August 11, 2016 -- Following the recent heated controversy over the scientific merits of flossing, DrBicuspid.com queried its informed readers to get their input about the issue. "Plaque control is considered the holy grail in dentistry," noted a dental instructor, while a dentist said flossing could become a blame game between dentists and patients.
An August 2 report by the Associated Press questioned the clinical evidence supporting the practice of flossing. The article examined 25 peer-reviewed studies on the effectiveness of flossing and found weak or unreliable evidence that flossing had long-term benefits.
The ADA and the American Academy of Periodontology fired back, maintaining that the use of "interdental cleaners," such as floss, are an "essential" part of periodontal care.
No harm, no foul?
Many dental professionals noted that flossing can't help but improve dental hygiene.
"Agitating the biofilm in the area of the proximal contact with floss in people with healthy biofilms is good and certainly does little or no harm," Paul Dirkes, DDS, of Atmore, AL, told DrBicuspid.com in an email.
But Dr. Dirkes said there are better alternatives to flossing.
"Other better options are water flossers with antimicrobials or using antimicrobial mouthwashes for 30 seconds, spit, and repeat," he wrote.
Retired dental hygienist Nancy Alleman, RDH, said she stopped recommending flossing after noticing that it didn't decrease caries.
"I have never found flossing to reduce dental decay and stopped that message several years ago," Alleman wrote. "I also stopped telling patients to floss daily. Three times a week works just as great if you want to floss."
High rates of periodontal disease
Others pointed out that flossing would help fight the high rates of periodontal disease in the U.S., which includes 47.2% of American adults or 64.7 million people, according to a 2012 report by the U.S. Centers for Disease Control and Prevention.
"Plaque control is considered the holy grail in dentistry," wrote Lance Vernon, DMD, an instructor at the Case Western Reserve University School of Dental Medicine. "You would be hard-pressed to find a periodontist who would not argue that [minimally in those with periodontal disease] flossing and/or interproximal cleaning is an important measure to arrest/slow the progression of 'gum disease.' "
But Dr. Vernon acknowledged that many people do well without flossing.
"Are there some people who don't floss and are just fine? Yes," he wrote.
Better advice than flossing?
Some said that dentists can give their patients other recommendations that can produce more significant improvements to their dental health.
"I agree that floss is cheap and has minimal harms, but does advocacy for it detract from better health promotion messages (e.g., smoking cessation, which is a much more effective prevention message compared to flossing)?" noted Robert Weyant, DMD, a professor and the chair of the department of dental public health at the University of Pittsburgh.
Dr. Weyant also wondered if flossing could result in a blame game between dentists and patients.
"Does nonflossing among patients result in victim blaming by dentists when they feel that their patients aren't participating in appropriate health behaviors?" he stated.
Others pointed out that many people floss just because it feels better to get rid of the gunk that gets between their teeth after eating.
"I reminded my friends about their own subjective experiences with what they remove from their teeth when they floss, e.g., rotten, stinky food, and why would they want to have that stay in their mouths!" wrote Gail T. Brown, director of the New Hampshire Oral Health Coalition.
Absence of proof doesn't prove anything
Finally, Scott Tomar, DMD, DrPH, noted that peer-reviewed research into the benefits of flossing would make little sense financially or logically.
"Well-conducted randomized controlled trials would be very expensive, and I doubt the National Institute for Dental and Craniofacial Research and other major funders of biomedical research would be interested in spending the millions it would take to conduct such studies," Dr. Tomar wrote. "At the end of this long, difficult, expensive study, you have an unmasked trial at high risk for bias."
Dr. Tomar is a professor and the interim chair of the department of community dentistry and behavioral science at the University of Florida College of Dentistry in Gainesville, FL.
He also pointed out that a lack of proof doesn't prove anything.
"One principle worth bearing in mind is that absence of evidence of effectiveness is not at all equivalent to evidence of absence of effectiveness. It then comes down to weighing the probable risks and benefits. I intend to floss my teeth in a few minutes," Dr. Tomar concluded.