What AP Didn’t Mention about Flossing

The recent flurry of news regarding the benefits of dental floss has left out an important point of view: while the evidence of flossing’s medical benefits may be weak, the evidence that it is pointless or harmful is even weaker. What’s more, flossing is an inexpensive oral hygiene practice accessible for people most in need of improved oral health.

But let’s break this down.

The Associated Press reported:

The evidence for flossing is "weak, very unreliable," of "very low" quality, and carries "a moderate to large potential for bias." … One study review in 2011 did credit floss with a slight reduction in gum inflammation — which can sometimes develop over time into full-fledged gum disease. However, the reviewers ranked the evidence as "very unreliable."

But the study review authors actually noted:

There is some evidence from twelve studies that flossing in addition to toothbrushing reduces gingivitis compared to toothbrushing alone. There is weak, very unreliable evidence from 10 studies that flossing plus toothbrushing may be associated with a small reduction in plaque at 1 and 3 months.

What is important to note here is:

1. The "weak, unreliable" language actually references the evidence that flossing specifically reduces plaque, not gum disease. But more importantly, the language used comes from a different lexicon than we use every day. “Weak, unreliable, low quality” all sound like common terminology, but in the research world, this type of language doesn’t indicate the science shouldn’t be believed. The terms actually may reflect that study authors left out some details (such as the exact method of randomizing people) that the study reviewers could not confirm, not that the research is bad. 
2. The fact the review of studies could not prove plaque reduction at 1 and 3 months is very likely because tooth decay and gum disease are slow progressing issues that would require multi-year studies. It may also be because the standard for measuring plaque reduction only scores visible surfaces, so plaque may be reduced on non-visible surfaces such as directly between teeth.
3. In March 2015, the same study review linked above also determined: the very low evidence for the efficacy [of flossing], however, does not preclude the use of floss. For instance, in inter-dental situations that only allow for the penetration of a string of dental floss, floss is the best available tool.

When the U.S. government removed flossing from its 2015-2020 Dietary Guidelines, it did so because the strength of published studies regarding the effectiveness of flossing were admittedly weak, as the AP reports. The studies were generally short-term with a small number of participants due to the cost of running what constitutes high-quality clinical trials. 

Aside from cost, a clinical study comparing patients who did and did not floss would also mean exposing and even encouraging control group patients to worsen their oral health – and watch as it happens without intervention. In the research world, this is considered unethical. We don’t allow people to develop diseases as part of research, and that helps protect every patient in the United States.

According to dental experts including the DentaQuest Institute’s Dr. Brian Nový, Director of Practice Improvement, the lack of long-term clinical trials is also because there is already significant scientific evidence indicating how cavities form and how to prevent them.

Clinical trials don’t investigate how teeth decay, they examine new types of interventions. Oral health experts thus have relied on evidence extrapolated from shorter term studies as well as years of clinical experience and practice standards.

We know the easiest way to prevent cavities is to keep your mouth clean and minimize plaque, and that premise is incorporated into many clinical trials because it is accepted as standard oral hygiene practice. 

In one small study out of the University of North Carolina Chapel Hill, researchers randomized 119 adults who already had gum inflammation. After two weeks, they found the group that only brushed achieved a 35 percent reduction in bleeding sites between teeth, while the other groups who brushed and used floss achieved “dramatic reductions of about 67 percent” – almost double the improvement.

While small, this particular study correlates with the evidence dentists see every day among their patients – flossing creates a healthier mouth and less disease.

“The real problem is that the modern American diet is full of refined carbohydrates, which has changed the type of plaque that forms on our teeth,” Dr. Nový notes. “It is much stickier and more dangerous and everyone should want to keep it off their teeth if they want to avoid dental problems.” 

Tooth decay and gum disease can occur anywhere that food debris and plaque accumulate. The ideal spot is between teeth since it is difficult for the toothbrush bristles to remove or even attempt to remove any of the debris. That is why flossing or use of an inter-dental brush is recommended - to best remove the food debris that would remain between the gums and the teeth where a toothbrush cannot fit.

In response to the AP article, Dr. Robert Compton, Chief Dental Officer, DentaQuest and President, DentaQuest Institute, recalled an observation frequently used by health experts: the evidence to support the effectiveness of parachutes is weak because there has never been a double-blind randomized controlled trial to demonstrate effectiveness. That does not mean that parachutes are not effective. It just means no one has conducted expensive research that compared the effectiveness of somebody jumping with a parachute to a control group jumping without one.

“There's not enough money to conduct research for cancer cures and treatment for heart disease,” said Dr. Compton, adding, “if there isn’t funding for life-saving interventions, there will likely never be funding for the kind of research the AP reports would be required to sanction flossing as a recommended oral health habit.”

While flossing may be a habit that is difficult for people to connect with, it definitely helps remove food debris from hard-to-reach places. It is a low-cost, easy-to-use intervention that has the potential to improve the oral health of many, in particular those already suffering from dental disease.

This, among other reasons, is why oral health clinicians Tim Iafolla of the National Institutes of Health and Wayne Aldredge of the American Academy of Periodontology both told the AP they maintain flossing is important.

And Dr. Nový adds, “It comes down to personal hygiene. Do you want to have bad breath, and puffy bleeding gums, or do you want people to notice your smile because it’s healthy and attractive?  Flossing will improve many aspects of your life and no one has mentioned the research that shows male patients who don’t floss are more likely to experience erectile dysfunction...”  

Make This a Fall for Smiles!

By Steve Pollock, President, DentaQuest

Good dental health starts at home, and parents and caregivers are THE most important role models for their children. Oral Health America has a nice booklet, Fall for Smiles, on their website that can help families talk about good oral health. Also, from September 19-25, Trident gum is donating 5 cents to Smiles Across America® for every pack of Trident gum sold. Smiles Across America helps children who do not get regular dental visits because their families lack resources, insurance, transportation, or because of language barriers.

Make this a fall for Smiles! Brush and floss your teeth daily. Be careful about the sugars in your diet. Avoid tobacco products. And schedule a visit with your dentist.

Tooth protection: Sealants for better oral health

We in the oral health community often take it for granted that everyone understands the importance of preventive treatments when it comes to good oral health. But the reality is that everyone isn’t aware of simple, cost effective things they can do—like brushing and flossing every day and seeing your dental care provider every year. And sometimes we don’t fully appreciate how difficult it may be for some to get dental services -- and that limits their use of preventive treatments.

Prevention is important for everyone, but especially so for children. If we can keep children free from dental disease, we are giving them a strong start to a healthy life. As I’ve said here before, it is hard to do well in school or in life, when you have constant tooth pain.

Dental sealants are a very good way to prevent tooth decay in children.

For those who may not be familiar with them, dental sealants are thin plastic coatings applied to permanent molars. The sealant is applied as a liquid that is brushed onto the deep grooves of teeth by your oral healthcare professional. Sealants dry into the plastic film that provides a physical barrier to bacteria and sugar and effectively protects the pits and grooves on the biting surfaces of teeth from dental decay.

Sealants are considered a cost-effective intervention to prevent tooth decay. Consider this: the cost of applying one dental sealant is significantly less than the average cost of filling that same tooth. And when you think that a single sealant may prevent that tooth from being re-filled many times over a lifetime, it is just pennies spent for every dollar saved.

In support of sealants as a proven preventive treatment, the U.S. Department of Health and Human Services’ Healthy People 2020 set a goal of increasing the number of children who have received dental sealants on their molar teeth to 50 percent. But, despite numerous studies confirming that sealants are a cost-effective intervention, only a handful of states have reached this goal.

To help reach this national goal, the DentaQuest Institute is working with five community health center dental programs to find effective ways to increase the use of sealants for children aged 6 to 8 and adolescents 12 to 14. Those are the ages when the permanent molars erupt into the mouth. We hope the results of this Dental Sealants Initiative will help other oral health care providers make sure sealants are a standard tool in their offices for preventing cavities in children and adolescents.

We are optimistic the results of this DentaQuest Institute quality improvement initiative will increase the number of children who receive dental sealants. And that means less dental disease.

Related Posts:
· Some Good News at Massachusetts’ Medicaid Dental Program
· Healthy Smiles in Miami Dade Schools
· Washington’s Unseen Oral Health Debate
· Let’s Talk About the Oral Health of America’s Children
· Is Anyone Listening?

Prevention is Key

It was great to see the National Prevention Council’s recently released action plan for health prevention – but I couldn’t help but notice that there was no mention of the importance of oral health—at all.

Prevention is what helps us have good oral health vs. poor oral health. And prevention is all about understanding your risk factors and protective factors. This is true if you are a child or an adult.

In this Oral Health Matters blog, I try to get my readers to think about the risk factors—the things in your life which contribute to poor oral health. There are protective factors too and I’ll talk about them in another blog post. Right now, however, I’ll highlight some common risk areas. I hope you will read through them thoughtfully. If you say ‘yes’ to any of them, it is time to make an appointment with your dentist.

Common risk areas:

1. Not brushing and flossing your teeth every day – to remove food and bacteria. Making this part of your daily routine is a small change that pays big benefits.


2. Irregular visits to the dentist. I encourage visiting your dentist at least once a year. Why? Your dentist can detect early signs of trouble and help you get on track.


3. Have you had a cavity within the last 3 years? Have you lost teeth because of tooth decay or gum disease? Do you have puffy or bleeding gums, receding (shrinking) gums, or areas of the gum line where the root surface of the tooth is exposed? This could mean there may be active gum disease in your mouth. Your dental professional will want to watch you closely for this.


4. How is your health? Are you pregnant? Have you been diagnosed with diabetes? Do you use/abuse tobacco (cigarettes, pipes, cigars, chewing) or drugs? Do you regularly take prescription/over-the counter-medicines? Do you have braces or partial dentures? Are you undergoing chemotherapy or radiation therapy? Do you have an eating disorder? Do you have dry mouth? Each of these conditions puts you at higher risk for tooth decay or gum disease. Your oral health professional will help you make adjustments to keep your mouth healthy.


5. Are you a between-meal-snacker? Do you have a fondness for sugary foods? Do you drink a lot of soda or energy drinks? The sugars and acids in these foods/drinks can encourage tooth decay—especially if you let them linger in your mouth for hours. Again, your oral health professional can help you understand how to lower your risk of oral disease with things as simple as rinsing your mouth with water after eating to keep your teeth healthy.

Think about your answers to these questions and use them to start a conversation with your dentist about managing your areas of risk.

I would like to see Americans get smarter about the role of oral health in their overall health. That’s why I write this blog. When consumers have the knowledge to prevent problems and know when to seek care, they will likely be healthier. That’s why it is upsetting to me that oral health was missing from the National Prevention Council’s action plan.

I’d like to hear what you have to say on the importance of prevention. What does prevention mean to you?

Related Posts:

• Making Coverage Matter: Pew’s 50 State Report on Children’s Oral Health
• State of Oral Health In America Is Not So Good
• A New Chapter for Prevention
• Let’s Talk About the Oral Health of America’s Children
• Healthy Smiles in Miami Dade Schools

Sonrie!

Oral care in the United States is undergoing many significant changes. One of these is the exciting growth in the number of Hispanic dental practitioners and patients.

I just returned from the Hispanic Dental Association’s Annual (HDA) Roundtable in Plano, TX where I had the privilege of representing DentaQuest. HDA is a rapidly growing organization and the growth is expected to continue well into the 21st century. That’s a good thing because some experts are projecting a U.S. population that will soon be 40% Hispanic. Being able to talk to patients in a way that respects their culture and background is so important in providing the right care, at the right time, so we make a real impact.

The Hispanic Dental Association is playing a major role in building leadership for Hispanic oral health professionals during this time of change and it, like DentaQuest, is focused on prevention, treatment and education. DentaQuest and the DentaQuest Foundation are proud to support their work in improving oral health in the Hispanic population.

It was good to hear about the plans, concerns, needs and passion for dentistry among the member dentists. Several chapter presidents are DentaQuest providers. For me, this was an opportunity to explain the many facets of the DentaQuest enterprise’s commitment to improving oral health – our benefit programs, philanthropy, and clinical care improvement projects. I talked about the work we are doing to support dentists and their patients, to make participating in our networks easier, and to make sure oral health providers can deliver the best care outcomes. The dentists at the Roundtable were very interested in DentaQuest’s dental home project, our broken appointment project, and the many ways our website makes their work easier.

The dentists I met are enthusiastic champions for good oral health. They are hopeful that we will continue to support their meetings with our presence and are anxious to work with the DentaQuest Institute to improve cultural competency at the practice level. I believe that we have a very effective partnership developing. But for any effort like this to truly be successful we will need the partnership to extend to patients as well. Patients can and should play an important role. I’d like to hear from you on your thoughts.

State of Oral Health in America is Not So Good

In April, the Institute of Medicine (IOM) released a report on the state of oral health in America, concluding a two year evaluation of the current oral health care system. The U.S. Department of Health and Human Services (HHS) requested and funded this report to inform its work in addressing oral health challenges across America. HHS asked the IOM to assess the current oral health system and make strategic recommendations for its future programming. HHS is the federal agency which directs many of the government’s dental delivery, research, training and other programs.

Here are highlights:

• Tooth decay continues to be a common chronic disease in the United States


• The prevalence of oral diseases pose a significant burden on the health and well-being of the American people


• Evidence shows that decay and other oral health complications may be associated with adverse pregnancy outcomes, respiratory disease, cardiovascular disease, and diabetes


• Tooth decay is a highly preventable disease


• The general public and many healthcare professionals remain unaware of oral disease risk factors and preventive approaches and they do not fully appreciate how oral health affects overall health and well-being.

The IOM recommended that HHS design an oral health initiative that addresses areas in greatest need of attention, using approaches that have the most potential for creating improvement s, and to support this effort with strong leadership, sustained interest, and the involvement of multiple stakeholders.

“The Committee on an Oral Health Initiative reaffirms that oral health is an integral part of overall health and points to many opportunities to improve the nation’s oral health,” IOM President Harvey V. Fineberg, M.D., PhD., said in the foreword to the report. “We issue this report in the hope that it will prove useful to responsible government agencies, informative to the health professions, and public, and helpful in attaining higher levels of dental health.”

The IOM report and brief are posted online at www.iom.edu/Reports/2011/Advancing-Oral-Health-in-America.aspx

Rating the Performance of Your State’s Health System

There’s an interesting new report by the Commonwealth Fund, Securing a Healthy Future: The Commonwealth Fund State Scorecard on Child Health System Performance, 2011 that is worth looking at.

The Commonwealth Fund’s researchers took a number of objective measures for good health -- such as access to prevention and treatment, the potential to lead a healthy life (defined as factors such as low prevalence of specific health problems, low obesity, and lack of habits and behaviors that impact health, such as smoking) and socio-demographic dimensions (such as income and where you live) -- and looked at how each of these measures impact the others. The result is a very interesting and comprehensive picture of elements that contribute to children's health in each state.

We’re pleased that this report includes preventive dental care and the absence of dental problems as measures of access to prevention and treatment and a factor in healthy lives. The Report concludes that the high rate of poor yet preventable dental health outcomes among children in many states points to the need to improve preventive dental health care.

Better access to oral health services can reduce tooth decay and lead to a better quality of life for children, as well as reduce financial and societal costs. The Commonwealth Fund found that almost one third of children did not see a dentist for a preventive visit in the bottom-ranked state and more than 10 percent did not have a dental check-up in the top-ranked state. Want to know who they are? Click the link on the report title and check out the report!

Dental disease is nearly 100% preventable when people have access to information about keeping their mouths healthy and access to dental services. Public education, expansion of access to dental care, and integration of oral health into routine well-child care are smart ways to do this.

It works best when FAMILIES are able get the services they need to maintain their oral health since parents need dental care themselves for their own good health AND so they can be a good example for their children. The U.S. Department of Health and Human Services Healthy People 2010 goals recommend that children have at least 1 dental visit annually. And the American Dental Association says that you can start this at the age of 1 or when the first tooth erupts.

So, check out the data for your state. And then let me ask you -- is an annual visit to the dentist something that you do for yourself and for your children?

Eradicating Early Childhood Caries

This year, the Centers for Medicare & Medicaid Services and other experts estimate that more than 300,000 children under the age of six, many from lower-income households, will suffer from Early Childhood Caries (ECC) and require hospitalization. These young children often have a mouthful of cavities and a potentially life-threatening bacterial infection that may cause them to seek hospitalization. Another 1.5 million children are considered at risk for ECC. Hospital resources are so limited that children requiring operating room care at one of the few hospital-based dental clinics commonly wait up to six months before receiving treatment. In the meantime, parents rely on powerful antibiotics to keep the infection in check. (Not much can be done about the pain).

Early Childhood Caries can be prevented. But to do this, young parents need the right information about the oral health of their babies and toddlers in time to prevent infection. Without access to preventive education and care, children may find themselves facing rampant cavities, a hospital stay, and residual lifelong disadvantages—such as malnutrition, school absences, and missed work.

We at the DentaQuest Institute are tackling this preventable, chronic childhood disease head on. Working in partnership with researchers at Children’s Hospital Boston, we have developed a clinical protocol for treating Early Childhood Caries that works with primary care providers and parents to improve treatment in the hospital and, most importantly, at home. This program is using education and case-management to help change behavior at home and the dental office. Where this treatment plan has been used, we have been able to reduce the percentage of young children (under 60 months) with new cavities by 69 percent; reduced those who needed treatment by 55 percent; and reduced reports of children with mouth pain by 50 percent. The DentaQuest Institute is now working to expand the ECC program to 10 dental clinics across 8 states—including MA, RI, OH, NY, FL, CA, WA and NY. In many ways, Early Childhood Caries is a parable for what plagues healthcare: small problems that turn into big problems because the right information and resources weren’t available in the first place to stop the progression. Preventive health care is part of the solution, but it means nothing unless you know how to use it.

Dr. Mark Doherty, Executive Director, DentaQuest Institute and Dr. Jay Anderson, Director of Quality Improvement, DentaQuest Institute