Dental patients around the globe were ecstatic following a 2016 Associated Press article disputing the merits of flossing in preventing cavities and gum disease. No more shaming during routine dental appointments. ‘Toss your floss’ parties became all the rage. Conversely, dentists were appalled, having long professed the importance of flossing. So what to make of this egregious finding? Could toilet paper be next?
The debate erupted with the AP reporting that in 2015 the US federal government dropped a decades-old recommendation regarding flossing in its Dietary Guidelines for Americans. The rationale was based on the government conceding that its effectiveness had never been adequately researched in order to satisfy legal requirements for inclusion in the guide. They contended that there was little or only weak evidence that flossing, compared to brushing alone, helped to prevent gum disease and cavities.
Pushback from the profession was swift. Dental associations worldwide defended the use of floss and other interdental devices. While acknowledging that current evidence fell short, The American Academy of Periodontology, in 2016 maintained; “In the absence of quality research, patients should continue to include flossing as a part of their daily oral hygiene habit.”
In 2019, a published review by the Cochrane Oral Health Group concluded that “Using floss or interdental brushes in addition to tooth brushing may reduce gingivitis or plaque, or both, more than tooth brushing alone.” However, due to limitations in the studies, they considered the evidence as “low to very low-certainty… and don’t know if the effects are large enough to be clinically important.” Typically, the report called for further, longer-lasting trials.
Predictably, the take-away for the general public from all the negative media attention was that flossing wasn’t particularly useful. Being somewhat tedious, we dentists know that many of our patients, despite our impassioned pleas, don’t floss. In my practice I have adopted some realistic goals when it comes to my patient’s oral hygiene:
Aside from gingivitis, a reversible inflammation of the gums, periodontal disease is not commonly observed in children. I don’t discuss flossing with youngsters, focusing instead on proper brushing technique and the importance of limiting sugary foods to prevent cavities, particularly around Halloween.
Convincing most teenagers to floss, let alone adequately brush their teeth, is about as likely as getting them to clean their room. One decent brushing per day is a reasonable expectation for this group, with the exception being those undergoing orthodontic treatment, where meticulous care is essential in maintaining healthy gums.
For many adults, gum disease, often combining both hereditary and inadequate oral hygiene factors, is a significant problem. Insidiously developing over years, it is a leading cause of tooth loss. Accordingly, I stress the importance of cleaning between the teeth and below the gumline, particularly for at-risk individuals, where brushing alone may not be adequate.
I confess to spending an inordinate amount of time in the dental aisles of pharmacies checking out all the latest gizmos to clean between your teeth, occasionally eliciting some odd looks from store employees. From floss to sticks to water picks, one can easily become bamboozled by the wide variety of products. So what’s a person to do?
Mother of Invention
True story: I once had an acquaintance ask for my business card during a dinner party, and thinking he was interested in becoming a patient gladly complied. I was somewhat aghast when he proceeded to use it to dislodge a large hunk of steak trapped between his upper molars. Thankfully he didn't offer it back to me. Though I wouldn’t recommend this somewhat unconventional technique, it illustrates that there can be many effective tools to clean between the teeth.
Skinning the Cat
While dental floss is a perfectly good option, it may not always be practical. Some people lack the dexterity required or find flossing too cumbersome. Good alternatives include floss with handles, interdental cleaning sticks, or my personal favorite, interproximal brushes. (Resembling miniature toilet bowl cleaners.) And while oral irrigation devices may be useful, pulling one out following a smoked meat sandwich at Le Centre Bell may be awkward. Essentially, in the words of one of my old professors, when it comes to cleaning between your teeth, there’s ‘more than one way to skin a cat.’
Something to Chew On
The scientific community depends heavily on well-controlled studies to guide its decision making. Meta-analyses help decipher the good from the bad, permitting us to draw conclusions from a wide body of research. But statistical significance or lack thereof does not always coincide with real-life experience. Sometimes you just have to rely on common sense, and when it comes to cleaning between your teeth, be it with floss or any other interdental device, I’d trust the professionals. Having witnessed the havoc wreaked by food particles, plaque and calculus lodged between the teeth and under the gums, I find it unconscionable to tell adult patients to throw away their floss. And at relatively low cost with little risk of causing harm, there’s really nothing to lose….. except maybe your teeth!
Dr. Mark Grossman is a practicing dentist and likes to take a bite out of nonsense when it comes to dental issues.