If flossing is ineffective, what’s next? Alternatives to floss gain acceptance

By Maria Perno Goldie, RDH, MS

First, it was floss or die. Now it is that flossing is “ineffective.”(1,2) According to a 2002 Harvard Medical School on longevity, proper flossing is considered a vital factor influencing a long life.(3) Proper flossing removes food particles and biofilm, which is a preventive measure to protect against periodontal disease. We also know that periodontitis can have a substantial impact on systemic health.

The hoopla began because the latest dietary guidelines for Americans, issued by the U.S. Departments of Agriculture and Health and Human Services, removed any reference of flossing.(5) The Associated Press reported that officials had not researched the effectiveness of regular flossing, as required, before coaxing Americans to use floss as a preventive measure.

The lack of recommendation of the use of floss seems to stem from a Cochrane review that stated: “There is some evidence from twelve studies that flossing in addition to toothbrushing reduces gingivitis compared to toothbrushing alone. There is weak, very unreliable evidence from 10 studies that flossing plus toothbrushing may be associated with a small reduction in plaque at 1 and 3 months. No studies reported the effectiveness of flossing plus toothbrushing for preventing dental caries.” **

We have known for years that dental plaque (biofilm) is the etiological agent responsible dental caries and periodontal disease.(6) It may also contribute to the severity of some systemic diseases, including diabetes, cardiovascular diseases, pneumonias, and some cancers.(6) Dental decay can cause tooth loss, and, in rare cases, even death.(7) A NHANES survey provided compelling evidence that a high incidence of periodontitis is present in the adult U.S. population.(8)

So who is failing? The patient, the clinician, or both parties?

We know that tooth brushing and interdental cleaning, when performed correctly and for an adequate amount of time, can remove biofilm and improve oral health. We also know that, despite our efforts, most patients do not use traditional dental floss or use it incorrectly, making it ineffective. A systematic review was performed to assess the effect of flossing on interproximal caries risk.(9) It concluded that self-flossing failed to show an effect. “No evidence on the effectiveness of floss in adults or under real-world clinical conditions could be identified.”(9)

Interdental biofilm control is essential for oral and general health. The best way to remove it must be tailored to every patient depending on their motivation and skill level. One study compared the effectiveness of using a toothbrush alone, dental floss with a toothbrush, and the use of interdental brushes in patients with moderate to severe periodontitis.(10)

The results showed that tooth brushing together with use of interdental brushes was more effective in plaque removal and reducing probing depth than the use of tooth brushing and dental floss. Studies also confirmed that interdental brushes are more efficient in removing dental plaque and biofilm from wide embrasures than dental floss.(11) Evidence does specify that flossing is an effective adjunct to tooth brushing in the management of gingivitis but not in the management of dental decay.(12)

The Canadian Dental Hygienists’ Association (CDHA) did have a position paper on flossing in 2009, but changed it in 2014. The “new” CDHA position statement, “Interdental Brushing,” was released on Feb. 25, 2014, to reflect recent research.(13)

The CDHA position paper said, “The use of an interdental brush is an effective alternative to dental floss in achieving interproximal health by eliminating both plaque and bleeding.”(13)

On Aug. 4, 2016, the American Dental Hygienists’ Association (ADHA) released “ADHA Comments on Interdental Cleaning.”(14) “ADHA does support flossing with proper technique as instructed by your dental hygienist among other interdental implements being beneficial to removing bacteria, biofilm, and food debris from interproximal areas that toothbrushing cannot access.”(14)

This author believes that we have choices, and, based on the evidence, that traditional string floss is outdated—unless a patient prefers it and uses it well. Because dental floss does not appear to be effective in the hands of the general public does not exclude it as a means of interdental cleaning, according to researchers. Instead, we should consider alternative aids including interdental brushes and mechanical devices, such as the Sonicare AirFloss or the Waterpik Water Flosser.(15, 16, 17)

One last note. “Based on the available literature with respect to interdental cleaning, the best available data suggest the use of interdental brushes. These brushes should therefore be the first choice in patients with open interdental spaces. Meta-analysis showed a superiority of the interdental brush to floss with respect to plaque removal.”(18) This statement came from an excellent review of the literature and systematic reviews. When interdental brushes and dental floss were compared, patients preferred the interdental brushes as they were “simpler to use.”(18)

If you must preach floss, go ahead. However, if you want to stay abreast of the latest literature, and ensure patient compliance, a different approach might make good sense. Tailor your recommendations to the desires of the individual patient.

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Maria Perno Goldie, RDH, MS, is the owner of Seminars for Women’s Health and Sex-based Medicine. She is the former editorial director of PennWell’s RDH eVillage Focus, and past president of the International Federation of Dental Hygienists and American Dental Hygienists’ Association. Maria is organizing the third International Dental Hygiene Educator’s Forum to be held March 2017 in Long Beach, CA, in conjunction with the American Dental Education Association (ADEA).

** Sambunjak D, Nickerson JW, Poklepovic T, Johnson TM, Imai P, Tugwell P, Worthington HV. Flossing for the management of periodontal diseases and dental caries in adults. Cochrane Database of Systematic Reviews 2011, Issue 12. Art. No.: CD008829. DOI: 10.1002/14651858.CD008829.pub2.

References

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2. http://www.perfectwinningsmile.com/blog/bid/80612/Health-Benefits-of-Flossing-Your-Teeth. Accessed August 7, 2016.
3. http://www.dentalgentlecare.com/floss_or_die.htm Accessed August 7, 2016.
4. Axelsson P, Lindhe J. Effect of controlled oral hygiene procedures on caries and periodontal disease in adults. Results after 6 years. J Clin Periodontol. 1981; 8:239–248.
5. http://www.nytimes.com/2016/08/03/health/flossing-teeth-cavities.html?_r=0.
6. Harvard School of Public Health. "Link Found Between Periodontal Disease And Pancreatic Cancer." ScienceDaily. ScienceDaily, 17 January 2007. . Accessed August 7, 2016.
7. Tragic Results When Dental Care Is Out of Reach. Frontline, PBS. http://www.pbs.org/wgbh/frontline/article/tragic-results-when-dental-care-is-out-of-reach/. Accessed August 7, 2016.
8. Eke PI, Dye BA, Wei L, et al. Prevalence of Periodontitis in Adults in the United States: 2009 and 2010. JDR August 30, 2012. Published online before print August 30, 2012. http://jdr.sagepub.com/content/early/2012/08/29/0022034512457373.abstract. Accessed August 7, 2016.
9. Hujoel PP, Cunha-Cruz J, Banting DW, Loesche WJ. Dental flossing and interproximal caries: a systematic review. J Dent Res. 2006; 85:298–305.
10. Hujoel PP, Cunha-Cruz J, Banting DW, Loesche WJ. Dental flossing and interproximal caries: a systematic review. J Dent Res. 2006; 85: page 302.
11. Christou V, Timmerman MF, Van der Velden U, Van der Weijden FA. Comparison of different approaches of interdental oral hygiene: interdental brushes versus dental floss. J Periodontol. 1998; 69:759–764.
12. Bowen DM. Flossing or Alternative Interdental Aids? J Dent Hyg Spring 2012 vol. 86 no. 2 58-62.
13. Canadian Dental Hygienists Association (CDHA). CDHA position statement: Interdental brushing. February 25, 2014. http://www.cdha.ca/cdha/The_Profession_folder/Resources_folder/Position_Papers_Statements__Standards_folder/CDHA/The_Profession/Resources/Position_Statements.aspx?hkey=51681bfe-1a4e-4383-829f-86c90f5cbb0a. Accessed August 7, 2016.
14. ADHA Comments on Interdental Cleaning. http://www.adha.org/. Accessed August 7, 2016.
15. http://www.usa.philips.com/c-m-pe/dental-professionals/products/interdental. Accessed August 7, 2016.
16. https://www.waterpik.com/oral-health/products/dental-water-flosser/. Accessed August 7, 2016.
17. http://www.sunstar.com/rd/story/soft-picks-advanced.
18. Van de Weijden GA and Slot DE. Interdental oral hygiene: The evidence. Multi-Disciplinary Management of Periodontal Disease. Edited by: PM Bartold, LJ Jin. 2012 Asian Pacific Society of Periodontology. http://r.search.yahoo.com/_ylt=A0LEVr7ZzadXPagAAsEnnIlQ;_ylu=X3oDMTE0MTJtMWwwBGNvbG8DYmYxBHBvcwMxBHZ0aWQDRkZVSTNDMV8xBHNlYwNzcg--/RV=2/RE=1470643801/RO=10/RU=http%3a%2f%2fwww.parodontologie-utrecht.nl%2fmedia%2fboeken%2fboekintraoralhygieneevidence.pdf/RK=0/RS=T9wA3ajJUlQvOKFpvpfgnpyty7U-.