Floss

Dental floss remains an almost universally recommended tool for removing dental plaque from proximal tooth surfaces.⁸⁶ Consistent flossing and toothbrushing has been demonstrated to decrease interproximal plaque and gingival inflammation over toothbrushing alone.⁷² Additionally, lower caries rates and gingival inflammation are observed in individuals who report frequent flossing when compared with those who do not floss.⁵⁶ In a matched twin cohort, supervised flossing and toothbrushing decreased visible plaque, gingival bleeding, and altered the subgingival flora to reduce the proportions and amounts of bacterial species associated with periodontal disease when compared to toothbrushing alone.^87,88 Those twins who flossed demonstrated fewer detectable bacterial species associated with both carries and periodontal diseases within the plaque present, including reductions inT. denticola, P. gingivalis, T. forsythia, P. intermedia, A. actinomycetmcomitans, and S. mutans. ⁸⁸ Current studies do not exist to confirm if the observed increased biofilm removal and shift towards a less dysbiotic microbial species results in lower caries rates in patients who floss, it is well-established that decreased plaque scores are associated with decreased decayed, missing, and treated (DMT) scores in both adults and children.^2,89,90

In patients seeking to prevent gingival inflammation, flossing provides a distinct benefit. Flossing even 2-4 days per week was associated with a modestly lower prevalence of periodontitis.⁹¹ Furthermore, flossing has been associated with decreased bleeding upon probing, including further reductions beyond what is seen with toothbrushing alone.^92,93 And even when used alone, flossing has been determined to be effective at preventing gingival inflammation and reducing plaque levels.⁹⁴ Interestingly, it is also recommended that flossing or other forms of interdental cleaning be performed prior to toothbrushing for maximal biofilm removal.⁹⁵

Flossing efficacy has demonstrated its adjunctive benefit in reducing gingival inflammation, bleeding upon probing, and plaque/biofilm deposits as an adjunct to toothbrushing, particularly in patients with periodontal health. It should, however, be noted that the evidence to support the use of floss to treat patients with established periodontitis remains equivocal and, for these individuals, where possible, the use of other interdental cleaning aids may provide additional benefit.^6,7 Nevertheless, for many patients, flossing is economical, effective when performed correctly, and aids in removal of plaque and food debris interproximally, but there are limitations to its use. At interproximal sites with deep probing depths, diastema, incomplete papillary fill, radicular grooves/concavities floss may not provide adequate plaque removal.⁸³ It is also noted that flossing habits are difficult to establish. It is reported only 8% of teenagers floss daily and the number of all individuals who floss daily may be as low as 2%.^17,96,97 Increasing patients’ willingness to floss and their ability to sustain the habit over time requires motivation and alteration of patient behaviors. This requires the treating dental healthcare professional to employ effective behavior modification techniques and engage in long-term coaching to achieve sustained behavioral changes. In conclusion, while floss is the most widely recommended and used interdental cleaning aid,⁸⁶ it can be difficult to use properly and adherence may be low.^96,97 In patients for whom flossing results in inadequate plaque/biofilm removal or those who cannot adhere to a flossing regimen, additional interdental cleaning aids may be beneficial.⁹⁸