Introduction

Dental biofilm contains over 700 species of microbes that include both non-disease and disease-producing organisms. In health, these organisms co-exist in a symbiotic state, however, if a dysbiosis of the oral microbiome occurs, the pathogenic microbes take over and play a role in the initiation of both dental caries and periodontal disease, the two most prevalent oral diseases. As an integral part of the prevention and treatment of caries and periodontal diseases, patients become co-practitioners with their oral health providers and their sustained daily maintenance of oral hygiene becomes critical to the success of professional oral health interventions. However, patient levels of home care vary considerably and are often suboptimal. Despite recommendations from the ADA that individuals brush for two minutes twice daily,¹⁵ the average individual performs 45-70 seconds of toothbrushing daily.¹⁶ Additionally, patient compliance with regular daily use of dental floss has been estimated to be as low as 2%.¹⁷  In a survey from the American Academy of Periodontology (AAP), more than 35% of respondents stated they would rather perform an unpleasant task, like filing their tax return or cleaning their toilet, than floss.¹⁸ This certainly indicates that flossing is considered a chore and not elevated to necessary self-care to prevent oral disease.

Given the public’s reticence and/or inability to adequately perform oral hygiene measures and, in particular, to floss regularly,¹⁸ there was a large amount of public interest in August 2016 when the U.S. government released a statement that discussed the rationale for the omission of references to oral hygiene from the 2015-2020 Dietary Guidelines for Americans.¹⁹ The text included in the 2015-2020 Dietary Guidelines for Americans omitted statements that had been included in previous guidelines that advocated for: 1) consumption of fluoridated water, 2) reduction of sugary food and beverage consumption, and 3) tooth brushing and flossing as effective methods to reduce the risk of dental caries.¹  In response to a government Freedom of Information Act (FOIA) request, it was reported by the Associated Press (AP) that the flossing recommendation was excluded due to a lack of definitive scientific evidence stating flossing prevents dental caries.²⁰ The government’s rationale cited a 2011 meta-analysis that concluded some scientific evidence currently exists to support interdental cleaning for the prevention and treatment of gingivitis, but more studies may be needed to demonstrate a definitive causative benefit for the prevention of dental caries and periodontitis.²

It is also important to note that the EFP’s 11^th European Workshop, held in Spain in 2014, also reviewed data on flossing’s therapeutic value in patients with periodontal and peri-implant diseases and concluded that floss is optimal for the primary prevention of gingival inflammation. However, in patients who may have established gingivitis and/or periodontitis, the use of interdental brushes, where interproximal space allows for their use without tissue impingement, improve the removal of biofilm and the reduction of interdental gingival inflammation when compared with flossing.^6,7

It is understandable that there would be heightened public interest regarding a change in paradigm with regard to oral hygiene recommendations. The EFP statement^6,7 in combination with the omission of oral health references from the 2015-2020 Dietary Guidelines for Americans for the first time since 1979,¹⁸ have heightened public interest in flossing’s utility and alternative interdental cleaning methods. There has also been an increase in technologies that can be used for adjunctive interdental cleaning that are of keen interest to patients and practitioners alike. It is therefore critical for dental healthcare providers to be able to review the current scientific evidence and recent recommendations from government and non-profit groups to make individualized recommendations for their patients, to allow for optimal implementation and compliance for oral self-care in their patients.