Dental floss is the most widely recommended tool for removing dental plaque from proximal tooth surfaces.90 Regular flossing as an adjunct to toothbrushing has been demonstrated to decrease plaque levels interproximally and to decrease gingival inflammation over toothbrushing alone.78 Furthermore, individuals who floss demonstrate lower levels of caries and gingival inflammation in observational studies.53 In a matched twin cohort the addition of flossing to toothbrushing alone decreased visible plaque, gingival bleeding, and altered the subgingival flora to reduce the proportions and amounts of bacterial species associated with periodontal disease and dental caries, including T. denticola, P. gingivalis, T. forsythia, P. intermedia, A. actinomycetmcomitans, and S. mutans.91,92 Additionally, while this increased plaque removal and a shift in microbial species may not necessarily translate into lower caries rates as it relates to flossing, decreased plaque scores are associated with decreased decayed, missing, and treated (DMT) scores in adults and children.1,93,94

Despite the conculsions in the lay media, flossing efficacy has been demonstrated its adjunctive benefit in reducing gingival inflammation, bleeding upon probing, and plaque deposits as an adjunct to toothbrushing. Flossing is economical, effective when performed correctly, and aids in removal of plaque and food debris interproximally, however it may not be optimally effective in areas with anatomical challenges including diastemata, open embrasure spaces, radicular grooves and/or concavities, etc. Additionally, adequate flossing habits are difficult to establish. It is reported only 8% of teenagers floss daily and the number of all individuals who floss daily may be as low as 2%.14,95,96 Increasing patients’ willingness to floss and their ability to sustaining the habit over time may depend upon the behavior modification techniques employed by the dental healthcare professional. Some patients may report better aderence with other methods of interdental cleaning.