After the recent claims in the press about flossing, I would guess that everyone who is reading this has been busy answering questions on the subject! For those of you who have somehow managed to avoid the news, I will provide a brief recap.
On Wednesday 3rd August, several national newspapers printed articles relating to an assertion that flossing is pointless. Some of these newspapers (including the one we have in the waiting room at the practice where I work) even had the headlines for these articles on their front pages. The first I knew of the claims was when a patient began asking questions – and once we had heard the first one, more quickly followed!
What Happened During My Day
I was working with a hygienist on the day the articles were published, so I am sure you can imagine how many patients wanted to discuss the issue! One patient simply told us: ‘Using floss or those little brush things is useless. It even says so in your newspaper’. She then proceeded to complain about the fact that we were making her gums bleed during scaling, stating that this was also ‘doing them no good’. The latter is a complaint that I know you are all faced with, particularly when treating patients with poor oral hygiene who do not attend regular appointments with the hygienist. This meant that the hygienist was well-prepared with an explanation of why the patient's gums can sometimes bleed at her hygiene maintenance appointments. But of course, at this point, we had no idea what was written in the newspaper.
The second patient who mentioned the news was more open-minded about our response – but again, we did not know exactly what was being reported in the news. Shortly after this patient left the surgery, I had time to read the article for myself. The headline was on the front page of the newspaper on our coffee table, and clearly declared that flossing teeth was useless and a waste of time. It was clearly designed to shock people and grab their attention, and I felt quite annoyed that such a statement could be published. However, when I read the actual article (which I summarised for the hygienist), I realised that the headline was actually very misleading. We realised that the first patient had not read the article thoroughly. The article’s actual claims were that using floss was of little value and that interdental brushes are superior and should be used instead. This was a point that our first patient had clearly missed, as she thought that all forms of interdental cleaning were being criticised. The article went on to say that floss should only be used in areas that are too small for interdental brushes. This is the advice that, at my practice, we always pass on to our patients. We always advise use of interdental brushes over floss where possible, as our specialist periodontist and our hygiene team feel that they are more effective at cleaning interdental spaces. Unfortunately, because of the headline, I am sure a lot of people will take away the same message that our first patient did and will not read the article fully.
The Articles – and the Damage?
Since reading the first article, I have read a number of other articles from different newspapers and their websites. The articles are all very similar and all state that there is little to no evidence to support flossing. They also state that if it is not carried out correctly, flossing can cause more harm than good.
The investigation leading to the news reports was conducted by the Associated Press. The Associated Press (AP) describe themselves on their website as:
… one of the largest and most trusted sources of independent newsgathering, supplying a steady stream of news to its members, international subscribers and commercial customers. AP is neither privately owned nor government-funded; instead, as a not-for-profit news cooperative owned by its American newspaper and broadcast members, it can maintain its single-minded focus on newsgathering and its commitment to the highest standards of objective, accurate journalism.
(Associated Press, 2016)
The Associated Press reviewed previous studies comparing brushing and flossing to just brushing alone. They concluded that the studies were of little value for reasons including that they were carried out on only a small number of participants or for only a short amount of time. They also argued that some studies were biased because they were conducted by companies who manufacture or sell dental floss.
The resulting newspaper articles do state that interdental brushes should be used and that floss should only be used where interdental brushes do not fit. But although the information contained in the article is accurate, many people will not read the article fully or will only read the headline, as the patient who initially told us about the article in our waiting room newspaper demonstrated. She had not read the article fully and had taken the headline to mean that all forms of interdental cleaning were of little value. If this was the message that she took away, then surely there are many more members of the public who will think the same. Furthermore, even if patients do go on to read the article, they may have already formed their opinions of the content of the article based on the headline, and this may lead them to read the article in a biased way.
This could have a major impact on the oral health of our patients. Patients who are regularly cleaning interdentally may decide, after reading these articles, that they are wasting their time. This may cause them to stop. Patients who regularly attend the practice can have their questions answered, and we can reassure them that we do advise daily interdental cleaning and hopefully get them back into their daily regime. However, there are many people who do not attend a dentist regularly and will not seek advice.
In my opinion, the press should not be able to use headlines that are as misleading as this. The same story could have been reported with a headline advising interdental brushes rather than floss, and this would have been far less confusing for patients.
What Should We Tell Patients?
As a profession, we cannot deny that the conclusions of the Associated Press are accurate and that more research should be done to explore the benefits of daily flossing. However, I think there are a great number of barriers to this research being carried out – two such barriers being the amount of time that patients would need to be monitored for, and variations in the mouths of individuals. It would not be accurate to compare the oral hygiene of a patient who has no restorations with that of a patient who has a large number of restorations. We would also not obtain an accurate result if we were to compare a patient who has excellent manual dexterity with a patient who has a disability which affects this. My mother has arthritis, and I know how difficult she finds keeping up with her oral hygiene regime. It will be the same for other patients with similar conditions. I work with a specialist periodontist, and although interdental brushes are our favoured option for interdental cleaning, we do recommend floss for tighter spaces. There are a lot of patients who simply could not use interdental brushes, as their teeth are too close together for cleaning with these – but I find quite clearly that some form of interdental cleaning is better than none. When working with the specialist periodontist, I see patients from their initial assessment appointment, through their treatment, and then at a review appointment two months after their treatment is finished. At initial and review appointments, a full periodontal pocket chart is carried out, recording six points around each tooth. Although the majority of interdental cleaning is performed by patients using interdental brushes, we still get reduction in pocket depths with those patients using floss. Because of what I see on a day-to-day basis, I have absolutely no problem promoting daily flossing to my patients because I really do believe it is effective – although we instruct patients to use interdental brushes where possible, as this is clearly preferable for removal of plaque.
I am sure that some patients will be concerned about the statements that flossing is harmful, but they can be reassured that it is only harmful when performed incorrectly. The simplest solution here is to demonstrate the correct flossing technique to patients so that we can encourage them to continue with their routine. There are such a lot of people who floss but have never been shown the correct technique; a simple demonstration could be worth a great deal to these patients and takes only a small amount of time in the surgery. Oral health educators are the ideal people to carry out these demonstrations, and they can use this time to educate patients about other ways to improve their oral health as well as promoting regular appointments with the hygienist. If your practice does not have an oral health educator, then the hygienist can offer help and advice at routine appointments. In my experience, the best way of teaching flossing technique is for me to demonstrate it in the patient’s mouth and then for them to repeat the demonstration. Being actively involved in learning has been proven to aid recall, so this method should help the patient to remember the technique. It also allows me to assess whether they can repeat my demonstration. It is using the 'sawing action' with floss that we often see on the television that is damaging to the gums. Some patients find that floss separates easily, so I tend to recommend dental tape over floss as it is flatter and does not seem to catch as easily.
Patients will no doubt be confused and possibly even worried about these new claims, so it is vital to keep things simple for them. We are faced with so many conflicting health messages these days that it is difficult to identify what is right for you. The key message I feel we should be passing on to our patients is this:
Speak to your dental professional.
Patients need to be aware that they are individual and that their mouths are too. There is no 'one-size-fits-all' oral hygiene regime. This means that they should be provided with advice that is bespoke to them. Not only do recommendations of oral hygiene aids vary depending on the size of their interdental spaces, but there are many other factors to consider. For example, good oral hygiene is much more difficult when a patient is wearing a fixed orthodontic appliance, so patients should always be instructed to clean around their appliances. At my practice, we ensure we promote cleaning underneath bridges with products such as Superfloss and X-Floss, and it is vital that these are demonstrated to patients to ensure they are being used correctly. As a specialist practice, we do a lot of implant work, and this can vary from a single implant restored with a crown to full-mouth implants restored with removable dentures or fixed bridges. There are many products on the market now that are designed specifically for these patients, but the patients themselves cannot be aware of everything that is available, so they should be offered appointments with the aim of introducing them to the variety of oral hygiene aids on offer. Patients may know of these items, but it is essential to provide a demonstration of their use so that patients can see their benefits.
Hopefully, the press coverage has started a debate which will encourage our patients to ask us questions in order to select the best methods for them – rather than simply giving up altogether. It is our job to turn the situation into a positive one and use it to promote oral health education appointments. If your practice does not have an oral health educator, patients should be directed to the hygienist. However, if you have a nurse who is keen to study the oral health education course, this could be an ideal time to raise the idea with your boss!
Katie Booth RDN
Associated Press (2016). About Us. Available at http://www.ap.org/company/about-us (accessed on 12th August 2016)
Knapton, S. (2016). Don't stop flossing, say British dental experts despite lack of evidence. Available at http://www.telegraph.co.uk/science/2016/08/03/dont-stop-flossing-say-british-dental-experts-despite-lack-of-ev/ (accessed on 11th August 2016)
Nelson, K. (2016). Flossing your teeth does not work and could be a waste of time, new research suggests. Available at http://www.independent.co.uk/news/uk/home-news/flossing-teeth-no-evidence-waste-of-time-research-a7168116.html (accessed on 11th August 2016)
BBC (2016). Should you floss or not? Study says benefits unproven. Available at http://www.bbc.co.uk/news/health-36962667 (Accessed on 11th August 2016)