Should You Floss Before or After Brushing Your Teeth?

It’s been generally accepted that dental floss has a positive effect on removing plaque. The question however is; should you floss before or after brushing your teeth?

It’s been generally accepted that dental floss has a positive effect on removing plaque. How do we know? You can use what is known as a random split-mouth design where each person can act as their own control. For example only flossing one quarter of their mouth.

Split-mouth design


They asked the study subjects (check NIH website for details on study) to stop brushing their lower jaws for the next 21 days so that plaque would build up; then they were randomized to floss half and leave the other half as the non-flossed control.

Upper and lower jaw


After three weeks, not only did the flossing cut plaque by about 60 percent, more importantly it cut the signs of gingivitis (a common and mild form of gum disease (periodontal disease) that causes irritation, redness and swelling (inflammation) of your gingiva, the part of your gum around the base of your teeth.) in half.

Plaque free teeth


Though this is comparing flossing to nothing, the study subjects weren’t allowed to brush their lower jaw to compare flossing to non-flossing. Given the result of the study therefore, flossing is better than nothing. The question that remains however is; does flossing plus brushing give better results than just brushing alone?

Toothbrush, toothpaste, and flosser


The advocacy of floss hinges in large part, on common sense, but common sense doesn’t go very far as a form of evidence. You don’t really know until you put it to the test. What’s the efficacy of dental floss in addition to a toothbrush? Surprisingly, only 3 of the 11 studies they looked at found a significant added benefit.

Pondering the efficacy of flossing


The anti-flossers were positively giddy, comparing dentists who continued to advocate flossing in the face of the data, to flat-earth advocates. Dentistry is a profession in denial. Over 80 percent of people don’t floss regularly, and it’s just hard for the “dental elite” to accept that the “great un-flossed masses” were right and that the dentist doctors, were wrong. Flossing doesn’t work get over it!

Flossing denial


Is flossing then just some tooth fairy tale? This review was published back in 2008. Since then, more studies were published and while the evidence on additional plaque reduction is weak, at least there’s some evidence it helps with gingivitis, which is a primary reason you want to reduce plaque anyway. Why might they have not found stronger evidence?

Flossing helps with gingivitis


Well, the trials were of poor quality; and so the conclusions must be viewed as unreliable. So, we basically don’t have good evidence either way because good studies really haven’t been done. Why not? Why wouldn’t big floss companies fund the studies?

Flossing denial is due to poor trial tests


Because it appears all floss works the same, if you compare Unwaxed to woven to shred-resistant floss, they all have about the same plaque removal efficacy, which it appears all such studies found. So why would a floss company fund a study to show flossing in general is good if they can’t show their product is better – otherwise you might just go buy their competitor’s floss.

Poor trials are due to lack of funding


Where do we stand today? Although technically the evidence for flossing is weak, more importantly, the methodology of the studies examining flossing effectiveness are also weak. For example they didn’t assess the quality of the people’s flossing. Bottom line the American dental association continues to recommend brushing and flossing every day. But what’s the proper sequence? Should you floss before or after you brush?

American dental association continues to recommend brushing and flossing


Some dentists argue that flossing comes first because you stir up the particles and plaque that the toothbrush can then brush away, and then the fluoride from the toothpaste might get in there better. But others recommend brushing first, thinking that that would remove the bulk of the particles first and then the floss could floss some of the fluoride from the residual toothpaste in there.

Do you brush and then floss or floss and then brush


In a randomized controlled clinical trial, flossing first won in terms of getting rid of significantly more plaque and getting more of the fluoride in there. When we floss after brushing, much of the particles that are being pushed out by the dental floss may stay in place on our teeth. The bottom line is flossing followed by brushing is preferred.     


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