Comment: The quality of evidence is downgraded by study limitations (lack of blinding, incomplete reporting) and by indirectness (differences between the outcomes of interest and those reported: only short-term outcomes reported).
A Cochrane review on the effectiveness of flossing in addition to toothbrushing for preventing gum disease and dental caries in adults included 12 studies with a total of 1 083 subjects. Flossing plus toothbrushing showed a statistically significant benefit compared to toothbrushing in reducing gingivitis at the three time points studied: SMD –0.36 (95% CI –0.66 to –0.05) at 1 month, SMD –0.41 (95% CI –0.68 to –0.14) at 3 months and SMD –0.72 (95% CI –1.09 to –0.35) at 6 months. The 1-month estimate translates to a 0.13 point reduction on a 0 to 3 point scale for Loe-Silness gingivitis index, and the 3 and 6 month results translate to 0.20 and 0.09 reductions on the same scale. Overall there is weak, very unreliable evidence which suggests that flossing plus toothbrushing may be associated with a small reduction in plaque at 1 or 3 months. None of the included trials reported data for the outcomes of caries, calculus, clinical attachment loss, or quality of life.
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