A String around Your Finger: Do We Really Need to Floss?

Controversies about the utility of flossing were thrust into the spotlight in 2016 in a controversy known amongst dental professionals as “Flossgate. As a part of the update to the 2015-2020 Dietary Guidelines for Americans, the federal government omitted a recommendation for flossing previously included in the guidelines in 2000, 2005, and 2015.¹ Citing the reasons for the omission, the Dietary Guideline Advisory Committee (DGAC) stated they focused on food and nutrient intake (e.g., added sugar) and cited the 2011 Cochrane systematic review,² which concluded there is currently a lack of strong evidence to support the use of floss as a preventative measure for caries and periodontal diseases, although the systematic review does acknowledge evidence that flossing results in a reduction in gingival inflammation and interdental plaque. The Surgeon General, Centers for Disease Control (CDC), the Department of Health and Human Services, and other federal and state health agencies continue to publish materials that support the importance of flossing and interdental cleaning, and that advice is available to the public through the National Institute of Dental and Craniofacial Health (NIDCR),³ CDC’s Division of Oral Health,⁴ and Healthy People 2020.⁵

The appropriateness of floss as an interdental cleaning aid for all individuals was further questioned with the release of the European Federation of Periodontology’s (EFP) statement regarding flossing efficacy in individuals with periodontal diseases. Iain Chapple, PhD, BDS, an EFP spokesperson, stated that the use of floss demonstrates utility in healthy patients without diastema and may prevent the development of periodontal diseases and gingival inflammation, but that in patients with gingivitis or periodontitis, evidence suggests that adjunctive floss use for interdental cleaning is not useful in reversing disease. He stated that interdental brushes are advocated for use in those patients.^6,7 Dr. Chapple indicated that dental healthcare providers should consider changing our behavior and recommendations based upon the current evidence.^6,7

Despite the support of governmental agencies and numerous nonprofit groups, this messaging has created confusion in the lay media and the public with regards to the role of patient-administered oral hygiene for the prevention of oral diseases. Interdental cleaning continues to be an essential part of oral hygiene to maintain a healthy oral environment.⁸ There are 700+ identified species of bacteria and up to 1,500 putative pathologic microorganisms found in dental biofilm.^9-11 Many of these organisms as well as other factors including bacterial nutrients, food debris, molecules that facilitate bacterial adhesion and invasion, and other extrinsic factors in the environment and the body’s own immune response contribute to diseases of the teeth and gingival tissues.^12,13 Current recommendations from the American Dental Association (ADA) include brushing for two minutes twice daily and cleaning between teeth to maintain a healthy mouth and smile, but these may be tailored to individuals based upon risk factors and their current oral health!¹⁴