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Letter From Dear Doctor

Issue 33 of Dear Doctor Magazine

To Floss or Not to Floss

Is that even a question? It shouldn't be. Yet it became one when the Associated Press reported that there is a lack of published evidence on the health benefits of using dental floss. This recently caused the federal government to drop the recommendation to floss from the Dietary Guidelines for Americans. While they may be required by law to take a neutral position absent specific research studies, I will continue to recommend flossing to my patients and the readership of Dear Doctor. Here's why.

We have known conclusively, since a landmark study by Dr. Harold Loe in 1965, that a buildup of bacterial plaque on teeth causes gum disease. Plaque bacteria can also cause tooth decay. So it's important to remove plaque from the teeth every single day. How do you do that? Brushing your teeth is one way, but it only removes plaque from the front and back surfaces of your teeth. It is just not possible for a toothbrush to reach all the surfaces between teeth.

A high percentage of people with gum disease lose supporting bone between the teeth. That's why you need to remove plaque with dental floss or another interdental cleaning device. And if you could invent something better than dental floss to clean between the teeth, the world would be thrilled!

So let's talk about research, and why we don't have definitive studies on the benefits of flossing. You can't design a study in the United States that results in people being irreversibly harmed. Also, how would you feel if the government spent 20 million dollars for a 10-year study to show flossing is important? We already know you have to remove plaque from your teeth, so that research would be a colossal waste of money.

Another study by Dr. Loe published in the Journal of Clinical Periodontology on the "Natural History of Periodontal Disease in Man" (1986) focused on untreated periodontal disease in Sri Lankan laborers from 1970 – 1985. The participants, who did not practice oral hygiene, lost teeth due to bone loss. In the United States, such a study would not be possible. To tell people to stop flossing over the course of years and watch how gum disease develops would be completely unethical. And even if it weren't, there surely would be better uses for limited medical research dollars.

Yet the sad thing is, this type of experiment is going on all the time — in real life. I see it in my periodontal practice year after year: Patients vulnerable to periodontal disease who haven't flossed for years get in big trouble. There are, of course, many other risk factors to consider, since gum disease is a complex condition. However, my clinical observations as well as those of thousands of other periodontists should not be ignored: Flossing is important and those who do floss improve their periodontal health.

So I will conclude with an old adage in dentistry that is as relevant now as it ever was:

"You don't have to floss all your teeth; only the ones you want to keep."


Mario A.Vilardi, DMD