It’s one of the most universal recommendations in all of public health: The dictum-Floss daily to prevent gum disease and cavities. Except there’s little proof that flossing works. Still, the federal government, dental organizations and manufacturers of floss have pushed the practice for decades. Dentists provide samples to their patients; the American Dental Association insists on its website that, “Flossing is an essential part of taking care of your teeth and gums.”
The federal government has recommended flossing since 1979, first in a surgeon general’s report and later in the Dietary Guidelines for Americans issued every five years. The guidelines must be based on scientific evidence, under the law.
Last year, the Associated Press asked the departments of Health and Human Services and Agriculture for their evidence, and followed up with written requests under the Freedom of Information Act. When the federal government issued its latest dietary guidelines this year, the flossing recommendation had been removed, without notice. In a letter to the AP, the government acknowledged the effectiveness of flossing had never been researched, as required.
The AP looked at the most rigorous research conducted over the past decade, focusing on 25 studies that generally compared the use of a toothbrush with the combination of toothbrushes and floss. The findings? The evidence for flossing is “weak, very unreliable,” of “very low” quality, and carries “a moderate to large potential for bias.”
“The majority of available studies fail to demonstrate that flossing is generally effective in plaque removal,” said one review conducted last year. Another 2015 review cites “inconsistent/weak evidence” for flossing and a “lack of efficacy.”
One study review in 2011 did credit floss with a slight reduction in gum inflammation — which can sometimes develop over time into full-fledged gum disease. However, the reviewers ranked the evidence as “very unreliable.” A commentary in a dental magazine stated that any benefit would be so minute users might not notice it. Remember, this was a commentary only.
The two leading professional groups — the American Dental Association and the American Academy of Periodontology, for specialists in gum disease and implants — cited other studies as proof of their claims that flossing prevents buildup of gunk known as plaque, early gum inflammation called gingivitis, and tooth decay. However, most of these studies used outdated methods or tested few people. Some lasted only two weeks, far too brief for a cavity or dental disease to develop. One tested 25 people after only a single use of floss. Such research, like the reviewed studies, focused on warning signs like bleeding and inflammation, barely dealing with gum disease or cavities.
Wayne Aldredge, president of the periodontists’ group, acknowledged the weak scientific evidence and the brief duration of many studies. In an interview at his private practice in New Jersey, he said that the impact of floss might be clearer if researchers focused on patients at the highest risk of gum disease, such as diabetics and smokers. Still, he urges his patients to floss to help avoid gum disease. “It’s like building a house and not painting two sides of it,” he said. “Ultimately those two sides are going to rot away quicker.” Aldredge also said many people use floss incorrectly, moving it in a sawing motion instead of up and down the sides of the teeth. Pressed about the origins of his organization’s endorsement of flossing, he said it may simply have “taken the ADA’s lead.” This is part of the problem and the studies need more time and a scientifically based study.
When the ADA was asked for proof of its claim that flossing helps prevent early gum disease and cavities, the group cited the 2011 review and a 2008 two-week study that measured bacteria and did not even consider gum disease.
In a later statement to the AP, the ADA said flossing “removes plaque” and “is proven to help remove” debris from between teeth. A video on its website proclaims that flossing “helps prevent gum disease.” When pressed, Matthew J. Messina, a practicing dentist and spokesman for the dental association, acknowledged weak evidence, but he blamed research participants who didn’t floss correctly.
Even companies with a big market share of the flossing business — by next year, the global market is predicted to reach almost $2 billion, with half in the United States, according to publisher MarketSizeInfo.com — struggled to provide convincing evidence of their claims that floss reduces plaque or gingivitis. Yet the industry has paid for most studies and sometimes designed and conducted the research.
Procter & Gamble, which claims that its floss fights plaque and gingivitis, pointed to a two-week study, which was discounted as irrelevant in the 2011 research review.
Johnson & Johnson spokesman Marc Boston said floss helps remove plaque. When the AP sent him a list of contradicting studies, he declined comment. The floss-making companies partner with the ADA through its Seal of Acceptance program. The ADA promotes the seal to companies as something that “directly affects the purchase decisions of consumers;” each manufacturer is charged $14,500 for the evaluation. If it approves the product, the ADA then charges an additional annual fee of $3,500. The ADA says it rigorously evaluates products and makes no profit from the program. However, floss companies themselves are allowed to design the studies.
“The funding can come from companies — no problem at all,” said dentist Marcelo W.B. Araujo, vice president of the ADA’s Science Institute, who joined the organization after serving as an executive for Johnson & Johnson. “The design can start from the company.”
When flossing first gained acceptance, no proof was required of remedies. Dentist Levi Spear Parmly is credited with inventing floss in the early 19th century. By the time the first floss patent was issued, in 1874, the applicant noted that dentists were widely recommending its use.
The ADA has been promoting floss universally since 1908. “They just looked into what they did every day in their clinical practice and what they would recommend for patients,” said Araujo.
Count dentist Damien Walmsley, scientific adviser to the British Dental Association, among the skeptics. “It’s important to tell people to do the basics. Flossing is not part of the basics.” And you are going to believe a British dentist when the British dental health is rated as some of the worse parts of their care and overall health.
Floss can occasionally cause harm. Careless flossing can damage gums, teeth and dental work. Though frequency is unclear, floss can dislodge bad bacteria that invade the bloodstream and cause dangerous infections, especially in people with weak immunity, according to the medical literature.
National Institutes of Health dentist Tim Iafolla acknowledged that if the highest standards of science were applied in keeping with the flossing reviews of the past decade, “then it would be appropriate to drop the floss guidelines.”
Regardless, he added, Americans should still floss. “It’s low risk, low cost,” he said. “We know there’s a possibility that it works, so we feel comfortable telling people to go ahead and do it.”
But discussing this with dentists, my wife and others, there is the question of where does this come and why now? They know the benefits and its effects on dental health it is just a bunch of flawed studies. These are not even acceptable research studies. But the technique has to be performed properly and when done decreases gum disease allowing patients to keep their teeth and avoiding the spread of bacteria to other sites such as heart valves. We, dentists and physicians, know the science behind flossing. It’s just hard to prove it and interestingly the company selling water flossing-The Water Pic Pro- are advertising like crazy.
And now Niantic Corporation has released Pokémon Go promoting it for increased physical activity. Niantic’s new smartphone game has unleashed a Pokémon fever that is spreading around the globe faster than swine flu. Now, researchers at Johns Hopkins are scrambling to study how Zubats and Pikachus might be affecting populations—possibly helping to combat another ongoing public health crisis: the global obesity epidemic.
From med students to middle-school kids, tens of millions have suddenly taken to the streets, phone in hand, in search of elusive virtual beasts. The more you walk, the more likely you are to find these pixel critters, gain expertise and “level up.” With its incredible worldwide popularity, this immersive, augmented-reality game has the makings of a social, or health, experiment on a global scale.
As the obesity epidemic continues to grow and physical activity continues to decline worldwide, could chasing Pokémon be part of the solution? Each day in the US, only 1 in 3 children are physically active and less than 5% of adults get the recommended 30 minutes of physical activity. Over the past 5 years, hundreds of wearable technologies have emerged, but the jury is still out on whether these actually improve physical activity, especially among the sedentary. Public health studies have sought answers to these tough questions: Do wearables actually enhance physical activity? Can they replace expensive gym memberships or exercise equipment? Will people keep using them once the novelty wears off? Roughly 13 million Americans bought smart activity trackers in 2015, but 1/3 abandoned those New Year’s resolutions within 6 months.
Maybe the secret sauce is not trying to be a healthy app, but instead focus on a game that gets people off the couch, into the real world, with inadvertent health effects. In 2006, Microsoft’s Kinect and Nintendo’s Wii game consoles were heralded by many as the solution to getting a nation of young gamers off their couches—but in this case, only as far as the carpet in front of the TV. In just a week, more people have downloaded and used Pokémon GO than have ever bought the Wii Fit game. Even major fitness giants such as Nike have tried, unsuccessfully, to capture users in NikeFuel “Missions,” powered by a digitally-enhanced sneaker, only to dissolve most of their Digital Sports division 2 years after launch.
As a commercial digital game, Pokémon GO may be better at engaging users, especially currently sedentary ones, than health apps disguised as games. Pokémon GO not only builds on the appeal of a massively successful gaming franchise but also adds a hefty dose of 21st century tech. Kids and adults alike seem to be having no problem walking for city blocks when it doesn’t seem like exercise—like hiding broccoli in a smoothie. The best high-def video games may be no match for the hybrid game + real world mix when it comes to propelling users out of the house. Pokémon GO’s augmented reality superimposes Charizards and Squirtles on once-familiar buildings and sidewalks and turns churches and parking lots into state-of-the art Pokémon Gyms, allowing this exciting virtual environment to attract users out into the real world. On the other hand, embracing fast-food chains as Pokémon Gym sponsors could negate gains as players are drawn to the nearest McDonalds to fuel more than just their virtual menagerie. It seems clear that the game could be very useful in prevention and health promotion in a variety of ways.
Gamified health and fitness apps don’t seem to share the “stickiness” of the best digital games. Already fans are discovering nature trails they never knew existed, or historic landmarks they’d never noticed, thanks to the lure of another wild Pokémon. Active games like Dance, Dance Revolution! are based on high-energy, frenetic jumps and twists, but so far haven’t shown evidence they reduce body mass index (BMI). The shininess of an exergame quickly wears off. But GO is a commercial franchise, likely to build momentum and keep players hooked well beyond the proverbial chasm of long-term adoption. Savvy physical therapists have already incorporated GO into therapy for hospitalized children. Most public health agencies trying their hand at digital health can hardly dream of competing on this level.
Many parents express surprise at screen-bound preteens’ sudden desire to head outdoors since wild Pokémon appeared in our neighborhoods. Getting kids out in the open has clear health advantages, like increased Vitamin D levels (which helps strengthen bones), strengthened immune systems, lower stress levels (Head Start Body Start), and reduced ADHD symptoms (NIH). Following specific routes and checking in at points of interest along the way could encourage people to explore their communities, allowing them to rediscover unappreciated real-world landmarks. Niantic could even partner with state and national park systems to host ‘Pokémon
Many multiplayer online games, from Farmville to World of Warcraft, promote (or even require) virtual socialization, but it is intriguing to see how Pokémon GO fosters real-world, face-to-face interactions—a strong predictor of both mental and physical health. This interaction could be useful, especially for those who otherwise have difficulty in social situations; some users are already reporting improvements in depression and anxiety. In fact, Niantic could capitalize on this through new features that could encourage social interactions—perhaps by increasing the chances of rare Pokémon sightings or speeding progress when traveling with a group.
Of course, as public health professionals, we are also wary of a few potential areas of concern. As concerns about potential problems mount, we question whether guidelines for use might be needed, such as those proposed alongside the game’s release in Japan. Pokemon’s intro screen warns players to stay alert, but media reports are flooding in of people injured while focusing on Bulbasaur and not the busy traffic intersection. We wouldn’t be surprised to see hospitals adopting a new injury billing code in the near future, or officers writing tickets for driving while Pokémon hunting. Safety features, which completely disable interaction when in a moving vehicle may be warranted in future releases.
GO’s game mechanics have already been used to rob players of their phones and money by luring unwitting players to attractive ‘virtual’ locations. Reports of malware, piggybacked on illegally-downloaded copies have emerged, potentially able to intercept a user’s communications and locations. And, people may be less vigilant than usual while playing—venturing into areas they might not otherwise, alone or during times of day where they might be at increased risk of crime. Some have even warned of the risk of racial bias affecting how police or the neighborhood watch might misinterpret game-inspired wandering.
As noted with other highly engaging games, some users might find GO interfering with real life, causing relationship conflicts, low bank balances, and possibly neglect of work, school or sleep–problems common to behaviors that spiral out of control. It’s the very elements of GO and other games that are so fascinating and engaging that also make them potentially problematic. Attention to basic theories of behavioral reinforcement is integral to game design, and newer free-to-play games (like GO) use the enormous amounts of data they collect to develop analytics. These analytics are often used to identify and exploit “social whales”—those 0.15% of players who account for 1/2 of the in-app purchases, creating an ethical embarrassment. To offset this quandary, developers and scientists could collaborate over these data to prevent problematic gaming and to extend insights into public engagement.
There is no doubt that we, in the health community, have a lot to learn from the Pokémon playbook— whether it’s the way GO captures and motivates players, or the social element of a shared gaming experience. Alternatively, this is an opportunity for the health community to identify existing commercial games with the potential to have real world health impacts.
Collecting information about benefits and risks is important to public health scientists the same way monitoring use and demographic data is critical to a game’s marketing analysts (and capturing Pokémon is for 30 million Pokémon GO users). The FDA is joining other health agencies worldwide to pave the way for apps to be allowed to make health claims, but this will require plenty of evidence. If Pokémon GO or other games can be used to prevent obesity or improve social anxiety and depression, we’ll need evidence to encourage their use as “digiceuticals.”
Public health and clinical investigators can design the studies that will figure out if a future prescription should read, “Capture 60 Pokémon and call me next month.” But studies cost money, and the time it takes to get a study done, from conception to funding to published guidelines, can take a decade or more, by which time we’ll likely be talking about Pokémon GONE. Intentional collaborations between the gaming industry, gamers and global health could shrink this timespan dramatically.
It’s not clear yet what impact (or duration) this Pokémon epidemic will have in terms of societal benefits and consequences. Certainly, Pokémon GO is challenging public health scientists to rethink how to leverage mobile technologies and video games to engage a clearly willing gaming public to combat the looming and very-real epidemics of childhood obesity, depression and other noncommunicable diseases. The staggering $190 billion spent currently on obesity, and the projected costs of over $1 trillion from cardiovascular diseases by 2030 demands that we identify new solutions. Beyond healthy bodies, the ability of wild Pikachus to unite crowds of strangers may be just the prescription-strength app for the socially tense and politically divided times we live in.
Alain Labrique, PhD, MHS, MS, is an associate professor in the Department of International Health at JHSPH and the director of the JHU Global mHealth Initiative, a University-wide Center of Excellence in digital health research. Yorghos Carabas is a marketing and communications specialist and creative designer at the Johns Hopkins University Global mHealth Initiative. Michelle Colder Carras is a postdoctoral research fellow in the Department of Mental Health at the Johns Hopkins Bloomberg School of Public Health who studies media and mental health. Bruce Y. Lee, MD, MBA, is an associate professor of International Health at the Johns Hopkins Bloomberg School of Public Health, director of the Global Obesity Prevention Center, and director of Operations Research at the International Vaccine Access Center.
The Pennsylvania hospital system is one of several that see the popular game as a threat to patients’ physical safety and privacy, and a threat to hospital data security. Outside of the presidential race, perhaps no topic has been as divisive in our culture this summer as Pokémon Go. Proponents of the video game sensation say it’s bringing people together—some towns sponsoring Pokémon walks and it’s encouraging physical activity. Mental health advocates say the game can help some persons with mental illness. Michigan’s Mott Children’s Hospital is one of several healthcare organizations that encourage young patients to get out of bed and play the popular game. But the tide may be quickly turning. Many dislike the fact that the game is a distraction, causing people to crash their cars and even walk off the edges of cliffs. And, on top of that, some oblivious players have been trying to catch Pokémon in inappropriate locations, such as Arlington National Cemetery and at the Holocaust Museum. So it’s no surprise that, despite the fitness and possible behavioral health benefits, some hospitals are beginning to ask that patients abstain from playing the game while in their facilities. Pennsylvania-based Allegheny Health Network, a division of Highmark Health, recently asked Niantic, Pokémon Go’s manufacturer, to remove all AHN locations from the app.
“Because Allegheny Health Network hospitals and other facilities are technically public places, they are open to being identified as Pokémon gym locations,” stated a memo to all AHN employees. “The presence of Pokémon Go players in our facilities compromises physical safety, patient privacy, computer security, and personal safety.”
The Pokémon gyms mentioned in the memo are locations where players can pick up helpful items and battle other players. The gyms can be anywhere the game manufacturer considers to be public, which apparently included some AHN facilities.
“Watch out for people walking around focused on their smartphone virtual world and not on their immediate surroundings—which is a concern for patients and visitors in our facilities,” the memo continued.
“Remind players that unauthorized photography is prohibited on AHN premises. Immediately contact physical security to report anyone observed taking unauthorized pictures on AHN premises.”
ANH isn’t the only health system to come out against Pokémon Go. Massachusetts General Hospital recently asked staff to stop using the app while at work, and the American Hospital Association requested that Niantic remove its locations from the game.
Are we all crazy! First we tell people that flossing is worthless and then we encourage people to use an APP to improve the health and wellbeing of our patients.