Basically, yes, flossing helps, but self-flossing really doesn't do anything more than just brushing daily.
I'm a little disappointed at the number of comments here along the lines of, "Well, it's obvious! Why do we need to study it?" That's a very unscientific attitude.
I had the opposite reaction: how on earth has no one looked into this!?
But if you dig into it, it's horrifying how little "evidence" goes into treating a lot of common medical conditions. For another trivial example, the stuff in Sudafed PE (phenylephrine) http://www.sciencedirect.com/science/article/pii/S1081120610... is much worse than the psuedophedrine it replaced.
I wish the NIH (and other funding agencies) would consider running big, confirmatory trials on a lot of "obvious" things that affect people every day, the money clearly isn't there and it's politically difficult to get it there:
There are a fair number of ignorant Congressman in the US who love to rant about 'wastes' of government money on studies like these.
What are the phases in this study? There's no explanation of the phases in the abstract:
"Phase 1 results showed a difference between phenylephrine and placebo that was 64% of the difference between pseudoephedrine and placebo, substantially greater than the 17% difference observed for all phases. "
Edit: Phase 1 may mean "Testing of drug on healthy volunteers for dose-ranging", from wikipedia:
That study uses a crossover design, which means that everyone gets all three treatments (in this case, phenylephrine, pseudoephedrine, and placebo), but in different phases. You might get the placebo this week and the pseudoephedrine next week, while I get the opposite. Each one of these time steps is a "phase".
A similar study might use a "batch design" instead, where the subjects are each tested once, after being given a single treatment. They might put you in the pseudoephedrine group, while I get the placebo.
Crossover designs have a big advantage in that are more robust to individual variability, and thus have more statistical power to detect differences. In essence, the crossover design allows you to compare the average of each subjects' difference between conditions while the block designs force you to examine the difference between the average scores of each group.
This power comes at a price--you have to be careful that the different treatments do not interact so you can correctly associate causes and effects. None of the treatments remain in the subjects' system for a week, but they are worried that people might remember* how well pseudoephedrine worked and "downgrade" the other treatments. One way to check this is to analyze the first phase of your data, where each subject has had only one treatment, as a batch design, which is what they reported there.
* The measurement here is a self-reported scale of nasal congestion. Note that they don't do this for most of the quantitative/physiological measurements.
Remember "chocolate is good for you"? Turns out that: "While research shows that cocoa can have a beneficial effect with regards to maintaining healthy vascular tone and insulin sensitivity, the reverse is true for sugar. Eating sweetened chocolate is still not good for you." [1]
Yet plenty of people seem to have fallen over each other to share that article (and this article). It seems anything that says you can have your cake and eat it too will have plenty of social media shares. In this case, it looks like flossing may be lightly studied, but is still good for us. Perhaps we can change that famous old adage to, "if it sounds too good to be true, it's probably clickbait".
Here's another piece of research on flossing, "In regression analyses, brushing thoroughness, flossing ability and frequency, and dental visit frequency were predictors of lower plaque, gingivitis, and calculus scores. In turn, these scores were predictors of shallower pocket depths and less attachment loss." [2]
That's on a study of 319 people, flossing regularity is based on surveys and dental health based on examinations.
Your point about science reporting is also one of Dr. Ritchey's points. It's actually something that comes up fairly frequently on the SBM blog.
As for the paper you cited, it seems (from what is publicly available) to conflict with the Cochrane review he cites. I can;t tell if the review looked at that particular paper or not.
Or, people who were assigned a professional flosser every single school day were also more likely to brush their teeth better and were reminded constantly about their teeth and even possibly taught stuff about teeth and so maybe even ate less sugary things. I don't have access to the paper: did they at least have the professional flosser supervise the self-flossing to control for this? Otherwise this just seems like a much more likely reason for these results.
I can't find a PDF of the original study, but in the review, they mention that one quadrant of the mouth was professionally flossed. This presumably lets them do within-subject comparisons: are there more/less cavities (or whatever) within the flossed portion?
This should remove confounds like 'ate more sugary things'. It's possible, of course, that kids brushed more on the flossed side (or the unflossed side), but you could presumably quantify that too.
The reference is a systematic review, not a single study; only one study in the review was run as you indicate.
Beyond that, I am not sure what you are getting at. The point of the post I posted and the original article here is that self-flossing as an augmentation to brushing does effectively nothing. What you stated corroborates that. Am I missing something?
My point was that from the information in the article that isn't actually clear; it is like when people say that condoms are X% effective as a contraception technique, and so people assume that means that condoms have an X% failure rate, but what they really mean is that "couples who report using condoms as their primary means of contraception have an X% success rate at avoiding pregnancy". While it is interesting from a clinical perspective as to whether "sending a child home and telling them to floss by themselves" is a working strategy or not, it would be taking into account "children don't really floss" and doesn't tell us if an adult who actually knows they are flossing (such as an adult who actually knows they are using the condom every time) has a particular success rate.
I wonder why they don't fund proper studies. Maybe because the effect is too obvious to question? My oral hygienist can tell whether I floss regularly or not, so there must be an observable difference in plaque buildup. Subjectively my gums also feel better and bleed less when I floss regularly.
For years my oral hygienist kept telling me to a get an electric toothbrush. When I finally got one, I didn't tell her, but I never hear the "get an electric tooth brush" again.
It was the same with flossing. When I started flossing I didn't say anything, and she hasn't commented that I need to floss since.
There's a ton of evidence in the literature supporting that gum disease and cavities are, obviously, a bacterial issue.
Flossing is an obvious way to disrupt pathogenic bacterial colonies by abrasion. I think irrigation is much better, as it reaches deep pockets below gums. But it doesn't replace flossing entirely.
Those two, coupled with regular brushing of teeth, gum and tongue, plus oral probiotics should keep issues at bay.
In particular, my experience with probiotics is that tartar calculus fell apart within a few months. I have never had a cavity.
Sadly most dentists don't place too much emphasis on these as it goes against their business model: drill, fill and bill.
Where is this research that flossing is "an obvious way to disrupt pathogenic bacterial colonies by abrasion".
Here's some research that claims flossing actually causes problems.
"Dental flossing can produce bacteraemia in periodontally healthy and periodontally diseased individuals at a rate comparable with that caused by some dental treatments for which antibiotic prophylaxis is given to prevent IE."
http://onlinelibrary.wiley.com/doi/10.1111/j.1600-051X.2008....
But in general, interdental flossing is very good against contact cavities [1]. Perhaps deep flossing is leading to bacteraemia. I have always found hard and awkward to perform deep flossing, and that's why I use oral irrigators instead. However, maybe irrigation also leads to bacteraemia. I've seen some references supporting that too.
Blis M18 and K12 strains. There are many brands using these. I prefer pills straight from Blis or Life Extension.
If your mouth has an unhealthy microbiome, you might need to place a lot of emphasis on killing bad bacteria initially. For this purpose, salt water or mild antibiotics (chlorhexidine) for 2 weeks combined with double dose of probiotics should do the trick.
Obviously, sugars feed bad bacteria, which metabolize it into acids to erode your enamel. Avoid entirely.
I reckon milk kefir is pretty good, apparentiy it has a particularly broad and strong co-operative of micro-overlords, ahem, micro-organisms! Dental-protection? probably? No studies to back that, but in my opinion, it's one of the best cultures for your insides.
Also worth noting that if you floss properly (maybe also use interdental sticks) the descaling routine becomes a lot more comfortable. For this reason alone it's worth doing.
Flossing was a painful, bloody mess for me the first week or so I did it. Then it felt great, then I ran out of the floss sticks (like a disposable razor, but with floss instead of a blade) and haven't done it since. Such is life.
I found this to be the same with a water pick. At first my gums bled and hurt, but after a few weeks I could turn the power to max and it feels like an awesome massage on my gums. I used to get some food stuck between my teeth, but now almost never do which I presume is due to much healthier gums.
I've never flossed, I don't have gaps in my teeth to get the floss in. My first trip to the dentist in 25 years was a few weeks ago and my teeth were perfect except for a wisdom tooth and the damage it caused.
So i'm kind of skeptical of the effect.
Edit - I always wonder what kind of toothbrush other people use. I've always used electric ones so I wonder if that helps.
You might find that if you go to the dentist for teeth cleaning and they clear away all the plaque buildup that you'll be able to get the floss in between your teeth.
Like you, I have good teeth (never had a filling) and on average have visited the dentist about once every 10 years.
Like you I also used to never be able to get floss in between my teeth, but after a dental checkup some years back the dentist cleared all the plaque buildup and from then on getting the floss between my teeth was no problem, and I've been flossing regularly since.
Once the plaque builds up and hardens, it's very difficult to break it up with just floss and you'll have difficulty getting floss in.
For what it's worth, my teeth definitely feel cleaner after flossing, and if I miss a couple of days they start to feel dirty.
I had the issue that I couldn't floss due to lack of gaps too, I even have a wire behind my bottom teeth keeping them together after having braces when I was younger. This meant I had to visit the dentist if I wanted to clean between my teeth and even after that, normal floss just didn't fit.
But now I have discovered floss tape; it's just what it sounds like, a thin strip of tape that you can slide between your teeth to floss. Now I can actually floss and it makes a big difference to how clean my teeth look and feel. I'm in the UK and the product I use is Oral-B Satin Tape - worth trying or finding an equivalent if you have teeth very close together.
My gaps are small. My dentist says my teeth are tight. I have found that using Glide is the best floss. Even with that I have at times cut right through the floss with a particular pair of teeth. You might want to try Glide.
I floss daily and sometimes twice a day. I keep floss at my desk at work and some mouthwash to kill some of germs that get stirred up. It is easy to fit that in when thinking through a problem.
I also take vitamin C twice a day. My dentists always comment on the good health of my gums and say "you take vitamin c don't you?" At 62 I want to maintain my gum and teeth health.
I have to use a plastic floss needle sometimes, you thread the needle with floss in order to get floss between teeth when there is some food stuck in there.
Amazing that people are wondering what the "scientific" value in getting food particles out of your mouth.
A few people are certainly "gifted" teeth-wise (I know another case), but not going to the dentist for 25 years would be disastrous if applied on large scale.
> Well that's the problem, we don't have better evidence.
We actually have had it for quite a while. The CAMBRA MOOC is put together by a dentist/statistician and lays out a point system based on correlation between patient behaviors/health and carries. It has been iteratively corrected based on effective and ineffective results when modifying behavior according to the system.
Notably in that system, floss is not given a point. Whatever effect it may have is either too weak or better described by other factors flossing correlates with.
When points like that come up, the teacher stresses that the system is only measuring odds of near term carries, so flossing may be effective for something else with regards to oral health or preventing one of the negative factors.
The sentence above was about considering the extreme case irrelevant.
Focusing on flossing itself, as person who started doing it regularly only as adult, I think that researching on how frequently one should floss (or not) is in a way like researching how frequently one should change underwear. It may make sense theoretically, but ultimately all it requires is just to pay attention.
I never noticed the bleeding and/or irritation of the gums (which dentists always mention) until I started flossing regularly.
Now I do feel a difference (as a matter of fact, I floss irregularly, depending on how the gums feel). Of course, I'm pretty sure I could survive without flossing at all.
This is in line with what dentists generally suggest. Given that flossing can be ultimately considered as simply extra cleaning, and that the presence (or not) of the effects can be easily observed, a couple of weeks of flossing should be enough for anybody to make a solid judgment more than any theory.
If it works for you, then no need to change it. For me, it depends on which tooth I'm flossing. Some are easier than others. Some are so tight that floss won't come out, it feels like I'm pulling a tooth out. For this reason, I don't floss often and not every tooth. I use toothpicks though.
I have tight straight teeth on one side and I wicked with little gaps on the other side. There is a big difference when I floss. On one side is usually clean, on the other is not. It requires a lot more maintenance.
For some teeth, I have to force it a little, my teeth are pretty close too. Its so worth it though: much better breath, clean feel, minimized risk of cavities.
I avoided purchasing one by forming a loop with the wire. I cut a 20cm (8in) piece, then I tie a triple knot (the simple over hand knot with both ends). The wire is very slippery so I move the first knot as close to the ends as possible, so as not to waste floss.
Having a loop allows to have a firm hold on the floss and adjust tension. I use it with both hands though. And I waste very little floss because I can rotate the loop and use every inch of it.
Thing is, teeth are so close to each other that literally nothing can get between them, not even food. I have however few teeth that get food in between, but these are the ones that already went bad and were fixed, and have gaps as a result of that.
The effect is very obvious. I'm not ashasmed to say that since the age of 18 - your last year of free dental care in Sweden - to the age of 31, I didn't go to the dentist at all.
I brushed mostly regularly the second half of this period, I never flossed. I'm a computer geek, I can get caught up in code for days without brushing my teeth but try to do it regularly.
The result was 13 years of plaque and two visits to a dentist to clean it all out.
Dental plaque is a coating over your tooth and your gums will grow over this coating. So I think it's pretty obvious that dental plaque can cause cavities between your gums and your teeth, infections in your gums and all this will in turn lead to periodontitis.
And also you have saliva glands at the bottom of your mouth that bring with them additional minerals and stuff that get stuck to your teeth, forming plaque. So the front bottom teeth are even more important to floss.
Now I floss regularly and I'm proud to have actually made it one of my daily habits.
Except that studies have now shown that the effect is not obvious at all.
"Since doctors began saying that a string-based tooth scrapping was good for oral health, a handful of studies have been conducted. However, they all fall far short of what’s needed to make a convincing argument. A 2011 review of a dozen randomized controlled studies concluded that, “Overall there is weak, very unreliable evidence which suggests that flossing plus toothbrushing may be associated with a small reduction in plaque at 1 or 3 months.”
The US Agriculture and Health and Human Services departments quietly removed the flossing recommendation from the latest version of dietary guidelines.
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If anyone thinks that this is because the study's parameters are too narrow to show an effect, that is not the case. Other studies have successfully shown the benefits of flossing... if the dentist is the one performing it. But they haven't been able to show similar results when regular people do the flossing.
"Maybe the evidence that flossing reduces tooth decay or gum disease does not hold up because we are all such poor flossers. Superflossers, like the zealous hygienist at your dentist’s office, aim to “hug the neck of the tooth” and get below the gum line, Dr. Hujoel said.
But we common folk, staring woefully at our bathroom mirrors, tend to lightly give it the once-over.
A review of six trials found that when professionals flossed the teeth of children on school days for almost two years, they saw a 40 percent reduction in the risk of cavities.
So maybe perfect flossing is effective. But scientists would be hard put to find anyone to test that theory."
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Honestly, I'm not surprised at all. Years ago, my dentist strongly urged me to get my asymptomatic wisdom teeth removed. I then went home and did my own research on this subject. And what I found was the complete opposite of my dentist's recommendation.
But a new study of more than 6,000 patients in Greece found that only 2.7 percent of the teeth had a cyst or tumor. An older study, often cited by critics of routine extraction, found that only 12 percent of 1,756 middle-aged people who had not had impacted wisdom teeth removed experienced a complication.
Numerous comprehensive reviews of research, conducted by independent bodies not affiliated with oral surgeons, have concluded that there was no evidence to support routine prophylactic extraction of impacted but healthy wisdom teeth.
Britain’s National Health Service stopped paying for the procedure if there was no good reason for it after an analysis by its Center for Reviews and Dissemination at the University of York concluded in 1998 that there was no solid scientific evidence to support it. Also that year, the Royal College of Physicians of Edinburgh said that for patients who do not have a condition related to third molars or whose teeth would probably grow in successfully, removal is “not advisable.”
In 2005, a review by the respected Cochrane Collaboration said the number of extractions could be reduced by 60 percent if they were done only when patients were in pain or developed a condition related to wisdom teeth. The group also said there is “reliable evidence” that suggests that removing wisdom teeth does not prevent or reduce crowding of front teeth.
In 2008, the American Public Health Association dismissed arguments typically made for removing wisdom teeth: that adjacent teeth might be damaged, or that the teeth may harbor bacteria that cause periodontal disease. The association approved a policy saying these concerns do not justify the risks of surgery, which include possible nerve damage, complications from anesthesia. loss of the sense of taste and, very rarely, death.
“The few studies of long-term retention of impacted teeth have shown little risk of harm,” the association concluded.
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I've since brought this up with a few other friends who are dentists as well. They always start off by haranguing me for doing my own research, instead of following my dentist's recommendation. Then once I show them all the above evidence, which they have never seen before, they change their minds and accept that I'm probably right.
With a track record like that, I wouldn't be surprised at all if flossing turns out to be yet another sacred cow that's virtually pointless in reality.
I do have to say kudos to the dental field though. At least they are making efforts to validate their recommendations, using empirical studies. I wonder how many of the recommendations given by programmers/teachers/fitness-trainers etc are similarly flawed.
Honestly, I only need myself as evidence to the personal benefit; I have nothing to say about the generalizability of my results.
I've always had bad, painful dentist visits until my mid-20s. They were quite bloody. Since I started flossing, my dental visits are not painful, and my gums never bleed. When they do the gum measurements, I now get 2s and 3s instead of 4s and 5s.
The only change I made was flossing. I don't argue that it reduces plaque or has all of these life-changing benefits, but it stops my gums from bleeding and makes dentist trips a breeze. That's enough for me. Maybe others won't get the same benefit.
I've had a somewhat similar experience, but with a slight tweak. I now actually carry around a container of floss with me in my standard pocket loadout. But I don't floss everyday. I floss when I eat something that tends to get stuck in my teeth, beef jerkey being the worst offender, or when I notice I've got a bit of local inflammation in my gums, which has always turned out to be some piece of food stuck in there.
Given how bad inflammation has proved to be lately (be it because the inflammation itself is bad or because what is causing it is bad doesn't matter much to me if it's bad either way), it's at least plausible that flossing may have an effect on gum disease, but also plausible that it's an entirely situational thing. A habit may be better than never doing it, but you may just need to do it when the situation calls for it.
Ultimately I carry the floss around because regardless of whether it has long term benefits provable by science, it definitely can have short-term benefits of having less inflamed and at times slightly-painful gums because it's trying to use the immune system to remove a chunk of food better physically removed.
My teeth are tight and food tends to get stuck between them. If left attended the effect is festering, pain and infection. A quick floss, some mouthwash as a few days and the healing is complete. I will continue to floss. For me, the study size of one, flossing is a benefit. YMMV
I wondered that too. But I also worry whether the immediate-term indices of dental health that hygienists are taught to look for correspond to long-term dental health endpoints.
Personal antecedent is that I never flossed for 18 years, and would always walk out of the dentist with a bleeding gum somewhere in my mouth, and my teeth would hurt drinking cold water, etc, but when I finally started flossing all those problems evaporated.
Some mouths probably need it more than others, and it appears that mine is one of them. Is flossing the best option for inter-teeth cleaning? Maybe not. However, even after a good brush I can pull bits of food out by flossing, and I don't think anyone will disagree that it's a good thing to leave it in there.
I spent years between dental visits when I was between my parents health insurance and getting a job that actually covered dental. By that time, it was almost too late.
I had severe Periodontitis and was told that if I didn't do something within a few years, my teeth would start falling out. I had a root planing surgery and some other procedures done to save my teeth. My dentist said I was given another chance, but in order to save my teeth, it was paramount to floss every day.
I started flossing and at first my gums bled like crazy, but over time, the bleeding lessened and after 6 months of flossing and several more visits to the dentist, my gums were almost fully recovered and my teeth were effectively saved.
Since then I still floss daily and see my dentist every 6 months like clockwork. Since I started flossing my teeth, my teeth cleaning appointments are literally 30-40 minutes. I can get in and out and its completely painless.
You floss after brushing? I always thought the reverse was the best practice. Of course... there has been zero science, so maybe the best is brush -> floss -> brush -> Listerine -> floss.
I am not a dentist, but based on my understanding (derived from reading commentaries by dentists) the "best" would be floss -> brush. Never mouth wash (except when recommended by your dentist for specific conditions).
That's derived from the idea that brushing is not about cleaning the teeth. It's about disrupting bio-films and depositing fluoride on the teeth. That's the reason why dentists recommend not rinsing your mouth after brushing. If brushing were about cleaning then clearly you would want to rinse to remove everything from your mouth. But since brushing is more about applying fluoride to your teeth, it makes more sense not to rinse as that would remove all the fluoride that you just worked to apply. (The recommendation is to brush, then take a teaspoon or two of water into your mouth to form a toothpaste slurry, swish around, then spit.)
I thus argue that flossing should come before brushing because flossing would remove the food from between your teeth, allowing fluoride to penetrate those areas.
And with regards to Listerine/mouth wash, the alcohol based stuff causes mouth cancer and hasn't shown any benefit to the reduction of cavities (I don't recall its effectiveness with respect to bad breath or gum disease). There is fluoride based mouthwash, which dentists do recommend to certain patients, but for most people there's no point since they're getting all the fluoride they need from the toothpaste. And of course there are mouth washes medicated for specific conditions, which again will be recommended by your dentist when needed.
My understanding is that, although possible, if the cancer risk does exist, it's very small; here's an article placing it at 3-4 cases per 1,000,000:
http://aaem.pl/fulltxt.php?ICID=1011054
(They cite a 2012 meta-analysis which showed no statistically significant effect of mouthwash)
Here's a recent large-sample statistical study:
https://healthcare.utah.edu/huntsmancancerinstitute/research...
They find an 1.15 odds ratio of cancer for mouthwash users, but in the non-smoking non-alcohol-drinking cohort this effect goes the opposite direction (OR 0.83); statistics is hard and there isn't high-quality data to give a real conclusion. But since the overall incidence of oral cancer is roughly 1 in 10000 (http://www.nidcr.nih.gov/DataStatistics/FindDataByTopic/Oral...) I wouldn't be too worried; all these show is that the effect is tiny. (Of course, if you only remember the big headline from ten years ago with a tiny sample size...)
There's a clear line of research showing benefits in mouthwash:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4948552/
It's true that the fluoride in mouthwash does little, and there are some stupid mouthwashes that don't have any real ingredients, but essential oil mouthwashes (like Listerine) and several others (as mentioned in the review) have been shown to have significant gum benefits.
There's also some interesting research with tetrapotassium pyrophosphate and tartar buildup: http://periogen.com/periogen-studies.html Although I expect these studies are manufacturer-funded and thus overstate the effect, it seems pretty hard to deny that it helps.
Note: I'm not a dentist either, but I read this book my dentist recommended: https://amzn.com/B009LPLMRU. It's well-referenced for everything except water fluoridation and her conflict of interest (xylitol products).
I don't really think there's a difference. My thoughts is that brushing pushes most of it off, but pushes some stuff into small holes and stuff, which is then removed by flossing.
From my own experience, I would have to agree. I've never had braces so the gaps between my teeth vary between wide enough to fit the tip of my tongue to so tight that floss has a hard time getting in. Brushing can't handle those very tight spaces.
I think the issue here is not if it is actually helpful or not, but that it was claimed (and advertised) to be without the necessary research.
The AP article explains that flossing had to be dropped from the federal guidelines as those are required to be backed by research.
The groups that claim it is good for you all have a financial reason to claim it. Not alone wrong, but wrong in the absence of quality research backing the claims.
Isn't it about time we got rid of the ridiculous "if we haven't researched it, we know nothing about it" fallacy?
Research is strong evidence that points towards something. Lack of research doesn't mean complete lack of a-priori knowledge. If something is obviously good for you, then that's probably a good start for recommending it.
Your argument is a slippery slope for the acceptance of every kind of pseudoscience.
How do we know something is 'obviously' good for you without research? NOTHING Is so cut and dry that you can make that statement. For example: organic food. Obviously, must be amazing for you. Got two great buzzwords in it: organic and food. Therefore, amazing for you. Does the research bear this out?
Vaccines: foreign substance entering our body. Therefore, terrible for you. Stands to reason right?
How could you make such a sweeping statement claiming the higher ground that we must exist in such an enlightened age that we don't have to continually fight the battle for evidence based activities in all activities?
Has anyone done the research on the health benefits of rubbing broken glass in your eyes twice a day? Somehow I doubt it. Would you say that we know nothing about it? Personally, I am quite happy to accept based purely on common sense and intuition that this is unlikely to be healthy.
Research is just another tool. It happens to be a really good one, and when research contradicts common sense and intuition, research usually wins. ("Usually" because it can be flawed, just like anything else.)
But in the absence of research, we can still do better than just saying "uh, I dunno" in many cases.
The alternative isn't reasoning based on buzzwords, it's based on thought and available evidence. No, that's far from perfect, but it's also not going to lead you into homeopathy, reiki, psychic surgery, or acupuncture. Flossing has a plausible mechanism of action, unlike any of your examples. If it turns out that this plausible mechanism of action doesn't actually have any long-term benefits, then that sucks, but it doesn't mean we should give up on thinking about anything that hasn't been researched.
Broken glass isn't abrasive so much as pointy and sharp.
Also, I doubt any of those documented effects are from properly designed studies, nor do they examine a long-term daily treatment regimen. Are you just assuming that daily treatment would be bad based on what happens after one instance, plus common sense and intuition?
I don't think it's much of a slippery slope. I think most of us would (or at least should) agree, up front, that intuition isn't worth much. Even when investigating topics that are considered obvious.
Devil's advocate: slippery slopes are only slippery if they slip both ways.
So I could argue that even research results aren't sufficient proof for efficacy. For example, why should a "significant result" be a better argument than personal experience?
I think that's missing the point. And, as an aside, so are all the comments in this thread that are essentially "flossing works for me, so I'm going to keep doing it." The point of this article is not that people should stop flossing, or that it's bad for some reason. The point is that an entire industry of medical professionals were saying "floss because it reduces you risk of tooth decay and gum disease," when in fact there is little evidence that it does either. It is a huge detriment to the credibility of dentists in my opinion.
Not everything needs research. Flossing removes decompsosing food from between your teeth. Dentists understand that tooth decay and gum disease result from prolonged exposure to decomposing food. If doctors told me that putting out shirt fires reduces the risk of burning to death, I would trust them without verified research.
Flossing can drive bacteria deeper into your gums, even causing them to be enter the bloodstream, which then (there's been some evidence) can have an influence on heart disease.
Public policy needs research. Human history is absolutely stacked with "obvious" truths turning out to be harmful falsehoods.
I just looked that up, and I did find some advice that flossing addresses the food issue but not the issue of a bacterial infection not attached to pieces of food, which is probably also obvious. There are suggestions to use a water pick instead of flossing, which dentists have also recommended for a long time, but it's just not as available as string or toothpicks. It's not productive to tell everyone only to use the best possible solution if only 1% will actually do it.
So you have a good point, there are always new things to discover, but this is obvious in a way that's understood and doesn't in any way call into question the legitimacy of dentistry.
My point isn't that there's always new things to discover, it's that nature has so routinely made fools of us that the argument of "it's obvious" should carry little weight.
"Dentists understand that tooth decay and gum disease result from prolonged exposure to decomposing food." Does the type of food matter, carbs, protein, sugar? How soon should one floss after eating to avoid damage? Does flossing just before bed help? By how much? Should you floss after every meal? How much does it help?
For all we know, sugary carbs that tend to get stuck between teeth do their damage in minutes or a few hours and flossing at night won't help. Or flossing too soon removes enzymes in your saliva that protect teeth from buildup or disease.
Those are some good points. Maybe there's an argument for using a water pick instead of flossing. But not everyone has access to one of those, and I wouldn't mistrust the entire dental profession because they tell people to clean their teeth without research.
Dental caries result from certain species (S. mutans et al) of bacteria digesting sugars into acids that chemically erode bioapatite. If you destroy the bacteria, such as by using mouthwash, or prevent them from adhering to the teeth, such as by using xylitol, or deprive them of sustenance, such as by not eating sugars or simple carbohydrates, you won't get cavities, and you won't need to worry about flossing--to prevent cavities.
But cavities are not the only problem you can have in your mouth.
Food particles left in the mouth for long periods can cause an inflammatory response in the gums. This can lead to bone loss in the jaw. And that can cause your cavity-free teeth to fall out.
Flossing through the space between tooth and gum can potentially remove such particles, which would help prevent gum disease. But it might not be necessary to do it every day. Once a week, maybe? After eating jerky or popcorn?
I have no idea how often it is necessary to floss to achieve a statistically significant reduction in any of the oral diseases, or how much of a difference there may be between flossing twice a day and flossing once a month.
My dentist recommends flossing whenever I brush. While the recommendation to floss is probably well supported, I suspect that the frequency may be more based on psychology than anything else. They just attach it to the brushing habit. Perhaps it would be better to attach it to "whenever you trim your fingernails", or "whenever you shave your legs", even though those are not related to oral hygiene.
Completely anecdotal, my brother totally neglected his teeth when he was young. He just didn't bother brushing. His teeth were fine. I on the other hand have been a stickler for cleaning them, and they are totally knackered.
Perhaps you can get a layer of magic plaque that protects the teeth. Who knows. Mine just get worse. They used to feel dirty without a brush. Now they feel horrible without a brush and floss. Sometimes I just wish for all my teeth to be ripped out.
The entire medical profession exists in a slipper slope due to the incredible volume of information a medical education requires. There is no way to validate, or even consider the validity of much of what is taught. Friends in med school went through personal crisis as they came to terms with their complete inability to verify the volume of all the information they were being taught. Trying to track down original resources and derive to current thinking proved too much for one friend, and she quit med school saying the layers of assumptions on tangential research then used a foundation for further research was way too thin, and she is now afraid of medical doctors, calling the profession dangerous blind parrots.
Dentists and dental hygienists look into tens of thousands of mouths over the courses of their careers. It's not difficult for them to see that patients who floss have far healthier smiles, in general.
That said, they should get more studies done.
You could also be a bad flosser, so even the study could be flawed.
Again, there's the comparison of people who sell ice cream and see that when they sell more, there will be more drownings. Correlation does not imply causation.
I think it is quite obvious that people who floss also brush their teeth more regularly, and that is enough to give them healthier smiles.
(Regarding the benefits of flossing, I'm agnostic.)
It's true that correlation does not imply causation, but you're still wrong from my experience with hygienists and dentists.
They definitely and easily see a difference seen between those who floss and brush and those who just brush.
Also, those who use Sonicare, especially when used properly around the gumlines, also tend to have healthier mouths than those who brush with an old brush.
The one thing that can throw a wrench in this whole thing is smoking. Smokers' mouths are disgusting basically no matter what.
Point being, I love research, but I trust those who put their hands in tens of thousands of mouths more than skeptics on ArsTechnica article comments.
They look in your mouth and make assumptions that fit their preconceived notions. ie: "These teeth are in good shape, this person must've followed my advice on brushing and flossing!"
You can brush your teeth like a moron 24/7, but you still won't reach between them and remove the long-term unhealthy plaque with it - it doesn't have to do anything with a profession, but it's a physical fact. Not to mention that brushing teeth ain't proper brushing as itself, since you can easily irreversibly damage and remove the gum if using wrong technique, pressure and hard brush.
A => B does not mean !B => !A.
In US (culturally): "Good dental hygiene" => "You floss".
So dentists looking in your mouth can guess if you floss. However in Europe flossing is not as common and the link breaks. All dentists can say is if you take good care of your mouth, not if you floss or not.
Many chiropractors will also claim that they can directly observe the much lower incidence of cancer and heart disease in their patients, but that doesn't make it true.
Not relevant given that chiropractors are making money off said claims, and dentists are not. Dentists stand to make less money when their patients take care of their oral health with something that costs literally a penny per day.
People aren't automatically wrong just because they state something in their interest, nor are they right just because it's not. To me, the important difference between the two is that dentists can explain the basis of their recommendations in terms that make some sort of sense, whereas the mechanisms proposed by chiropractors are clearly nonsense.
No. Gums (and possibly even tongue) are also part of your "smile". Could have said "mouth" but smile sounds better.
On the note of tongues, using a tongue scraper is a great way to get rid of nasty bacteria that causes bad breath and spreads to the rest of the teeth/gums. Cheap and effective.
Gist is that tongue cleaning yields less bacteria (that's one major cause of bad breath), but they still recommend both brushing and tongue cleaning since the reduction of tongue bacteria didn't reduce plaque. I never claimed that it did though.
Tongue scrapers are cheap and awesome. It's amazing what kind of disgusting stuff you'll scrape off that thing. I'll nearly guarantee you better breath unless you have some serious other problems, like periodontitis.
Except even when we have researched something, it turns out we were wrong half of the time. We've only had a couple centuries since the Age of Enlightenment - we know practically nothing for sure (ie: well enough to take for granted). Unfortunately human nature seems to be vastly overconfident, so that's not a popular opinion.
For me the water flossers (oral jet irrigators) are the best solution yet. I was never able to floss correctly with a wire, especially between the teeth in the back row but then my dentist told me about "the jet thing from amazon" and I wish I had it a lot earlier because it's so easy to use and quite efficient. (Just don't jet your gums with the highest power; it can hurt and make your gums bleed)
In the shower? Why didn't I think of that? I've used a Waterpik before and ended up throwing it away because I invariably made a big mess with it (especially my mirror).
I have one of those and it made big difference with my gums. It washes away pieces of food that often don't get removed by brushing. My dentist noticed a difference after a year even though I didn't tell him that I use an irrigator.
I don't know what model you use but mine is quite powerful (it's not a "portable/battery" model and it has 10 steps of jet intensity) and obviously it's best used in combination with the brush. If this does not work, I don't know what else could work.
Most patients, even if they bother to get the minty-waxed out the box, are exceptionally heavy-handed and macerate their gums like they’ve been chewing on bare vacuum cleaner flex. Even in controlled studies, after instruction, the patients taking part couldn’t floss properly. I know of no dentist who flosses. Not one.
This is an interesting thread to read and think about rationalisations, habits and culture. You have a good control group too: Floss usage is about 60%+ in the USA, and 20% or less in Europe.
My mother-in-law is a dentist. When she heard I always brush my teeth but rarely floss, she told me flossing is more important than brushing your teeth. For once I didn't get into the science of things, but still I accept that getting old bits of food and other junk away from between my teeth can only be a positive thing.
It runs counter to my sceptic nature, I like to question everything, but I'm slowly starting to learn that sometimes you just have to take an expert's advice.
I'm sure any half-way decent dentist can see pretty quickly how well you take care of your teeth, in the same way a seasoned programmer can often point out a beginner's bad code or a civil engineer warn about the wrong way to build a bridge or a house on a swamp.
My father in law is a dentist in Germany and he never recommended flossing. In fact flossing is not common in Germany and we don't hear that Germans have very bad teeth compared to Americans.
So although dentists could notice if you have good dental hygiene I'm not sure they can spot easily if you floss or not. It might just mean that in US good dental hygiene means that you floss, but converse might not be true.
> My father in law is a dentist in Germany and he never recommended flossing. In fact flossing is not common in Germany and we don't hear that Germans have very bad teeth compared to Americans.
It's all the sauerkraut. It acts as a natural floss.
All the dentists I've tried so far in Germany have recommended flossing. The last one actually showed me how to do it properly and gave me a free sample to use until I bought my own. Perhaps things are changing here too?
Flossing can have benefits. That still doesn't mean that we should be ok with medical professionals making specific claims like, "flossing reduces the risk of tooth decay," that have no good science behind them.
When I feel food stuck in the teeth I'll floss. Rarely have I flossed out anything that I didnt feel - usually the tiny bits are taken out by a strong rinsing. I just dont see the point of taking more minutes out of my day for little reason. (I have never had issues with plaque so ymmv).
From what I read and from personal experience it is a diet that has strongest effects on tooth health, not the the way to toothbrush or floss. For example, in Europe tooth health became much bigger problem after crusades when knights brought various dessert recipes from Lebanon and Syria.
This would be my guess too. I've never had a cavity in my life, which I'm sure is partially genetic, but I don't floss and brush only once a day in the morning. I haven't been to a dentist in ~6 years. My diet is very clean though -- no soda, candy, or really anything else high in sugar other than fruit. I eat a lot of raw vegetables too, which I think clean my teeth as I chew.
The few cavities that I have had were all extremely tiny and hardly visible to the eye. You won't really know on your own that you have a cavity until it's much more fully developed. At that point, getting it repaired is much more aggravating and a pain. I'd highly recommend getting to the dentist more than once every 6 years.
Don't you need to avoid unrefined sugar and starch too? Which is not impossibly difficult (lots of folks do keto), but is more difficult than just avoiding refined sugar.
It is not necessary sugar that causes the damage, but combinations. My personal experience is that a combination of meat or cheese and sweet desserts/drinks after that was the real problem.
There are also no studies on whether parachutes prevent death when falling from the sky[1], but I'm sure as shit still wearing one when I jump out of a plane!
If you had as many people jumping out of planes as those that have teeth, you assuredly would have studies about parachute design, packing methods, survivability in the face of failure. You absolutely would have research that shows that parachutes prevent death.
This is the same bullshit around how fat and salt was really bad and no one could be bother changing that rule, because it might/is technically correct.
Except everyone just ate sugar in mass quantities and we never moved forward (and probably moved backwards)
We not only need to know if it works, we need studies to know how well so we can compare it to other methods people actually will implement.
I agree that most animal fats are healthy (ex. saturates) but I believe excess salt is still considered unhealthy even by current studies? Or am I mistaken on that?
No disagreement on sugar either, definitely unhealthy in excess (in particularly when artificially added disproportionately to the other nutrition within the food).
Generally, unless you have a specific medical condition that warrants restricting salt (kidney disease, high blood pressure), there's no need to worry about normal doses of salt in the diet. In fact, too little salt can actually be very harmful.
This study [1] and the response from the CDC is very similar to the OP's article: despite research showing the recommendation is wrong, $BIG_AGENCY refuses to change its recommendation over fears of looking like boneheads.
Clickbait based on a 5-year old source which actually says, "Twelve trials were included in this review which reported data on two outcomes (dental plaque and gum disease). Trials were of poor quality and conclusions must be viewed as unreliable. The review showed that people who brush and floss regularly have less gum bleeding compared to toothbrushing alone. There was weak, very unreliable evidence of a possible small reduction in plaque. There was no information on other measurements such as tooth decay because the trials were not long enough and detecting early stage decay between teeth is difficult."
So studies showed flossing helps prevent gum bleeding. This is not what the article reports.
Are there studies of effectiveness of tooth brushing? Imagine the control group - people who don't brush their teeth at all!
The recommendation to floss was not justified by reduced gum bleeding, it was justifies by reduces tooth decay. Indees, its now been removes from official FDA recommendations. Likewise, flossing might very reliably make the backs of your teeth whiter, but this is a negligible benefit and is not curing a disease. The headline is a fair summary, even if it could have been more informative by not trying to be funny.
I used to floss more or less regularly and had constant gum problems. I then switched to interdental brushes, same frequency of use, and my gum problems have since disappeared.
So in my case _something_ was needed for the gum's health, but flossing itself proved to be useless.
I use both depending on inter-teeth space. There are different techniques of flossing and different floss types. So, trying different may solve the problem with flossing itself.
For those who cannot use interdental brushes. Some doctors suggest moving the floss up and down along the teeth. Others to put it inside teeth and the pull to the side. I found the second more convenient and less traumatic at the same time. But you need a wider floss to make it work. Try different. Me and my wife use different: one brand works better for her, but is too narrow for me. Experiment.
I had chronic inflammation since school. Flossing completely solved the problem in a month or two.
I read the conclusion so that flossing is useless, because it isn't done correctly or it is just a wrong way to clean teeth.
I've had a similar personal experience. My dentist asked me to floss because my gums were bleeding. I flossed for few years, but it didn't cure my bleeding gums. Then my dentist suggested using interdental brushes. I did it for a while and it helped. My gums are no more bleeding.
So, I say no to flossing, yes to cleaning teeth with better means.
For most of my life I brushed but never flossed. I had no cavities but I was at risk of losing my teeth due to plaque below the gum line. My teeth were loose and gums would bleed when I brushed. I've had all that fixed and now floss regularly. In retrospect flossing seems more important than brushing.
Hooks right up to your faucet or shower head, has multiple tips, and is effectively an endless and super-quiet WaterPik.
I do own a WaterPik-like device, but I use saline water and a special adapter for sinus irrigation (making it a post-modern Neti Pot I guess). OralBreeze, brushing and sinus irrigation every day. Helps fight bad breath — post-nasal drip contributes a lot to bad breath, as does rotting food stuck between your teeth. For me, it's helped reduce the incidence sinus infections, too. Plus the more advanced "Neti" usage involves allowing the saline solution to flow out of your mouth, so if you're prone to tonsil stones, it can help reduce those.
I read this about 15 years ago in a book published a decade or two before that, IIRC. Unfortunately the book did not really make a case, just claimed there was no evidence. It was a book about evidence-based medicine before that was a popular term (unfortunately I've also lost the name the book).
My dental hygienist recently told me that I have to shove bits of wood between all my teeth twice a day. I asked why I hadn't heard this before and for how long, and she said "for the rest of your life because it's good for you". Hmm.
> Still, many dentists will continue to recommend flossing for removing debris between your chompers. "It's low risk, low cost," National Institutes of Health dentist Tim Iafolla told CNBC. "We know there's a possibility that it works, so we feel comfortable telling people to go ahead and do it."
Instead of talking about flossing you could talk about keeping a pet rock in your pocket and it'd also be "low risk, low cost ... we know there's a possibility that it works".
On a side note, most cavities/caries which get filled can be remineralized. That's particularly unfortunate because fillings need to be redone after two years on average, destroying even more of the natural tooth: http://www.wsj.com/articles/simple-dental-treatments-may-rev...
In 2011 I became aware of pain in my lower left chewing teeth. I had no health insurance, and no money to see a dentist. Over the course of two months, the pain got worse and worse. Finally, I decided I would rinse with Listerine, for long periods of time. I would take a swig of Listerine and hold it in my mouth for 30 minutes, spit it out and take another swig, and hold that in my mouth for another 30 minutes. I would do that all day, while I worked at my computer. My thought was that the bacteria could only do limited damage if my mouth was full of Listerine, so I kept Listerine in my mouth for several hours a day. Maybe I was right, or maybe the effect was psychosomatic, but after ten days of such treatment, the pain faded away.
Either that or the nerve died, so you stopped feeling pain. I went through that with a tooth (was also unemployed at the time and couldn't afford proper dental treatment for it), and eventually it had to get removed because it decayed so much. It used to hurt a lot but eventually it stopped hurting entirely, even as it cracked and chipped away slowly.
Lack of studies doesn't mean it's not true. Anecdotally, whenever I see a new dentist, the first thing they say (usually the assistant) is "I see you're a flosser!". Then they comment about how healthy are my gums. I'd guess every dental employee on the planet thinks flossing helps prevent gum disease at the very least.
I'm sure a lot of individual observations come down to genetics. In my own case, I challenged myself to go from flossing once a week to every day over the past six months. Just recently went to the dentist and my gum pocket depths all decreased (signaling healthier gums apparently). Diet remained exactly the same.
I never learned flossing, and then in my early twenties I kind of ignored the dentist for around 7-8 years. I still brushed my teeth throughly two times a day, every day.
Got me paradentosis and almost lost me my teeth.
It's completely anecdotal, but I recomend flossing.
This doesn't surprise me. If I had $10 for every experienced, certified specialist I saw until the age of 13 that said "The best thing for your condition is little-to-no activity, certainly not weight lifting!" I'd be able to pay for my legal steroid cycles for a good 10 years. The only thing that improved my quality of life was getting bigger, stronger, and tougher. That's why I don't look like one of their normal patients - because I refused to believe the counter-intuitive notion that weakness is a good thing biologically. FTR I don't disclose my condition but it's a physical one.
Basically, yes, flossing helps, but self-flossing really doesn't do anything more than just brushing daily.
I'm a little disappointed at the number of comments here along the lines of, "Well, it's obvious! Why do we need to study it?" That's a very unscientific attitude.