How do we convert the unconvertible into faithful flossers?
By Sheri B. Doniger, DDS
How many of us went through dental assisting school, listening to our teachers and nodding our heads when oral hygiene instruction was demonstrated? We took notes, we watched the demonstrations, and we even dutifully explained oral physiotherapy devices to our patients. And we still do. If we were ever truly successful, we conceivably could put ourselves out of business.
But, how many of us actually perform these same tasks we ask our patients to do? I had a dental hygiene instructor, Ms. Rita Khouri. Her words were: “How can you be so hypocritical as to teach dental flossing when you don’t do it yourself?” After that fateful day, too many moons ago, I have been a faithful flosser. Yes, I do my best, but doesn’t everyone (or mostly everyone) use a toothbrush? It is the floss we need to get between the teeth. Not only for the two weeks (wait, who am I kidding - more like two days or two hours) prior to the dental preventive visit, but every day. If we can’t get ourselves to floss on a daily basis, how do we get our patients to do the same?
The perpetual dilemma. How do we get patients to use the floss we give them? How do we motivate our patients into putting something between their teeth more often than when they have corn for dinner? Wouldn’t it be nice if all of our patients had such a defining moment, and became lifelong flossing artists? Is there a clear answer to this problem?
We need to look at the whole picture of patient compliance. For the most part, our patients do show up for appointments. We try to stress the importance of regularly scheduled preventive maintenance to safeguard their dental investments. Even if they do not have costly dental restoratives and are free of caries, we impress upon them the magnitude of maintaining oral health. Our job, as assistants, is to be true ambassadors for the dental health of our patients. We strive to show them how they can maintain a healthy dentition for a lifetime. So, where do we go wrong? Why don’t they all floss and brush as we so painstakingly explained? We try to cajole and make flossing more of a game (“just floss twice a week more than you normally do this year”), sometimes without any luck.
All patients come into a practice with preconceived notions and habits. Some were taught improper brushing at an early age. Some feel they must use a hard brush to take off any buildup on their teeth. Others feel that flossing is a nuisance, a pain in the mouth, a procedure that splatters up their bathroom mirror, or a task that is physically impossible to achieve given the size and shape of their fingers. They forget to take the floss out of the medicine cabinet/bathroom drawer. Out of sight, out of mind, right? They do have clever excuses why they don’t floss. They can’t get the floss between their teeth, or they used up the floss that we gave them on their last visit, and haven’t had the time to replace it. And on, and on, and on. I feel the generation of a “top five” list, coming via e-mail.
Patients think they fool us by flossing the few days before their preventive appointments. How many times do we tell them not to bother because they are only macerating their tissue? We all know there is an inverse bell curve regarding the motivation factor for flossing. Patients are highly motivated for a period of time after their scheduled preventive visit. Then they slack off to nonexistence. All of a sudden, when they receive the reminder notice of an impending dental maintenance appointment, they scrounge around to find the five-yard floss container we gave them six months ago. Then they begin again, in earnest, to floss. This causes their gums to bleed, and generates not-so-nice thoughts about why they started flossing in the first place.
So, how do we convert the inconvertible? How do we help them to decrease periodontal disease at the same time? We need to look at all the available floss and floss devices on the market, and attempt to match the patient’s personality with the appropriate means to attack his or her plaque.
Dental floss comes in all shapes and sizes. From unwaxed to waxed to tape, there are a variety of flosses from which to choose. True unwaxed floss is an acquired taste. Butler, POH, and J&J offer unwaxed varieties. Flosses are now coated with materials other than wax to help ease their way between the teeth. Glide floss was the innovator in the marketplace with polytetrafluoroethylene fibers, which slide between the teeth more easily than the bulky waxed flosses. Glide, which has been available for some 14 years, historically has been a Gore company. It now is owned by Proctor & Gamble. Oral-B has responded with its Satin Floss, which is similar in capabilities to Glide. But it is made from nylon and Pebax, a different nonwax combination material. J&J Clean Burst floss is a newer, shred-resistant floss that has individual bundles of filaments. These appear to be exceptionally effective in plaque removal as well as ease of interproximal placement.
There is also an array of flavors for both adults and children to help entice the patient to remove interproximal plaque. J&J offers a variety of waxed flosses, ranging from fluoride-incorporated floss to its newer Clean Burst, which offer a dynamic blast of flavor. With all the varieties available, surely we can find one that will suit each patient. So, what else can we do to both make patients understand the importance of flossing, and motivate them to change their personal habits so they will incorporate this important oral health component into their daily lives?
As purists, we would like patients to wind the floss around their middle fingers, grasp it between the thumb and first finger, and gently guide it between the teeth while using a new portion of floss for each new tooth. We know the floss needs to be configured or wrapped around the tooth, avoiding the col for maximum coverage. Finally, as purists, we realize that the tooth must sound “squeaky clean” in order to know that we have adequately removed the offending plaque from the surface. We all know that mechanical plaque removal is the most efficient in reducing interproximal colonization. Does this manual plaque removal happen all the time? No. So, what can we do to help tilt the scales to better compliance?
In recent years, flossing has seen an explosion in adjunct products. Flossing aids will assist patients in guiding the floss between their teeth and removing some of the interproximal plaque present. As electric- and battery-powered toothbrushes have burst upon the market, so have different methods of cleaning the interproximal areas of teeth. Will the newer aids accomplish all of these tasks? Possibly not. But they will get the floss between the teeth, remove plaque, and lead to a higher level of dental health if the patients do manage to actually put the flossers to use. The first step in flossing compliance is to show patients that it can be done - the floss does fit between their teeth, and they can maneuver it without tearing the interproximal tissue.
Dental floss aids have been around for a long time. Some are old standards. The “Flossmate” by Sunstar Butler has been available to patients for more than 30 years. Patients with rheumatoid arthritis or other physical disabilities, who have limited ability to hold the floss, were offered these tools. On occasion, the handles needed to be enlarged to accommodate their grip. Individual floss picks were created by J&J, Glide, and Denticator, among other companies. Aside from the floss fork, the piece of dental floss in these products remained one length. In theory, if the patient does not wipe off the apparatus between each tooth, the patient would be moving the plaque from one interproximal area to another. Additionally, the piece of floss is rather short and the plastic inflexible, rendering it almost impossible to adequately wrap the floss around the teeth. The floss also is placed on a bow-shaped piece of plastic, which does not allow for ease in posterior placement. Both J&J and Oral-B offer these products, which are geared to children. Due to their portability and single use, these are great for the occasional flossing need during a dining event when an entire roll of dental floss is usually not available.
Two products, Floss Brush (Sunstar Butler) and Ultimate Flosser (Almore International) have the ability to change the section of floss after each use. A small container of refillable floss is incorporated into the disposable handle. The difference between these two products is in the circumference of the handle. While both handles are relatively short, the Floss Brush is round and the Ultimate Flosser is a flat, palm-sized handle. The Ultimate Flosser allows for the floss to be advanced with the push of a button.
Several newer products have emerged recently. Some use a manual approach while others add a power component to the mix. These powered flossers add vibration to either a flossing bow piece or a nylon massaging tip. This may assist in easing the floss interproximally, as well as help in removing interproximal plaque.
Waterpik flosser is a battery-powered device that utilizes a short piece of flexible nylon, which is inserted interproximally. The piece vibrates at a rate of 10,000 strokes per minute. Patients are advised to change the tip on a daily basis. The handle is wide enough to grip, similar to a battery-operated toothbrush.
Oral-B Hummingbird is another battery-operated product, which incorporates two types of tips on a powered handle. A power flosser, similar to a floss bow, is inserted in the handle. It gently vibrates interproximally while massaging the interproximal area.
The Hummingbird also has a flat, stimulator-style flossing pick, which vibrates interproximally. Due to its size, it is portable and ideal for a purse or briefcase.
J&J Reach Clean Access Daily Flosser is a floss aid that allows the patient all the maneuverability of a toothbrush. It also can help eliminate the “my fingers don’t reach” excuse. The handle, which is shaped like a toothbrush, has a textured grip for easy, non-slip finger placement. The handle is shaped to fit into a standard toothbrush holder, providing an excellent visual reminder to patients to floss daily since it is positioned next to the toothbrush.
Additionally, the handle is long enough to reach the furthest distal tooth surface without many fingers needing to enter the mouth. Disposable snap-on heads, containing shred-resistant floss, allow for easy replacement after plaque removal.
We want patients to put us out of business. We want patients to comply with the oral hygiene instruction they receive. We want them to have healthy hard and soft tissues. Since we know that bad habits are hard to break, the best we can do is offer additional techniques to ease the perceived difficulty of flossing, thereby eliminating some of the barriers to compliance.
Author’s note
Please forward flossing excuses to [email protected]. I will compile the list for a future issue. I look forward to receiving your most outrageous excuses. Thanks, and may the floss be with you.
Dr. Sheri B. Doniger has been in private practice of family and preventive dentistry for 20 years. She is currently focusing on women’s health and well-being issues. She can be contacted at (847) 677-1101 or at [email protected].
