Flossing 101: The Case For Floss

The first concepts of floss can be traced back to ancient Egypt and Rome, where various natural materials like twigs and branches were utilized to clean between the teeth. Formally, dental floss was invented by Levi Parmly in 1815, after expressing concern about the lack of cleaning on the approximate surfaces of the teeth. Despite Parmly’s ideas, floss was not widespread until long after World War II, as prior to nylon floss’ development, toothpicks were more commonly utilized amongst Victorians of that era. Since the 19th century, dentistry has evolved to incorporate natural silk as floss. This further progressed into the introduction of nylon floss by Dr. Charles C. Bass after World War II. Nylon serves as the world’s second most common textile, and its strength, durability, lubricability, temperature resistance, and abrasion shielding helped it become one of the leading materials of floss.

Today, the market sees a wide variety of dental floss brands, incorporating various materials that cause changes in elasticity, texture, and ease of use. Overall, dentists recommend any type of floss, as long as the marked logo for the American Dental Association (ADA) is present, ensuring quality. Floss has expanded from just a single strand of nylon fiber to incorporating many strands, Gore-Tex fabric, electric flossers, floss picks, and water picks.

2. Scientific Evidence of the Benefits of Flossing

Flossing is used primarily to clean plaque in areas of the teeth that a conventional toothbrush can’t reach. Made up of bacteria and food particles, dental plaque is a sticky biofilm that develops on surfaces of teeth, as well as synthetic prosthetics like crowns and dentures. If left untreated, plaque can cause gingivitis, or inflammation of the gums, which can lead to more severe forms of gum disease. Studies indicate that flossing in conjunction with daily brushing can work to reverse gingivitis, but, if the plaque remains uncleaned for an extended period of time, calculus that builds up from hardened plaque that’s absorbed the calcium from saliva will need to be removed by a dental professional.

Furthermore, studies have demonstrated that in tandem with mouthwash, a random selection of patients under supervised flossing who underwent a 12 week clinical trial saw significant improvement and reversal in gingivitis compared to control groups who only underwent daily brushing.

3. Understanding what Floss Is

After the development of nylon floss, companies expanded on the materials and structure of floss. In general, however, most brands of floss can be categorized into groups based on their lament, presence of wax, and source of material.

Monofilament floss serves as a single strand of floss, whilst multifilament floss is composed of interwoven strands of various materials. Unwaxed floss is generally thinner than waxed nylon floss, and is made up of 35 strands twisting together. Studies suggest that unwaxed floss can fit into tighter spaces of teeth, but remains more prone to “shredding or breaking.” This is opposed to waxed floss which, although sturdier and less likely to break, can be more difficult to use in tighter spaces. Physical limitations, injury, and ease of use are all factors that one should consider when choosing the right floss.

Natural flosses are composed of silk generally, whilst synthetic flosses can range from the common textile nylon, to Polytetrafluorethylene (PTFE) floss which is the same material used in Gore-Tex fabric that protects against water loss. There have been studies demonstrating that PTFE floss allows for increased elongation and elasticity, combined with the less likelihood of shredding after use. On the other hand, traditional nylon floss is overall more sturdy, but provides an increased difficulty of usage with higher friction.

So what floss is best for you? Overall, dentists claim that any type of floss is better than not flossing at all. However, to ensure the best plaque removal and prevention of gingivitis, research has been done comparing various brands of floss across different patients. Slight adjustments in patient preferences outweighs the minimal differences in plaque reduction and gingivitis prevention amongst the patients, and the results indicate that patients with larger gaps between their teeth may prefer alternatives to traditional floss such as dental tape or Super Floss. Dental tape is a broader, fatter version of standard floss with unwaxed and waxed versions, which may be beneficial to help increase the surface area of the cleaning device for people with larger gaps. Similarly, super floss has stiffer, yarn-like ends that are best for cleaning around braces and other dental prosthetics that may make traditional dental floss difficult to use.

Overall, the best floss should be comfortable to use while providing a proper cleaning of plaque between teeth.

4. On The Hazards of Floss

Little discussion has arisen on any toxic consequences of flossing. A study, however, in 2019 showcased increased concentrations of PFAS–a Flouropolymer coating that helps resist water and oil—in certain demographics of middle aged, non-Hispanic white women. Studies have displayed that PFAs have had notable potential toxic outcomes, including changes in cholesterol, birthweight, and immune response.

These results were more correlated with Oral-B Glide floss. A large caveat to these studies, though, is seen with the influence of external factors correlating to similarities between patients with negative results. Patients which showcased an increase in toxic PFASs concentrations also exhibited stain-resistant carpet or furniture in households, lived in a city with “PFAS-contaminated drinking water supply”, and consumed products from “coated cardboard containers.”

Some dentists believe that in spite of the intense correlation of these external factors, these results correlate Oral-B with a meaningful increase to PFASs.

5. Do We Really Need to Floss Everyday?

Debate has always surrounded the necessity of flossing everyday. The nature of this argument lies within the notable lack of proper scientific research on the concrete benefits of flossing. A major source to the lack of structured research is the time frame that periodontitis needs to develop– periodontitis may take up to several years to develop from plaque to a serious gum disease. As such, most studies on flossing have been smaller-scale studies over a shorter range of time. In addition, the lack of research can also be credited towards the inability to monitor large populations for accurate measurements– unlike traditional medication, it can be difficult to determine consistent usage of flossing in research subjects.

Of these studies, many also showcase that flossing still remains underutilized by much of the American population. Between 2011-2014, studies have described flossing to be prevalent only amongst “ 32% of adults aged 30 years and older” and that only “26% of men, and 37% of women floss daily.”

This lack of widespread flossing can be attributed to several factors. Most notably, flossing requires a much harder physical technique compared to simply brushing teeth. To properly remove approximal plaque, subjects should wrap at least 18” of floss around their index fingers and use their thumb to guide it into spaces between teeth. Forming a “C” shape around the tooth, people should lift up a few times in order to drive the plaque up and out of the tooth, and remove any lasting gingival sulcus. This should be followed by moving to a new area of floss, as food particles and bacteria are often trapped on used portions of floss.

Difficulty flossing is the main reason why people stray away from consistent flossing. Dentists recommend to people who have physical limitations or dental prosthetics that inhibit traditional floss to look into alternatives such as water picks, which shoot streams of water to remove plaque, or superfloss. Studies have shown both of these options have equal if not better percentages of plaque removal, and the ability to prevent gum disease.

Overall, dentists still recommend daily flossing. Even without large-scale research that showcases hard statistical evidence for flossing, nearly all dentists claim that a lack of flossing in patients is easy to see and that brushing alone generally trends towards higher risk of periodontitis and other forms of tooth and gum decay.

6. Conclusion

Flossing has been a staple recommendation by dentists ever since its invention and scientific evidence has supported the use of floss in the prevention of gum disease and plaque build up. For individuals who have difficulty flossing everyday, either due to physical limitations or ease of use from orthodontic ailments, alternatives are widely available across the market. These alternatives have been proven by research to be equally as effective as traditional floss, which already comes in several different options for different tooth structures.

Although there has been stirs of risk of PFASs increase in flossing across certain demographics, these risks are also strongly correlated with external factors outside of floss. Dentists strongly believe that the benefits of flossing heavily outweigh the minor risks that showcase confounding variables and low rates of occurring.