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In August 2016, there was a flood of news items about an Associated Press(AP)-initiated report which found an apparent lack of direct evidence to prove that flossing was effective.
The AP reported on an article that looked at two previous systematic reviews on this topic comparing the use of a toothbrush alone versus a combination of toothbrush and dental floss, the most recent one being the prestigious Cochrane Library report published in 2011. The article claimed the evidence for flossing was “weak, very unreliable” and “very low” quality, as well as having “a moderate to large potential for bias.”
We asked members of the Editorial Advisory Group of the Journal of the Canadian Dental Association to comment on these findings and to provide advice on how Canadian dentists could talk with their patients about flossing. Here are the insights of these experts that we spoke to.
NEWS ITEMS/REPORTS
- The AP presented its article as a dramatic exposé, but it did not actually reveal any new clinical findings since the 2011 Cochrane review
- The subsequent news items didn’t explain how there are multiple risk factors for developing tooth decay and gum diseases and that these diseases can take a long time to develop.
- By presenting faulty or incomplete information, without proper context, to those who might be looking for justification not to floss, these stories could jeopardize the public’s oral health.
WHAT WE KNOW
- Dental plaque can begin the processes that cause tooth decay and gum disease if it’s allowed to remain on the surfaces of teeth for more than 24 hours.
- The only way plaque can be removed is mechanically, with a manual or electric toothbrush (which gets the cheek and tongue surfaces of teeth) and floss or other cleaning aids (which clean the hidden or hard-to-reach surfaces of teeth).
- Although there is no 100% direct scientific evidence at this time which proves that flossing on its own reduces the chance of tooth decay and gum disease, there is strong indirect evidence that the mechanical removal of dental plaque from hard-to-reach tooth surfaces is effective in preventing these conditions. We also have evidence collected in the Cochrane Library review that people who brush and floss regularly have less gum bleeding compared to toothbrushing alone.
- Not every outcome can be studied using randomized clinical trials (which can show direct evidence), especially chronic diseases (like periodontitis) that take years to develop. This is just one of the reasons there may not be strong direct evidence proving that flossing can prevent dental decay and gum disease.
- It’s also important to consider that the harms of flossing are minimal to none and the cost is very low.
MESSAGES FOR OUR PATIENTS
Based on the research we do have, flossing is an effective, inexpensive and safe method for cleaning the hidden, hard-to-reach, parts of your teeth.
- Set realistic goals. Clean all surfaces of your teeth daily, but don’t feel too guilty if you miss once in a while. The goal of a clean mouth is more important than how you reach that goal.
- Do your best with your brushing, flossing and other measures to clean all surfaces of your teeth and gums.
- Seek your dentists’ and dental hygienists’ advice and discuss with them any oral health news items which you come across in the media. They will give you the best personalized advice for your oral health.
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CDA Statement on Flossing
The Canadian Dental Association supports flossing as one step of maintaining healthy teeth and gums. Flossing is an effective preventative measure to remove plaque, the main cause of gum disease. The weakness of the evidence supporting the value of floss in the prevention of gum disease is a reflection of the difficulty of conducting the necessary studies, not of the value of flossing for the maintenance of good oral health. Brushing, flossing, eating a healthy diet, and seeing your dentist regularly are all steps in preserving a healthy mouth.
I have a unique “flossophy”. To clean bacteria biofilm interproximally you have to disturb tooth and gingival biofilms that are different as well as planktonic and pieces of biofilm in the sulcus/crevicular fluid area. The the sulcus space is wider than floss so when you pull against the tooth it can not touch the gingival biofilm with pressure so it remains undisturbed until you start scaling and then bleeding starts. Next floss can adapt to a convex shape -tooth- but not the inside of a bowl- shape of interproximal tissues! Finally you can pull string/rope/floss but not push it to do what you want. You can push floss against the gum. Therefore flossing cleans teeth not gums. Use softpics or stimudents and life changes. People will use them to clean tooth and gum. Tissues shrink because the healthy looking but actual beer belly gums go to six pac Antibiotics in three days and they shrink to health.
I tell my patients we do know that removal of plaque helps prevent dental disease, and we do know that flossing helps remove plaque. But no-one has spent the considerable time and money required to do a long term study which confirms that flossing helps prevent dental disease – possibly because they had other things to do studies on – questions with less obvious answers. I sometimes will make an analogy that I am unaware of anyone doing a controlled scientific study which shows that driving on bald tires will result in more automobile accidents.
You only need to brush and floss the teeth you want to keep.
The reality is flossing as performed by most of the public is rather haphazard and done inconsistently. Further, the correct technique is rarely performed. As I tell my patients, poorly executed flossing is about the same as not flossing at all. Therefore, the “study” concluding that flossing is of little value in preventing dental disease is a conclusion I could have told you just from my daily practice. We always demonstrate the correct method and get the patient to practice it in front of us. Even then, relapse to old habits resurfaces and we almost always have to demonstrate the proper way again at their recall. Apathy is the hardest problem to overcome. We always promote using an oral irrigation device as well such as Water Pik to debride the interproximal areas of bacterial “toxins”
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