Without question, the accumulation of dental plaque and biofilm contributes to the most frequent dental disease, caries, periodontal disease, and gingivitis. The contribution of plaque and biofilm to dental disease makes it imperative to manage the accumulation in interproximal areas. In a systemic review and meta-analysis published in the International Journal of Dental Hygiene this year aimed to “assess whether flossing before or after influences plaque index reduction.”1
The authors hypothesize that flossing before brushing is most effective at removing plaque. Using the PRISMA checklist the authors identified 2 articles eligible for the systematic review and meta-analysis. The risk of bias was assessed using the Cochrane risk of bias tool, both studies were determined to be of high quality with low risk of bias.
Interestingly, one of the studies indicated a clear difference in men and women regarding oral hygiene habits. The order in which an individual performed their oral hygiene care either brushing-flossing or flossing-brushing was not significantly different among females. Whereas in men flossing before brushing showed a significant reduction in plaque index. Overall, it was determined that women have lower BOP and lower dental plaque indexes than men. A follow-up survey determined the likely explanation is that women visit the dentist more often and brush and floss their teeth more often than men. Women also tend to have more knowledge and positive attitudes about oral health than men.
Another study that was evaluated, yet not included in the systemic review evaluated effectiveness of four different oral hygiene regimes, 1) manual toothbrush, 2) manual toothbrush and dental floss. 3) manual toothbrush plus interdental brushes, and 4) manual toothbrush plus rubber interdental picks. The results showed that interdental inflammation was significantly reduce din participants that used picks compared to those that used floss.
There was no statistically significant difference between flossing before or after brushing. The authors hypothesis of this study was rejected, the use of dental floss before brushing is not more effective in removing dental plaque.
The authors conclude by stating, “Several devices have been developed and suggested for performing interdental cleaning, including flossing that can help tooth brushing, reaching as interproximal areas. However, many devices appear to be more effective than flossing in interproximal cleaning of teeth. Regarding the sequence of flossing and brushing, this systematic review with meta-analysis revealed that flossing before or after brushing had no significant effect on plaque reduction. However, further clinical studies must be carried out in relation to the topic.”
Do you recommend flossing before or after brushing? Did you believe there was a difference between flossing before brushing or after? Do you often recommend other methods of cleaning in interproximal areas?
1. Silva, C., Albuquerque, P., de Assis, P., Lopes, C., Anníbal, H., Lago, M., & Braz, R. (2021). Does flossing before or after brushing influence the reduction in the plaque index? A systematic review and meta-analysis. International journal of dental hygiene, 10.1111/idh.12546. Advance online publication. https://doi.org/10.1111/idh.12546