The sequence of mechanical cleansing may affect oral health

Is it better to floss before brushing or brush before flossing ?

Regular brushing and flossing are traditional oral hygiene deterrents against gingivitis and periodontal disease. However, the sequence of cleansing can enable greater removal of plaque and aid fluoride retention.

Mechanical cleansing is a dentist-recommended oral hygiene maintenance procedure. It easily removes dental plaque and also prevents the occurrence or reoccurrence of caries and periodontal disease. One of the most common questions patients ask their dentist is: can they only brush or only floss or perhaps follow a routine that combines both that works out better? The answer to the first question is no though the jury is out on the second question.

How Did Mechanical Cleansing Become Popular?

According to the fourth edition of Medical Microbiology, the increasing incidences of dental decay at the beginning of the 20th century lead to the development of many modern dental practices. In fact, during both the World Wars and the Korean War, many individuals were rejected from military service due to dental decay. To address this issue, dentists took the initiative and began emphasizing the importance of routine mechanical cleansing, and also helped attain a significant breakthrough in US oral health—mandatory water fluoridation in communities across the country.

Are There Proven Benefits Of Mechanical Teeth Cleansing?

There aren’t many clinical research studies that statistically establish the effectiveness of mechanical cleansing at plaque removal. Most studies tend to focus on comparing the effect of brush sizes, shapes, techniques, and the type of toothpaste used. Many studies also illustrate how flossing is beneficial in maintaining oral hygiene. However, there are few studies that analyze the combined effect of brushing and flossing.

A study conducted by the Dental Materials Research Center at Mashhad University of Medical Sciences in Mashhad, Iran, in spring 2018, involved the participation of dental students who reported and analyzed the combined efficiency of brushing and flossing.

The students were made to split into two groups and were asked to give up their routine oral habits and products for 48 hours and given fluoride-rich toothpaste for brushing. The first group was made to brush its teeth before flossing. The second group was made to floss its teeth before brushing. Then participants were made to record their dental plaque activity as per the Rustogi Modified Navy Plaque Index, and their fluoride levels were also noted using fluoride ion-specific electrodes. After a two-week break was taken to let things go back to normal, the groups and their activities were swapped and findings recorded.

Upon examination of the recorded data, the researchers found that the whole and interdental plaque buildup was significantly reduced in participants who flossed before brushing. Additionally, participants who flossed before brushing saw higher fluoride residue within the interdental spaces. Dr. Richard T. Kao while explaining the fluoride retention said that flossing clears up interdental spaces so those who flossed before brushing exposed more area.

However, the study was mired in a bit of controversy as subjects were made to change their routine for 48 hours twice and that could have made them susceptible to infection. Moreover, the participants were fee-paying students of the institution, which was moderating the research. The official press release of the study clarified that the participants were given a prophylaxis treatment to prevent the risk of infection. Despite the participants being students of the dental institute, the students were given an intensive examination alongside meticulous teeth care instructions.

Dr. Richard T. Kao, periodontist and president-elect of the Academy of Periodontology, supported the study. He appreciated the methodical approach of the study. Dr. Kao also stressed on how the students were not susceptible to infection as they were brushing their teeth as per instructions for the period of the study, which was not long enough to create any problems. “This was actually a very good study, simple-minded, that answers a lot of basic questions…,” said Dr. Kao, reported website Dental Products Report.

The Iranian study did prove that flossing before brushing one’s teeth reduced plaque buildup and enhanced fluoride retention. “…while this study finds that flossing before brushing may result in the reduction of plaque, it’s important for everyone to remember to do both every day to maintain the health of their smiles,” said Dr. Stephen R. Daniel, president of the American Academy of Periodontology.