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TomBAvoider

Do you floss? If it's for dental health, you needn't bother.

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I admit, flossing is part of my dental routine and has been for decades. Shamefacedly, I admit, I have never researched its effectiveness, although I have researched mouthwashes, brushing and also toothpaste. For some reason I never did any research on flossing. Shame on me - it's always the stuff you don't bother researching that gets you - somewhat akin to the famous Mark Twain quote "It ain't what you don't know that gets you into trouble. It's what you know for sure that just ain't so." Mea culpa.

 

Anyhow, for decades and decades every medical authority recommended flossing, and we followed unquestioningly. But, as the government covers financially more of our medical needs, they have been obligated to follow Evidence Based Medicine - no use paying for unproven procedures. And guess what. Upon extensive investigation of flossing, it was found that there is no real scientific evidence of any benefits to flossing. None. Nada. Zilch. Oh the humanity! All those years and years of flossing. I weep for the lost time and my own stupidity and carelessness. Read, and cry:

 

 

Medical benefits of dental floss unproven

 

That said, like a superstitious savage, I still continue the cargo cult of flossing, in equal parts out of habit and fear that perhaps there are medical benefits that while not proven still exist. I'll continue flossing for the time being, but I'm re-evaluating. 

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Tom,

 

I saw and was surprised by the same article. Like you, I'm skeptical of the lack of benefit from flossing, particularly for folks like us who eat a very fibrous diet. Given the chucks of stringy vegetable matter I dislodge from my teeth by flossing (I know, pretty picture...), I can only imagine how much worse my teeth would be today had I left that stuff in there for bacteria to feed off. Heck,  Heck, having all that plant matter between my teeth after I eat just feels bad, so I'd continue to floss for the hedonic pleasure of it, even without proven benefits.

 

And I have to point out the obvious, namely that absence of evidence is not the same as evidence of absence. From the article, it doesn't appear like there have ever been any large clinical trials to put the benefits of flossing to the test. Yes, I too find it very strange it has never really been validated, given how ubiquitous the recommendation to floss is.

 

So I'll remain in your cargo cult of flossers until there is evidence that flossing is actually detrimental to dental health - which really would rock my world.

 

--Dean

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Lacking the manual dexterity to conventionally floss I've been using a water flosser.  Prior to using it I got a gum line cavity between molars but I haven't had one since which provides sufficient motivation to continue despite a lack of scientific evidence.

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All I can say is anecdotal. In my youth I never flossed, had bleeding gums real bad. Dentist said floss and scrape the sides of the teeth 10 times with the floss to get rid of plaque. Well it worked and I never have bled since. These studies suck because most people don't floss at all properly.

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The absence of evidence argument is only useful in comparing to null. In reality there are other things you could be doing with the time, some of which have stronger pro-health evidence. So sure, if flossing isn't very unpleasant to you, then it's a good bet that it's better than spending those minutes watching incrementally more TV. But vs. sleep? Vs. A few min of stretching? Exercise? Meditating for a few min? Pre-chopping some veggies so you are more likely to eat them the next day even if in a rush? Or even vs. just brushing for the extra time you would have spent flossing?

 

Not to mention vs. reading a few more CR Society forum discussions! :-)

 

Which activity is going to be best for your long term health, in a statistically expected sense (based on available evidence to date)? Flossing would seem to have just been demoted down the list relative to a bunch of these. At least for those of us who are far from perfect at doing everything.

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I have to wonder if brushing is so good because it removes plaque then would it not stand to reason that the part of the teeth not brushed would also need to be free of plaque. It makes no sense to me that if plaque, which you can sense and feel if it is abundant, needs to be removed from the iexterior enamel would not also need to be removed from the interior enamel.correct flossing does this. Experiment by not flossing for a week and then very carefully move the floss up and down between the teeth. You will probably notice the mushy texture that built up. It's very subtle but by flossing diligently the inner teeth will become quite squeaky almost like a clean window vs a very dirty one.

Edited by mikeccolella

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Mike,

 

I couldn't agree more about the obviousness of the benefits of flossing, especially for folks who eat lots of fiber like we do.

 

To demonstrate, I did a little experiment this morning immediately after my big breakfast. Rather than flossing first and then brushing a half hour later (my usual practice to keep from brushing off enamel), I decided to do the following:

  1. Gargle and rinse to get rid of any loose food particles in my mouth.
  2. Brush with my Oral-B for a full 2 minutes being sure to cover average accessible surface of my teeth.
  3. Gargle and rinse to get rid of any food particles the brushing dislodged.
  4. Floss my teeth, depositing on a paper towel any food particles that brushing missed but that flossing removed.
  5. Photograph the paper towel to show just how much brushing misses and flossing catches.

Here is the clean paper towel before (top) and after (bottom) flossing:

 

 

ScYr0qJ.png

 

c4gQ1mS.png

 

No - the penny was not stuck between my teeth (it is in the picture for scale!). But everything else you see was lodged between my teeth, even after I did the best job I could brushing.

 

Of course I eat an extremely fibrous diet, and have rather large spaces between my teeth, so your mileage may vary. But I can only imagine what all those little (and big!) particles would do to my teeth and gums if they sat between my teeth all day. I wouldn't think of not flossing after every meal.

 

I'm reminded of what Jesus said in Matthew 7:3:

 

Why worry about a speck between your friend's teeth when you have a log between your own?
 

Or something like that... ☺

 

--Dean

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Or something like:

 

Matthew 7:4
How can you say to your brother, 'Let me take the speck out of your [teeth],' while there is still a beam in your own eye?

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I have to wonder if brushing is so good because it removes plaque then would it not stand to reason that the part of the teeth not brushed would also need to be free of plaque. It makes no sense to me that if plaque, which you can sense and feel if it is abundant, needs to be removed from the iexterior enamel would not also need to be removed from the interior enamel.correct flossing does this. Experiment by not flossing for a week and then very carefully move the floss up and down between the teeth. You will probably notice the mushy texture that built up. It's very subtle but by flossing diligently the inner teeth will become quite squeaky almost like a clean window vs a very dirty one.

 

My understanding from reading some of the articles that have come out this week is that there is very little evidence that brushing without fluoride is particularly important either. So perhaps it isn't removal of plaque or food matter that is as important as delivery of fluoride. I'm no expert, but IIRC there is evidence of health benefit at a community level from fluoridating water supplies too.

 

Dean's experiment where he shows how much food he gets out from his teeth by flossing seems silly. If it were conclusively shown that leaving food on your teeth causes big long-term negative health benefits, then I would think it would be trivial for the committee to justify a flossing recommendation based on easily, quick, and cheap experiments like Dean's (but more carefully and repeatably done and generalized to a wider cohort of people of course). The fact that such a body of research does not justify a flossing rec currently strongly suggests that your intuition of food on teeth causing health problems is not yet a linkage with good science connecting the dots.

 

Or perhaps plaque is important and flossing doesn't remove plaque nearly as well as brushing. I don't know.

 

But the idea that any of us can do an n=1 experiment in a day or a couple weeks and see results that justify flossing's long-term health benefits is just silly and quite unscientific.

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kpfleger,

 

But the idea that any of us can do an n=1 experiment in a day or a couple weeks and see results that justify flossing's long-term health benefits is just silly and quite unscientific.

 

Let's see. Try to follow the logic here, and please point out any flaws:

  1. Cavities and dental erosion are caused by an acidic environment.
  2. Acid on teeth is created by bacteria that live on and between teeth, which excrete acidic compounds that erode teeth. See here.
  3. These acid-producing bacteria feed on carbohydrates, and these carbs come from the food we eat. [1]
  4. Many of us eat a lot of carbs in the form of plants, including plants with sugars (e.g. fruit) and plants with lots of stringy fiber (vegetables)
  5. As my experiment showed, at least for some of us, a significant amount of this plant material gets stuck between our teeth, even with thorough brushing.
  6. My experiment also showed that flossing properly dislodges and removes this plant material.

I recognize and acknowledge that evidence is scant for the complete end-to-end benefit of flossing on cavity prevention and overall dental health. But it seems to me each step in the multi-step argument above in favor of flossing is quite well-supported. That, coupled with the fact that many prominent raw food vegans (who eat diets pretty similar to ours - lots of fruit and veggies) report dental health problems when they neglect proper dental care (incl. and esp. flossing) in favor of a more "hands off" natural approach, for example, herehere, herehere, here, here, is good enough evidence for me that proper dental hygiene, including flossing, is important for the health of one's teeth.

 

Flossing for a couple minutes a day seems like a small price to pay, given the likelihood in my mind of beneficial results (despite the tenuous evidence), and given the extremely small chance of harm as a result of proper flossing.

 

But I encourage you to go for it kpfleger - try your own n=1 experiment by not flossing (or brushing) for a year or two and report back to us how that works out for you.

 

P.S. Here are two Cochrane reports, one on brushing + flossing and one on regular brushing + interdental brushing (which I also do). Here is a summary from the second:

 

Main results: 
 
There were seven studies (total 354 participants analysed) included in this review. We assessed one study as being low, three studies as being high and three studies as being at unclear risk of bias. Studies only reported the clinical outcome gingivitis and plaque data, with no studies providing data on many of the outcomes: periodontitis, caries, halitosis and quality of life. Three studies reported that no adverse events were observed or reported during the study. Two other studies provided some data on adverse events [ranging from difficulties manipulating floss, reaching back teeth, interdental brushes distorting and buckling and also (noted to be the most serious) the fact that floss can make gums sore]. Two studies did not report whether adverse events occurred.
 
Interdental brushing in addition to toothbrushing, as compared with toothbrushing alone
 
Only one high risk of bias study (62 participants in analysis) looked at this comparison and there was very low-quality evidence for a reduction in gingivitis (0 to 4 scale, mean in control): mean difference (MD) 0.53 (95% CI 0.23 to 0.83) and plaque (0 to 5 scale): MD 0.95 (95% CI 0.56 to 1.34) at one month, favouring of use of interdental brushes. This represents a 34% reduction in gingivitis and a 32% reduction in plaque.
 
Interdental brushing in addition to toothbrushing, as compared with toothbrushing and flossing
 
Seven studies provided data showing a reduction in gingivitis in favour of interdental brushing at one month: SMD -0.53 (95% CI -0.81 to -0.24, seven studies, 326 participants, low-quality evidence). This translates to a 52% reduction in gingivitis (Eastman Bleeding Index). Although a high effect size in the same direction was observed at three months (SMD -1.98, 95% CI -5.42 to 1.47, two studies, 107 participants, very low quality), the confidence interval was wide and did not exclude the possibility of no difference. There was insufficient evidence to claim a benefit for either interdental brushing or flossing for reducing plaque (SMD at one month 0.10, 95% CI -0.13 to 0.33, seven studies, 326 participants, low-quality evidence) and insufficient evidence at three months (SMD -2.14, 95% CI -5.25 to 0.97, two studies, 107 participants very low-quality evidence).
 
So there is evidence in favor of flossing and interdental brushing on top of brushing, it just that it is based on small studies with dubious sponsorship (by companies with a vested interest in the outcome). Plus there is no evidence of significant adverse effects.
 

--Dean

 

---------

[1] PLoS One. 2013 May 30;8(5):e64645. doi: 10.1371/journal.pone.0064645. Print 2013.

 
Dietary carbohydrates modulate Candida albicans biofilm development on the
denture surface.
 
Santana IL(1), Gonçalves LM, de Vasconcellos AA, da Silva WJ, Cury JA, Del Bel
Cury AA.
 
Author information: 
(1)Department of Dentistry I, School of Dentistry, Federal University of
Maranhão, São Luis, Maranhão, Brazil.
 
The purpose of this study was to investigate whether dietary carbohydrates can
modulate the development of Candida albicans biofilms on the denture material
surface. Poly (methyl methacrylate) acrylic resin discs were fabricated and had
their surface roughness measured. Biofilms of C. albicans ATCC 90028 were
developed on saliva-coated specimens in culture medium without (control) or with 
carbohydrate supplementation by starch, starch+sucrose, glucose, or sucrose for
72 h. The cell count, metabolic activity, biovolume, average thickness, and
roughness coefficient were evaluated at the adhesion phase (1.5 h) and after 24, 
48, and 72 h. The secretion of proteinases and phospholipases, cell surface
energy, and production of extra/intracellular polysaccharides were analyzed after
72 h of biofilm development. Data were analyzed by one- and two-way ANOVA
followed by Tukey's test at 5% significance level. In the early stages of
colonization (adhesion and 24 h), the glucose group showed the highest cell
counts and metabolic activity among the groups (p<0.05). After maturation (48 and
72 h), biofilms exposed to glucose, sucrose, or starch+sucrose showed higher cell
counts and metabolic activity than the control and starch groups (p<0.001).
Compared to the control group, biofilms developed on starch or starch+sucrose had
more proteinase activity (p<0.001), whereas biofilms developed on glucose or
sucrose had more phospholipase activity (p<0.05). Exposure to starch+sucrose
increased the production of extracellular and intracellular polysaccharides
(p<0.05). Biofilms developed on starch or without carbohydrate supplementation
presented cells with more hydrophobic behavior compared to the other groups.
Confocal images showed hyphae forms on biofilms exposed to starch or
starch+sucrose. Within the conditions studied, it can be concluded that dietary
carbohydrates can modulate biofilm development on the denture surface by
affecting virulence factors and structural features.
 
DOI: 10.1371/journal.pone.0064645 
PMCID: PMC3667795
PMID: 23737992

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Hi ALL!

 

I use interdental brushes twice a day, rather than flossing -- I find it much more effective in removing vegetable debris from between my teeth (and I keep interdental brushes in my back pocket, to use during the day as needed).  I brush with a rotary electric toothbrush with a toothpaste with more than average flouride -- carefully rinsing the toothpaste out of my mouth when I brush, to avoid ingestingany flouride (probably not good for bones).

 

I've had excellent dental health for many years.

 

BTW, my dentists work for the Eastman Dental Faculty Group -- this is part of the Eastman School of Dentistry, one of the top graduate dental schools in the world.  (A Dental Graduate school is one that dentists go to to receive training in specialties.)  The "Eastman Bleeding Index" that Dean refers to there was invented at this facility.

 

  -- Saul

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Flossing may cause gum tissue trauma leading to oral bacteria transmission into the bloodstream ("bacteraemia"):

 

1. J Clin Periodontol. 2009 Apr;36(4):323-32. doi: 10.1111/j.1600-051X.2008.01372.x.

Epub 2009 Mar 11.

 

Bacteraemia due to dental flossing.

 

Crasta K(1), Daly CG, Mitchell D, Curtis B, Stewart D, Heitz-Mayfield LJ.

 

Author information:

(1)Discipline of Periodontics, Faculty of Dentistry, University of Sydney, NSW,

Australia.

 

AIMS: The aims of this study were to (1) investigate the incidence of bacteraemia

following flossing in subjects with chronic periodontitis or periodontal health;

(2) identify the micro-organisms in detected bacteraemias; and (3) identify any

patient or clinical factors associated with such bacteraemia.

MATERIAL AND METHODS: Baseline blood samples were obtained from 30 individuals

with chronic periodontitis (17 M:13 F, 29-75 years) and 30 with periodontal

health (17 M:13 F, 28-71 years) following a non-invasive examination. Each

subject's teeth were then flossed in a standardized manner and blood samples

obtained 30 s and 10 min. after flossing cessation. Blood samples were cultured

in a BACTEC system and positive samples subcultured for identification.

RESULTS: Forty per cent of periodontitis subjects and 41% of periodontally

healthy subjects tested positive for bacteraemia following flossing. Viridans

streptococci, which are commonly implicated in infective endocarditis (IE), were

isolated from 19% of positive subjects and accounted for 35% of microbial

isolates. Twenty per cent of subjects had a detectable bacteraemia at 10 min.

post-flossing. No patient or clinical factors were significantly associated with

post-flossing bacteraemia.

CONCLUSIONS: Dental flossing can produce bacteraemia in periodontally healthy and

periodontally diseased individuals at a rate comparable with that caused by some

dental treatments for which antibiotic prophylaxis is given to prevent IE.

 

DOI: 10.1111/j.1600-051X.2008.01372.x

PMID: 19426179 [PubMed - indexed for MEDLINE]

http://www.ncbi.nlm.nih.gov/pubmed/19426179

Edited by Brett Black

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This meta-analysis concludes that there is a lack of scientific evidence to support routinely recommending flossing:

 

1. Int J Dent Hyg. 2008 Nov;6(4):265-79. doi: 10.1111/j.1601-5037.2008.00336.x.

 

The efficacy of dental floss in addition to a toothbrush on plaque and parameters

of gingival inflammation: a systematic review.

 

Berchier CE(1), Slot DE, Haps S, Van der Weijden GA.

 

Author information:

(1)School of Dental Hygiene, INHOLLAND University for Applied Sciences,

Amsterdam, The Netherlands.

 

Comment in

Int J Dent Hyg. 2008 Nov;6(4):251-2.

 

OBJECTIVES: The aim of this study was to assess systematically the adjunctive

effect of both flossing and toothbrushing versus toothbrushing alone on plaque

and gingivitis.

MATERIALS: The MEDLINE and Cochrane Central register of Controlled Trials

(CENTRAL) databases were searched through December 2007 to identify appropriate

studies. The variables of plaque and gingivitis were selected as outcomes.

RESULTS: Independent screening of titles and abstracts of 1166 MEDLINE-Pubmed and

187 Cochrane papers resulted in 11 publications that met the eligibility

criteria. Mean values and SD were collected by data extraction. Descriptive

comparisons are presented for brushing alone or brushing and flossing. A greater

part of the studies did not show a benefit for floss on plaque and clinical

parameters of gingivitis. A meta-analysis was performed for the plaque index and

gingival index.

CONCLUSIONS: The dental professional should determine, on an individual patient

basis, whether high-quality flossing is an achievable goal. In light of the

results of this comprehensive literature search and critical analysis, it is

concluded that a routine instruction to use floss is not supported by scientific

evidence.

 

DOI: 10.1111/j.1601-5037.2008.00336.x

PMID: 19138178 [PubMed - indexed for MEDLINE]

http://www.ncbi.nlm.nih.gov/pubmed/19138178

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Brett,

 

I think one of the comments on the Longecity thread about the first study (PMID: 19426179) are likely on the money. If you floss someone's teeth who regularly doesn't floss (particularly when a hygienist does it who doesn't know how hard they need to push down to get the floss between two teeth) then:

  1. There is likely to be a lot of bacteria build up between teeth.
  2. Their gums aren't used to being rubbed and so will likely bleed.

The combination will naturally lead to bacteria getting into the bloodstream. But when you floss regularly, correctly, and gently, gums don't bleed (at least that's my experience), and there is little bacteria build up to get into the bloodstream even if they did.

 

--Dean

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Brett,

 

I think one of the comments on the Longecity thread about the first study (PMID: 19426179) are likely on the money. If you floss someone's teeth who regularly doesn't floss (particularly when a hygienist does it who doesn't know how hard they need to push down to get the floss between two teeth) then:

  • There is likely to be a lot of bacteria build up between teeth.
  • Their gums aren't used to being rubbed and so will likely bleed.
The combination will naturally lead to bacteria getting into the bloodstream. But when you floss regularly, correctly, and gently, gums don't bleed (at least that's my experience), and there is little bacteria build up to get into the bloodstream even if they did.

 

--Dean

 

 

Sure, that may be a possibility, but obviously it's speculation. My past reading on these and related issues suggested to me that there is a lack of quality evidence surrounding common dental hygiene practices in general. Thus speculation and hypothesis may be necessary guiding forces unfortunately. If I recall correctly, other comments on the Longecity thread mentioned bacteremia resulting from teeth brushing and even eating. So bacteremia induction may not require unusual/unaccustomed gum stresses. Of course, even if bacteremia is a common daily occurence resulting from everyday living, that doesn't mean it's desirable. Here's a study that showed bacteremia from toothbrushing alone, with powered toothbrushing inducing more bacteremia than manual toothbrushing:

 

1. Pediatr Dent. 2002 Jul-Aug;24(4):295-9.

 

Transient bacteremia induced by toothbrushing a comparison of the Sonicare

toothbrush with a conventional toothbrush.

 

Bhanji S(1), Williams B, Sheller B, Elwood T, Mancl L.

 

Author information:

(1)Dental Medicine, Children's Hospital, Seattle, Wash, USA. shamib@hotmail.com

 

PURPOSE: Several investigations have demonstrated toothbrush-induced bacteremias.

Transient bacteremias are well tolerated by healthy individuals but may increase

endocarditis risk in patients with cardiac conditions. This study assessed

bacteremia levels after brushing with either the Sonicare electric toothbrush or

a manual toothbrush.

 

METHODS: Fifty healthy children receiving dental treatment under general

anesthesia with oral intubation were randomly assigned to a manual or Sonicare

group. Plaque levels and gingival health were scored and a blood sample

collected. Teeth were brushed for 1 minute and a postbrushing blood sample was

drawn. Samples were analyzed for aerobic and anaerobic bacterial growth.

 

RESULTS: Gingival health and plaque scores did not differ between groups. No

correlation was detected between plaque and gingival scores and occurrence of

bacteremia. The frequency of bacteremia was 46% with manual brushing: 18%

aerobic, 9% anaerobic and 73% both. This differed significantly (P = .022) with

78% bacteremias in the Sonicare group: 22% aerobic, 22% anaerobic and 56% both.

 

CONCLUSIONS: The Sonicare induced significantly more bacteremias than manual

toothbrushing. These results show that vigorous brushing increased bacteremia

from one brushing but does not answer whether bacteremia incidence would decrease

with a program of vigorous daily brushing; this should be clarified before

recommending brushing methods for patients with compromised cardiac conditions.

PMID: 12212870 [PubMed - indexed for MEDLINE]

http://www.ncbi.nlm.nih.gov/pubmed/12212870

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Brett,

 

The new Sonicare brushing study you posted (PMID 12212870) is fascinating. Obviously less than ideal, since it was done in kids (who likely don't have terrific dental hygiene) while under anesthesia (so they probably swallowed some of the bacteria, despite oral intubation). 

 

It is shocking to me that there haven't been more high quality studies done of long-term oral hygiene practices. Isn't there rigorous dental research going on, analogous to medical research?

 

It seems like it shouldn't be that hard for a dental school to conduct a 6-12 month study of a few hundred people with reasonable oral health either getting their teeth brushed and flossed by someone who knows what they are doing, or doing it themselves under supervision to make sure they are doing it right.

 

Even if it were sponsored by Proctor and Gamble or one of the manufacturers of electric toothbrushes, that would be better than nothing, analogous to drug trials sponsored by big pharma companies. As long as it was well-controlled and peer reviewed, we should be able to learn something from such a trial.

 

--Dean

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Some studies examining the evidence(or lack thereof) for routine 6-monthly dental check-ups:

 

1. Br Dent J. 2003 Jul 26;195(2):87-98; discussion 85.

 

The effectiveness of routine dental checks: a systematic review of the evidence

base.

 

Davenport CF(1), Elley KM, Fry-Smith A, Taylor-Weetman CL, Taylor RS.

 

Author information:

(1)Department of Public Health and Epidemiology, University of Birmingham,

Edgbaston, Birmingham B15 2TT. C.F.Davenport@bham.ac.uk

 

Comment in

Br Dent J. 2004 Feb 28;196(4):187; author reply 187.

Br Dent J. 2003 Jul 26;195(2):63.

 

AIMS: To systematically review the effectiveness of routine dental checks of

different recall frequencies in adults and children.

 

METHODS: Search methods included electronic bibliographic databases up to March

2001, relevant internet sites, citation checking and contact with experts and

professional dental bodies.

 

INCLUSION CRITERIA: (1) STUDY DESIGN: any; (2) POPULATION: deciduous, mixed and

permanent dentition; (3) INTERVENTION: 'Routine dental check': 'clinical

examination, advice, charting (including monitoring of periodontal status) and

report' as defined in the NHS Executive General Dental Service Statement of

Dental Remuneration; (4) Comparator: no routine dental check or routine dental

check(s) of different recall frequency; (5) PRIMARY OUTCOMES: caries, periodontal

disease, quality of life, oral cancer.

 

RESULTS: Twenty eight studies were identified for the review. Studies were poorly

reported and clinically heterogenous which restricted comparison between studies

and limited generalisability to the UK situation. There was no consistency across

multiple studies in the direction of effect of different dental check frequencies

on measures of caries in deciduous mixed or permanent dentition, periodontal

disease or oral cancer in permanent dentition. No studies were identified linking

empirical measures of quality of life associated with oral health and dental

check frequency.

 

CONCLUSIONS: There is no existing high quality evidence to support or refute the

practice of encouraging six-monthly dental checks in adults and children.

 

DOI: 10.1038/sj.bdj.4810337

PMID: 12881749 [PubMed - indexed for MEDLINE]

http://www.ncbi.nlm.nih.gov/pubmed/12881749

---

 

1. Evid Based Dent. 2005;6(3):62-3.

 

Insufficient evidence to support or refute the need for 6-monthly dental

check-ups. What is the optimal recall frequency between dental checks?

 

Mettes D(1).

 

Author information:

(1)College of Oral Sciences, Radboud University Nijmegen (formerly University of

Nijmegen) Medical Centre, Nijmegen, The Netherlands.

 

Comment on

Cochrane Database Syst Rev. 2005;(2):CD004346.

 

DATA SOURCES: Trials were sourced using the Cochrane Oral Health Group Trials

Register, the Cochrane Central Register of Controlled Trials, Medline and Embase.

Reference lists from relevant articles were scanned and the authors of some

papers were contacted to identify further trials and obtain additional

information.

 

STUDY SELECTION: Trials were selected if they met the following criteria:design:

random allocation of participants;participants: all children and adults receiving

dental check-ups in primary-care settings, irrespective of their level of risk

for oral disease;interventions: recall intervals for either clinical examination

only, clinical examination plus scale and polish, clinical examination plus

preventive advice, clinical examination plus scale and polish plus preventive

advice, no recall interval/patient-driven attendance (which may be symptomatic),

or clinician risk-based recall intervals;outcomes: clinical status outcomes for

dental caries including, but not limited to, mean dmft/DMFT, dmfs/DMFS scores,

caries increment, filled teeth (including replacement restorations), early

carious lesions (arrested or reversed); periodontal disease (including, but not

limited to, plaque, calculus, gingivitis, periodontitis, change in probing depth,

and attachment level); oral mucosa (presence or absence of mucosal lesions,

potentially malignant lesions, cancerous lesions, and size and stage of cancerous

lesions at diagnosis). In addition, the following outcomes were considered where

reported: patient-centred outcomes, economic-cost outcomes, other outcomes such

as improvements in oral health knowledge and attitudes, harms, changes in dietary

habits, and any other oral health-related behavioural change.

 

DATA EXTRACTION AND SYNTHESIS: Information regarding methods, participants,

interventions, outcome measures, and results were independently extracted, in

duplicate, by two authors. Authors were contacted, where deemed necessary and

where possible, for further details regarding study design and for data

clarification. A quality assessment of the included trial was carried out. The

Cochrane Oral Health Group's statistical guidelines were followed.

 

RESULTS: Only one study (with 188 participants) was included in this review and

was assessed as having a high risk of bias. This study provided limited data for

dental caries outcomes (dmfs/DMFS increment) and economic cost outcomes (reported

time taken to provide examinations and treatment).

 

CONCLUSIONS: There is insufficient evidence from randomised controlled trials

(RCT) to draw any conclusions regarding the potential beneficial and harmful

effects of altering the recall interval between dental check-ups. There is

insufficient evidence to support or refute the practice of encouraging patients

to attend for dental check-ups at 6-monthly intervals. It is important that high

quality RCT are conducted for the outcomes listed in this review in order to

address its objectives.

 

DOI: 10.1038/sj.ebd.6400341

PMID: 16184154 [PubMed]

http://www.ncbi.nlm.nih.gov/pubmed/16184154

---

 

1. Cochrane Database Syst Rev. 2013 Dec 19;(12):CD004346. doi:

10.1002/14651858.CD004346.pub4.

 

Recall intervals for oral health in primary care patients.

 

Riley P(1), Worthington HV, Clarkson JE, Beirne PV.

 

Author information:

(1)Cochrane Oral Health Group, School of Dentistry, The University of Manchester,

Coupland III Building, Oxford Road, Manchester, UK, M13 9PL.

 

Comment in

Evid Based Dent. 2014 Jun;15(2):40.

 

Update of

Cochrane Database Syst Rev. 2007;(4):CD004346.

 

BACKGROUND: The frequency with which patients should attend for a dental check-up

and the potential effects on oral health of altering recall intervals between

check-ups have been the subject of ongoing international debate in recent

decades. Although recommendations regarding optimal recall intervals vary between

countries and dental healthcare systems, six-monthly dental check-ups have

traditionally been advocated by general dental practitioners in many developed

countries.This is an update of a Cochrane review first published in 2005, and

previously updated in 2007.

 

OBJECTIVES: To determine the beneficial and harmful effects of different fixed

recall intervals (for example six months versus 12 months) for the following

different types of dental check-up: a) clinical examination only; b) clinical

examination plus scale and polish; c) clinical examination plus preventive

advice; d) clinical examination plus preventive advice plus scale and polish.To

determine the relative beneficial and harmful effects between any of these

different types of dental check-up at the same fixed recall interval.To compare

the beneficial and harmful effects of recall intervals based on clinicians'

assessment of patients' disease risk with fixed recall intervals.To compare the

beneficial and harmful effects of no recall interval/patient driven attendance

(which may be symptomatic) with fixed recall intervals.

 

SEARCH METHODS: The following electronic databases were searched: the Cochrane

Oral Health Group's Trials Register (to 27 September 2013), the Cochrane Central

Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 9),

MEDLINE via OVID (1946 to 27 September 2013) and EMBASE via OVID (1980 to 27

September 2013). We searched the US National Institutes of Health Trials Register

(http://clinicaltrials.gov) and the WHO International Clinical Trials Registry

Platform (http://www.who.int/ictrp/en/) for ongoing trials. Reference lists from

relevant articles were scanned and the authors of some papers were contacted to

identify further trials and obtain additional information. We did not apply any

restrictions regarding language or date of publication when searching the

electronic databases.

 

SELECTION CRITERIA: We included randomised controlled trials (RCTs) assessing the

effects of different dental recall intervals.

 

DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the

search results against the inclusion criteria of the review, extracted data and

carried out risk of bias assessment. We contacted study authors for clarification

or further information where necessary and feasible. If we had found more than

one study with similar comparisons reporting the same outcomes, we would have

combined the studies in a meta-analysis using a random-effects model if there

were at least four studies, or a fixed-effect model if there were less than four

studies. We expressed the estimate of effect as mean difference with 95%

confidence intervals (CIs) for continuous outcomes. We would have used risk

ratios with 95% CI for any dichotomous outcomes.

 

MAIN RESULTS: We included one study that analysed 185 participants. The study

compared the effects of a clinical examination every 12 months with a clinical

examination every 24 months on the outcomes of caries (decayed, missing, filled

surfaces (dmfs/DMFS) increment) and economic cost outcomes (total time used per

person). As the study was at high risk of bias, had a small sample size and only

included low-risk participants, we rated the quality of the body of evidence for

these outcomes as very low.For three to five-year olds with primary teeth, the

mean difference (MD) in dmfs increment was -0.90 (95% CI -1.96 to 0.16) in favour

of 12-month recall. For 16 to 20-year olds with permanent teeth, the MD in DMFS

increment was -0.86 (95% CI -1.75 to 0.03) also in favour of 12-month recall.

There is insufficient evidence to determine whether 12 or 24-month recall with

clinical examination results in better caries outcomes.For three to five-year

olds with primary teeth, the MD in time used by each participant was 10 minutes

(95% CI -6.7 to 26.7) in favour of 24-month recall. For 16 to 20-year olds with

permanent teeth, the MD was 23.7 minutes (95% CI 4.12 to 43.28) also in favour of

24-month recall. This single study at high risk of bias represents insufficient

evidence to determine whether 12 or 24-month recall with clinical examination

results in better time/cost outcomes.

 

AUTHORS' CONCLUSIONS: There is a very low quality body of evidence from one RCT

which is insufficient to draw any conclusions regarding the potential beneficial

and harmful effects of altering the recall interval between dental check-ups.

There is no evidence to support or refute the practice of encouraging patients to

attend for dental check-ups at six-monthly intervals. It is important that high

quality RCTs are conducted for the outcomes listed in this review in order to

address the objectives of this review.

 

DOI: 10.1002/14651858.CD004346.pub4

PMID: 24353242 [PubMed - indexed for MEDLINE]

http://www.ncbi.nlm.nih.gov/pubmed/24353242

Edited by Brett Black

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This popular press article points to both observational and interventional studies (which I haven't looked at in detail myself) suggesting that the anti-inflammatory effects of Omega-3 fats may be beneficial for preventing / reversing periodontal disease and other oral health issues.

 

Note - it mentions the Weston A. Price foundation favorably, so take it with a grain of salt...

 

--Dean

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Here is a dentist's counterpoint article to the "who needs to floss?" study, with the subtitle "America doesn’t need any excuses to slack off on dental hygiene." It talks about her own struggle with root canals and extraction which she attributes to poor dental hygiene during college. These are a couple interesting statistics I hadn't heard:

 

[T]he World Health Organization estimates that nearly 100 percent of adults worldwide have dental cavities. The CDC estimates that nearly 50 percent of Americans have some sort of gum disease.

 

She does acknowledge that:

 

Little research has been done on what oral care can tell us about one's overall health, although one study did find that tooth loss may be associated with increased coronary artery disease and another found gum disease is risk factor for coronary disease. There is also some evidence that gum disease can worsen glycemic control in people with Type 2 diabetes by exacerbating the underlying inflammatory state that aggravates insulin resistance.

 

I hadn't heard about that last one (worsening of glycemic control), and since it is something many of us care a lot about. Here is the reference [1]. The review paper doesn't talk about oral hygiene per se, but simply the (likely bi-directional) link between periodontal disease and diabetes.

 

Here is the conclusion of the dentist's article:

 

Future research in the realm of oral health could work toward better establishing the benefits of cleaning between your teeth. But for now we don’t need a large body of evidence to tell us that flossing could help alleviate bacteria that contributes to plaque buildup and subsequent tooth and gum disease. Taking a few seconds to floss every night is well worth it to save you from the risk of tooth loss.

 

--Dean

 

-------

[1] J Can Dent Assoc. 2010;76:a35.

 
Impact of periodontitis on the diabetes-related inflammatory status.
 
Santos Tunes R(1), Foss-Freitas MC, Nogueira-Filho Gda R.
 
Author information: 
(1)School of Dentistry of Bahiana Medical School and Public Health, Salvador,
Brazil.
 
 
Wide-ranging activation of the innate immune system causing chronic low-grade
inflammation is closely involved not only in the pathogenesis of type 2 diabetes 
mellitus and its complications, through an ongoing cytokine-induced acute-phase
response, but also in the pathogenesis of periodontal diseases, whereby cytokines
play a central role in the host's response to the periodontal biofilm. Although
there is extensive knowledge about the pathways through which diabetes affects
periodontal status, less is known about the impact of periodontal diseases on the
diabetes-related inflammatory state. This review attempts to explain the
immunobiological connection between periodontal diseases and type 2 diabetes
mellitus, exploring the mechanisms through which periodontal infection can
contribute to the low-grade general inflammation associated with diabetes (thus
aggravating insulin resistance) and discussing the impact of periodontal
treatment on glycemic control in people living with both diabetes and periodontal
disease.
 
PMID: 20831852

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