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September-October 2016 | No. 5, Vol. 6 Published in Dubai www.dental-tribune.me To floss or to brush—that is the (interdental) question ByMarcChalupsky,DTI LEIPZIG, Germany: Should dental floss still be used as a tool to combat plaque, caries and periodontal dis- ease? After almost 40 years, the US Department of Health and Human Services and Department of Agricul- turehaveremovedtheirrecommen- dation to use dental floss from their latest Dietary Guidelines for Ameri- cans. And the dental world discussed a recent report which made world- wide headlines and concluded that noscientificevidencehasproventhe effectivenessofflossing.So:Whatare alternativesfordentalprofessionals? Dental Tribune Online posed these questionstothreedentalhygienists. For a long time, dental professionals have recommended daily flossing as a necessary part of health care. How- ever, the Associated Press reviewed 25prominentstudiesthatcompared the combination of toothbrushes and floss and their effectiveness in plaque removal. As Dental Tribune Online reported earlier, the investi- gation found only weak and unreli- able evidence. According to the arti- cle,somestudieswerenotvalidsince they included very few participants and had a short duration of only a couple of weeks. When asked for a statement, dental floss manufactur- ers were not able to provide scien- tific evidence even though many of the previously mentioned stud- ies were funded by this industry. In the meanwhile, manufacturers have already announced new fund- ing for comprehensive research to determine the effects of flossing on oral health. As periodontal disease and caries develop over months and years, future research will have to fo- cusonalargerstudypopulationover a longer period in order to measure periodontal health effectively. In the meantime, how should dental pro- fessionals deal with this issue? Do they have an alternative to dental floss? Are interdental brushes an- othersolution? According to Swiss oral health care provider Curaden, not cleaning in- terdentally would be going too far. Choosing a suitable interdental cleaner and using the proper tech- nique are always important. Floss is appropriateforanteriorteeth,where long, flat approximal surfaces and narrow spaces make access with an interdental brush difficult. Ideally, one should use dental floss for the narrow interdental spaces between the anterior teeth and interdental brushes for the posterior teeth. Ac- cording to the Swiss company, inter- dentalbrushesareveryeffectiveand extremely easy to use compared to dental floss, but must be used gen- tly in order not to injure the gums. Interdental brushes help prevent build-up of plaque between teeth and that causes bleeding gums, gin- givitis and periodontitis and dental caries. In addition to interdental brushes, the company produces toothbrushesandtoothpastesunder its CURAPROX brand and supports educational prophylaxis training callediTOPfordentalprofessionals. CEO and owner of Curaden Ueli Breitschmid said, “Since 1972, our companyhasbeenthepacesetterfor interdental brushes, which remove both food residue between the teeth and—more importantly—dental plaque. Since they do not damage tissue, our interdental brushes are not only recommended by the den- talprofessionalsglobally,butarealso prescribed totheir patientsand their use taught to each patient individu- ally.” According to Curaden, the ad- vantages of interdental brushes over flossing have been demonstrated in numerous studies. For example, in a study titled “Comparison of differ- ent approaches of interdental oral hygiene: Interdental brushes versus dentalfloss”,patientswithperiodon- titis used dental floss and interden- tal brushes to reduce plaque over a six-week period. Interdental brushes were found to remove significantly more plaque than dental floss did. Furthermore, patient acceptance seemedtobehigherwithinterdental brushes. “Everyone knows dental floss, but only few like to do it—because they do not know how,” according to Edith Maurer, a Swiss-based dental hygienist with 40 years of experi- ence.Sheadded:“Averyshortthread should be kept between the fingers, moving up and down the sides of the teeth. But most of the time, it slips away, cuts into the gums and soconstantlyinjuresthestructureof the gingivae. Dental floss should be used if something is stuck between your teeth but not for cleaning be- low your gums. After all, it has been a razor-sharp tool for over 200 years and is quite dangerous if you do not use it correctly. Imagine cutting a pudding with floss. It will work per- fectly,nothingwillbeattachedtothe floss.Butifyouuseafineinterdental brush, it will take away more of the pudding. Interdental brushes should be the preferred tool if you want to clean your gums at least in the pos- teriorregion.” Individually trained oral prophylaxisisthekey According to dental hygienist Cath- erine Schubert, the space below the contact area should be the focus. “We need to carefully differentiate between gum disease and dental caries. Interdental brushes are more effective for the prevention of gum disease owing to their space-filling properties.However,athinshaftand longer bristles are necessary to reach below the interdental contact point where caries mostly develops. Inter- dentalbrushescanpreventinterden- talcariesifappliedcorrectly,whichis below the interdental contact point. Of course, floss also cleans below the contact point. However, using floss just because it is normal, without thinking about the right technique, will not lead to the prevention of caries. At the same time, using an interdental brush without proper instruction will not lead to the pre- vention of gum disease. After all, it is not a government or institution that should decide about one’s oral hygiene, but the dental professional needstochoosewhichcleaningtech- niqueismostefficientforeachofhis patients. Individually trained oral prophylaxis has always been the key toone’shealth.” Elizabeth van der Ham, a South Af- rican dental hygienist, agrees that one has to choose carefully between flossing and interdental brushing: “Dental floss throughout the years has been a saving grace for many patients overcoming oral health issues. Clinical observations over manyyearsofflossusageinpatients is strong evidence that floss indeed does have a place in the oral hygiene regime.Discardingtheuseofittotal- ly would be irresponsible to say the least. In 1965, Prof. Harald Löe and others did the famous ‘Experimen- tal gingivitis in man’ study. The out- come was that gingivitis disappears within two weeks if the tooth struc- ture is sufficiently cleaned. There- fore, there are three criteria we as dental professionals need to adhere towhenselectingatreatmentoption for our patients: the regime needs to be acceptable to the patient, it has to be atraumatic to the soft and hard tissueoftheoralcavity,anditshould be effective in removing biofilm and plaque to establish a healthy status quointheoralcavity.” However, no matter what interden- talcleaneronechooses,almostevery tooth has to be treated uniquely. “Flossing is more acceptable in the anterior and difficult crowded areas of the mouth. The interdental brush has easier access in the posterior re- gionsthataremoredifficulttoreach. Flossing is not as effective in the mo- lar regions because of the concave- shape of the root structures. Flossing is also more technique-sensitive and greater dexterity needs to be applied when doing it effectively and with- out damage. Interdental brushes need to be selected with careful con- sideration of the tooth and interden- tal shape and size,” stated Van der Ham. “Most importantly, patients need to be constantly educated and their oral hygiene regime adjusted to their individual needs and prefer- ences.”