The evidence on flossing and other methods of cleaning between the teeth

Tooth decay and gum diseases affect most people. They can cause pain, difficulties with eating and speaking, low self-esteem, and, in extreme cases, may lead to tooth loss and the need for surgery. The cost to health services of treating these diseases is very high.

As dental plaque is the root cause, it is important to remove plaque from teeth on a regular basis. While many people routinely brush their teeth to remove plaque up to the gum line, it is difficult for toothbrushes to reach into areas between teeth (‘interdental’), so interdental cleaning is often recommended as an extra step in personal oral hygiene routines. Different tools can be used for interdental cleaning, such as dental floss, interdental brushes, tooth cleaning sticks, and water pressure devices known as oral irrigators. Continue reading

No conclusion is possible on the best methods of delivering one-to-one oral hygiene advice

Dentist using props to show a patient how to brush her teethPoor oral hygiene habits are known to be associated with high rates of dental decay and gum disease. The dental team routinely assesses oral hygiene methods, frequency and effectiveness or otherwise of oral hygiene routines carried out by their patients. Oral hygiene routines can include toothbrushing, reducing sugar intake, interdental cleaning with floss or interdental brushes, and using a fluoride mouthwash or dentifrice. One-to-one oral hygiene advice is regularly provided by members of the dental team with the aim of motivating individuals and improving their oral health. The most effective method of delivering one-to-one advice in the dental setting is unclear. This review’s aim is to determine if providing patients with one-to-one oral hygiene advice in the dental setting is effective, and if so what is the best way to deliver this advice. Continue reading

Review of the Month: To floss or not to floss, that is the question…

634px-Dental_floss_(whole)In honour of National Smile Month (May 20 to June 20, 2013), the Cochrane Oral Health Group Review of the Month is Flossing for the management of periodontal diseases and dental caries in adults. Does using dental floss every day help to prevent gum diseases like periodontitis, and tooth decay?

What was the research?

A systematic review of the evidence to find out whether using dental floss in addition to brushing teeth helps to prevent gum disease and tooth decay in adults.

Who conducted the research?

The research was conducted by a team led by Dario Sambunjak from the School of Medicine at the University of Split in Croatia, on behalf of the Cochrane Oral Health Group. Jason W Nickerson, Tina Poklepovic, Trevor M Johnson, Pauline Imai, Peter Tugwell and Helen V Worthington were also on the team.

What evidence was included in the review?

Data was extracted from 12 randomised controlled trials, which had included 1,083 people as participants. The trials looked at using dental floss plus toothbrushing compared with toothbrushing alone.

What did the evidence say?

There is evidence from 12 trials that flossing reduces gum disease. There is very weak evidence that flossing plus toothbrushing may reduce the amount of plaque (a biofilm caused by bacteria) in your mouth, but no trials reported on whether flossing prevents tooth decay.

How good was the evidence?

The trials were generally consistent in their findings, but the reporting of the methods in some cases was not clear enough to decide whether or not there was bias. The quality of the evidence was generally low.

What are the implications for dentists and the general public?

Despite the uncertain or low quality of most of the studies, these results support the use of regular flossing with toothbrushing.

What should researchers look at in the future?

Well designed and conducted randomised controlled trials are needed, specifically trials which run for longer periods. Trials which run for longer than three months may help to determine whether flossing prevents tooth decay.


Sambunjak D, Nickerson JW, Poklepovic T, Johnson TM, Imai P, Tugwell P, Worthington HV. Flossing for the management of periodontal diseases and dental caries in adults. Cochrane Database of Systematic Reviews 2011 , Issue 12 . Art. No.: CD008829. DOI: 10.1002/14651858.CD008829.pub2

New publications by the Cochrane Oral Health Group in Issue 12 of the Cochrane Library for 2011

Issue 12 of the Cochrane Library for 2011 has been published – the final edition of the year. It was a bumper month for the Cochrane Oral Health Group. We published three brand new reviews:

Flossing for the management of periodontal diseases and dental caries in adults by Dario Sambunjak, Jason W. Nickerson, Tina Poklepovic, Trevor M Johnson, Pauline Imai, Peter Tugwell, Helen V Worthington

The review included 12 trials with a total of 1083 participants. It found that overall there is weak, unreliable evidence to suggest that flossing plus toothbrushing is associated with a small reduction in plaque after 1 or 3 months. However, the trials were generally of poor quality and conclusions are therefore unreliable.

Fluoride supplements (tablets, drops, lozenges or chewing gums) for preventing dental caries in children by Stéphanie Tubert-Jeannin, Candy Auclair, Emmanuel Amsallem, Paul Tramini, Laurent Gerbaud,
Christiane Ruffieux, Andreas G Schulte, Martin J Koch, Myriam Rège-Walther, Amid Ismail

11 studies were included in this review, involving 7,196 children. The review found that no conclusion could be reached about the effectiveness of  supplemental fluoride treatments in preventing tooth decay in young children with deciduous teeth.

Interventions for the management of dry mouth: topical therapies by Susan Furness, Helen V Worthington, Gemma Bryan, Sarah Birchenough, Roddy McMillan

36 trials were included, with 1597 participants. The review found that there is no strong evidence that any one topical therapy is effective for relieving the symptoms of dry mouth. It did find some differences between treatments: for example, oxygenated glycerol triester spray used as a saliva substitute was more effective than a water based electrolyte spray. Chewing gum and mouthcare systems are also evaluated in this review.

Other highlights of the Cochrane Library, Issue 12 for 2011:

This is the last issue of the Cochrane Library for 2011! The next publication date is 18 January 2012. Merry Christmas and a happy new year to all our authors, referees and contributors. Let’s make 2012 a successful year for the Oral Health Group.