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This paper discusses the behavior of flossing for oral health specifically in relation to its effectiveness in preventing cardiovascular disease. It explores the current claims posted on websites and evaluates them using recent scientific studies. It explores the preventative nature of flossing and its effectiveness. This paper has found that flossing is an important means of reducing plaque and therefore the risk of both periodontal disease and potentially cardiovascular disease in the long run. However, flossing is not sufficient alone nor is it exclusively an effective means to prevent cardiovascular disease. Other methods of maintaining oral health are equally effective. It is recommended that flossing teeth is an important behavior to continue but it is not a guaranteed means of prevention.
Think Flossing is not so Flossy?
General Information about Flossing
Flossing teeth has been a method to enhance oral hygiene for centuries, and it is now considered an essential element in oral health. Floss consists of a long strand of twisted fibers made of either nylon filaments or plastic monofilaments that is often waxed or favored for comfort (http://www.ada.org/public/topics/cleaning.asp ). It is used to remove food caught between the teeth as well as oral bacteria. The bacteria may harden into plaque and eventually tarter if not removed promptly. The American Dental Association (ADA) suggests flossing as a method of its removal asserting that brushing alone is insufficient. Floss is commended for its flexibility and ability to reach tight spaces. This paper will address the media’s claim that flossing is important in reducing the risk of cardiovascular disease according to recent scientific studies.
Figure 1. Proper Flossing Techniques.
Purpose of Flossing Without flossing, the plaque buildup on teeth can cause serious irritation to the gums which may become inflamed, tender and bleed (http://www.ada.org/public/topics/cleaning.asp ). These are the first symptoms of developing gum disease and are classified as gingivitis. If the gums are neglected for long enough, they will separate from the teeth and pockets of bacteria and pus will develop. Bacterial toxins will work to fight the infection but will eventually destroy the teeth and bone in addition to the gums. The condition is then classified as periodontal disease (http://www.nidcr.nih.gov/OralHealth/Topics/GumDiseases/PeriodontalGumDisease.htm). To preserve the teeth and gums, and avoid periodontal disease, in addition to flossing once daily, brushing your teeth and eating a well-balanced diet are known to help.
Figure 2. Gingivitis and Periodontitis.
Connection between Periodontal and Cardiovascular Disease Cardiovascular problems, specifically coronary heart disease, are caused by atherosclerosis or when plaque collects on the coronary arteries (http://www.americanheart.org/presenter.jhtml?identifier=4478 ). Periodontal and cardiovascular disease were first studied comparatively because both seem to be related to the poor health behavior of smoking (http://www.ada.org/prof/resources/pubs/adanews/adanewsarticle.asp?articleid=1735 ). Both have show to have an increased risk of developing the disease if you smoke. There is no determined causal component between periodontal and cardiovascular disease, however the two share plaque build up as a cause of problematic inflammation. Now some websites and even scientific journals are suggesting that their relationship is no coincidence. The worst known direct consequence of periodontal disease is tooth loss, however for cardiovascular disease it is death. For this reason, many organizations are investigating whether flossing can reduce one’s risk for heart problems.
Figure 3. Atherosclerosis.
Website Claims about Flossing
Flossing is recommended by the ADA, and other websites such as WebMD, as an essential method of preventing periodontal disease. Other sources, like the media, claim to be linked to preventing cardiovascular disease as well. The most well respected sources, however, such as the ADA and the United States Department of Health and Human Services have not publicly announced a direct connection between flossing and cardiovascular disease (http://www.ada.org/public/topics/periodontal_diseases.asp ; http://www.nidcr.nih.gov/OralHealth/Topics/GumDiseases/PeriodontalGumDisease.htm ). These particular associations have primarily only exposed the risk of getting gingivitis (an early stage of gum disease) and periodontal disease. An explanation for this may be that gingivitis is a more immediate effect of not flossing. It is much easier to understand a direct risk of a behavior even though cardiovascular disease is much more dangerous. Also, the relationship between flossing and gum diseases has been much more widely accepted in the realm of research compared to more recent studies on cardiovascular disease. This will be shown later in a more in depth review of the literature. Aside from the ADA and U.S. Department of Health and Human Services, other online health services like Medline Plus and WebMD do not make the claim that flossing prevents cardiovascular disease (http://www.webmd.com/news/20000919/is-flossing-good-for-your-heart ). They say the empirical evidence is not conclusive enough to draw a causal connection.
Figure 4. Periodontal and Cardiovascular Disease.
Since the National Health Associations and well-known websites have not supported this claim, the question is: who has? This claim has mostly been evident in the media including print sources like health magazines and in the news. These sources are less conservative when presenting a relationship between flossing and cardiovascular health. For example, Fox news recently published a report identifying a causal connection (http://www.foxnews.com/story/0,2933,254513,00.html ). This is especially notable because the article even says its position is contrary to what was believed previously. The U.S. News has also reported that flossing reduces the risk of heart disease (http://health.usnews.com/usnews/health/briefs/oral/hb050209a.htm ). Aside from the news, health magazine like Men’s health also encourages flossing as a means of preventing heart disease asserting that “signs of [periodontal] disease in multiple spots in your mouth can hike CRP [C-reactive protein which tests for cardiovascular disease] by 14 percent” (http://www.menshealth.com/mhlists/prevent_heart_disease/Floss_Like_a_Fiend.php). The quality of these sources is unknown. They all refer to research studies but the detail of those studies is not presented nor is any information to trace them.
Interestingly, the media has been quick to promote flossing as an important way to help reduce risk of having a heart attack, however a number of reputable sources and associations are not willing to support this assertion. Not even companies that produce dental floss like Crest have chosen to use the risk of getting cardiovascular disease as a means of promoting their product (http://www.glidefloss.com/smart-tips.php). They do, however, present the risk of gum disease, but not cardiovascular disease. This is rationalized by the idea that the media’s motives may be to draw interest from their audience and present new information, whereas other organizations may remain neutral until there is more conclusive evidence. The legitimacy of this rationale is questionable. There has been a considerable amount of research done to connect oral health behaviors with reduced risk of cardiovascular disease. The presentation of this research will be evaluated in this paper.
Figure 5. Dental Floss.
Review of the Literature
Studies that investigate the relation ship between periodontal disease and cardiovascular disease are not necessarily a new trend. Researchers have been evaluating this relationship for some time now. Earlier studies from 1996 and 2000 have resulted in inconclusive findings (Joshipura, 1996; Hujoel, 2000). The more dated evidence was conducted using self-reported surveys. One survey of 44,119 males looked at causal relationship between poor oral health and coronary heart disease (Joshipura, 1996). This study may have inconclusive results since self-reported evaluations are not always accurate. Another study that had inconclusive results was a prospective cohort study that controlled two groups with and without periodontal disease and tested for coronary heart disease (Hujoel, 2000). This was a very large and extensive long-term study with 8,032 participants over a span of ten years which indicates that there may be a weak relationship between periodontal and coronary disease, but it is not a direct cause.
This issue has come to the surface again more recently because of revised studies that have identified not simply that a mere relationship exists, but what the mediators of that relationship are. Rather than studying the prevalence of the disease and risk factors, one cross-sectional study looked specifically at the factors that increase cardiovascular risk, and are also associated with periodontal disease (Wu et.al, 2000). These factors include total cholesterol, c-reactive protein and fibrinogen. Blood specimens were taken from a large group of participants to determine a relationship along with an assessment of gingival health. The study could not determine the relationship with cholesterol levels, however c-reactive protein and fibrinogen were both found to be risks for cardiovascular disease due to oral bacteria. Another similar study by Buhlin (2003) supports these findings. It also compared plasma levels relating to inflammation of the gums and cardiovascular disease.
There are two other studies that strongly support the connection between periodontal disease and cardiovascular disease. Spahr’s study (2006) compared the prevalence of cardiovascular disease and analyzed the periodontal pathogens or subgingival biofilm samples. Specifically, certain infections that occur in the mouth that lead to chronic inflammation can increase one’s risk of cardiovascular disease. This study found that they relationship was statistically significant by means of microbiological factors. This study is important because it investigates the bacteria involved and how that may cause cardiovascular problems rather than simply poor oral health in general.
Figure 6. Periodontal Pathogen.
Finally, a meta-analysis of nine cohort studies found that there is a greater risk of developing cardiovascular disease later in life if periodontal disease is present (Janket et. al, 2003). This study that complied the results of other similar research found that on average, periodontal disease attributes to a 19% increase in risk of developing cardiovascular disease. So although the earliest studies found that a relationship between the two diseases cannot be empirically established, more recent studies, especially ones that cover a variety of methods, do indicate that a relationship does exist at a microbiological level. Some of the most comprehensive studies say there is a direct correlation and that there are mediators linking the two together.
The studies presented thus far in the paper have established the connection between periodontal disease and cardiovascular disease. However, it is important to also look at flossing as a means of plaque removal. We now know it is important to have good oral health to avoid chronic gum inflammation, but how effective is dental floss? There are two different types of floss, waxed and unwaxed. Past studies such Finkelstein (1979) show that there is no significant difference between the types of floss. Both waxed and unwaxed floss have proven to remove the same amount of plaque build up when properly administered.
Figure 7. Waxed and Unwaxed Dental Floss.
As for floss compared to other means of plaque removal, a comprehensive study by Bauroth (2003) compared the effectiveness of dental floss in removing plaque compared to essential oil antiseptic mouth rinse. Using a randomized comparative study, treatment and control groups were assigned to either brush, floss or rinse. This evidence concluded that there is also no significant difference between flossing and using the antiseptic mouth rinse. However, this study is important for this analysis because there was a significantly greater amount of plaque removed when groups used floss and the rinse as opposed to brushing alone. This finding is also supported by the ADA as well (www.webmd.com/oral-health/flossing-recommended ). This indicates that brushing does not prevent gingival or periodontal disease alone; flossing is an important health behavior to control the onset of these diseases. This establishes the importance of flossing as opposed to simply maintaining oral health in general in preventing periodontal disease. Since periodontal disease has been empirically linked to cardiovascular disease, some may argue that flossing can also indirectly help to prevent cardiovascular disease. However flossing is not an excusive means of reducing these risks, other behaviors such as using a mouth rise could be equally effective.
Figure 8. Orajel Antiseptic Mouth Sore Rinse.
Motivations for Flossing
Trends in Flossing as a Health Behavior
Flossing or using an antiseptic mouth rinse is important for preventing periodontal disease and potentially helping to avoid cardiovascular disease in the long term, but have these findings been influential in encouraging people to floss regularly? A study by Halvari (2006) determined that perceived competence of flossing and level of motivation was influenced by an intervention explaining the importance of the behavior. This is significant for the findings of this analysis because a number of associations and online health websites do not present cardiovascular disease as a potential risk if periodontal disease develops due to not flossing. This study may suggest that if this information was more readily available, it may increase people’s motivation to floss their teeth. Additionally, the way the message is framed may also increase the level of intention to floss (Sherman et. al, 2006). Congruently framed messages according to the individual’s tendencies determined their intention to floss. Dental floss companies as well as health promotion organizations should consider this framing when encouraging people to floss.
Plaque buildup from not flossing is not the only cause of periodontal disease, other factors such as hormonal changes, illnesses, taking certain medications, smoking and one’s family history also contribute. Thus, flossing may help to prevent the onset of disease in the mouth and potentially the heart, but there are many other contributors as well. One should not rely on flossing alone to avoid disease. Further, poor oral heath is not, by any means, the only cause of cardiovascular disease. Flossing is recommended both thoroughly and regularly as an extra preventative measure, however it should not be the only preventative measure taken. It is also suggested to stop smoking, eat a well balanced diet and take other measures to remove plaque in the mouth such as brushing or using an antiseptic rinse.
Thus, flossing is an important means of removing plaque beyond simply brushing, however it is not an exclusive factor in preventing heart disease. Many articles in the news and health magazines lead consumers to believe that flossing is a necessary behavior in maintaining a healthy heart. According to the scientific research, this is true to an extent since not flossing can be linked to types of cardiovascular disease, however it is not as strong of a correlation as these articles suggest. And so, flossing is a good means of maintain oral health, however in promising prevention of cardiovascular disease, it is not as flossy as the media portrays it to be.
Bauroth, K., Charles, C., Mankodi, S., Simmons, K., Zhao, Q., & Kumar, L. (2003, March). The efficacy of an essential oil antiseptic mouthrinse vs. dental floss in controlling interproximal gingivitis. Advances in Dental Products, 134, 359-365.
Buhlin, K., Gustafsson, A., Pockley, A. G., Frostegard, J., & Klinge, B. (2003). Risk factors for cardiovascular disease in patients with periodontitis. European Heart Journal, 24, 2099-2107.
Finkelstein, P., & Grossman, E. (1979, March). The effectiveness of dental floss in reducing gingival inflammation. Clinical and Materials Sciences, 58(3), 1034-1039.
Halvari, A. E., & Halvari, H. (2006). Motivational predictors of change in oral heath: An experimental test of self-determination theory. Motiv Emot, 30, 295-206.
Hujoel, P. P., Drangsholt, M., Spiekerman, C., & DeRouen, T. (2000, September). Periodontal disease and coronary heart disease. American Medical Association Journal, 284(11), 1406-1410.
Janket, S.-J., Baird, A. E., Chuang, S.-K., & Jones, J. A. (2003, May). Meta-analysis of periodontal disease and risk of coronary heart disease and stroke. Oral Medicine, 95(5), 559-569.
Joshipura, K., Rimm, E., Douglass, C., Trichopoulos, D., Ascherio, A., & Willett, W. (1996, August). Poor oral health and coronary heart diesase. Rapid Communication, 1631-1636.
Joshipura, K., Wand, H., Merchant, A., & Rimm, E. (2004). Periodontal disease and biomarkers related to cardiovascular diesase. Clinical Research Reports, 83(2), 151-155.
Spahr, A., Klein, E., Khuseyinova, N., Boeckh, C., Muche, R., Kunze, M., et al. (2006, March). Periodontal infections and coronary heart diesase. Archive of Internal Medicine, 166, 554-559.
Wu, T., Trevisan, M., Genco, R. J., Falkner, K. L., Dorn, J. P., & Sempos, C. T. (2000). Examination of the relation between periodontal health status and cardiovascular risk factors: Serum total and high density lipoprotein cholesterol, c-reactive protein, and plasma fibrinogen. American Journal of Epidemiology, 151(3), 273-282.
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