Research Assesses Impact of Interdental Cleaning on Cardiovascular Disease Events and Mortality

Cardiovascular disease (CVD) is responsible for one-third of all-cause mortality globally and places a considerable burden on health care systems. Increasing evidence indicates an association between periodontal disease and CVD. Population-based studies and systematic reviews report a consistently increased risk of developing CVD in patients with periodontal disease.¹

Primary prevention of periodontal disease is rooted in consistent and thorough daily oral hygiene practices. Additionally, research across different population groups suggests an association between proper oral hygiene practices and a reduced risk of CVD-related events, mortality, and improved CVD risk markers. Subsequently, some suggest poor oral hygiene practices should be added to the spectrum of CVD-related risk factors.¹

While these studies demonstrate this association, the primary focus has often been on the relationship between toothbrushing behavior and CVD events or the impact of toothbrushing on CVD risk markers, such as dyslipidemia, C-reactive protein (CRP), fibrinogen, vascular function, and hypertension. However, there is currently limited evidence on the additional benefits of interdental cleaning, beyond toothbrushing, in lowering the incidence of CVD-related events, risk markers, and mortality.¹

A recently published population-based study aimed to assess the impact of self-reported flossing (interdental cleaning) behavior on the prevalence of CVD and the risk of experiencing CVD-related mortality. A secondary endpoint for this study was to determine if daily flossing can lower CVD-related inflammatory risk markers.¹

The Study

Data was gathered and analyzed from four National Health and Nutrition Examination Survey (NHANES) cycles. From those four survey cycles, 18,801 participants answered questions regarding flossing habits. NHANES used the term flossing to refer to using traditional dental floss or any other interdental cleaning aids.¹

The survey questions regarding flossing habits were only asked of participants who were 30 years or older. Pregnant women were excluded due to potential lifestyle changes during pregnancy.¹

The survey participants were asked, “Aside from brushing teeth with a toothbrush, in the last seven days, how many days did you use dental floss or any other device to clean between your teeth?”¹

Based on the participant’s answers, they were categorized into four groups:¹

1. Not flossing (zero days a week)
2. Occasional flossing (one to three days a week)
3. Frequent flossing (four to six days a week)
4. Daily flossing (seven days a week)

Participants were then asked if they had ever received a diagnosis consistent with CVD, such as congestive heart failure, coronary heart disease, angina, heart attack, or stroke.¹

CVD mortality was classified by utilizing codes associated with CVD-related deaths.¹

The secondary outcome of assessing CVD risk markers was determined through laboratory components of the NHANES. Inflammatory markers were evaluated through blood tests to determine C-reactive protein (CRP) levels.¹

Covariates or independent variables selected included age, sex, race, ethnicity, education level, smoking status, alcohol consumption, energy intake (kcal/day), Healthy Eating Index (HEI) score, and physical activity.¹

The Results

The participant’s flossing behavior was directly associated with self-reported CVD events. Those who reported daily flossing had fewer CVD events. These participants were younger, more likely female, had higher education and income levels, more likely to engage in physical activity, and less likely to smoke and drink alcohol. Additionally, they had lower energy intake and higher HEI scores when compared to participants who did not floss.¹

The participant’s flossing behavior was also associated with all-cause mortality. Participants who reported daily flossing had a significantly decreased risk of all-cause mortality compared to those who did not.¹

Participants who reported flossing less than seven days a week had increased levels of CRP in two of the four cycles of surveys used for this study. The other two cycles did not evaluate CRP levels. These findings indicate that interdental cleaning is beneficial in lowering the risk of experiencing CVD mortality, all-cause mortality, secondary CVD events, and improved CRP profiles.¹

This study had multiple limitations, including its observational and cross-sectional design. This design did not allow for assessing temporal relationships. The information gathered was based on self-reported behaviors over the previous seven days, which may not represent consistent long-term behaviors. Lastly, the question included interdental cleaning methods other than traditional dental floss.¹

A strength of this analysis was the large sample size. However, the authors state the findings should be considered hypothesis-generating. Further, well-designed studies are needed to better define the relationship between flossing and CVD events.¹

Conclusion

Even after adjusting for confounders, the result of this study provides evidence that poor flossing habits were associated with a higher prevalence of CVD events. Additionally, the study determined elevated CVD-linked mortality and elevated CRP levels were observed in participants with poor flossing habits.¹

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Reference

1. Philip, N., Tamimi, F., Al-Sheebani, A., et al. The Effect of Self-Reported Flossing Behavior on Cardiovascular Disease Events and Mortality: Findings from the 2009-2016 National Health and Nutrition Examination Surveys. J Am Dent Assoc. 2025; 156(1): 17-27.e3. https://jada.ada.org/article/S0002-8177(24)00565-8/fulltext