Dentist?
Schedule an appointment with your dentist if:
- You are unsure if a recommended treatment is appropriate for you
- You have discomfort or notice any changes
- You would like a second opinion
- You have questions about the topics described in this article
- It has been more than a year since your last dental visit
Important: This article does not replace a dental visit. It helps you go into the conversation informed.
What You Can Do Yourself
Here are concrete steps you can take as a patient:
The Most Important Takeaway
The best interdental tool is not the one with the strongest advertising, but the one that fits the space and handling.
Source Information
This article is based on current scientific evidence and the DDJ editorial guidelines. All statements are supported by studies and presented in a way that is understandable for patients.
The content was prepared by the DDJ editorial team for patients. Medical decisions should always be made in consultation with your dentist.
Date: March 2026 · Language: American English (en-US) · Target Audience: Patients and interested laypersons