“Floss or Die” Really?
“Floss or Die” Really?
By Angie Littlefield
I was surprised by a recent smattering of headlines that stoked fears of heart disease for failure to floss. My brother, Dr. F. Michael Eggert, a successful periodontist, researcher and retired professor of dentistry, has long emphasized prevention and good oral hygiene as the best route to a long, healthy life—with your teeth. I decided to ask him about the dental scare. First, he told me about the long history of the “Floss or Die” movement and its tactics to drive people to dentists and hygienists. Then he reassured me that there was no definitive causality between bad mouth bacteria and heart disease. Statistically, periodontal disease (PD) and cardiovascular disease (CVD) have a propensity to partner up, but, after two decades of research and discussion, there is no absolute proof that PD leads to CVD. No causality. Two women in identical blue dresses who show up at the same party, do not need to be related in any way.
My own personal expert referred me to an overview article from 2018, “Floss or Die,” in Dentistry IQ, meant for an average reader. It ended with, “Floss or die is an exaggeration at this point, but there was a time when “stop smoking or die” was also considered an exaggeration. Time will tell about flossing. But for now, this is something to think about.” He also referred me to a 2019 article from above the snow line of academia, where the air is thin for the average reader. To keep with the mountaineering analogy, the article, “Association between atherosclerosis and periodontitis: a brief review” in Drug Invention Today by Thasleema and Don buried me under an avalanche of scientific terms. I did get this takeaway, however: “Epidemiological studies have clearly shown a moderate but significant association between periodontitis and CVD. However, no compelling evidence suggests that preventive periodontal care or therapeutic intervention will influence cardiac health. Unless and until definitive clinical studies can demonstrate or further explain the associations between periodontitis and CVD, it is premature to counsel our patients to ‘floss or die.’”
Okay, a moderate link between PD and CVD, but no imminent death if I forgot to floss. Ah, but there was a rub. The readings had shown the very large amounts of bacteria that co-habited in my mouth, and I was worried about the bad kind. 
Just as the human intestines are rife with good bacteria going about their business of extracting nutrients, so also, “[M]ore than 700 bacterial species . . . have been detected in the oral cavity.” In 2005, a team of intrepid researchers from the Harvard School of Dental Medicine and from the Department of Molecular Genetics at the University of Oslo set about trying to identify the bacteria in healthy mouths with the aim of distinguishing between friend and foe. They ended up identifying thirteen new bacterial species in our incredibly busy oral cavity, but they were left with the conclusion that there was a great deal more to do: “It is important to fully define human microflora of the healthy oral cavity before we can understand the role of bacteria in oral disease.”
I should have left it there, with a mouthful of bacteria. Unfortunately, by this point I had spotted the same sinister bacterial suspect lurking around—like a murderer returning to the scene of the crime. Recent studies, both those highly technical, like “Porphyromonas gingivitis in Alzheimer’s disease brains: Evidence for disease causation and treatment with small molecular inhibitors” in Science Advances, 2019, and more readable ones, like “Large study links gum disease with dementia,” National Institute on Aging, July 9, 2020, showed a certain “P gingivalis” abundantly present in Alzheimer’s disease patients (AD). As in the case of CVD, the studies highlighted that PD and AD were often seen together. They stopped short of concluding causality. That reservation again: causality. Yes, periodontal disease and cardiovascular disease and Alzheimer’s disease went “Ring around the Rosie,” but the researchers, up to now, have concluded there was no reason for us to all fall down.
Now, even as I believe in my brother’s expertise and in the research standards that set a very high empirical bar to establish causality between PD, CVD, and AD, I’m going with the cautionary article that pointed out that there was once no causality between smoking and certain cancers—and now there is. “This is something to think about” that article said.
Well, I’ve thought about it and as part of physical and emotional self-care, I’ve concluded that I’m not waiting for absolute proof for causality between PD and either CVD or AD to take superb care of my oral hygiene. I’m not taking chances. The effort to practice oral hygiene in a preventive way is just not that onerous. Here’s the list:
- Brush your teeth at least twice a day.
- Use a mild mouthwash that does not kill good bacteria along with the bad.
- Floss regularly, but in particular before bedtime.
- Brush your tongue and palate, regardless of whether you have teeth or not.
- Drink plenty of water.
I am going on my mid seventies, and I have all my own teeth (except for the wisdom teeth). I have no signs of PD, CVD, or AD—yet. My brother’s advice about the importance of prevention has served me well. And, thanks to my little investigation, I am not concerned about the “Floss or Die” movement, and I am happy that it brought me back to an affirmation of prevention.
So, why not do everything we can to improve our chances for a longer and healthier life—with all our teeth intact!
Photo credit by: Amir Esrafili (Iran) @amirvisuals
