Parroting the flossing message

Every time I work a clinical day, I ask my adult patients - new and recare - how they approach the daily disruption of oral biofilm. The answer I get from “slackers” is always the same: I brush twice a day and I don’t always floss as often as I should. If I bottled this message and threw it in the ocean every time I heard it, I’d be contributing to some serious ocean pollution!

Why are patients habitual parrots, regularly vocalizing what they think they should do when it comes to daily string flossing?

Are we (dental professionals) at fault when we hear this mantra coming from our patients? Yes, I think we are, in part, and the one way to change it is to modify the message.

Evidence-based professionals regularly look at systematic reviews and I found an excellent summary and appraisal of evidence to date on the efficacy of various interdental devices for mechanical biofilm removal in managing gingivitis.¹ There is moderate evidence to support the efficacy of interdental brushes on biofilm removal and reduction of gingivitis but only weak evidence supporting the use of dental floss, woodsticks and the oral irrigator.

More from the author: Why it's important to include periodontal probing in a hygiene appointment

The message is clear: Dental floss in the goody bag is not always a good choice and it would be better to customize an interdental brush for our adult patients and drop one in the goody bag instead.

I recently attended the Georgia Dental Hygienists’ Association (GDHA) Annual Session and had the pleasure of listening to Michelle Strange, RDH, an educator for TePe Oral Health Care. Michelle is very entertaining in a refreshing and creative way and she discussed the morphology of teeth, including embrasures, and offered a lot of practical suggestions for dental professionals. TePe offers an array of interdental brushes with nine sizes (brush diameter) for embrasure customization.

I decided to follow-up with Michelle and ask her some questions about some of the positive changes I’ve observed in interdental self care recommendations.

1. There’s been a huge shift in hygiene recommendations for patients in all age groups when it comes to biofilm disruption in proximal areas. Can you discuss the various changes in the different age groups?

In the U.S., we are seeing a paradigm shift from begging our patients to floss and seeing them continue to not floss to finding something the patient will and can do to maintain the proximal surfaces. This is such a great shift because parents can now help their young children without having to put their hands in their child's mouth with a piece of floss. The aging population now has options to fit their level of dexterity and fine motor skills. Even caregivers can benefit from the different options for proximal home care. Proximal surfaces have always been a difficult area for patients to maintain and require a high level of skill and motivation. We can now find products that can be used anywhere, at anytime and are easier to use, thus increasing motivation and compliance. 

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2. Why do you think such a small percentage of patients have never adopted the string floss habit?

Can you remember in hygiene school when you learned to floss another person’s teeth? I watch students learn how to do this and they struggle to get the proper technique even though they have the advantage of good motor skills. Now, think about a person who has no understanding of tooth morphology, has fewer fine motor skills than dental professionals, and who is probably not spending the time to make sure he or she is doing it slowly and thoroughly. There are also very few people who are going to be able to floss properly without causing trauma. I would also postulate that many people don’t want to put their fingers in their mouth or can’t for various reasons. 

3. Now that more patients (especially boomers) are restoring dentitions with single tooth implants, implant bridges, and implant retained fixed or removable dentures, what recommendations do you have for these patients to make biofilm disruption easier and more thorough?

There are so many variables to consider when managing dental implants at home: how it was restored, the patient’s motivation, their capabilities, etc. Finding products that are right for their skill level, implant case and level of motivation will need to be considered. Don’t let them “wing it” in the pharmacy aisle. This is a new restoration for them and they will need a professional's guidance to know what is actually going to work for this restoration. They need a professional’s guidance to know if it is working, and if not, what are the next set of products they can use. We need to prescribe our patients’ home care routines because this will be what maintains their oral health. Left to their own decision making, they will not choose the correct products.

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I also find it really great to have an alternating home care regimen. Why would we use the same products everyday? We see our patients missing the many nooks and crannies they have around natural teeth and implants. If we give them a combination of products to use, multiple scenarios can happen: They won’t feel guilty because they didn’t have the time or forgot to use the one product that was recommended; If they have time, I tell them to use one of the products that might take more time to use; If they don’t have time, I give them a product that they could use while sitting in traffic, for instance. Also, patients notoriously miss the same areas every time when they are using just one particular product. Giving them another tool to use, they may reach that area that is usually missed.  I compare it to house cleaning. Some days I sweep, some days I vacuum, some days I do nothing. 

These days there are specialty brushes, end-tufted brushes, on-the-go options, oral irrigations options and a sized interdental brush for every space. We need to be as familiar with those products as we are with our scalers. What the patient does at home and how well he or she does it will help to maintain our hard work and his or her oral health.

4. Where can hygienists find evidence-based information about interdental care? 

I am a big fan of scholar.google.com. You may not be able to access all the journal articles, but you can get peer-reviewed articles when doing internet searches versus websites. Webinars are becoming increasingly popular, as are podcasts. These are great ways to hear information on demand and in the comfort of your home. I hope that hygienists are not taking the information they hear or read with a grain of salt but are instead reading it and investigating further. If you hear something that interests you and you would like to implement it, be sure to do your own research instead of trusting completely the word of the presenter. CE courses and dental publications are probably the easiest ways to find evidence-based information. I would, again, encourage everyone to take a look at the references and do their own investigating. Be sure to understand that research is changing constantly and what we knew in school is not everlasting. Be open to reading the research and making changes in your treatment based on the strength of the evidence.

References:

1. https://www.nationalelfservice.net/dentistry/periodontal-disease/which-interdental-cleaning-aids-for-managing-gingivitis