Dentistry’s Defense of Flossing Continues

12 Aug 2016
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When the Associated Press questioned flossing’s effectiveness last week, dental organizations like the ADA, the Canadian Dental Association, and the American Academy of Periodontology (AAP) quickly jumped to its defense. Since then, other defenders have joined the discussion to advocate for daily flossing.

The American Dental Hygienists’ Association (ADHA), for instance, supports practices that are both based on evidence and centered on the patient. Its recently revised Standards for Clinical Dental Hygiene suggest personalization of dental plans due to unique needs, abilities, and other factors.

While the ADHA recognizes that not all adjunct devices such as floss are appropriate for all patients, it urges dental hygiene professionals to work with patients to determine which interdental cleaning method fits their needs to best remove bacteria, biofilm, and food debris from interproximal areas that toothbrushing can’t access.

“The typical patients who come in with periodontal disease have bad oral hygiene. Their brushing and flossing are not what we feel they should be,” said Andrew Sullivan, DDS, chair of the Rutgers School of Dental Medicine’s department of periodontics and a dentist with 48 years of experience.

“Usually, when they’re put on appropriate oral hygiene procedures, including flossing, it reduces the clinical signs and symptoms. We see reduced inflammation, reduced bleeding of the gums,” Sullivan said. He added that people don’t floss because it’s difficult, it’s time consuming, and often, they never had been taught how to properly do it.

“The dental profession is behind flossing 100%,” said Dr. Paulo Camargo, associate dean of clinical dental sciences and the Tarrson Family Endowed Chair of Periodontics at the UCLA School of Dentistry. “The cost of telling people not to floss would be a lot higher in terms of exposure to bacteria that can cause cavities and gum disease.”

While the Associated Press deemed previous studies about flossing’s effectiveness to be of little value, Camargo said that the evidence for flossing seems shaky because these studies followed subjects for short periods of time—some for only 2 weeks. That isn’t enough time for periodontal problems to develop, he said.

“In order to evaluate the effect of flossing on the onset and progression of periodontal disease, a prospective study would require that a group of people not floss for a few years,” Camargo said. “Ethically, you can’t do that type of study.”

“Gum disease is typically caused when prolonged exposure to bacteria in dental plaque causes an inflammatory reaction,” said AAP president Dr. Wayne Aldredge. “Flossing is an effective and useful way to remove the plaque, especially in between the teeth or under the gumline—places where a toothbrush cannot reach.”

While gingivitis often is reversible with periodontal therapy and consistent home care, it can progress into more severe periodontal disease if left untreated, followed by tooth loss and other systemic diseases such as heart disease and diabetes. The Centers for Disease Control and Prevention says that nearly 50% of American adults ages 30 years and older have some form of periodontal disease.

“It’s essential that in addition to diligent oral hygiene, which includes flossing, patients receive an annual comprehensive periodontal evaluation each year,” Aldredge said. “Those diagnosed with or at risk of periodontal disease should seek the care of a periodontist, a dental expert specially trained to treat the gums.”

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