Dental Tribune Asia Pacific No. 9, 2016

06 Dental Tribune Asia Paciﬁc Edition | 9/2016 WORLD NEWS The ﬂossing debate and what to make of it By DTI LONDON, UK/LEIPZIG, Germany: Last month, a story by the Associated Press (AP) claiming that the beneﬁts of ﬂossing have never been properly researched went viral. The resulting extensive media reports have taken one message from this: ﬂossing is overrated. Is it really that simple though? This article attempts to summarise recent reporting on the topic and reactions by the dental community around the globe. “There’s no solid evidence that ﬂossing actually works”—this state- ment by his son’s orthodontist gave US reporter Jeff Donn the impetus thatstartedtheentiredebate.Inves- tigating this issue further, the AP national writer found out that since 1979 the US federal government has recommended ﬂossing, ﬁrst in a surgeon general’s report and later in the Dietary Guidelines for Americans issued every ﬁve years.“A combined approach of reducing the amount of time sugars and starches are in the mouth, drinking ﬂuoridated water, and brushing and ﬂossing teeth, is the most effective way to reduce dental caries,” the 2010 guidelines state. Because these national recom- mendations must be based on scien- tiﬁc evidence under the law, Donn asked the US departments of Health and Human Services and Agriculture for their evidence under the Free- dom of Information Act. In their re- sponse to the AP, the government ac- knowledged that the effectiveness of ﬂossing had never been sufﬁciently researched. The ﬂossing recommen- dations were consequently excluded from the 2015–2020 dietary guide- lines. However, the same applies to the advice to drink ﬂuoridated water and brush one’s teeth, which were both removed from the latest guide- lines—yet nobody has concluded from this that toothbrushing is a negligible part of oral hygiene. To be objective, existing re- search about the effects of ﬂossing is weak, of low quality or has a mod- erate to large potential for bias (having been conducted mainly on behalf of companies that manufac- ture ﬂoss), several review studies have found. As one of the many dental professionals commenting on this fact, Dr Wayne Aldredge, President of the American Academy of Periodontology, acknowledged the weak scientiﬁc evidence and the brief duration of many studies. However, he still urged his patients to continue to ﬂoss in order to help avoid periodontal disease. “It’s like building a house and not painting two sides of it,” he explained in an interview. “Ultimately those two sides are going to rot away quicker.” Just like Aldredge, dentists and dental associations around the globe have issued statements—for the most part vigorously defending ﬂossing as an effective way to help remove plaque and food build-up between the teeth and thereby lower the risk of developing gingivi- tis, periodontitis and tooth decay. For example, the American Dental Association (ADA) stated that“a lack of strong evidence doesn’t equate to a lack of effectiveness”. Moreover, the ADA stressed that the Depart- ment of Health and Human Ser- vices reafﬁrmed the importance of ﬂossing in a statement to the ADA on 4 August, stating that “profes- sional cleaning, tooth brushing, and cleaning between teeth (ﬂossing andtheuseofothertoolssuchasin- terdentalbrushes)havebeenshown to disrupt and remove plaque”. The German Dental Association stated that ﬂossing remains an important means of cleaning inter- dental spaces, especially the narrow spaces of the anterior teeth. Accord- ing to the organisation, current studies have neither demonstrated nor disproved the effectiveness of ﬂossing. Nevertheless, patients should not conclude that less thor- ough dental care is advised. Dr Øyvind Asmyhr, head of the Norwegian Dental Association, ac- knowledgedinhisstatement:“There is much we do in medicine and den- tistry that is not evidence-based, but that does not mean it does not work. All sense and clinical experience suggests that daily brushing com- bined with ﬂossing helps to reduce the amount of bioﬁlm (bacteria coating) on all tooth surfaces, which prevents the development of caries, gum problems and bad breath.” Moreover, Asmyhr remarked that untilresearchconductedoverlonger periods proves the contrary, the dental association will continue to recommend ﬂossing and sees no reason for people to change their oral health routine. Commenting on the debate as well, the British Society of Perio- dontology emphasised that the evidence supports the use of small interdental brushes for cleaning be- tween the teeth, where there is space to do so, in preference to ﬂossing. In addition, the organisation referred to the ofﬁcial recommendation to patientsagreedonduringthe11th Eu- ropean Workshop in Periodontology on the prevention of periodontal disease in 2015: “Daily cleaning be- tween your teeth using special interdental brushes is essential for treating and preventing gum dis- ease. Floss is of little value unless the spaces between your teeth are too tight for the interdental brushes to ﬁtwithouthurtingorcausingharm.” Taking all these opinions into account, what is it that patients and dentists can take away from the cur- rent discussion? Regardless of deﬁ- cientstudydesigns,inconclusivere- sults or media sensationalism that picked up on only a tiny part of the underlying facts, there are at least two statements regarding ﬂossing that can be acknowledged univer- sally: First, ﬂossing can cause harm if performed incorrectly. For exam- ple, careless ﬂossing can damage the gingivae, teeth and dental work. Moreover, there is evidence that ﬂoss can dislodge bacteria that may invade the bloodstream and cause dangerous infections, which is es- pecially of concern in people with a weak immune system. Second, common sense suggests that com- mon oral problems such as caries and inﬂammation in the interden- tal spaces can be avoided solely by removing debris between the teeth, which makes ﬂossing beneﬁcial for one’s oral health regardless. Maybe the entire debate is best summarised with the words of Dr Tim Iafolla from the US National Institutes of Health, who said that, if the highest standards of science were applied in keeping with the ﬂossing reviews of the past decade, then it would be appropriate to drop the ﬂossing guidelines. How- ever, he continued:“It’s low risk, low cost. We know there’s a possibility that it works, so we feel comfortable telling people to go ahead and do it.” Dental Tribune International ESSENTIAL DENTAL MEDIA www.dental-tribune.com AD ©Alliance/Shutterstock.com

Dental Tribune Asia Pacific No. 9, 2016

Pages Overview