Supplemental plaque removal measures beyond toothbrushing are necessary in order to thoroughly remove plaque (buildup) from teeth. Although toothbrushing can be effective at removing the plaque residing on buccal (cheek-side) and lingual (tongue-side) aspects of teeth, it is generally ineffective for interproximal surfaces (between the teeth). There are numerous sites and conditions in the mouth better served by plaque removal methods and devices other than toothbrushing. Examples of these sites include, fixed prostheses, crown margins, furcations of multirooted teeth, orthodontic appliances, the tongue, implants, and dentures.

Interproximal aspects of teeth (surfaces in-between the teeth) are not very accessible for the removal of plaque by the toothbrush. These sites have consistently been shown to harbor high amounts of plaque.

Regular interproximal plaque removal is recommended to reduce:

  • plaque and calculus (calcified/hardened plaque) buildup.
  • an increase in the rate and growth of new plaque not only on interproximal surfaces, but also on additional tooth surfaces.
  • gingival and periodontal infections while reducing or eliminating diseases in these soft tissues.
  • the interproximal site tendency for gingivitis, periodontitis, and caries (cavities).
  • dental caries (cavities).

Effective use of dental floss accomplishes the following objectives:

  • Removes plaque and debris that adheres to the teeth, restorations, orthodontic appliances,fixed prostheses and pontics,gingiva in the interproximal embrasures,and around implants.
  • May arrest or prevent cavities between the teeth.
  • Reduces gingival inflammation and bleeding.

Several types of floss are available. Clinical trials have shown no significant differences in the cleansing ability between waxed and unwaxed floss. Wax residue has not been found on tooth surfaces cleaned with waxed floss. Unwaxed floss is frequently recommended because it is thin and slips easily through tight contact areas. However, unwaxed floss can fray and tear when contacting rotated teeth, heavy calculus deposits, or defective and overhanging restorations. Frequent floss breakage may discourage continued use. For these conditions, waxed, lightly waxed, or shred-resistant floss are recommended.

Flossing Methods

The Spool Method is particularly suited for teenagers and adults who have acquired the coordination required to use floss. When using the spool method, a piece of floss approximately 18 inches long is utilized. The bulk of the floss is lightly wound around the middle finger. Space should be left between wraps to avoid impairing circulation to the fingers (Figure A). The rest of the floss is similarly wound around the same finger of the opposite hand. This finger can wind, or “take up,” the floss as it becomes soiled or frayed to permit access to an unused portion. The last three fingers are clenched and the hands are moved apart, pulling the floss taut, thus leaving the thumb and index finger of each hand free (Figure B). The floss is then secured with the index finger and thumb of each hand by grasping a section three quarters to 1 inch long between the hands (Figure C).

The Loop Method is suited for children as well as adults with less nimble hands or physical limitations caused by conditions such as poor muscular coordination or arthritis. Flossing is a complex skill, so until children develop adequate dexterity, usually around the age of 10 to 12 years, an adult should perform flossing on the child.

For the loop method, the ends of the 18-inch piece of floss are tied in a knot. All of the fingers, but not the thumbs of the two hands are placed close to one another within the loop.

Whether using the spool or the loop method of flossing, the same basic procedures are followed. The thumb and index finger of each hand are used in various combinations to guide the floss between the teeth.

When inserting, floss, it is gently eased between the teeth with a seesaw motion at the contact point. The gentle seesaw motion flattens the floss, making it possible to ease through the contact point and prevent snapping it through, thus avoiding damage to the gums. Once past the contact point, the floss is adapted to each interproximal (between the teeth) surface by creating a C-shape. The floss is then directed toward the gum into the sulcus (the space between the gums and the tooth where the gums attach to the tooth) and back to the contact area (up-and-down against the side of the tooth) several times or until the tooth surface is clean. The procedure is repeated on the adjacent tooth in the proximal area, using care to prevent damage to the papilla (pink triangle of gums in-between the teeth). A clean, unused portion should be used for each interproximal area.

In general, flossing is best performed by cleaning each tooth in succession, including the distal (back) surface of the last tooth in each quadrant. Incorrect use of dental floss could result in gingival cuts, soft tissue clefting, and cervical wear on interproximal root surfaces. In certain circumstances, the use of a floss holder, floss threader, variable-thickness floss, or precut floss strands with a stiff end may be more effective.