Is flossing important and should I floss my teeth?

 The first question must be, what is dental floss?

Dental floss is simply a piece of thread which can slide or fit in between the teeth in order to remove the plaque from them.

Dental Floss is made out of a Polymer. The 2 polymers are either Nylon or Teflon. These are then coated with wax or flavourings which enhances the appeal of flossing your teeth daily. You should floss as soon as your adult teeth come through and definitely by the age of 13 when most of your adult teeth have come through.

 So what is exactly is the floss doing?  To put it simply, it is removing the bacteria from your teeth which cannot be removed with your toothbrush.

Firstly let’s look at all the surfaces of teeth that need plaque removing from them. The smooth surfaces of the teeth which are generally outside next to the cheek and Inside next to the tongue or the palate are quite easily cleansable  with a normal toothbrush. On the whole the biting surfaces of the teeth are also accessible with a toothbrush however all biting surfaces also have deep pits and fissures which cannot readily be reached by the bristles of your toothbrush. Next we have the interdental surfaces.

The interdental surface is the surface where the teeth meet next to each other. The bristles of your toothbrush cannot reach these areas therefore there are three alternatives. The first alternative is to ignore them and not brush the plaque from interdental surfaces at all. This can result in dental decay and gum disease including gum recession.The other alternatives are to use interdental brushes or dental floss in order to reach these inaccessible areas and take the plaque away from these inaccessible areas. The decision to use dental floss or interdental brushes largely depends on the size of the interdental gaps between your teeth. Most of the time the gaps are quite tight and therefore dental floss is what you should be using to clean in between your teeth.

We keep mentioning the word plaque period so what exactly is plaque?

Plaque is a sticky film of bacteria that forms underneath the gum line and on the tooth surfaces. If you have fillings or dentures or crowns or dental implants the plaque also sticks onto all these 

surfaces as well. The plaque in your mouth contains over 1000 different types of bacteria and they multiply very very quickly and that is the reason why brushing twice a day is advocated.

So the next question must be why you should be getting rid of this plaque or bacteria in the first place. This is because plaque is Sticky and it cannot be removed by just rinsing your mouth out. The only way to remove it, is to literally scrub it physically and that’s why we use a toothbrush and interdental brushes and dental floss. There is one thing that any dentist will tell you and that is to floss your teeth but in reality very few patients actually  do floss and we will look into this later as to the reasons why generally people tend not to floss their teeth when being instructed by their dentist.

Recently The Associated Press carried a review of 25 articles on the benefits of flossing and their conclusion was that it may not be totally necessary to floss in order to eradicate gum disease and tooth decay. Obviously when this associated Press article review came out patients must have been really happy knowing that finally the dentist may tell them to stop flossing because flossing your teeth may not have any proven benefits. But in reality dentists just kept on telling their patients to still floss and there are a number of reasons for this advice.

Firstly not all dental academics agree with these findings. Certainly the evidence in floss causing the reducing of cavities is a little bit uneasy because the most important Factor in reducing cavities is your sugar intake and especially the frequency of that sugar intake. There is a much stronger link that flossing does help against gum disease and in The Journal of Dental Hygiene a review of 12 studies was carried out and the conclusion was that flossing does reduce your gums from bleeding and it also reduces bad breath which increases a person’s confidence. Importantly it removes the food debris in between your teeth that remains after a meal. So in conclusion flossing may not help significantly to reduce cavities because that is more related to sugar intake but flossing does have a beneficial effect on the health of your gums and we know that more teeth are lost through gum disease and tooth decay in general. Gum disease is an Insidious disease and it destroys your gums quietly in the background and for many years you may not even know that you have gum disease. The time when you do notice that you have gum disease is when your teeth start to become loose or gaps start appearing between your teeth and the fact is that it may then be too late and abscesses can also start occurring. When gum disease is left too late the only option often is to have your teeth taken out. We know that in the UK 60% of patients will have some form of gum disease and flossing does help to reduce gum disease. The two types of gum disease are gingivitis and periodontitis. Gingivitis is the early form of gum disease and it is the less invasive type.

Periodontitis is the more advanced gum disease where your gums will start to recede and your teeth will get including the formation of gum abscesses. A particular type of bacteria associated with gum disease is called Porphyromonas Gingivalis.

Periodontitis is termed as a chronic inflammatory disease which eventually leads to tooth loss so although flossing clearly has benefits with in your mouth on the state of your gums it has long been recognised that the mouth is also a mirror to your general health.

There are now countless articles which have found evidence that the bacteria found in your mouth can find their way into your bloodstream and cause problems elsewhere. These problems have been linked to heart disease, rheumatoid arthritis, diabetes, premature birth and recently Alzheimer’s disease. A very recent study found that patients who had Alzheimer’s disease also had periodontal disease and in particular the bacteria called Porphyromonas Gingivalis was found in the brain cells of patients with Alzheimer’s disease. Porphyromonas Gingivalis is a bacteria found in the mouth which is implicated in periodontitis and it is a gram negative anaerobic pathogenic bacteria which produces toxins causing harmful effects in the mouth leading to gum disease. The toxins that the bacteria Porphyromonas  gingivalis produces were found in significant quantities in patients with Alzheimer’s disease. So by now you should be getting an idea that flossing does have benefits to your mouth  in general and it also has an effect on your overall health. Despite the article by The Associated Press, dentists out there are still continuing to advocate flossing.

 

Let’s look at how flossing should be used in conjunction with tooth brushing. It is usually better to brush your teeth as thoroughly as possible first and then rinse out all the toothpaste before you start using the dental floss. This ensures that as much plaque has been removed with your toothbrush and the function of the Floss is then to clean off any plaque that is still remaining behind especially in the areas which we mentioned earlier as being in between the teeth also known as the interdental or interstitial areas. Before you floss you should really wash your hands because you don’t know where your hands have been and bacteria on your hands are then being transferred back in your mouth. So once you have brushed your teeth you can then follow the guidelines by the American dental hygienists Association which gives easy steps to floss your teeth and they are easy to remember. Firstly take a piece of floss about 6 inches in length which is the same size as a small ruler length worth of dental floss. You then wind one end with the middle finger  and the middle finger of the other hand for the other end. You should be left with about half an inch to 1 inch of floss in between your fingers so now you glide or guide the floss with your index fingers.  You push the Floss gently in between your teeth and this is often why patients get stuck because they find it too difficult or the Floss won’t slide down easily and it tears when doing so. When gliding the Floss in between your teeth it is usually best to move the Floss backwards and forwards gently almost like a saw in between your teeth. This is especially important if the contact points between your teeth are very tight or if the Floss rips or even breaks off  altogether. So once the Floss is in between your teeth and next step is where you use the surface of the Floss to physically clean and scrape the plaque and bacteria off your teeth. This also means that the Floss will need to be passed under the gumline because plaque initially starts by forming under the gumline. I tell my patients that if you brush your teeth twice a day and floss twice a week, over a period of time you will find the Floss easier and eventually the initial difficulties that you had, will be overcome so then you start using it more regularly. One of the main difficulties is that when flossing you are looking at a mirror and therefore you are working backwards to front which is obviously tricky for some people. One way around this, is to choose a few teeth for example the top 6 at the front of your mouth and just start flossing those first once a day. Once you have got the hang of that then you can start to progress more onto your back teeth which can be more difficult. It doesn’t really matter whether you start off with your upper teeth or lower teeth as long as you eventually do get around to all the teeth but you start off with what you feel is easiest. Some people do have very tight contact points on the lower teeth 

so I recommend that they start flossing their upper teeth first because it will be easier and once you get the hang of it, the other teeth will generally over a period of time becomes easier to floss. Once you have been flossing your teeth regularly you will find how clean your mouth feels and when you don’t brush your teeth or floss for any reason you will quickly become conscious that your teeth are not clean and they need to be Flossed. Once you have got the hang of flossing in reality it doesn’t take up a long time and it can take less time to floss then it takes to brush all your teeth properly. 

 

Patients often asked me if there is any particular type of loss that I recommend as there are a huge vast array of different types of floss. We have carried out a Review of The Best Dental Floss to use.

You can get floss which is waxed and you can get floss which is unwaxed and floss which is spongy and floss which has got different tastes for example mint flavour and even bubblegum flavour. In

 addition you also have the choice of dental tape, Dental floss and something called Super Floss. Usually it’s best to ask your dentist as to which type of floss they would recommend for your particular teeth as they will instantly and easily know which is the best one for your mouth. One advantage of dental tape is that it is thicker than the normal dental floss which means that it will clean substantially more plaque between your teeth than a thinner one however if your teeth are really tight together the dental tape may not easily slide and you may have to go back onto the regular floss. One remark that all dentists have heard including myself is that a patient will say that one day they did try to floss their teeth and their filling came out or that it hurt or that their gums started bleeding. Some will even tell you that a whole crown may have even come off when they were trying to floss their teeth around a dental crown. Floss used properly should not pull out a sound filling or a sound crown and if it does pull it out it means that the filling or the Crown was loose and was going to come out shortly anyway despite flossing or not flossing.

Patients often complain that it is painful to floss but the best way to think about this is that initially if your gums are sore and painful this means that you probably already have some chronic inflammatory gum disease and whenever inflamed gums are touched they do feel sore or painful. So this soreness or pain is only temporary because it means there is inflammation initially when you start off. However when you do start removing the plaque from your teeth with the Floss, the gum inflammation will subside and after a while you will no longer be getting any pain from the flossing. Over time the tender parts of the gum will get stronger and then the flossing can be done a little bit more vigorously so that it doesn’t hurt anymore.

Another objection that people have is that their gums bleed when they floss and this is similar to when your gums bleed when brushing because of underlying gingivitis or periodontitis. The inflammation is due to the plaque and if you don’t remove the plaque the information gets worse and the bleeding and the soreness also starts to increase. So this is where you do have to bite the bullet and not worry about your gums starting to bleed or become sore because over a period of time you will find that the flossing causes the bleeding to stop due to the inflammation or the gum disease disappearing.

There may be particular areas where the bleeding does continue however much you floss, and this is when you should mention that particular spot to your dentist as there could be some underlying chronic advanced periodontitis and therefore the dentist can start to treat that accordingly. Finally, is it better to floss only or brush only? I would say that if you haven’t got time to do both for instance then you should brush as thoroughly as possible and then maybe at a later time during the day or at night time you should floss if you can. So brushing always comes first and flossing does come second but they both have benefits in reducing dental decay and gum disease in your mouth which can eventually lead to tooth loss.

 

Sources

 

• Does flossing improve oral health? – September 2018 – Volume 21 – Issue 8 – p 54–55
•  Dental care during pregnancy – The Journal of the American Dental Association

• Comparison of Dental Flossing and Oral Health Status among Dental Students and High School Students – CB Benedek, L Lazăr, IZ Buka, A Vlasa – Journal of Interdisciplinary. 2018

• Oral Streptococcal Endocarditis, Oral Hygiene Habits, and Recent Dental Procedures: A Case-Control Study – Clinical Infectious Diseases, Volume 64, Issue 12, 15 June 2017, Pages 1678–1685,Xavier Duval by  1Inserm CIC-1425, AP-HP, Hôpital Universitaire Bichat; Inserm UMR-1137 IAME; Université Paris Diderot, UFR de Médecine-Bichat, and Xavier Duval

• Why do children and adolescents neglect dental flossing? – European Archives of Paediatric Dentistry
• We may finally know what causes Alzheimer’s – and how to stop it – Sarah Millot – 2UMR 1149-Inserm, CRI, Université Paris Diderot, Faculté de médecine Bichat, Paris; 9Inserm, CIC-1433 Epidémiologie Clinique, Centre Hospitalier Régional Universitaire, Nancy;