Joshua San Mateo HSC 4730 November 25, 2013 Systematic Review Introduction Personal oral hygiene is an important

self-care habit that can help prevent disease. Oral care helps prevent problems, such as periodontal disease due to plaque buildup. Improper oral hygiene can lead to life threatening diseases, such as heart disease and brain damage. Although oral hygiene habits are theoretically easy to acquire and maintain, many fail to develop this habit. One habit that is simple to attain is dental flossing. Even though flossing takes only a small amount of time, only 10-30% of adults floss (Bowen, 2012). Yes, brushing regularly with a toothbrush and toothpaste helps remove plaque buildup, but many people forget to remove plaque in between their teeth. Flossing after teeth brushing removes 19-54% more plaque compared to teeth brushing alone (Wiener et al., 2012). Though it may not seem as important when younger, many more oral health problems arise as one ages. The progression of periodontal disease increase with age. At the same time, 10% of the population is highly susceptible to the disease (Sambunjak et al., 2012). If one does not floss, the progression of periodontal disease is more likely to become faster compared to those who do floss. This systemic review was conducted to provide a comparison of periodontal disease in two situations: progression of the disease with tooth brushing alone, and progression of the disease with tooth brushing and flossing. In comparison, flossing does help with the halt of the disease. In everyday life, flossing is often ignored and not considered helpful. This review is aimed to shed new light on the importance of flossing. Such as that of many diseases, easy

primary steps can be used for the prevention of periodontal disease. The purpose of this review is to synthesize recent literature on the impact of flossing on oral health outcomes.

Methodology The databases used for this research were PubMed as well as the Cumulative Index to Nursing and Allied Health Literature (CINAHL). In order to be included in this review, articles followed these parameters: published after 1990, human subjects, full text available, and adults. While searching in the databases, the key words/ MeSH terms used were periodontal disease, AND flossing, AND oral hygiene. Inclusion criteria were English, peer-reviewed, and had to be full text. Excluded articles included those that were in a language other than English, abstract only results, and those less than 3 pages. In addition, for the results matrix the following information author, sample size, intervention/outcome and overall support were:

Results Table 1 Flossing in Relationship to Periodontal Disease Author Sample size

Bowen (2012) 1083 Participants

Intervention/ Exposure
501 Control (Teeth brushing without flossing) 582 Experimental (Teeth brushing with flossing)

Outcome
Month 1 - 0.13 point reduction of plaque Month 3 0.2 point reduction of plaque Month 6 - 0.09 point reduction of plaque

Overall Support
Flossing, compared to the control group, reduced the amount of plaque

Sambun jak et al. (2011)

1083 Participants

501 Control (Teeth brushing without flossing) 582 Experimental (Teeth brushing with flossing)

Month 1 - 0.13 point reduction of plaque Month 3 0.2 point reduction of plaque Month 6 - 0.09 point reduction of plaque

Flossing, compared to the control group, reduced the amount of plaque

Schz et al. (2009)

192 Participants

62 Control (Told to floss) 132 Experimental (Instructed to floss)

Week 2 Control flossed 3.9x per week; Experimental flossed 4.24x Week 8 Control flossed 2.98x per week; Experimental flossed 4.02x -0.17 correlation between flossing selfefficacy and plaque level 0.02 correlation between tooth brushing and dental plaque 80% Women reported brushing their teeth daily

Though there is not a huge difference in flossing, those who were instructed on to how to floss flossed more frequently than those who were told to floss without instruction The correlations show that flossing is more effective in removing plaque than only teeth brushing

Stewart et al. (1999)

154 Participants

Questionnaire. Self-efficacy. Health value. Self-Value.

Wiener et al. (2012)

245 total participants

Oral self-care. Teeth brushing.

Women had more self-care than men. Those who had a positive outlook oneself image had greater plaque reduction than those who dont.

Table 1 shows the results of the five studies that were reviewed in this study. The same studies were reviewed by Bowen (2012) and Sambunjak (2011). Prior to the experiment, interdental plaque was measured of each participant. At 3 time points- 1, 3, and 6 months- plaque was measured between teeth using the Loe-Silness gingival index (which ranges from a 0-3 point scale). At one month there was a 0.13 reduction of plaque, and at 3 and 6 months, a 0.2 and 0.09 point reduction, respectively. Flossing did in fact reduce the amount of plaque. In Schzs (2009) study, there were a total of 194 participants. This experiment was an exposed 132 participants to an instructed procedure on flossing their teeth while the other 62 were essentially told to floss. Those who received a detailed plan on flossing, their performance activity increased, compared to those who did not have any guidance. As a result, measured at two weeks, those who received planning flossed 4.24 times a week compared to those without planning, only 3.9 times a week. Again at 8 weeks, participants were asked their frequency of flossing; those with planning still flossed more than those without planning; 4.02 times compared to 2.98 times. Though there is not a huge gap in flossing frequency, this difference can help to remove more plaque than those who do not floss. With plaque removal, the chances of acquiring periodontal disease declines. Stewarts (1999) study consisted of a self-efficacy questionnaire, addressing various oral self-care habits, comparing frequency of brushing and flossing to plaque interdentally. Some of the questions included oral care frequency, how much they value their selves and personal knowledge of dental health. Similar to Schzs experiment, interdental plaque was measured prior to the experiment. Of those responses, there was a negative correlation of -0.17 between flossing self-efficacy and plaque level. On the other hand, there was a correlation of 0.02 5

between tooth brushing and dental plaque. This proves that flossing, with the right mind set, does reduce plaque removal more than teeth brushing itself. Weiners (2012) study had a total of 245 participants. This study focused on the self-care of oral adults and their ability to maintain their oral care. Overall, women were more likely to take care of themselves orally than that of men (80% women and 52.3% men). Women in West Virginia had better oral practices than men, especially in tooth brushing.

Discussion The purpose of this systemic review was to examine and synthesis recent literature to assess the effect of flossing on oral health. Results of all five studies reviewed revealed that flossing has a positive association with oral hygiene. Flossing removes more plaque than just tooth brushing alone, thus reducing the risk of periodontal disease. Along with flossing, those who had a positive outlook one their self-image, especially their smile, are more likely to floss compared to people who do not have a positive self-image. While this review provided insight into the relationship between flossing and periodontal disease, there is a plethora of others ways to improve dental health. Some reductions of this study is that only five articles were reviewed and the study was conducted over a short period of time. Though 14 years of research was examined, only five of the numerous studies were examined, thus overlooking possible important data and major findings. The results of this review can be beneficial to public health practitioners, especially those who focus on oral health. Flossing is often ignored, but if patients are concerned of their oral health, practitioners can successfully implement flossing by not only stating some of the results of the findings, but also can plan out questionnaires and surveys to assess further health needs, especially the patients self-efficacy. Self-efficacy is especially important because patients who are determined and persistent in their own care will most likely successfully reduce their risk of periodontal disease. To become health conscious is easy, but to actually act on ones conscious can be a difficult task. Flossing is acting towards a healthier mouth. Interdental flossing is helpful in reducing the risk of periodontal disease, resulting in a healthy mouth.

References Bowen, D. M. (2012). Flossing or Alternative Interdental Aids?. Journal Of Dental Hygiene, 86(2), 58-62. Sambunjak, D., Nickerson, J., Poklepovic, T., Johnson, T., Imai, P., Tugwell, P., & Worthington, H. (2011). Flossing for the management of periodontal diseases and dental caries in adults. Cochrane Database Of Systematic Reviews. Schz, B., Wiedemann, A. U., Mallach, N., & Scholz, U. (2009). Effects of a short behavioural intervention for dental flossing: randomized-controlled trial on planning when, where and how. Journal Of Clinical Periodontology, 36(6), 498-505. doi:10.1111/j.1600051X.2009.01406.x Stewart, J., Strack, S., & Graves, P. (1999). Self-efficacy, outcome expectancy, dental health value, and dental plaque. American Journal Of Health Behavior, 23(4), 303-310. Wiener, R., Wu, B., Crout, R. J., Plassman, B. L., McNeil, D. W., Wiener, M. A., & ... Caplan, D. J. (2012). Hygiene Self-Care of Older Adults in West Virginia: Effects of Gender. Journal Of Dental Hygiene, 86(3), 231-238.