Do You Really Need to Floss?
Many dentists find daily flossing habits to be a hard sell to their patients. In fact, the American Academy of Periodontology (AAP) conducted a survey on how often Americans lie to their dentists about flossing in 2015. About a quarter (27 percent) of the over 2000 adults polled admitted that they lie to their dentist about flossing. More than a third of the individuals who were surveyed said that they would rather do such unpleasant activities as washing a sink full of dirty dishes than floss their teeth.
What do dirty dishes have going for them that flossing doesn’t? Noticeable results. People can generally feel the immediate benefits of good brushing habits, so they are dedicated to their brushing routine. Flossing doesn’t always offer such evident satisfaction.
Some dentists encourage it as a meditative act. Other dentists rely on scaring their patients into good flossing habits by mentioning periodontitis, also known as gum disease. All of this being said, recent press has called into question whether a daily flossing routine is necessary at all.
The Controversy Around Daily Flossing
In 2016, the Associated Press published an article that challenged the almost universal claim that a daily flossing habit prevents cavities and gum disease. By looking at medical studies on the benefits of flossing, the article was able to state that there’s “little proof” that flossing works. The weakness of the evidence pointed out by the Associated Press called into question the applicability of medical studies that were conducted over insufficient time-parameters, with little control over study participants, and which were often funded by the dental floss industry itself.
The Origin of Flossing
Dentist Levi Spear is credited with inventing the practice of flossing in the early 19th century. However, the first patent for dental floss was issued in 1874. At the time, the patent application was already mentioning that dentists widely recommended the use of dental floss.
The American Dental Association (ADA) has been promoting floss universally since 1908. Presently, daily flossing is an almost unanimous recommendation among dentists, fueling a massive industry.
How the Debate Began
The Associated Press (AP) did not start the fire with their article, but they did stoke the flames.
Flossing has been under suspicion among medical professionals and researchers since studies came out in 2008 and 2011 which, in the words of Joann Gurenlian of RDH Magazine in 2015, indicated that “flossing was not effective in reducing inflammation in patients with periodontal disease.” Similarly, an article published in Forbes Magazine in 2013 concluded that medical studies do not sufficiently support the necessity of flossing.
The Associated Press, with the aid of the Freedom of Information Act, asked the Department of Health, Human Services, and Agriculture to show them scientific evidence that flossing works to prevent cavities and gum disease. Following this request, the flossing recommendation was removed from the Federal Dietary Guidelines. As a result of this, the AP took up the case in 2015.
The Associated Press’s Take on Flossing
The Associated Press pointed out that the latest Dietary Guidelines for Americans issued in 2015 by the Department of Health, Human Services, and Agriculture quietly dropped any mention of flossing without drawing attention to it. The federal government has been recommending in their guidelines that Americans floss since 1979. These Dietary Guidelines may only give suggestions that are based on scientifically validated information. Each release lasts for five years, so the next guidelines will be issued in 2020.
In an effort to find research that validates the effects of flossing as an effective preventative practice against tooth decay and gum disease, the AP reviewed 25 different studies. They found the studies to either be inconclusive on the utility of flossing or to lack control over the experimentation process. In one case, the experiment did not measure the benefits of flossing for a long enough amount of time to be certain of long-term benefits. Some studies of this nature measured bacteria without considering gum disease itself. Measures of bacteria in this way could include good bacteria that the body needs as well as the sort of bad bacteria that cause infections.
The AP article notes that the flossing industry has paid for most of the available studies, if not entirely designing and conducting them. This brings the concern of study bias into the forefront. Furthermore, when the AP asked industry leaders questions about the validity of flossing studies, some industry leaders declined to respond, including the spokesman for Johnson & Johnson.
The article does admit that flossing has been proven to stop the progression of severe diseases such as gum disease by reducing gingivitis. While these are the most conclusive studies available in favor of flossing, they are for some not sufficient to justify the recommendations for developing a universal daily habit.
Why Was the Associated Press’s Article So Incendiary?
– By implying that the Department of Health withdrew federal support for flossing practices, the AP upset many dentists.
– Some dentists were also insulted by the tone that the AP article took when it suggested that inconclusive studies regarding flossing were funded by the industry, thus implying that dentists might be pushing the practice of flossing in order to get kickbacks from the flossing industry. Dentists have assured their patients that they would get much more money from dental surgeries resulting from bad oral hygiene than the flossing industry could offer them.
– The article circulated quickly and was covered by many major news and media outlets, including the New York Times.
– The American Dental Association released official news responses, which added volume to the conversation.
– Individual dentists took to writing articles on personal websites, social media, and major media outlets in order to discuss and refute the claims made by the article, thereby increasing the article’s circulation.
– Among readers, lack of evidence for the benefits of flossing was a proof against a number of harsh articles circulating during the past couple of years shaming patients about inconsistent flossing habits.
– It had been something of an open secret among dental professionals that flossing has shown minimal effectiveness in preventing cavities. Yet dentists continue to universally recommend flossing. Some of the outrage felt by the public had to do with not having been let in on the secret. This created a desire for scientific evidence for a hygiene practice that most, including dentists and researchers, thought to be common sense.
Almost immediately after the AP article was released, the American Dental Association posted a reaffirmation of flossing in a news release, stating that “a lack of strong evidence doesn’t equate to a lack of effectiveness.” The ADA recommends some form of interdental cleaning practice so individuals clean between their teeth when at home, but they recognize that toothbrushes with interdental bristles could work just as well as flossing.
The AP is not a medical, governing, or scientific press, so dentists have not felt any need to change their recommendations because of this reporting. Instead, many dentists have joined the debate hoping to help the population make good choices. Ultimately, dentists want the last word in recommending practices to patients, since dentists best understand their patients’ oral health status and history.
The ADA does not want the removal of flossing from the Dietary Guidelines for Americans to be seen as a withdrawal of support for the practice of flossing. Instead, it represents a shift of focus in the guidelines towards food-intake and nutrition-based concerns, such as educating Americans about the nutritional realities of sugar.
In a rebuttal of the AP article published in the Huffington Post, Andrew Swiatowics writes that “No dentist would ever claim that flossing is harmful, nor are there studies which say that health is improved by eliminating flossing from the daily routine.” Dentists instead wish to emphasize proper flossing. One study showed that individuals who floss at home may not derive as many benefits as when a dentist helps them floss. Individuals who can master proper flossing techniques will be best protected against gingivitis and gum disease.
What’s Going on Now?
There are more articles concerned with the habit of flossing than with its scientific applicability. Studies seem to be caught up on what percentage of the population flosses or lies to their dentist about flossing. There are even academic articles being published which seek to help dentists better inspire their patients to floss more often by making the case to patients with scientific proof, which are then unable to offer qualifying clinical or scientific proof.
Research on flossing has been sparse in the past because it seems like common sense. Doctors find themselves faced with more important things to study and spend valuable research funds on. Evaluating the benefits of flossing requires difficult studies which would need to be sensitive to factors such as skill level and self-report biases in a field where patients very commonly lie to doctors.
However, these debates may have sparked the development of further clinical studies about flossing. Clinical studies, as well as any published results in medical journals, tend to take a long time. Contemporary scholarship is advancing the idea that it’s too soon to disregard interdental care until more substantial studies can be published.
Potential Benefits of Flossing
Despite the lack of scientific evidence, British and American dental associations still recommend flossing for daily oral hygiene. Flossing is a low cost, low-risk method of cleaning the two difficult-to-reach surfaces of the teeth. Removing plaque from between the teeth will most likely help to prevent cavities, otherwise known as tooth decay, and gum disease, scientifically known as periodontitis.
Bacteria live in the plaque around teeth which is made up of food fragments, microbes, and proteins found in saliva. The mouth cultivates this bacteria because of its perfect temperature for bacterial growth. The main purpose of flossing is to remove food product from between the teeth while it is still soft.
Flossing can help to reduce bloody gums and inflammation from gingivitis which leads to gum disease. Gum disease, or periodontitis, is an infection of the bone that, when left unchecked, can cause irreversible destruction of the teeth and systemic diseases such as heart conditions.
Those who practice regular interdental care tend to have less gum bleeding, a sign of gingivitis, than those who do not. While flossing won’t do anything to disinfect areas that have already been attacked by infections, flossing can remove plaque, helping to prevent these infections from happening in the first place.
Risks Involved in Flossing
If done incorrectly, flossing can damage the teeth and the gums. These problems occur when individuals floss too close to the gums and work the floss too aggressively in a sawing motion. By doing this, they are liable to slice up and damage the gums, leaving them open to infection. It’s also possible to damage existing dental work when flossing too aggressively. Additionally, very infrequently and only in the worst cases, flossing can dislodge bad bacteria from your gums into your bloodstream and cause infections throughout the body. Take note that gingivitis and bacteria buildup in the mouth can cause problems like this as well.
But the biggest risk involved in flossing is incorrect or ineffectual flossing, which can leave you open to infection even while you think you’re protecting yourself. For those who, like the participants in the AAP study, prefer just about any other unpleasant activity over flossing, there are other options to improve oral hygiene and help to reduce the risk of gum disease, plaque buildup, and cavities.
Does this Mean I Should Stop Flossing?
The experts explain that there is nothing to lose and everything to gain from correctly flossing. However, as Dr. Tim Pruett writes, “If you’re not flossing correctly, absolutely don’t floss at all.” Essentially, it’s up to you. If you haven’t mastered the techniques of flossing then it won’t do you any good, and you should find another form of interdental cleaning.
Some experts wish to cut back on the amount that they ask patients to floss, while others argue that reducing flossing expectations will make it so that fewer people develop a flossing habit. Damien Walmsley, a scientific advisor to the British Dental Association, mentions that flossing is not among the basics of a dental hygiene practice, and therefore does not need to be practiced daily. Studies have also shown that flossing two to four times a week would probably be just as beneficial as flossing every day.
Joann Gurenlian discusses that, while studies show that flossing does little for those that already have periodontitis, flossing is most appropriate for those with healthy mouths who are able to floss properly. Dentists wish to reiterate that even though data is limited, most studies do conclude that the potential benefits outweigh the risks, especially when those risks have been mitigated through good habits.
How to Floss Correctly
Proper flossing technique is the key to making flossing work for you as a preventative measure. For a full guide as to how to floss and what alternatives you could consider, take a closer look at this infographic below:
As displayed in the infographic above, the American Dental Association suggests that you visualize a “C” shape when flossing, so that you remember to insert the floss in between your teeth and then curve it around your tooth. Move the floss up and down the sides of the tooth. Try to stay away from your gums as much as you can, so that you don’t run the risk of injuring them. Flossing should be a gentle cleaning, so don’t do it too often or too hard.
To avoid pain and damage, make sure not to use a sawing motion or pluck the floss out harshly. Be aware of sore or bleeding gums, pain or discomfort in your teeth, or any loosening teeth.
String vs. Floss Pickers
Using string or floss pickers tends to be a matter of personal preference. The American Dental Association endorses the use of either string or floss pickers indiscriminately.
Floss pickers give you more control over the angle at which you’re flossing, but they can be difficult to maneuver in tight spaces, like the back teeth. However, dentists find that individuals are more likely to overdo it and hurt themselves when they floss with string.
Ways to Maintain Good Oral Health Aside from Flossing
Brushing Your Teeth Thoroughly
Whether or not you decide that flossing should be a part of your daily routine, brushing your teeth absolutely should. Most people brush in the morning, but brushing at night is just as important for helping to remove food particles that have clung to your teeth all day. Twice daily brushing with a clean, quality toothbrush will do wonders for your oral hygiene.
You can also improve your brushing efficacy by purchasing an electric toothbrush. Dentists say the results of electric toothbrushes are noticeably different from manual toothbrushes when it comes to plaque removal and healthy gums. Powerful, quicker brushstrokes mean that electric toothbrushes can get more done in the same time, and some even have built-in timers to make sure that your brushing is as effective as possible.
Using a Brush with Interdental Bristles
Brushes with interdental bristles are now highly recommended by dentists to do the job of brushing your teeth and flossing all at once. Interdental bristles are designed to squeeze into the tight spaces in between your teeth in order to help you reach hidden plaque buildup. This means that these toothbrushes target the same spaces that you would when flossing.
Using a Water Flosser
Water flossers are like pressure washers for your teeth. They are a safer way to clean in between your teeth than either floss or picks. They are frequently used by dentists in routine cleanings, and some dentists recommend them to patients as a replacement for flossing. Water flossers tend to be on the pricier side of oral hygiene aids, but they are reusable and often make flossing an enjoyable experience.
Use Toothpaste with Fluoride
Fluoride is a mineral that helps to prevent tooth decay by repairing the tooth’s enamel layer. Make sure to use toothpaste with fluoride in order to help prevent tooth decay and cavities. A toothpaste that does not contain fluoride will help you to keep away plaque and bacteria from your teeth, but they will not help to protect or rebuild tooth enamel.
Rinsing with Alcohol-Free Mouthwash
Mouthwash is highly recommended to kill bacteria in the mouth. Some individuals focus their routines on vigorous tooth brushing and daily mouthwashes, rather than daily flossing. Mouthwash helps to kill some of the bacteria that make plaque so dangerous for your teeth.
Mouthwashes that contain alcohol tend to give off a noticeable burn that makes people feel like they’re being scrubbed clean, but this burn may not necessarily be a good thing. Dentist Thomas P. Connelly advises that mouthwash that contains alcohol can put you at risk of oral cancer. Alcohol-free mouthwashes are becoming more available and easier to find. They are safe for children and less likely to destroy the good bacteria in your mouth along with the bad.
Staying Away from Sugar
Sugar coats your teeth and feeds the bad bacteria living inside the plaque. It’s one of the leading culprits of tooth decay and bad breath. Reduce your sugar intake to help clean up your oral health. This includes reducing the amount of time that sugar stays in your mouth or on your teeth, so be aware of candies that stick to your teeth. Rinse your mouth with water after eating sugar and remember to brush your teeth soon after.
What’s the Verdict: Should You Floss or Not?
If you can keep good oral hygiene without flossing by using alternative methods, then you may be able to cut flossing from your essential daily routine.
That being said, if you see benefits from your flossing practices and you’re able to continue flossing without damaging your teeth and gums, then flossing is a good oral hygiene practice that will likely help to keep you healthy in the long run.