It’s one of the most universal recommendations in all of public health: Floss daily to prevent gum disease and cavities.
Except there’s little proof that flossing works.
Apparently the federal government has been recommending flossing since 1979 in a Surgeon General’s report as well as the “Dieteary Guidelines for Americans.” However, anything that the federal government recommends is required to have an adequate evidence base to be considered.
It turns out that flossing hasn’t really been researched very much. In order for the federal government to recommend something it has to be able to point to a pretty serious body of research. Earlier this year the federal government removed it’s recommendation for flossing with little fanfare. After the AP requested the evidence the feds used to recommend flossing…they caved.
If you take a look at the research base, they’re right to have caved. The best studies on flossing that they have are not convincing. They kind of had to remove the recommendation to be consistent with their standards. I understand what they did and cannot fault them.
Here’s the thing…there will be no rush to research flossing. The research design would be difficult and expensive and I doubt that there is the will for it.
All this said…#Istandwithfloss.
I can hear what you’re thinking: “Mead, you claim to be interested in evidence and science! How can you possibly recommend flossing to patients if the federal government retracted their recommendation! The science says it’s no better than brushing alone!”
Let me explain myself.
Everyone’s teeth are covered with a layer of gunk called biofilm. It doesn’t matter how well you brush them and floss them, they’ve got biofilm on them. When dentists and hygienists accuse you of not taking care of your teeth they call this biofilm “plaque” and they get all bent out of shape that you have lots of it on your teeth. We’ve been instructing patients to do their very best to remove this plaque from their teeth for as long as we’ve been in the profession.
The goal is to remove as much of the biofilm as you can.
So you brush. And that can remove a lot of the biofilm. But there are places your toothbrush can’t get to. What is a person to do? The research says flossing doesn’t work.
So I guess you should just leave that gunk sitting in between your teeth, right?
Do me a quick favor. Grab a long piece of floss and wrap it around your fingers. Slide that floss in between a few pairs of teeth, wrap it in a “c-shape” and gently stroke up and down. Then take that floss out and take a good hard look at it. Is it clean as a whistle or does it have a bunch of gunk on it?
If you’re like virtually every patient I’ve seen, it will have a little gunk on it.
So why do #Istandwithfloss?
The problem is the research, not the flossing. Maybe the design of the studies hasn’t been adequate. That’s a huge problem in medical research. Often times we think we’re measuring one thing when we’re not measuring that at all. You’ll notice that the evidence hasn’t recommended against flossing either. Flossing has been an accepted recommendation by dentists and hygienists for so long that it is no longer a hotbed of research inquiry.
Getting back to what a dentist or hygienist should recommend to patients: if our goal is to remove as much biofilm from our teeth and gums as possible, flossing does that. I don’t actually need peer reviewed research to observe that.
There is a word that I really like. That word is “plausible.” Plausible is defined as:
(of an argument or statement) seeming reasonable or probable.
The idea that flossing helps remove biofilm, which in turn helps reduce a person’s risk for cavities and gum disease is plausible. An idea that is plausible, even if it doesn’t have tons of great evidence, is worth keeping around.
Flossing is not expensive nor is it risky. It observably removes biofilm from in between the teeth that brushing cannot always get. And even though our current level of evidence does not allow the federal government to recommend flossing, it is still likely a worthwhile effort.
That’s why #Istandwithfloss.
Did this make you feel plausible? Do you feel like flossing? I’d love to hear about it! You can share any Mead Family Dental post with a “Like” on Facebook, a “+1″ on Google+ or you can even “Tweet” it with Twitter! All you need to do is hover over the heart shaped button next to the title of the post. Or you can leave a comment by clicking on the balloon shaped icon next to the title.
I remember when Bubble Yum bubble gum came out. Wikipedia says it was in 1975 and that feels about right. I remember commercials with a puppet that was trying to steal a kid’s Bubble Yum.
I also remember the gum itself. It was the first “soft chewing” gum in memory. Before Bubble Yum, it was either sticks like Trident or rock hard little nubs like Bazooka. Bubble Yum made chewing gum more fun. It also had a ton of sugar in it. So much you could feel the little grains of sugar as you bit into it. It was glorious, but it promoted tooth decay. The rare times we were allowed candy (yep, my dad was a dentist) I usually chose grape Bubble Yum. It was one of the flavors that defined my childhood!
Fast forward about 40 years. My diet includes things that cause tooth decay. The saliva in my mouth is a natural defense mechanism of my teeth. Healthy levels of saliva can keep the acid that causes cavities in check.
I’m not alone. I see lots of patients with decay problems. They have sugary diets, too. And many of them have a dry mouth as well. Any time a person takes more than one medication (which is very common) there is a high likelihood that their medications has induced dry mouth.
Dentistry has done a terrible job with dry mouth. We see it all the time. We can explain to our patients why they might experience it. But we don’t have much in the way of treatment for it. We can offer dry mouth rinses and toothpastes, but my patients that have tried them overwhelmingly feel like they don’t work very well. I don’t recommend that patients change their medications to treat blood pressure, depression or anything else. So mostly people just live with dry mouth.
I’ve found a solution that takes me back to my childhood. No, it’s not grape Bubble Yum. But it tastes and chews almost exactly the same. I’m here to tell you that Arctic Grape Ice Cubes gum is my suggestion for dry mouth. It’s as close to a perfect solution for dry mouth as I could invent.
It’s delicious. It tastes identical to the Bubble Yum I remember from the 70’s. Right down to the little grains of sugar. Except that it’s actually sugarless.
It really increases your saliva. Pop a couple of pieces in to chew and your mouth becomes flooded. It’s nothing short of amazing!
It’s sugarless. So even though it tastes really good, it won’t promote tooth decay. In fact, it’s flavored with xylitol which is known to inhibit acid production by the bacteria in your mouth in high doses. The amount of xylitol in this gum isn’t clinically proven to do that, but it’s still better than using sugar to sweeten the gum.
The best treatment I’ve found for dry mouth takes me back to my childhood. How cool is that?
Did this make you feel juicy? I’d love to hear about it! You can share any Mead Family Dental post with a “Like” on Facebook, a “+1″ on Google+ or you can even “Tweet” it with Twitter! All you need to do is hover over the heart shaped button next to the title of the post. Or you can leave a comment by clicking on the balloon shaped icon next to the title.
Every dentist has experienced it before. Patients refuse x-rays because they don’t want to be exposed to too much radiation. What is “too much radiation?” That’s a great question.
Medical professionals have been taught since the 1940’s that medical and dental imaging carries a tiny chance of increasing a person’s cancer risk, no matter how low the dose. The model that we were taught is called the “linear no-threshold model” (LNT) and it basically claims that any dose of radiation, no matter how small, carries an increased risk of causing cancer. As dentists, we are supposed to weigh this tiny (but not zero) increase in risk against the benefits of whatever x-ray image we wanted to see.
New research published in the American Journal of Clinical Oncology has re-evaluated the original research that we based the LNT model on and has found it to be unconvincing. The original research was performed by exposing fruit flies to various doses of radiation. The damage at each level was measured and the research made the assumption that there is no completely risk-free level of radiation.
In the LNT model, the well-established cancer-causing effects of high doses of radiation are extended downward in a straight line to very low doses. The LNT model assumes there is no safe dose of radiation, no matter how small. However, the human body has evolved the ability to repair damage from low-dose radiation that naturally occurs in the environment.
Basically, the radiation doses that were studied in the 40’s were much to high to extrapolate into low dose medical uses of radiation. We’ve based our concerns about x-ray radiation on doses that are much higher than those experienced by patients. The recent paper was specifically about CT scans, which actually have a much higher exposure to radiation than dental x-rays.
As a profession, dentistry has gone out of its way to expose patients to as little x-ray radiation as possible. But many patient still balk. The effectiveness of x-rays for dental diagnosis cannot be underestimated. But not only are they effective, current research suggests that they are completely safe.
Did this make you feel radiant? Do you feel relieved? I’d love to hear about it! You can share any Mead Family Dental post with a “Like” on Facebook, a “+1″ on Google+ or you can even “Tweet” it with Twitter! All you need to do is hover over the heart shaped button next to the title of the post. Or you can leave a comment by clicking on the balloon shaped icon next to the title.
I recently had a patient cancel her appointment at the last minute. This happens sometimes. It’s frustrating for a dentist or hygienist when we’ve set time aside for a patient and they don’t come. Usually there’s a good reason. In this case, no reason was given.
As I sometimes do…I took it personally. Why did this person choose not to have the treatment done that we discussed? What could I have done better?
This particular patient has been coming to our office for years. She is someone you might describe as “skeptical” of dental treatment. I suspect she had some bad dental experiences before I even came into the picture. She’s at least mildly phobic of dental treatment, too. However, I think she’s probably one of those people that believe that when I come in the room that I’m simply looking for work to do, probably to line my pockets.
It’s a difficult spot for a dentist. Often times we’re both the internist that diagnoses the problem and the surgeon that fixes it. Patient see this as a conflict of interest. The guy who is telling me that I have cavities is also the guy who benefits from them being fixed. I completely understand this. I take my role as a doctor very seriously and I put my patient’s needs first. But can you blame a patient for being skeptical of a doctor’s motivations?
When I examine a patient I’m looking to see what level of dental health the patient has. And when I see a problem, I’m obliged to tell them about it. I have found what I believe is the most effective way to do this. I do all of my recall exams with a dental operating microscope. This microscope magnifies what I can see and has a very bright light that allows me to see parts of the mouth that don’t get lit up very often. I’ve attached an HD camera to the microscope with a monitor mounted over the patient to allow them to see exactly what I’m seeing…as I see it. I feel like this is a great solution to the problem of showing the patient what I see instead of me just describing it. I like it more than still photos because I can show it to them “live” as I’m describing it.
Back to my patient that chose not to come in today. I definitely examined her with the microscope and I definitely showed her what I was seeing. I recommended to some treatment because I saw some problems. I try and do this dispassionately. I try not to “sell” a patient on treatment by showing them what I’m seeing. I try to help the patient choose dental health by showing them what I’m seeing and describing what we can do to correct dental problems.
I have a suspicion that this patient still thinks what I’m describing isn’t a real problem. Like many dental problems, what I’m describing probably doesn’t hurt. Most cavities don’t hurt. Gum disease almost never hurts. Even broken teeth often aren’t painful. If you use pain as the threshold for dental treatment, you’re probably going to end up choosing the most expensive way to fix the problem or worse, sometimes the problem can’t be fixed leading to the loss of a tooth. A small cavity left untreated almost always becomes a bigger cavity, so what may have been easy to fix with a filling could end up needing a crown or even a root canal. This sounds like a scare tactic used by a dentist. Ask any dentist and they’ll explain that they see it. All. The. Time.
So I’m going to suggest that you listen to your dentist’s recommendation. The choice to treat is always yours. But almost always, the sooner you treat a problem, the less expensive and potentially painful the fix is.
Did this make you feel skeptical? Are you feeling put under the microscope? I’d love to hear about it! You can share any Mead Family Dental post with a “Like” on Facebook, a “+1″ on Google+ or you can even “Tweet” it with Twitter! All you need to do is hover over the heart shaped button next to the title of the post. Or you can leave a comment by clicking on the balloon shaped icon next to the title.
A couple of days ago a friend was complaining to me that he had gotten something stuck between his teeth. He’d had lunch at a barbecue joint and wouldn’t you know it he had some brisket jammed between his molars. He was looking for a toothpick or a straw to get it out because it was kind of uncomfortable.
If you’ve ever suffered the same fate you’ll know what I’m talking about. It isn’t necessarily painful, but it’s a kind of persistent pressure that doesn’t really let up until you get whatever is jammed in there out. There are a lot of nerve endings in the gums and the tissues that support the teeth that tell you brain, “hey, something funny is going on here.”
So I whipped out the floss that I carry in my pocket and rescued him. It took him about to seconds to snap the offending piece of brisket out and he was good to go.
“I’m lucky you’re a dentist,” he said as if it’s a given that dentists don’t go anywhere without floss, a toothbrush and maybe a spare dental mirror for good measure. The reality is my dirty little secret.
In a perfect world, the contacts between your teeth are tight enough that normal chewing doesn’t wedge food between them. Too tight makes it so flossing to remove plaque and food debris is difficult or impossible, but too loose means food can become impacted. Food impaction is an inconvenience to be sure, but it can become a problem. A spot where food impacts is more prone to decay simply due to the fact that you cannot remove the debris. The bugs (and by bugs, I mean bacteria) that sit there will metabolize the sugars in the impacted food into acid. When the pH of that part of the mouth reaches a critical level (5.5 to be exact) then the enamel of your teeth will start to dissolve. The longer impacted gunk sits there, the greater the chances that the pH can drop into dangerous levels and cause cavities.
Impacted food can also cause gum problems. I’ve spoken with periodontists (gum specialists) that have removed popcorn kernels from gum abscesses. People with gum disease are more prone to food impaction because their teeth are slightly more mobile than those without bone loss around their teeth. The bottom line is that places where food gets impacted are at greater risk for cavities and gum disease.
Why do we have spots where food gets stuck? Well, some people have naturally loose contacts between their teeth. As I mentioned, people with gum disease are definitely more likely to get stuff stuck in their teeth. If you have a broken or badly decayed tooth they will often be a spot that holds food debris. Finally, dental restorations like fillings or crowns can have inadequate contacts and be a risk factor on their own.
How do we fix it? Well, if you have naturally loose contacts between your teeth I’m not going to “fix” them if they don’t have disease. Those folks need to be extra careful in their brushing and flossing habits. Contacts that are particularly annoying to a patient can usually be “closed” in a minimally invasive fashion if the patient chooses. But if the loose contact in question is caused by decay or worse, the tooth is broken, we better fix it pretty fast!
Dentists probably floss more often than regular folks, but there is no law that requires dentists to carry floss. I carry floss because I have two very loose contacts. Both of them are caused by restorations that have opened up over time. I need to get them fixed and I’ve been procrastinating. That’s my dirty little secret. It may surprise you that dentists are like other human beings…some of us put off treatment that’s necessary, too. But that’s no excuse! Let’s unite in our commitment to close open contacts! No more food impaction!
Did this make you feel ashamed? Do you feel differently about dentists? I’d love to hear about it! You can share any Mead Family Dental post with a “Like” on Facebook, a “+1″ on Google+ or you can even “Tweet” it with Twitter! All you need to do is hover over the heart shaped button next to the title of the post. Or you can leave a comment by clicking on the balloon shaped icon next to the title.