“Frustrating” is the word most dentists and hygienists I’ve spoken with use when describing the Associated Press report questioning the value of flossing. With the potential of reversing decades of preventative educational efforts, is the suggestion of an oral care conspiracy warranted?

When considering oral health consequences, I believe the media storm this report generated will have minimal impact, if at all. Why? Because the vast majority of people, estimated at 80 percent in our dental practice, don’t floss regularly in the first place.

The value provided by this report is the public discussion it created. Most agree with pursuing informed healthcare decisions and have grown tired of being told what to do without understanding why. My goal is to provide this perspective, a second opinion if you will. It will definitely address the “why” and also might surprise you: If you aren’t flossing correctly, then I agree with the report; you shouldn’t floss at all.

From July 2004 to May 2016, our dental practice placed 4,283 multi-surface fillings. These restorations involved at least two of five tooth surfaces: Occlusal, Mesial, Distal, Facial, and Lingual.

Of those fillings, 3,676 included an interdental flossing surface; the mesial or distal surface that is cleaned by flossing and cannot be reached by a toothbrush. If you do the math, this means over 80 percent of these fillings involved an interdental surface that was inadequately cleaned. This of course is only if you agree that decay is prevented by cleaning your teeth. (If not, go ahead and toss your toothbrush as well.)

Keeping it simple, brushing only cleans three of five exposed tooth surfaces, or 60 percent of the tooth. By not flossing, you’re missing the forgotten 40 percent and at greater risk for interdental decay; not to mention gum disease and a host of other issues.

I remind our patients that teeth are not fingernails, they don’t grow back. We can make them look pretty, but every time we have to remove tooth structure it increases the potential for problems down the road. Fillings involving interdental surfaces have a greater likelihood of failure due to an increased risk of recurrent decay and tooth fracture, requiring either replacement or treatment escalation (think crowns and root canals).

Preventive Care is Key

The key? Prevention. At a basic level, flossing is recommended to help prevent decay and gum disease. These two conditions are distinct in nature, but from the standpoint of preventative hygiene, are treated the same.

Tooth decay is caused by bacterial metabolism of food debris, resulting in acid production that destroys enamel and underlying tooth structure. It can occur anywhere bacterial plaque is allowed to remain attached to the tooth and undisrupted. Additional causes of enamel breakdown also exist including acid reflux, bruxism, toothbrush abrasion, acidic diets, and systemic disease; which is why we spend significant time on dietary and systemic health reviews during check-ups.

Saliva does an amazing job at buffering acids in the oral environment and helping to prevent decay, however it has a tough time protecting interdental “flossing” surfaces due to the inability to flow between tight tooth contacts. Since these surfaces can’t be adequately reached by saliva or your toothbrush, flossing is necessary to disrupt acid producing bacterial plaque and reduce the risk of enamel breakdown.

Home hygiene is also essential when it comes to preventing periodontal (gum) disease. Almost always painless until advanced stages, it involves an inflammatory reaction (driven by your immune system) to the presence of pathogenic bacterial plaque, resulting in the loss of tooth-supporting bone. Much like an allergy, periodontal disease is highly variable between individuals, limiting diagnosis to clinical and radiographic observation. Complicating matters, gum inflammation can also be triggered by impacted food, metabolic disease, hormonal changes, ill-fitting dental work, traumatic brushing and flossing, and autoimmune diseases.

Understanding both disease processes can help explain the lack of longitudinal controlled studies referenced in the AP report as proof, or rather lack thereof, that flossing is beneficial. Attempting to prove or disprove a cause and effect relationship for flossing with control and without bias is extremely difficult, expensive, and nonsensical; especially when acknowledging that floss is prescribed, no differently than a tooth brush, as a mechanical cleaning instrument. Foundational knowledge concerning the origin of both of these highly variable and multifactorial disease processes suggests without question that proper mechanical cleaning is a best-practice preventative approach.

The Problem with Flossing

As the AP report accurately describes, there are real problems with flossing. I absolutely agree that flossing can actually be harmful. The gum can easily be damaged by sawing floss between teeth. Flossing this way traumatizes the delicate junctional epithelium, which I describe as the gasket that separates the inside world from the outside world around a tooth. If you’re flossing this way, I definitely recommend not flossing at all. Floss should be moved gently between teeth in a shallow vertical direction along the curvature of the tooth, which neither hurts nor makes your gums bleed when healthy.

Remember, floss is simply recommended as a mechanical cleaning instrument, just like a toothbrush. It moves between teeth in the interdental space, disrupting food debris and bacterial plaque that a brush can’t reach. Keeping it simple and with few exceptions; a clean tooth is a healthy tooth.

If you agree that flossing is beneficial, and yet consider it from the economic perspective eluded to in the report, it makes little sense to conclude that a financial incentive is connected to this recommendation. Preventative measures such as flossing are aimed at reducing the burden and cost of dental care. It felt like this reference was merely an instrument used to entertain thoughts of economic collusion and honestly it worked brilliantly: #Flossgate was born.

About Dr. Pruett

Dr. Tim Pruett founded Flossolution, a patented system of products designed specifically for interdental hygiene. Dr. Pruett continues clinical practice with over 12 years of experience. Attended Marshall University, Bachelor of Science Chemistry and the University of Florida College of Dentistry, Doctorate in Dental Medicine. He is a member of the Lake County Dental Society, Central Florida District Dental Association, Florida Dental Association, American Dental Association, Academy of General Dentistry, American College of Dentists, International College of Dentists, and past president Central Florida District Dental Association.