The evidence-based message about flossing should be more flexible
By JOANN R. GURENLIAN, RDH, PhD
By now you have all probably seen those cute cartoons in the dental magazines and journals with the patient on the witness stand admitting to the judge: "and I lied about flossing." According to marketing research conducted by a Harris Poll in March on behalf of the American Academy of Periodontology (AAP), among 2,021 U.S. adults in the top 10 U.S. markets, 27% of those surveyed admitted that they lied to their dentist about how often they flossed their teeth. To be honest, I am surprised that number is not considerably higher.
If you visit the story about this survey on the AAP website (perio.org/consumer/quarter-of-adults-dishonest-with-dentists), you might enjoy seeing that many of those respondents would rather wash a sink full of dirty dishes, wait in a long check-out line, sit in gridlock traffic for an hour, do their taxes, or clean a toilet rather than floss their teeth. The AAP recommends that all Americans take better care of their gums by brushing their teeth at least twice daily, flossing daily, and discussing periodontal health with a dental professional. Maybe it is time the AAP get in touch with their patients, not to mention current evidence on flossing.
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In 2008, we started seeing scientific literature being presented indicating that flossing was not effective in reducing inflammation in patients with periodontal disease. This evidence was upheld in further studies, and more recently addressed at the 11th European Workshop in Periodontology. At this workshop, Professor Iain Chapple reviewed years of studies on the efficacy of interdental mechanical plaque control, demonstrating that there is no evidence of effectiveness of flossing in plaque removal or in reducing inflammation for patients with gingivitis or periodontitis. Further, he reported that inter-dental brushes (IDBs) have demonstrated effectiveness in reducing biofilm and inflammation provided they fit between the proximal spaces. The conclusions of this workshop are now available in a special April issue of the Journal of Clinical Periodontology for those interested in learning more about this science.
In the EFP Prevention Workshop News, Professor Chapple stated: "What it means for the profession is that we're going to have to change our mindset and our behavior to accepting that floss doesn't have any value in patients who have had periodontitis or those who have gingivitis.
"...Essentially, we are going to have to get over the fact that this is what the evidence tells us and start recommending the interdental brushes instead of floss for patients with gingivitis and those with a history of periodontitis, provided they fit between the spaces.
"...We found no evidence that the use of dental floss in patients who have gingivitis or periodontitis confers any benefits whatsoever in terms of efficacy. The flossing story appears to be a big myth."
There are exceptions to every rule, and occasions where flossing is appropriate. Healthy mouths are one exception where flossing is most appropriate. There are patients who actually like to floss and have the dexterity to manage the skill. Some patients do not have the space to accommodate IDBs and there are plenty of aids available that can be offered in those circumstances besides floss.
The important take-away message here is that we need to move away from our usual message that flossing is the only or best way to manage interproximal biofilm management. The evidence does not support this home-care instruction, and it is not in the best interest of our patients to provide this advice.
Despite the fact that other specialty organizations continue to make that recommendation to patients, dental hygienists are preventive specialists who must use current science to support their recommendations. The prevailing literature clearly suggests an alternate approach is warranted. Take this new information and transform your home-care instruction and toolkits so that patients are learning new strategies for interproximal biofilm management. Perhaps they and we can look forward to better treatment outcomes as a result. RDH
References
1. American Dental Association Center for Evidence-Based Dentistry. A summary of The efficacy of dental floss in addition to a toothbrush on plaque and parameters of gingival inflammation: A systematic review. Publication date: September 11, 2010 Available at www.ebdada.org. Accessed July 18, 2012.
2. Asadoorian J. Flossing. Canadian Dental Hygienists' Association position statement. CJDH. 2006;40:1-10.
3. Barouth K, Charles CH, Mankodi SM, Simmons K, Zhao Q, Kumar LD. The efficacy of an antiseptic mouthrinse versus dental floss in controlling interproximal gingivitis. A comparative study. JADA. 2003;134:359-365.
4. Berchier CE, Slot DE, Haps S, Van der Weijden GA. The efficacy of dental floss in addition to a toothbrush on plaque and parameters of gingival inflammation: A systematic review. Int J Dent Hygiene. 2008;6:265-279.
5. Bowen DM. Flossing or alternative interdental aids? J Dent Hyg. 2012;86(2):58-61.
6. Hujoel PP, Cunha-Cruz J, Banging DW, Loesche WJ. Dental flossing and interproximal caries: A systematic review. J Dent Res. 2006;85(4):298-305.
7. Sambunjak D, Nickerson JW, Poklepovic T, et al. Flossing for the management of periodontal diseases and dental caries in adults. Cochrane Database Syst Rev. 2011 Dec 7;12:CD0088209.
8. Sjögren K, Lundberg A, Birkhed D, Dudgetdon DJ, Johnson MR. Interproximal plaque mass and fluoride retention after brushing and flossing-a comparative study of powered toothbrushing, manual toothbrushing, and flossing. Oral Health Prev Dent. 2004;69:759-764.
9. Van der Weijden F, Slot DE. Oral hygiene in the prevention of periodontal diseases: The evidence. Periodontology 2000. 2011;55:104-123.
JOANN R. GURENLIAN, RDH, PhD, is president of Gurenlian & Associates, and provides consulting services and continuing education programs to health-care providers. She is a professor and dental hygiene graduate program director at Idaho State University, and president of the International Federation of Dental Hygienists.
