Flossing. Should I or shouldn't I?

LAS CRUCES - Joseph Lopez, 31, of Las Cruces, is an advocate of flossing as a key part of dental health.

“I floss because it keeps my breath pleasant and mouth healthy,” Lopez said. “I haven’t managed to be as regular with it as I’d like, but usually I try to floss almost as often as I brush.”

While recent news reports have sparked a debate over whether existing scientific research supports the benefits of flossing, cleaning in between the teeth is "an essential part of taking care of your teeth and gums," according to the American Dental Association.

The federal government has recommended flossing since 1979 and has continued to recommend the practice in the Dietary Guidelines for Americans issued every five years by the U.S. departments of Health and Human Services and Agriculture. However, when the latest dietary guidelines were issued this year, the flossing recommendation had quietly been removed, according to The Associated Press.

This was after AP had asked the departments of Health and Human Services and Agriculture for evidence that flossing helps keep teeth and gums healthy. In an investigation of the most rigorous research conducted over the past decade, focusing on 25 studies comparing the use of a toothbrush with the combination of toothbrushes and floss, the AP found the evidence for flossing to be “weak,” and “very unreliable,” of “very low” quality, and carries “a moderate to large potential for bias.”

But Dr. Mathew Peterson, doctor of dental surgery at Las Cruces Dental Solutions, said this hasn’t swayed his opinion about the importance of flossing.

“There’s certain things that just make sense that I don’t think people need to rely on a government agency to tell them,” Peterson said. “But if they are, there’s still other government agencies that back (flossing)…You can still turn to the CDC (Centers for Disease Control and Prevention), the Surgeon General — there’s several other government agencies that haven’t removed that from their guidelines.”

In an Aug. 4 statement to the ADA, the Department of Health and Human Services also reaffirmed flossing as "an important oral hygiene practice,” according to the ADA.

Dr. Michael Law, doctor of dental surgery at the David D. Warren and Michael D. Law dental office in Las Cruces and past president for the New Mexico Dental Association, said he will continue recommending flossing to his patients.

“Brushing just gets the stuff you can see on the teeth and gums, it doesn’t get anything in between the teeth or underneath the gums,” Law said. “…The use of an interdental type of cleaner (like floss) gets underneath the gums and in in between those teeth, and gets off the bacteria that brushing misses.”

Multifactorial disease

In response to previous research conducted on flossing, Peterson said performing a study that accurately shows the oral health benefits of cleaning between the teeth is very difficult since cavities are caused by so many different factors.

“Cavities are something that’s caused by 100 different things,” he said. “It’s a big multifactorial disease, where you have a bunch of things that are on the protective side, and things that are on the side of the bacteria that are going to eat a hole in your teeth.”

Along with inherited factors that can make teeth more vulnerable to cavities, a person’s chances of forming a cavity also depend on diet, how much saliva they have, the mineral content of their saliva, medications they are taking, brushing and flossing habits, hormones, immune system factors and the type of bacteria that live in their mouth, Peterson said.

“Some people are better hosts to bacteria that likes to cause cavities, and some people aren’t, and so the kind of bacteria that live in our mouths affect (how susceptible our teeth are to cavities),” he said.

Peterson said a study on flossing would have to track participants for at least five years and take all of those factors into consideration.

"Chances are we’ll probably never get good data on flossing," he said. But there are a few things we do know for sure about oral health.

“We know for sure that bacteria in our mouths is the cause of cavities,” Peterson said. “We know for sure that there are certain things that can break them up and make it where it’s difficult for them to colonize on our teeth —  flossing, brushing, possibly some rinses that kill and lower the bacteria count.”

Peterson said it’s also known that bacteria present around the gums can lead to inflammation, or gingivitis, which can then lead to gum disease — an infection that can cause major damage to the soft tissue and bone that support the teeth, according to the National Institute of Dental and Craniofacial Research.

"There are over 500 different types of bacteria in the mouth, but we generalize it and call it plaque," Law said. "When that plaque gets under the gums or in between the teeth, it can cause either tooth decay or what we call periodontal (gum) disease."

According to the ADA, cleaning between the teeth with an interdental cleaner helps remove plaque that can lead to cavities or gum disease.

Make it a habit

While dentists may repeatedly tell patients to floss, many people struggle to make it a daily habit.

“The majority of people tend not to floss until they’re ready to come to the dentist and then they floss like crazy the week before, and we can tell when they haven’t,” Law said.

Peterson said he thinks many people may use the recent news reports about flossing to justify a habit that that they already don't engage in.

"Flossing is just like any other habit," he said. "I’ll hop on my soap box and try to inspire them to be 'born-again' flossers the best I can."

Law and Peterson said they recommend patients brush at least twice a day with a fluoride toothpaste and clean between the teeth at least once a day (the same recommendation as the ADA). Options for cleaning between the teeth include using dental floss, tiny brushes that reach between the teeth, a water flosser, air flosser or a wooden plaque remover, according to Law and the ADA.

“Patients should talk to a dentist to see which is best for them because what works for some people doesn’t necessarily work for everyone,” Law said.

Law suggests kids begin flossing as soon as they have the dexterity to do it. Parents can also floss their child’s teeth for them to get them in the habit early on, he said.

Flossing should be done in a saw-like motion, rather than an up and down motion, which can cause damage to, and cut, the gums, he said.

However, if gums begin to bleed when flossing, it could be a sign that the gum tissue is inflamed and not necessarily that the person is doing something wrong, Law said.

According to the National Institutes of Health, bleeding gums can be a sign that you have or are at risk for gum disease. Other causes of bleeding gums include: brushing too hard, leukemia, use of blood thinners, infection to the tooth or gum or ill-fitting dentures or other dental appliances.

If bleeding is severe or long-term, NIH recommends consulting a health care provider.

Peterson said once people get to the point where they are able to floss well, it should only take 30 seconds to a minute to get the job done. But making it a permanent part of your routine is the difficult part.

“Until it’s a habit, you’re not going to like it and it’s going to be uncomfortable and it’s going to be something you have to force,” he said.

Peterson said he suggests writing a note to yourself or putting a reminder on your phone to floss until it becomes a natural part of your daily regimen.

Oral maintenance 

Flossing and brushing are just a couple of the protective factors that can help keep your oral health in balance, Peterson said. Those who are more susceptible to cavities may need to incorporate additional protective factors, such as using a prescription-strength fluoride toothpaste or rinses that kill and lower bacteria count in the mouth.

“For some people it’s really easy for them to stay in balance and then there’s other people that for them, it’s really hard to stay in balance — they just tend to get cavities,” he said. “So, if you’re one of these people, we just keep adding to the protective factors until you are in balance, because the recommendations that work for one person don’t always work for another person."

Because everyone is unique, it’s import to find a “dental home,” or a dentist that you see routinely who can talk with you about what’s best for your specific needs, Law said.

“Generally, we’re just trying to fight bacteria and keep them in check in your mouth," Peterson said. "You always have bacteria in your mouth, we just need to use different tools and methods to control it."

Alexia Severson may be reached at 575-541-5462, aseverson@lcsun-news.com or @AlexiaMSeverson on Twitter.