The Current Usage and

Effectiveness of Dental Floss

Among Adults

By: Jordan Andrud, Adilene Benitez, Abdi

Hassan, and Connor Moberg

Abstract:

Recently, media outlets and reports have questioned whether there is sufficient evidence
linking daily dental flossing to good oral health and the prevention of cavities. Whether a person
flosses is a personal choice, but in dentistry, flossing is considered the only proper way to clean
in between the teeth and remove plaque and other food particles that cause dental cavities.
Without anyone to tell them to brush or floss their teeth, college-aged students as well as adults
may not brush their teeth at least twice a day, or they may even go days or weeks without
flossing their teeth. The combination of busy schedules along with weak or non-established oral
hygiene practices can often lead to poor oral health. This research report conducted a research
survey regarding the use and effectiveness of flossing as well as other oral health habits from a
trial of adults aged 18-50 from a university setting including the students, faculty, and staff of
North Dakota State University (NDSU). The primary outcome demonstrated that the vast
majority, over 75% of the individuals surveyed floss on a daily basis, which correlates with zero
cavities detected by dental visits in the past two years. Secondary outcome measures were
reasoning behind the choice to floss or not, as well as having any gum or oral tissue bleeding
during or after flossing. The results suggest that oral health and flossing in particular are a
priority among the sampled adults in the university setting.

Introduction:

Flossing your teeth is the most vital part of your overall oral care in preventing bad breath
and cavities (Keats, 2017). When you floss, you are eliminating food particles and bacteria
between your teeth that are not removed during normal toothbrushing. In the media and different
research outlets, there has been controversy regarding the effectiveness of flossing and if it truly
prevents cavities and erosion of good oral health. Prior research in the field raises the interesting
question, How often do individuals floss and how many cavities have they had the past two
years? Modern-day research has explored the use of floss, since it has been claimed by dentists
to be beneficial for oral and gum health. As a general rule, The American Dental Association
(ADA) suggests flossing between teeth at least once a day to maintain good oral health (ADA,
2016). In this research report, we are assessing the current usage of dental floss among young
and middle-aged adults and how it correlates to the frequency of dental cavities and overall oral
health. It is hypothesized that individuals who floss everyday will have fewer cavities over the
previous two years than those who do not floss, as well as better oral health. People eat at least
two to three times a day, with most meals consisting of some form of carbohydrate that gets
broken down into simple sugars in the mouth by chewing and mixing with saliva (Selwitz et al.,
2007). Effective flossing can protect a beautiful smile and keep teeth from building up plaque
and the development of cavities; it can also help prevent serious diseases from occurring that can
be life threatening as well as the high cost of dental repair. There is often a lack of sufficient
knowledge regarding the benefits of dental floss in the general public, and how it is necessary for
good gum health. The majority of dentists mention lack of awareness of benefits as the major
factors affecting flossing among individuals. In addition, dexterity constraints and the difficulty
of flossing between teeth in the back of the mouth also plays a role. Health education programs
regarding dental floss are important to spread awareness among the general public and to
increase the frequency of daily dental flossing in our society (Buglar et al., 2010).

Various studies have explored the use and effectiveness of dental floss, as well as its
impact when used everyday. In dentistry, flossing is considered the only proper way to clean in
between the teeth and remove plaque and other food debris that cause and lead to dental cavities
and gum diseases such as periodontitis, leading to tooth loss (Sambunjak et al., 2011). Most
research regarding the effectiveness of flossing also studies the development of periodontitis,
which is an irreversible gum inflammatory condition that can cause tooth structure loss.
Periodontitis affects nearly half of the adult population in some manner and rates increase with
age. It is a preventable disease, which when averted allows the individual to have much greater
oral health and quality of life (Imal et al., 2012). Dental plaque is the primary factor for
periodontal disease and cavity formation. Thus, the removal of plaque is the primary preventative
factor for the prevention of periodontal disease (Kressin et al., 2003). Research has found that
one of the biggest factors that prevents people from flossing is a lack of self-motivation and lack
of awareness of its importance. Whether an individual flosses his or her teeth or not is a personal
preference, but its crucial to understand the proper way to floss so that it is most effective and
not damaging to gums or painful. Individuals should speak with a dentist or dental hygienist to
learn how to floss to ensure efficacy. Without anyone to tell them to brush or floss their teeth,
college-aged students, as well as adults, may not brush their teeth at least twice a day, or they
may even go days or weeks without flossing their teeth (Rise et al., 1998). Poor oral health and
hygiene is often a result of the combination of busy schedules along with weak or non-
established oral hygiene practices. As a group, we are all aiming for careers in the medical field
once we finish our undergraduate degree. If and when our future patients ask us questions, we
would like to give correct and informed opinions about their oral and overall health care matters;
this led us to do research into dental and flossing conditions among individuals of NDSU. This
research study sought to find the frequency of flossing in college students and adults which has
not been studied extensively before, as well as its effectiveness in preventing cavities and
maintaining good oral hygiene within the university setting. This population was chosen due to
being easily accessible along with the possible presence of weak oral health and hygiene due to
time constraints with overloaded schedules.

Methodology:

To conduct the proposed research in an efficient and timely manner, this study was
conducted utilizing the study body, faculty and staff at North Dakota State University (NDSU)
and 72 responses were collected. Volunteers from this participation pool were between the ages
of 18-50 years old, with no individuals participating above this threshold. The age of 50 was
determined as a cut-off age on the basis that after this age, many individuals begin to experience
large amounts of gum recession, often leading to substantial tooth structure loss as well as
overall tooth loss (Kressin et al., 2003). The feedback and opinions of adults, primarily as college
students, were focused on in this research report as they act independently and their oral health
choices are their own. Brushing, flossing, and regular trips to the dentist are all dependent on
their own decisions. Unfortunately, this is often what causes young adults to let loose and
decrease the habits and importance of oral hygiene (Schwarzer et al., 2007). College students and
staff at the university were utilized as a population of convenience, as there is easy access to the
university email listserve and contacts of former or current professors.

Administration of Survey

The research conducted in this report was collected using survey software from North
Dakota State Universitys Qualtrics system. This system has enabled us to send an email with an
attached survey link to the students, faculty, and staff, as well as being posted on Facebook for a
larger study group of students. The surveys were provided to individuals within the NDSU email
listserve on a voluntary basis to those with various ethnic, racial, and academic backgrounds, as
shown in Appendix 1. The survey requested each participant to give their age, major of study or
type of work, and sex for data collection and analysis purposes only, with no names or additional
personal information requested for ethical reasons. Participation in the survey was completely
voluntary with the option to decline any or all questions, although all responses collected were
completed fully. The survey was emailed out on March 20, 2017 and data collection was closed
on April 6, 2017. Surveys via the NDSU email listserve have been chosen for this particular
research proposal as a vast amount of them can be collected in a short amount of time at a high
convenience to both the participant and researcher. At the end of the data collection period,
survey responses were compiled and analysis began shortly thereafter.

Analysis

Analysis of the research surveys included an overall computation and average of all the
data for each of the survey questions. Advanced analysis was completed to determine the
information and opinions of people of various ages, majors, and educational backgrounds. A
largely diverse pool of students and adults from different educational topics and levels were
emailed to be surveyed to help provide that the results and responses collected were not skewed
or bias in any form. The results were organized using the qualtrics survey software as well as
Microsoft Excel before being exported and included into this report. The results from the opinion
or typed questions were compiled and entered into Microsoft Excel before being made into
graphs and tables, which were analyzed. The data collected could help provide student health and
dental care centers with the opportunity to provide dental and flossing educational programs to
increase awareness regarding good oral hygiene habits. College student health centers, as well as
general practice physicians, should ask individuals if they are routinely visiting dental offices for
checkups as well as performing daily flossing and brushing. Increasing oral health awareness and
its connection to overall health is important for an individuals long-term health and well-being.

Results:

The results gathered and organized from the qualtrics survey showed that among the population
sampled from the university environment, there was an importance and high frequency of good
oral health habits present with these individuals. The data and responses collected helped
demonstrate that among busy college students, faculty and staff within the university, there is an
importance and goal of good oral health and hygiene, including flossing regularly. Of the
responses collected, the majority expressed positive feedback and opinions regarding oral
hygiene habits such as regular trips to the dentist, tooth brushing every day, flossing daily, and
resulting in the absence of cavities from the majority of those individuals as well as good oral
health.
Figure 1. The blue-colored portion represents surveyed individuals who currently have
regularly scheduled dental visits, and the red-colored portion illustrates those who do not
have annual oral health care visits.

As displayed in Figure 1, the vast majority of individuals surveyed currently have an oral health
provider they visit on a regular basis. Over 89% of individuals polled fall into this category, with
only 11% disclosing that they do not have regularly scheduled visits. In Figure 2, the question of
whether individuals floss or use flossing brushing on a regular basis is given.

Figure 2. Surveyed individuals who floss or using flossing brushes daily within the
university-setting.

Of those individuals surveyed, the vast majority indicated they were flossing or using flossing
brushes regularly. Over 78% of the population surveyed indicated to flossing on a regular basis,
with only 22% showing that they do not floss regularly. When asked to briefly explain why they
do or do not floss, individuals reported that it helps them prevent plaque from building up, as
well as aids in preventing cavities. The minority of individuals reported that it takes time, is
painful, as well as they are lazy or often forget.
When asked how many cavities they have had in the past two years, displayed in Figure 3, 81%
percent responded to having zero cavities, while 4% percent reported unknown and 8% percent
representing only one cavity. The remaining percentage of individuals had two or more cavities
discovered in the past two years.

Figure 3. Number of cavities individuals reported having in the past two years. Participants
who selected unknown expressed uncertainty to the amount due to either absence from
scheduled dental cleanings or being unaware.

The dispersal of programs of study and current majors is displayed in Figure 4. If education was
completed, the individuals field of work and highest degree obtained was listed. Over 55% of
the individuals indicted a life-science related field, with the next common reply being education
followed by nursing. Other educational backgrounds included university studies, electrical
engineering, computer science, music education, and business management. Individuals included
in the survey were between the ages of eighteen and fifty years old, with the highest degree
obtained ranging from a high school diploma to a Ph.D.

Figure 4. The pool of surveyed individuals from the university-setting was predominately
life-science related majors and backgrounds, followed by education. Nursing was the next
most common followed by other educational backgrounds comprised of 5 other majors
such as university studies and electrical engineering. All individuals surveyed indicated an
educational focus or career.

Discussion:

The results indicate that a majority of the surveyed individuals of NDSU floss and brush
their teeth on a daily basis. This, along with the majority of the individuals visiting their dentist
regularly shows that the students, faculty, and staff surveyed care about their oral hygiene and
take an active role in maintaining it. Our main question of how often young to middle aged
adults floss and the frequency of cavities shows a strong, positive correlation. Most individuals
in our study pool floss daily and have had zero cavities in the past two years, suggesting that
flossing does indeed have a positive impact on oral health overall and the prevention of cavities.
Given what prior research has shown in a lack of true effectiveness and benefits of daily flossing,
our results suggest that flossing lowers the risk of tooth decay and gum disease by removing food
particles and the accumulation of plaque that causes cavities. This finding from our research
demonstrates that while evidence is limited and low quality, flossing is beneficial to preventing
cavities and the development of periodontal disease. In this case, the average benefit may be low,
but daily flossing is still correlated with the lack of cavities and greater oral health.

An interesting and equally puzzling result was the percentage of our participants that
experienced pain in their gums or along the gum line in the past two years. Almost one third of
the answers (see Appendix 1, Q15) were that they have experienced gum bleeding or pain more
than 5 times in the past two years. This does not correlate with the 20% of individuals who
answered that they do not regularly floss, which would lead us to believe that flossing is not the
only factor involved, and may depend on variables such as including brushing too hard, genetics,
hormonal changes, and food or dental appliance irritation. However, this does not correlate with
answers of how often they brush their teeth. Since all but one participant answered that they
brush their teeth at least once teeth daily, this suggests that flossing and/or brushing technique are
the limiting factor in gum health.

If we had to conduct this research again, we would distribute the survey out to a wider
audience over a longer time period to collect data from a broader, more diverse audience. Over
half of the results collected in this study were from life science majors alone, of which 30% were
in a healthcare-related field that could have slightly skewed the results since people who study in
these fields may be more likely to care about their oral health. The survey being distributed to
other students and faculty from other majors, particularly non-STEM majors would give a
largely more accurate data set for the general college population. Research questions that still
remain include the importance of oral hygiene, flossing and regular trips to the dentist among
non-STEM related majors, as well as collecting data regarding individuals do not have dental
cleanings regularly, whether it be due to cost, lack of dental insurance, personal choice or other
factors. Though the research and distribution could be improved slightly, the results show that
the university population in general is taking a role in their oral health care that shows a positive
future if this trend continues. The data collected and insights offered to dental care practices and
student health centers help show that there is awareness to oral health and dental hygiene habits
that have been developed among this population often stick for life. Therefore, this awareness of
oral hygiene and flossing can positively impact an individuals overall health and well-being.
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Appendix 1

1. What is your sex?

Male or Female

2. What is your age? (Please Enter)

3. What is your program of study and current major? If education is completed, please list your
field of work and highest degree obtained. (Please Enter)

4. Do you currently have a dentist or oral health provider that you visit on an annual basis?

Yes or No

5. How many visits to the dentist have you had in the past year?

None, 1 visit, 2 visits, 3 visits, 4 or more visits

6. If none, how many years has it been since your last dental visit?

N/A, 1, 2, 3, 4+ years

7. Do you have regularly scheduled dental cleanings or oral exams performed by a dental
hygienist?

Yes or No

8. How many times a day do you brush your teeth?

0, 1, 2, 3, 4+

9. Do you floss or use flossing brushes regularly?

Yes or No
10. If yes, briefly explain why you floss. If no, briefly explain why you do not floss. (Please
Enter)

11. How many times a day do you floss or use flossing brushes?

0, 1, 2, 3, 4+
12. Do your gums or oral tissue bleed during or after flossing?

Yes or No

13. How many cavities have you had the past two years?

Unknown, 0, 1, 2, 3, 4+

14. How many cavities between your teeth (non-surface) cavities have you had the past 2 years?

Unknown, 0, 1, 2, 3, 4+

15. Have you had any pain in your gums or along the gum line in the past 2 years?

None, Yes 1-2 Times, Yes 3-4 Times, Yes 5+ Times