Flossing is widely accepted as a mechanical means to disrupt and remove interdental plaque, and an early preventive strategy for dental caries and gingivitis, two common oral health problems in children. It is also an important skill to develop during childhood as it may serve to establish valuable, life-long oral hygiene habits. C-shape flossing, a proper flossing technique, is challenging for children with developing manual dexterity to perform with conventional string floss. Currently, the AAPD recommends that parents should floss or supervise flossing for their children up until the age of 10 to ensure proper flossing. Limited research investigating the effectiveness of flossing devices has been conducted in children, and most found no additional benefit when comparing to brushing alone, suggesting the need for an alternative flossing method to assist children in the removal of interdental plaque and maintaining oral health.
This study indicates that children were able to remove interdental plaque more effectively, decrease gingival inflammation and floss faster with GumChucks in comparison to string floss. Of note, after first use, children aged 4–9 years were able to achieve comparable reduction in interdental plaque with children aged 10–15 years (49.1% versus 46.1%), suggesting that, with proper instructions, this age group can floss effectively using GumChucks. After 4 weeks of usage, GumChucks also demonstrated greater interdental plaque reduction than string floss, but only in children aged 10–15 years. While the efficiency in interdental plaque removal of the floss is an important measurement, the reduction in gingival inflammation is clinically relevant. Both GumChucks and string floss significantly decrease gingival inflammation in children aged 10–15 years after 4 weeks of usage. This result, however, is unexpected as children in the string floss group were shown to have a significant increase in mean interdental plaque scores from the baseline. This could be due to the fact that GI does not always positively correlated with plaque scores27. In terms of total flossing time, children flossed about 25% faster with GumChucks compared to string floss (106 s vs. 145 s). This is less than the two-minute brushing time generally recommended by oral health professionals. In addition, the questionnaire data revealed a strong preference towards GumChucks by children, parents and dentists.
The results of this study are in agreement with a previous study in an Indian population of children ages 6–12 in which reduction of plaque and increased flossing frequency was observed with the use of GumChucks compared to standard floss28. Studies in adult populations have demonstrated a reduction in clinical parameters and preference toward flossing devices compared to conventional finger flossing29,30,31,32. In contrast, a study in children concluded that a combination of toothbrushing and different flossing devices (finger-floss, looped-floss and floss-holders) did not produce significant clinical improvement in comparison to toothbrushing alone in third grade schoolchildren20. The impact of flossing devices may be underestimated in the latter study since both free and interproximal sites were assessed together for clinical indices33.
This study contributes a clinical investigation in children to the existing body of research comparing the efficacy between flossing modalities. The strength of our study is the investigative question assessing whether children under the AAPD recommended age would be able to floss independently and effectively with a new flossing device (GumChucks) compared to a conventional string floss. In addition to providing evidence to support an effective flossing alternative to assist children with developing manual dexterity, our results suggest an effective supplementary flossing tool for the current oral hygiene guidelines for children. We also incorporated an intra-individual study to assess the flossing speed and efficacy in interdental plaque removal after first use. This design lessens the variable effect of participants’ manual dexterity and motivation on the outcomes of total flossing time and interdental plaque scores after first use34. Additionally, our examiners were calibrated for consistency, and the clinical parameters were assessed only at the interproximal sites where the effect of the flossing devices is most correlated.
This study is not without limitations. First, the total sample size for this study is 40 children. This sample size gave adequate power for the present comparison study; however, in the age subgroups, the statistical power was reduced with less numbers of children in 4–9 age group. This could potentially explain why the reduction in the interdental plaque in this age group was not significant at 4-week post usage. The duration of this study was 4 weeks without the addition of the intermittent basic hygiene period. This length of study time may not be sufficient to allow the establishment of stable clinical parameters and the comparison of these clinical parameters between basic hygiene and experimental period34. As mentioned in material and methods, the blinding of examiners during the assessment of the flossing speed and interdental plaque scores immediately after use was not feasible as they were present to ensure that each participant flossed properly. This may be a potential source of bias in the clinical outcomes.
Caution should be exercised when interpreting data from this study. The significant improvement in gingival condition and interdental plaque scores in the GumChucks group compared to string floss could come from the motivation effect of children34. Children in GumChucks group may be motivated by kid-friendly packaging that also included a picture of C-shape flossing and an encouraging quote to develop a healthy flossing habit. It is also important to note that children in the 4–9 age group had a gingival index score equivalent to mild inflammation at baseline. Therefore, appreciable improvement may be clinically detected, but not statistically significant.
The present study provided evidence that children over 10 years old are able to floss more effectively, with less time, and have better improvement in gingival inflammation with GumChucks compared to the conventional string floss after 4-week of usage. Findings also suggested that children under 10 years old can floss faster and potentially more effectively with GumChucks over time. However, a larger and longer confirmatory study is needed. Parental supervision is recommended for children under the age of 10 when using GumChucks. In this study, children and their parents reported preference for GumChucks over string floss. In an ongoing study with an adult population, greater efficacy in the removal of interdental plaque is also observed after first use compared to string floss. GumChucks could be an effective alternative to string floss to establishing flossing habits and maintaining oral health not only for children but for the entire family.