04 Aug Why To Keep Flossing
This is a banner week for dentists. We have been able to talk about flossing more this week than in any time in our lives. Flossing is the hot dental topic of the week. It started with the great investigative journalism by the Associated Press. They pressed the government to produce evidence regarding the association between the benefits of flossing and disease prevention. In this year’s dietary guidelines by the federal government, the flossing recommendation was omitted. Here is an article about that: http://bigstory.ap.org/article/f7e66079d9ba4b4985d7af350619a9e3/medical-benefits-dental-floss-unproven. As we all realize now, the evidence supporting flossing is weak. But, that does not necessarily mean there is no association. There is no evidence that flossing doesn’t work either.
What I would like to tell you today is that I believe flossing works at doing several things, and, for the record, I do not have a 7-year, random, double blind study with over one-hundred participants to prove it. This is one clinician’s point of view.
Flossing does a few things for people:
- It keeps the build up off of of people’s teeth. When plaque hardens, it forms calculus. In the image above, you can see what calculus looks like on an x-ray. It is the spicules between the teeth. The toothbrush typically does not get down in these areas. If I were to touch this patient’s teeth with an instrument to remove this build up, I can almost guarantee the area would bleed like a stuck pig. The body does not like this stuff on it. But, without removal, does it cause disease? Well, that is the controversial question. I know it causes inflammation. That is for sure. And, inflammation is the evil empire right now in medicine. Researchers are working long hours to help us learn how to reduce inflammation in our bodies because inflammation has been linked to all kinds of problems like heart disease, cancer, and arthritis related illnesses.
- It keeps bacterial breath at bay. Many times patients come to me with complaints of breath disturbances. Often, with removal of these built up deposits and food debris from their mouths, they find relief from bad tastes and bad breath. One of the most acute states of odor problems occurs with something called acute necrotizing ulcerative gingivitis or ANUG for short–also known as trench mouth. This nickname came from a time when soldiers in the trenches could not take care of their mouths well (and probably due to having a poor diet and high stress as well).
- It teaches people to take care of themselves. Bone loss and heart disease start at levels we don’t see. And, for many of us, seeing is believing. If I don’t see the loss of bone around my teeth (because only x-rays tend to show this) or see the clogging of my arteries (because ultrasounds are needed for that), then I assume all is well. And, it may be o.k., or it may not be o.k. The point is…we don’t know. I know if I lose a tooth or have a heart attack. But, if I accept the fact that things can happen in my body without me seeing it, I realize I must do things to prevent problems or illnesses. Flossing primes the pump for this type of thinking. It helps people learn to take care of themselves before bigger problems arise. I feel quite accomplished when I convince patients to brush and floss properly because I know I am helping them see their bodies differently. I help them see their bodies like cars or trucks that need periodic maintenance. And, if I can get them into this pattern of thinking, I may just prevent them from having a heart attack some day, too–not only because we are linking dental disease to heart disease from a bacterial perspective, but because I am teaching them to care for themselves all the way around. It’s part of the Beyond 32 Teeth concept I preach about and the oral and systemic connections that continually come up in dentistry and medicine.
While this has stirred the public up and got the word flossing back into household conversations, it also raises a level of skepticism about what the ADA (American Dental Association) is recommending, how much money they get paid to provide seals of approval on products, and what we as dentists are recommending. That’s not good. We are in the trust business, and we want our patients to believe our advice.
However, this also demonstrates something else to me: there is not always enough evidence for every single thing we say. We can strive to get evidence. We can continually research topics, but at the end of the day, the money needed to research everything, with unbiased results, is enormous and filled with possible flaws and certain bias towards the originator of the study. We are stuck somewhere between telling people to use snake oil on their ailments and telling people to use only the products that have undergone long- term, double blind studies, with wide numbers of participants. Science often moves too fast for the latter, and it’s too scary to imagine the former snake oil concepts. So, we are stuck somewhere in between. The best we can do, in my opinion, is to use our thoughtful clinical judgment, keep up with latest studies, and tell our patients medicine constantly evolves. What might be great and cutting edge today may be a thing of the past in ten years. Will flossing be a thing of the past in ten years? I don’t really know. For now, I see less inflammation in my patients when they floss or use interdental cleaners of some kind. I see less calculus to remove during cleanings when patient’s floss correctly. I see less bone loss in my flossers. Is this bias? Do I just think this way because I want to think this way? Did I teach them better with floss versus another type of interdental cleaner? Maybe. I am always open to better information and better studies. I recognize my own biases–usually, and I learn every day from my patients and from my peers. If there are better ways to remove interdental plaque and build up and prevent dental disease, I am ready to learn about it.
I know I am one of the few who appreciates investigative journalism, but as you can see, when we ask questions like those at the Associated Press, we learn more, and we continue to evolve in our knowledge bases. This benefits all of us, even though it is not always what we want to hear and can have financial consequences for certain businesses (like the makers of floss in this case).
Floss on, though, or use something to clean in between your teeth. Self-care and preventative strategies are the best ways to stay healthy and keep less inflamed.
Dr. Lisa Knowles is a practicing dentist in the state of Michigan. She has broad knowledge in the field as a dental coach to dentists and a public speaker to all dental professionals. She is particularly passionate about helping the dental profession stretch and grow beyond 32 teeth. She speaks about mindfulness based stress reduction for teams, leadership culture and eco-friendly LEED concepts, oral and systemic health links, and communication effectiveness for business results. Contact her at IntentionalDental@gmail.com to inquire about speaking events or to book your next speaking engagement. Phone: 517-331-3688.