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Periodontal Disease and the Flossing Controversy

Periodontal Disease and the Flossing Controversy


In the previous post, we reviewed the evidence on the link between periodontal disease and systemic disease, and focused on whether treating periodontal disease produces better outcomes or not.

But this begs the question that periodontal disease is a major cause of tooth loss, especially in older patients. Tooth loss leads to poorer nutrition and overall health, since using dentures reduces chewing efficiency to only approximately 20% of natural teeth.

While preventing caries (decay) is more strongly associated with dietary carbohydrates and fluoride exposure, it is critical to point out that preventing periodontal disease is associated with effective oral hygiene, including flossing.

So why has the recommendation on flossing been dropped from the HHS Dietary Guidelines for Americans? Basically, the evidence on flossing is fairly weak. Periodontal disease takes years to develop while studies are usually only funded for weeks to months. Instead, surrogate markers like bleeding are used, which is problematic.

So what recommendations can nurses rely on for their patients?

  • Flossing is an important oral hygiene practice, particularly for patients with systemic diseases associated with periodontal disease. The patients who most need advice are diabetics and patients with cardiovascular disease.
  • Absence of evidence is not evidence of absence. The reality of this research is that it would be very expensive with no "product" involved (like a new drug) to recoup the cost. However, dentists, and particularly periodontists who specialize in treating gum disease, have no doubt that flossing is crucial to control. 
  • Flossing is not popular. One survey showed that 15% of patients would rather clean a toilet than floss their teeth, and it's understandable that people hearing this might misunderstand and think it has been "shown" that flossing can be skipped. 

The bottom line is that, like many common sense hygiene measures that may not have high quality evidence, flossing is cheap, has minimal harm, and is an important part of preventing periodontal disease, which has adverse dental and health effects.