Dentalcare logo

A String around Your Finger: Do We Really Need to Floss?

Course Number: 550

Take the Test

References / Additional Resources

  1. US Department of Health and Human Services. Previous Dietary Guidelines. Accessed November 3, 2021.

  2. Sambunjak D, Nickerson JW, Poklepovic T, et al. Flossing for the management of periodontal diseases and dental caries in adults. Cochrane Database Syst Rev. 2011 Dec 7;(12):CD008829. doi: 10.1002/14651858.CD008829.pub2. Update in: Cochrane Database Syst Rev. 2019 Apr 23;4:CD008829.

  3. National Institute of Dental and Craniofacial Research. Accessed November 3, 2021.

  4. Centers for Disease Control and Prevention. Oral Health. Accessed November 3, 2021.

  5. Office of Disease Prevention and Health Promotion. Healthy People 2020. Accessed November 3, 2021.

  6. European Federation of Periodontology. Iain Chapple: flossing of no benefit to periodontitis patients. 2015 Aug 28. Accessed November 3, 2021.

  7. Chapple IL, Van der Weijden F, Doerfer C, et al. Primary prevention of periodontitis: managing gingivitis. J Clin Periodontol. 2015 Apr;42 Suppl 16:S71-6. doi: 10.1111/jcpe.12366.

  8. ADA. Government, ADA recognize importance of flossing. ADA News. 2016 Aug 02. Accessed November 3, 2021.

  9. Cho I, Blaser MJ. The human microbiome: at the interface of health and disease. Nat Rev Genet. 2012 Mar 13;13(4):260-70. doi: 10.1038/nrg3182.

  10. Lourenço TG, Heller D, Silva-Boghossian CM, et al. Microbial signature profiles of periodontally healthy and diseased patients. J Clin Periodontol. 2014 Nov;41(11):1027-36. doi: 10.1111/jcpe.12302. Epub 2014 Sep 22.

  11. Mombelli A. Microbial colonization of the periodontal pocket and its significance for periodontal therapy. Periodontol 2000. 2018 Feb;76(1):85-96. doi: 10.1111/prd.12147. Epub 2017 Nov 30.

  12. Tanner ACR, Kressirer CA, Rothmiller S, et al. The Caries Microbiome: Implications for Reversing Dysbiosis. Adv Dent Res. 2018 Feb;29(1):78-85. doi: 10.1177/0022034517736496.

  13. Nyvad B, Crielaard W, Mira A, et al. Dental caries from a molecular microbiological perspective. Caries Res. 2013;47(2):89-102. doi: 10.1159/000345367. Epub 2012 Nov 30.

  14. ADA. Mouth Healthy. Flossing. Accessed November 3, 2021.

  15. ADA. American Dental Association Statement on Regular Brushing and Flossing to Help Prevent Oral Infections. News Releases. August 22, 2013. Accessed November 3, 2021.

  16. Kaiser M. How long does the average person brush? Dentistry IQ. Academy of General Dentistry. September 30, 2014. Accessed November 3, 2021.

  17. Bader HI. Floss or die: implications for dental professionals. Dent Today. 1998 Jul;17(7):76-8, 80-2.

  18. U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015 – 2020 Dietary Guidelines for Americans. 8th Edition. December 2015. Accessed November 3, 2021.

  19. Saint Louis C. Feeling Guilty About Not Flossing? Maybe There’s No Need. The New York Times. August 2, 2016. Accessed November 3, 2021.

  20. Gumpert K. One-fourth of Americans lie to dentists about flossing: survey. Rueters. June 23, 2015. Accessed November 3, 2021.

  21. Southam JD, Soames JV. Dental Caries (Ch 2). Oral Pathology Oxford, Oxford University Press. 1993.

  22. 48th ORCA Congress. Caries Research, 2001; 35(4), 265-316.

  23. Ten Cate JM. In vitro studies on the effects of fluoride on de- and remineralization. J Dent Res. 1990 Feb;69 Spec No:614-9; discussion 634-6. doi: 10.1177/00220345900690S120.

  24. Abou Neel EA, Aljabo A, Strange A, et al. Demineralization-remineralization dynamics in teeth and bone. Int J Nanomedicine. 2016 Sep 19;11:4743-4763. doi: 10.2147/IJN.S107624.

  25. Griffin SO, Jones K, Tomar SL. An economic evaluation of community water fluoridation. J Public Health Dent. 2001 Spring;61(2):78-86. doi: 10.1111/j.1752-7325.2001.tb03370.x.

  26. CDC. National Center for Health Statistics. Prevalence of Total and Untreated Dental Caries Among Youth: United States, 2015–2016. NCHS Data Brief No. 307, April 2018. Accessed November 3, 2021.

  27. CDC. National Center for Health Statistics. Oral and Dental Health FastStats. Accessed November 3, 2021.

  28. NIH. Dental Caries (Tooth Decay) in Adults (Age 20 to 64). Accessed November 3, 2021.

  29. Yeh DY, Kuo HC, Yang YH, Ho PS. The Responsiveness of Patients' Quality of Life to Dental Caries Treatment-A Prospective Study. PLoS One. 2016 Oct 24;11(10):e0164707. doi: 10.1371/journal.pone.0164707.

  30. Waldman HB. Another perspective on children's dental needs and demand for services during the 1980s. ASDC J Dent Child. 1987 Sep-Oct;54(5):344-8.

  31. Jackson SL, Vann WF Jr, Kotch JB, et al. Impact of poor oral health on children's school attendance and performance. Am J Public Health. 2011 Oct;101(10):1900-6. doi: 10.2105/AJPH.2010.200915. Epub 2011 Feb 17.

  32. Kelekar U, Naavaal S. Hours Lost to Planned and Unplanned Dental Visits Among US Adults. Prev Chronic Dis. 2018 Jan 11;15:E04. doi: 10.5888/pcd15.170225.

  33. CDC. 2008 National Health Interview Survey (NHIS) Public Use Data Release. NHIS Survey Description. June 2009. Accessed November 3, 2021.

  34. AAP. Glossary of Periodontal Terms. Accessed November 3, 2021.

  35. Chapple ILC, Mealey BL, Van Dyke TE, et al. Periodontal health and gingival diseases and conditions on an intact and a reduced periodontium: Consensus report of workgroup 1 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. J Periodontol. 2018 Jun;89 Suppl 1:S74-S84. doi: 10.1002/JPER.17-0719.

  36. Kornman KS, Page RC, Tonetti MS. The host response to the microbial challenge in periodontitis: assembling the players. Periodontol 2000. 1997 Jun;14:33-53. doi: 10.1111/j.1600-0757.1997.tb00191.x.

  37. Papapanou PN, Sanz M, Buduneli N, et al. Periodontitis: Consensus report of workgroup 2 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. J Periodontol. 2018 Jun;89 Suppl 1:S173-S182. doi: 10.1002/JPER.17-0721.

  38. Needleman I, Garcia R, Gkranias N, et al. Mean annual attachment, bone level, and tooth loss: A systematic review. J Periodontol. 2018 Jun;89 Suppl 1:S120-S139. doi: 10.1002/JPER.17-0062.

  39. Tonetti MS, Greenwell H, Kornman KS. Staging and grading of periodontitis: Framework and proposal of a new classification and case definition. J Periodontol. 2018 Jun;89 Suppl 1:S159-S172. doi: 10.1002/JPER.18-0006. Erratum in: J Periodontol. 2018 Dec;89(12):1475.

  40. Eke PI, Thornton-Evans GO, Wei L, et al. Periodontitis in US Adults: National Health and Nutrition Examination Survey 2009-2014. J Am Dent Assoc. 2018 Jul;149(7):576-588.e6. doi: 10.1016/j.adaj.2018.04.023.

  41. CDC. National Diabetes Statistics Report 2020. Estimates of Diabetes and its Burden in the United States. Accessed December 7, 2021.

  42. CDC. Heart Disease Facts. Accessed November 3, 2021.

  43. Löe H, Anerud A, Boysen H, Smith M. The natural history of periodontal disease in man. The rate of periodontal destruction before 40 years of age. J Periodontol. 1978 Dec;49(12):607-20. doi: 10.1902/jop.1978.49.12.607.

  44. Michalowicz BS, Aeppli DP, Kuba RK, et al. A twin study of genetic variation in proportional radiographic alveolar bone height. J Dent Res. 1991 Nov;70(11):1431-5. doi: 10.1177/00220345910700110701.

  45. Michalowicz BS, Aeppli D, Virag JG, et al. Periodontal findings in adult twins. J Periodontol. 1991 May;62(5):293-9. doi: 10.1902/jop.1991.62.5.293.

  46. Kornman KS, Crane A, Wang HY, et al. The interleukin-1 genotype as a severity factor in adult periodontal disease. J Clin Periodontol. 1997 Jan;24(1):72-7. doi: 10.1111/j.1600-051x.1997.tb01187.x.

  47. Winning L, Linden G. Periodontitis and systemic disease. BDJ Team 2, 15163 (2015). doi: 10.1038/bdjteam.2015.163. Accessed November 3, 2021.

  48. Perls T. Living to 100 Life Expectancy Calculator. Boston University. Accessed November 3, 2021.

  49. Paganini-Hill A, White SC, Atchison KA. Dental health behaviors, dentition, and mortality in the elderly: the leisure world cohort study. J Aging Res. 2011;2011:156061. doi: 10.4061/2011/156061. Epub 2011 Jun 15.

  50. Jamie Holmes. Flossing and the Art of Scientific Investigation. Gray Matter. The New York Times. November 25, 2016. Accessed November 3, 2021.

  51. Löe H, Von der Fehr FR, Schiött CR. Inhibition of experimental caries by plaque prevention. The effect of chlorhexidine mouthrinses. Scand J Dent Res. 1972;80(1):1-9. doi: 10.1111/j.1600-0722.1972.tb00257.x.

  52. Axelsson P, Lindhe J. Effect of controlled oral hygiene procedures on caries and periodontal disease in adults. J Clin Periodontol. 1978 May;5(2):133-51. doi: 10.1111/j.1600-051x.1978.tb01914.x.

  53. Theilade E, Wright WH, Jensen SB, Löe H. Experimental gingivitis in man. II. A longitudinal clinical and bacteriological investigation. J Periodontal Res. 1966;1:1-13. doi: 10.1111/j.1600-0765.1966.tb01842.x.

  54. Löe H. Oral hygiene in the prevention of caries and periodontal disease. Int Dent J. 2000 Jun;50(3):129-39. doi: 10.1111/j.1875-595x.2000.tb00553.x.

  55. Santos A. Evidence-based control of plaque and gingivitis. J Clin Periodontol. 2003;30 Suppl 5:13-6. doi: 10.1034/j.1600-051x.30.s5.5.x.

  56. Kressin NR, Boehmer U, Nunn ME, Spiro A 3rd. Increased preventive practices lead to greater tooth retention. J Dent Res. 2003 Mar;82(3):223-7. doi: 10.1177/154405910308200314.

  57. Jepsen S, Blanco J, Buchalla W, et al. Prevention and control of dental caries and periodontal diseases at individual and population level: consensus report of group 3 of joint EFP/ORCA workshop on the boundaries between caries and periodontal diseases. J Clin Periodontol. 2017 Mar;44 Suppl 18:S85-S93. doi: 10.1111/jcpe.12687.

  58. Merchant A, Pitiphat W, Douglass CW, et al. Oral hygiene practices and periodontitis in health care professionals. J Periodontol. 2002 May;73(5):531-5. doi: 10.1902/jop.2002.73.5.531.

  59. American Academy of General Dentistry. Know Your Teeth. Should I Floss? Accessed November 3, 2021.

  60. American Academy of Periodontology. Statement from the AAP on flossing efficacy. August 2, 2016.

  61. US Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. National Institutes of Health. Rockville, MD. 2000. Accessed November 3, 2021.

  62. Thornton-Evans G, Junger ML, Lin M, Wei L, Espinoza L, Beltran-Aguilar E. Use of Toothpaste and Toothbrushing Patterns Among Children and Adolescents - United States, 2013-2016. MMWR Morb Mortal Wkly Rep. 2019 Feb 1;68(4):87-90. doi: 10.15585/mmwr.mm6804a3.

  63. Delta Dental. 2014 Oral Health and Well-Being Survey. Accessed November 3, 2021.

  64. Wainwright J, Sheiham A. An analysis of methods of toothbrushing recommended by dental associations, toothpaste and toothbrush companies and in dental texts. Br Dent J. 2014 Aug;217(3):E5. doi: 10.1038/sj.bdj.2014.651.

  65. Ebel S, Blättermann H, Weik U, Margraf-Stiksrud J, Deinzer R. High Plaque Levels after Thorough Toothbrushing: What Impedes Efficacy? JDR Clin Trans Res. 2019 Apr;4(2):135-142. doi: 10.1177/2380084418813310. Epub 2018 Nov 14.

  66. Carroll GC, Sebor RJ. Dental flossing and its relationship to transient bacteremia. J Periodontol. 1980 Dec;51(12):691-2. doi: 10.1902/jop.1980.51.12.691.

  67. Fleming EB, Nguyen D, Afful J, Carroll MD, Woods PD. Prevalence of daily flossing among adults by selected risk factors for periodontal disease-United States, 2011-2014. J Periodontol. 2018 Aug;89(8):933-939. doi: 10.1002/JPER.17-0572.

  68. Hamilton K, Bonham M, Bishara J, Kroon J, Schwarzer R. Translating Dental Flossing Intentions into Behavior: a Longitudinal Investigation of the Mediating Effect of Planning and Self-Efficacy on Young Adults. Int J Behav Med. 2017 Jun;24(3):420-427. doi: 10.1007/s12529-016-9605-4.

  69. Liu B, Faller LL, Klitgord N, et al. Deep sequencing of the oral microbiome reveals signatures of periodontal disease. PLoS One. 2012;7(6):e37919. doi: 10.1371/journal.pone.0037919. Epub 2012 Jun 4.

  70. Arweiler NB, Auschill TM, Sculean A. Patient self-care of periodontal pocket infections. Periodontol 2000. 2018 Feb;76(1):164-179. doi: 10.1111/prd.12152. Epub 2017 Dec 1.

  71. Straub AM, Salvi GE, Lang NP. Supragingival plaque formation in the human dentition. Lang NP, Ättstrom R, Löe H. Proceedings of the European workshop on mechanical plaque removal. Quinessence, Chicago; 1998.

  72. van der Weijden GA, Hioe KP. A systematic review of the effectiveness of self-performed mechanical plaque removal in adults with gingivitis using a manual toothbrush. J Clin Periodontol. 2005;32 Suppl 6:214-28. doi: 10.1111/j.1600-051X.2005.00795.x.

  73. Van der Weijden GA, Timmerman MF, et al. A comparative study of electric toothbrushes for the effectiveness of plaque removal in relation to toothbrushing duration. Timerstudy. J Clin Periodontol. 1993 Aug;20(7):476-81. doi: 10.1111/j.1600-051x.1993.tb00394.x.

  74. Ganss C, Schlueter N, Preiss S, Klimek J. Tooth brushing habits in uninstructed adults—frequency, technique, duration and force. Clin Oral Investig. 2009 Jun;13(2):203-8. doi: 10.1007/s00784-008-0230-8. Epub 2008 Oct 14.

  75. Macgregor ID, Rugg-Gunn AJ. Toothbrushing duration in 60 uninstructed young adults. Community Dent Oral Epidemiol. 1985 Jun;13(3):121-2. doi: 10.1111/j.1600-0528.1985.tb00423.x.

  76. Bass CC. An effective method of personal oral hygiene. J La State Med Soc. 1954 Feb;106(2):57-73; contd.

  77. Gilson CM, Charbeneau GT, Hill HC. A comparison of physical properties of several soft toothbrushes. J Mich State Dent Assoc. 1969 Nov;51(11):347-61.

  78. Van der Weijden GA, Timmerman MF, Danser MM, Van der Velden U. Relationship between the plaque removal efficacy of a manual toothbrush and brushing force. J Clin Periodontol. 1998 May;25(5):413-6. doi: 10.1111/j.1600-051x.1998.tb02464.x.

  79. Deery C, Heanue M, Deacon S, et al. The effectiveness of manual versus powered toothbrushes for dental health: a systematic review. J Dent. 2004 Mar;32(3):197-211. doi: 10.1016/j.jdent.2003.11.006.

  80. Deacon SA, Glenny AM, Deery C, et al. Different powered toothbrushes for plaque control and gingival health. Cochrane Database Syst Rev. 2010 Dec 8;2010(12):CD004971. doi: 10.1002/14651858.CD004971.pub2.

  81. Warren PR, Ray TS, Cugini M, Chater BV. A practice-based study of a power toothbrush: assessment of effectiveness and acceptance. J Am Dent Assoc. 2000 Mar;131(3):389-94. doi: 10.14219/jada.archive.2000.0183.

  82. Drisko CL. Periodontal self-care: evidence-based support. Periodontol 2000. 2013 Jun;62(1):243-55. doi: 10.1111/prd.12012.

  83. Gjermo P, Flötra L. The plaque removing effect of dental floss and toothpicks a group-comparison study. J Periodontal Res. 1969;4(2):170.

  84. Biesbrock A, Corby PM, Bartizek R, et al. Assessment of treatment responses to dental flossing in twins. J Periodontol. 2006 Aug;77(8):1386-91. doi: 10.1902/jop.2006.050399.

  85. Corby PM, Biesbrock A, Bartizek R, et al. Treatment outcomes of dental flossing in twins: molecular analysis of the interproximal microflora. J Periodontol. 2008 Aug;79(8):1426-33. doi: 10.1902/jop.2008.070585.

  86. Axelsson P, Nyström B, Lindhe J. The long-term effect of a plaque control program on tooth mortality, caries and periodontal disease in adults. Results after 30 years of maintenance. J Clin Periodontol. 2004 Sep;31(9):749-57. doi: 10.1111/j.1600-051X.2004.00563.x.

  87. Hellström MK, Ramberg P, Krok L, Lindhe J. The effect of supragingival plaque control on the subgingival microflora in human periodontitis. J Clin Periodontol. 1996 Oct;23(10):934-40. doi: 10.1111/j.1600-051x.1996.tb00514.x.

  88. Cepeda MS, Weinstein R, Blacketer C, Lynch MC. Association of flossing/inter-dental cleaning and periodontitis in adults. J Clin Periodontol. 2017 Sep;44(9):866-871. doi: 10.1111/jcpe.12765. Epub 2017 Aug 7.

  89. Walsh MM, Heckman BL. Interproximal subgingival cleaning by dental floss and the toothpick. Dent Hyg (Chic). 1985 Oct;59(10):464-7.

  90. Graves RC, Disney JA, Stamm JW. Comparative effectiveness of flossing and brushing in reducing interproximal bleeding. J Periodontol. 1989 May;60(5):243-7. doi: 10.1902/jop.1989.60.5.243.

  91. Barendregt DS, Timmerman MF, van der Velden U, van der Weijden GA. Comparison of the bleeding on marginal probing index and the Eastman interdental bleeding index as indicators of gingivitis. J Clin Periodontol. 2002 Mar;29(3):195-200. doi: 10.1034/j.1600-051x.2002.290302.x.

  92. Macgregor ID, Balding JW, Regis D. Flossing behaviour in English adolescents. J Clin Periodontol. 1998 Apr;25(4):291-6. doi: 10.1111/j.1600-051x.1998.tb02443.x.

  93. Mazhari F, Boskabady M, Moeintaghavi A, Habibi A. The effect of toothbrushing and flossing sequence on interdental plaque reduction and fluoride retention: A randomized controlled clinical trial. J Periodontol. 2018 Jul;89(7):824-832. doi: 10.1002/JPER.17-0149. Epub 2018 Jul 20.

  94. Kinane DF. The role of interdental cleaning in effective plaque control: need for interdental cleaning in primary and secondary prevention. Lang NP, Ättstrom R, Löe H. Proceedings of the European workshop on mechanical plaque control. Quintessence, Chicago, 1998.

  95. Bergenholtz A, Olsson A. Efficacy of plaque-removal using interdental brushes and waxed dental floss. Scand J Dent Res. 1984 Jun;92(3):198-203. doi: 10.1111/j.1600-0722.1984.tb00879.x.

  96. Kiger RD, Nylund K, Feller RP. A comparison of proximal plaque removal using floss and interdental brushes. J Clin Periodontol. 1991 Oct;18(9):681-4. doi: 10.1111/j.1600-051x.1991.tb00109.x.

  97. Noorlin I, Watts TL. A comparison of the efficacy and ease of use of dental floss and interproximal brushes in a randomised split mouth trial incorporating an assessment of subgingival plaque. Oral Health Prev Dent. 2007;5(1):13-8.

  98. Lee JY, Park HJ, Lee HJ, Cho HJ. The use of an interdental brush mitigates periodontal health inequalities: the Korean National Health and nutrition examination survey (KNHANES). BMC Oral Health. 2019 Jul 29;19(1):168. doi: 10.1186/s12903-019-0858-6.

  99. Goyal CR, Lyle DM, Qaqish JG, Schuller R. Comparison of Water Flosser and Interdental Brush on Reduction of Gingival Bleeding and Plaque: A Randomized Controlled Pilot Study. J Clin Dent. 2016 Jun;27(2):61-65.

  100. Slot DE, Dörfer CE, Van der Weijden GA. The efficacy of interdental brushes on plaque and parameters of periodontal inflammation: a systematic review. Int J Dent Hyg. 2008 Nov;6(4):253-64. doi: 10.1111/j.1601-5037.2008.00330.x.

  101. Hoenderdos NL, Slot DE, Paraskevas S, Van der Weijden GA. The efficacy of woodsticks on plaque and gingival inflammation: a systematic review. Int J Dent Hyg. 2008 Nov;6(4):280-9. doi: 10.1111/j.1601-5037.2008.00335.x.

  102. Lewis MW, Holder-Ballard C, Selders RJ Jr, et al. Comparison of the use of a toothpick holder to dental floss in improvement of gingival health in humans. J Periodontol. 2004 Apr;75(4):551-6. doi: 10.1902/jop.2004.75.4.551.

  103. Cronin MJ, Dembling WZ, Cugini M, Thompson MC, Warren PR. A 30-day clinical comparison of a novel interdental cleaning device and dental floss in the reduction of plaque and gingivitis. J Clin Dent. 2005;16(2):33-7.

  104. Poli PP, Cicciu M, Beretta M, Maiorana C. Peri-Implant Mucositis and Peri-Implantitis: A Current Understanding of Their Diagnosis, Clinical Implications, and a Report of Treatment Using a Combined Therapy Approach. J Oral Implantol. 2017 Feb;43(1):45-50. doi: 10.1563/aaid-joi-D-16-00082. Epub 2016 Oct 19.

  105. World Dental Federation (FDI). Oral Health Worldwide: A report by the FDI World Dental Federation. Accessed November 3, 2021.

  106. Jönsson B, Ohrn K, Oscarson N, Lindberg P. An individually tailored treatment programme for improved oral hygiene: introduction of a new course of action in health education for patients with periodontitis. Int J Dent Hyg. 2009 Aug;7(3):166-75. doi: 10.1111/j.1601-5037.2008.00350.x.

  107. Renz A, Ide M, Newton T, Robinson PG, Smith D. Psychological interventions to improve adherence to oral hygiene instructions in adults with periodontal diseases. Cochrane Database Syst Rev. 2007 Apr 18;(2):CD005097. doi: 10.1002/14651858.CD005097.pub2. Update in: Cochrane Database Syst Rev. 2016;2:CD005097.

  108. Hollister MC, Anema MG. Health behavior models and oral health: a review. J Dent Hyg. 2004 Summer;78(3):6.

  109. Gillam DG, Yusuf H. Brief Motivational Interviewing in Dental Practice. Dent J (Basel). 2019 May 1;7(2):51. doi: 10.3390/dj7020051.

  110. Koppelman J. Millions of Medicaid Dollars Spent on Dental Emergencies. Pew Trust. 2015 Jun 19. Accessed November 3, 2021.

Additional Resources


  • No Additional Resources Available
0/15Next