Flossing Guidelines: Should They Be Dropped?

Alfred Lord Tennyson had spent fifteen or twenty minutes a day strangling both distal interphalangeal joints with horsetail hair In Memoriam A.H.H. would have never been written. Certainly not all 133 cantos. Ten maybe. There’s a lot of flossing to be done over seventeen years. Regularly cutting off the circulation in your fingertips can’t make holding a fountain pen brilliant.

Few people ever cite flossing as the answer to an interview question about extracurricular activities that make them a more well-rounded person. If they do it’s because they have the etiquette and boundaries of a trade steer to an indifferent stock fence. For them flossing is a social flexing, bringing the indoors out, the personal to the public. It’s a sports arena for the squalid that embraces toenail cutting at the table and plucking of any kind when it should be limited to ducks and chickens. Maybe even squab. These are people who take comfort in gross things flying or flicking from them that’s somehow implicitly justified by either the training gear they’re wearing or the corporate busy suit they’re strapped and wrapped in.

Most people don’t floss. Most people don’t want to floss. There are many, many stories people tell about why they don’t floss. Every dentist in the world knows at least four of them. That means 6,400,000 Tales of Unflossed Teeth criss-cross the globe like flag of convenience shipping. It makes dropping the floss almost a no-brainer. Except what’s really questionable though, is how proficient we are at knowing what’s good for us.

After all, we are a world of alcohol, tobacco and WhatsApp.

How about we turn to Timothy J Iafolla DMD, MPH. A fifteen-year veteran of the NIDCR’s Office of Science Policy & Analysis in the US National Institutes of Health’s Chief of Program Analysis and Reports Branch, with with 30 published papers under his belt. (Including Data visualisation of the relationship between smoking and periodontal site-specific effects across the lifespan in the US adult population. A slow burner across fifty states, it starts at a dental exam age of 1. It may be the tooth equivalent of Tennyson.)
Anyway he said that from a purely scientific view “it would be appropriate to drop the floss guidelines”.

And he also said people should still floss. Maybe in same breath. Not sure if nitrous oxide was involved.

“It’s low risk, low cost. We know there’s a possibility that it works, so we feel comfortable telling people to go ahead and do it.”
That could be someone talking about investments. Or discounted fish oil capsules. Hardly ground breaking goss on floss.

We know the purpose of flossing. It’s to clean between, where tooth brushing can’t reach, in order to disrupt dental plaque from calcifying into calculus. Aside from the mathematical study of change, calculus cannot be removed without professional dental cleaning, and causes periodontitis, which destroys, tooth support tissue, gums and jawbones.

It does have its sceptics. The British Dental Association states that, “Small inter-dental brushes are best for cleaning the area in between the teeth, where there is space to do so. Floss is of little value unless the spaces between your teeth are too tight for the interdental brushes to fit without hurting or causing harm.”

That’s the short answer to a long story.

Avoiding periodontal disease and the knock-on effects of this type of chronic inflammation on the human system is surely a good thing; so the long answer to TJI’s nah-yeah answer to be, or not to be flossing should be told.

Long-term, large-scale studies on flossing are limited – but what researchers have found in small, short-term studies is that there are modest benefits from flossing. Recent studies found that the use of floss or interdental brushes in addition to tooth brushing may reduce gingivitis, plaque, or both, more than brushing alone. However, these studies measure outcomes over the short term.

In the kingdom of science and medicine it’s like having Charles and Di’s wedding foretell the result and OJ Simpson’s charm and grace deem him good husband material.

Because long-term studies are very expensive and because of the months or years it can take for periodontitis to develop, it is commonplace for the studies use other end points – like plaque development, for example – rather than the formation of the disease it’s researching. Another challenge is the difficulty in documenting accurate in-home health behaviours of large numbers of participants.

Particularly over time.

Each of us knows the lies we already tell about how often or not we actually do certain things in the home. Somewhere, someone believes we vacuum once a week. Specifically vacuuming what makes an open-and-shut case study of the short end of the sticking-point stick.

What we’re left with is that there isn’t been the motivation, means or measure for any long-term, population-based studies on flossing; but that that in and of itself doesn’t necessarily mean it’s is not an effective oral hygiene practice. It just means that sales of dental floss must be sufficiently buoyant with no need for many, multimillion-dollar, multi-year studies of individual health behaviours because Procter & Gamble and Johnson & Johnson are still picking money from their teeth.

The first floss was patented in 1874, after its early 1800s invention by Levi Spear Parmly. By 1908 the American Dental Association was recommending the practice. So it’s been around a while. It’d be worth looking up the stats on the reduction of periodontitis for the last 120 years.

Could be telling.

Maybe it’s more that plaque is regularly removed from between the teeth rather than the specific method. Maybe a corner of cardboard is better than using nothing at all if there’s not been a household dental floss purchase since 1983. Apparently a Dutch periodontist who conducted flossing studies says he uses a toothpick.

Hard to tell if that’s advice, personal preference, arrogance or issues of translation because it’s not always gloss with floss. Improper technique can damage gums, teeth, and dental work and release harmful bacteria into your bloodstream.

Some countries still recommend it. The Australian Dental Association flossing guidelines maintain, “Flossing … is an essential part of caring for your teeth and gums, and not some kind of ‘nice-to-have’ added extra,” and that it’s a health habit that should start around the age of 12. The Argentine Ministry of Health states that good oral health means to “clean between all your teeth everyday with dental floss or a similar product”.

US studies on the benefits of flossing are mostly funded and directed by floss manufacturers and conclude that flossing helps to remove plaque.

But Associated Press has revealed evidence used in Procter & Gamble’s statement was discredited in 2011 and Johnson & Johnson declined to respond to the news agency after also being notified of research that refutes its claims.

Evidence was found that flossing is “unreliable” “very low quality” and with “a moderate to large potential for bias” with one recent review stating: “The majority of available studies fail to demonstrate that flossing is generally effective in plaque removal.”

The British Dental Association knows that more sophisticated trials are needed. The difficulty is getting reliable evidence. People are different. Large studies are costly. Until they happen you can’t really confirm or deny.

Advice from the UK National Health Service website is that “Dental floss helps to prevent gum disease by getting rid of pieces of food and plaque from between your teeth.” Meantime, for the record, Prof Damien Walmsley of the University of Birmingham concludes there is “only weak evidence” to suggest flossing is beneficial.

While the US Department for Health and Human Services and Agriculture admitted in a letter that the benefits of flossing had never been properly researched, a statement released by the American Dental Association vigorously defends flossing as an “essential part of taking care of your teeth and gums”.

In the world of regret, inaction – when you don’t do something you wish you had – lasts longer than the dismay of doing something you wish you hadn’t.

So floss or don’t floss. On the subject of floss, the experts remain divided.

BOOK NOW

Note: All content and media on the  Sunbury Dental House website and social media channels are created and published online for informational purposes only. It is not intended to be a substitute for professional medical advice and should not be relied on as health or personal advice.

Services Mentioned