A dude camp for flossers (Where they cant be as bad as they wannabe)

April 1, 1998
The dilemma for dental hygienists through the ages has been motivating patients to clean between their teeth. No matter what cleaning device is used, patients view interproximal plaque removal as a time-consuming exercise in frustration, particularly when miraculous results aren`t apparent on the first try. That`s why only 23 percent of patients claim to floss, and another 20 percent floss rarely - despite ongoing encouragement and training by dental professionals.

Cindy Quinn, RDH, BS

The dilemma for dental hygienists through the ages has been motivating patients to clean between their teeth. No matter what cleaning device is used, patients view interproximal plaque removal as a time-consuming exercise in frustration, particularly when miraculous results aren`t apparent on the first try. That`s why only 23 percent of patients claim to floss, and another 20 percent floss rarely - despite ongoing encouragement and training by dental professionals.

Research supports the effectiveness of floss. Reductions in interproximal bleeding or plaque are as high as 35 percent over brushing alone. Patients rationalize the avoidance of interproximal cleaning with any number of excuses. Those who have had healthy teeth in the past see no need to add to their daily routine, and those who`ve had periodontal treatment often expect the surgery, scaling and root planing, or frequent recall to cure the problem. It`s as if hygienists wear, "I`m a trained professional. Do not attempt this at home," buttons on their uniform. In any case, the real issue lies in the education and motivation of patients.

Of course, legitimate reasons exist for those who don`t clean between their teeth. Some people lack the dexterity required to use many types of interdental cleaning products. Other patients rely on a caregiver for their personal hygiene needs, such as the institutionalized or handicapped person. But such legitimate reasons do not eliminate the need for interdental cleaning.

Hygienists should resist the temptation to simply chant chairside lectures about interproximal cleaning to patients who are unwilling or unable to do it. The diversity of patients` values, expectations and interpretations, circumstances, and perceived costs affect the acceptance of maintenance procedures and subsequent care. Beyond that, the physical limitations and dexterity of patients greatly influence the likelihood of success.

Alternatives may be more motivational

It is the dental hygienist`s responsibility to find a workable solution for patients, rather than watch for the onset of periodontal disease. Hygienists must find "patient preferred" alternatives to traditional floss because patients do not know enough about these products to make a wise decision or use them correctly. This requires "thinking outside the box" of traditional dental floss, a product fraught with characteristics that contribute to non-compliance.

Documented clinical studies have even caught dutiful floss users skipping or skimming over their posterior teeth. A probability sample survey of 662 adults, reported by Ronis et al., concluded that about one in five (21.1 percent) subjects reported both flossing daily and flossing all teeth. According to this study, the most frequently cited disadvantages of flossing were:

- The time required to floss (46.7 percent).

- Soreness or potential damage to gums or teeth (21.2 percent).

- The difficulty of using floss (8.6 percent).

The authors concluded, "Interventions to increase flossing might productively focus on the skill deficits associated with these problems. A complimentary approach would be to encourage people who do not floss to use other devices for cleaning between the teeth and under the gumline. Many people find these devices easier and more comfortable to use than floss."

Related research reveals similar results when floss is compared to other interdental cleaning methods. Mauriello et al. compared the outcomes of patients who combined flossing and brushing to patients who combined rubber tip stimulators and brushing - all evaluated against toothbrushing alone in a nine-week crossover study. They found both interdental cleaners equally effective in removing interproximal plaque over toothbrushing alone.

Products available for interproximal cleaning include rubber-tip stimulators and short, conical brushes affixed to a handle (Butler, Oral-B); yarn-like floss (Oral-B); wood wedges (Johnson & Johnson) ; and single-tuft toothbrushes (Sulcabrush). Each provides varying levels of plaque removal, depending on use and technique, but certainly produce a cleaner surface than complete neglect.

Perhaps the biggest breakthrough in interdental cleaning during the last two years is a power-assisted, rechargeable device in which a filament rotates to gently clean interproximal spaces (Interclean by Braun Oral-B). This hand-held device is recognized to be as effective as floss for removing plaque and reducing gingivitis. Designed with a small, tapered tip which fits between teeth, the soft filament emerges from the disposable tip, once activated. The filament extends through the interdental area and spins at over 100 strokes per second to disrupt and remove plaque.

Initial studies indicate that patients find this power-assisted product easier to use than manual flossing, preferring it 2:1 over floss. A laboratory study, conducted by Schemehorn et al., demonstrated that the device does not cause abrasion of hard tissues any more than an ADA-approved toothbrush.

A summer camp for neglectful flossers

The challenge for the dental professional is to match the appropriate product to the need, depending on the size of the interdental space or dentition, patients` dexterity, and their mindset. It is often easier to place patients in "camps" according to their mindset about interproximal cleaning, the way they view their oral care circumstances and dexterity, and then make recommendations to motivate in a sequence that can be documented in the patient`s chart. A visit to each of these camps will provide useful information about cleaning between teeth - without sacred dental floss.

Patients virtually belong in one of four camps: Idun Neetoo, Idun Wannu, Ican Nodoo, or Liddlespot Bigmess. Over half the members of each camp are not cleaning adequately between their teeth, though they have different reasons for it. When hygienists evaluate patients from the vantage point of the "camp" they belong to, it is easier to classify their mindset and motivate them to action.

For purposes of explanation, the mindset of particular patients is characterized by "camp" memberships described below.


Patients in Camp Idun Neetoo feel they do not need to do anything but a 20-second toothbrushing to keep their teeth. Some of these patients are young and have healthy teeth and gingiva, despite the care their teeth receive. Others have been through periodontal surgery and liken the experience to removing an appendix -- problem removed, so expect no further difficulty. Still other periodontal surgery patients believe that the three-month recall, performed by a trained clinician, should erase all effects of their neglect between appointments. Finally, this camp also houses those who believe the latest dental gizmo on the market, be it a fancy brush or mouthrinse, is an insurance policy against the progression of periodontal disease.

A study by Wilson et al. revealed that only 16 percent of 961 periodontal patients, followed over an eight-year period, complied with the recommended maintenance schedules. They summarized, "The results of this study are an excellent example of the differences that often exist between our perceived ideal and clinical reality. The survey deals with an active periodontal practice that strongly emphasized the importance of regular maintenance visits to maintain oral health. Even so, the vast majority of the patients did not comply with the recommended recall interval."

A similar retrospective study of 14 years, conducted by Demetriou et al., demonstrated that 38.6 percent of 521 patients became noncompliant at some point during supportive periodontal therapy.

Members of Camp Idun Neetoo really need education about the onset of periodontal disease and the consequences of not flossing as it relates to the progression of the disease. If they`ve never had active disease, they need to learn that periodontal disease begins at any time, often between the teeth when interproximal plaque reduction is neglected. They also need to recognize that the disease progresses slowly and painlessly without glaring symptoms. Those with a history of minor periodontal problems need education concerning the importance of continuing supportive periodontal therapy to slow down disease progression. Members need to learn and be shown that cleaning between the teeth is essential, and simple with the appropriate device. Emphasize these points verbally and in writing for future reference.


Attendees of Camp Idun Wannu have the ability to clean between their teeth, but have strong opinions which they`ve used to convince themselves it is impossible. Patients in this camp usually sum up their delinquent behavior with practiced retorts such as, "no time" or "gags me." Many patients complain that they are anatomically ill-suited to put fingers in their mouth, usually because of large hands or a limited opening. Similarly, patients who have had bad experiences with dental floss, such as fillings coming out, bleeding, or fraying are convinced that floss is the enemy, not the ally. They need more than a hygienists` suggestion to practice until perfect or switch to another type of floss. Some of the toughest patients in Camp Idun Wannu are adolescents and those wearing orthodontic appliances. These hard-core members often have appliances, never listen to adults, AND aren`t bothered by week-old lettuce between their molars.

Lectures about plaque, pus, and pockets will do little to motivate someone who considers their defense without argument. Address their retort with a specific product recommendation and demonstrate how correct use of the appropriate interdental cleaning product takes very little effort. For example, hygienists should suggest that patients with no time use an interdental cleaner that can be used while watching the news or reading outside the bathroom.

If patients cite bad experiences with floss, discuss the problem, explain the probable cause, and demonstrate a solution. Show an interdental cleaner to patients who cannot access their teeth, demonstrating how it is not bulky and doesn`t require fingers in the mouth. Then let the patient try. Recommend the rubber-tip stimulator or power-assisted interdental cleaner to these patients. This approach works well for gaggers as well, once they`re instructed to breathe slowly through their nose while using the device.

An analogy often helps patients recognize the benefits of new technology as it affects dental care. For example, cite the benefits of new medical technology when detecting or treating disease. Once patients realize the reason for their trouble, and the value of well-designed devices to treat it, they`ll be more amenable to repeated practice.

Usually, products that appear effortless motivate Camp Idun Wannu patients far better than a discussion of cause and effect. Site-specific mechanical toothbrushes and the new interdental cleaner mentioned earlier hold the most promise for compliance. At minimum, they make the task look easier than threading dental floss around the archwire of more than 20 contacts to ward off gingivitis and interproximal decay.

Dr. Herra Kim, a professor of orthodontics at West Virginia University, reports success using the power-assisted interdental cleaner to motivate adult patients who need to clean fixed lingual retainers following orthodontics. "It is a convenient device that patients can do in a hurry, so their compliance increases," she states, adding that the best way to achieve patient acceptance is to show them the short product video, then let them practice under supervision in the office.

Dr. Kim found that patients need to practice about three different times to get the feel of the power-assisted interdental cleaner and correct mistakes common with its initial use. For example, patients tend to use the product in an up-and-down motion at first, rather than holding it stationary between teeth. They do this because they mimic known techniques for brushing and flossing. They also forget that the filament should not emerge from the tip until it is placed interproximally. Both errors make the filament break off. "Patients get frustrated if the filament breaks off during use, so compliance goes down. That`s why it`s so important to educate the patient first," she cautions.


At Camp Ican Nodoo, patients are physically unable to clean between their teeth adequately because of an impairment which is physical or mental. Disabling conditions which result in activity limitations appear in an estimated 35 million Americans, or 1 in 7. Orthopedic impairment (16.0 percent) and arthritis (12.3 percent) top the list. These two conditions certainly have the potential to limit one`s ability to clean between teeth. Many members of this camp are familiar with home care products and may have been proficient at using them in the past. They usually have a calm resignation that nothing can help, and experimenting with interdental cleaners sounds like a fruitless task.

Similarly, many people in Camp Ican Nodoo must rely on someone else to attend to their oral care needs. According to the National Center for Health Statistics, 2.2 million people in the U.S. with disabilities require care in an institutionalized setting. This includes nursing homes, and facilities for the retarded and mentally ill. Often this staff is untrained in oral conditions and burdened with competing priorities. In addition, staff in these facilities are somewhat uncomfortable using a toothbrush, much less an interdental cleaner, in their patients` mouths. It is difficult to access posterior teeth on a cooperative patient, much less someone with neuromuscular problems. Many times, caregivers just won`t do it.

The mechanized interdental cleaner suits many of the patients in Camp Ican Nodoo. Because somewhat less dexterity is necessary with the larger diameter handle grasped by one hand, some patients can actually learn to use this product with their non-dominant hand. Home health providers and family members caring for the infirm, disabled, or handicapped by themselves may also feel more comfortable using alternative interdental products.

When another person is needed to maintain a patient`s oral health, the motivation must center on the caregiver`s needs and comfort level. Dental professionals must coordinate this care for family members of patients currently in the dental practice who are unable to be treated in a conventional setting. This is most often easiest with a traditional "tell, show, do" teaching method. Hygienists need to explain the reason for adequate plaque removal to the caregiver, pointing out specific areas that are difficult to reach or where most accumulations form. Then they should show the caregiver which devices to use and how they work. It is also important to include information on product maintenance.

Finally, the hygienist should perform oral health care on the patient and then let the caregiver practice repeatedly under supervision, allowing the patient to master the anterior teeth before progressing to the posteriors. Once caregivers are comfortable with daily cleaning procedures, it is imperative that they are properly motivated to continue care.

According to research by J.W. Atkinson, motivation is not a stable personality trait. Three variables determine motivation: the subjectively estimated chance of a successful completion, the perceived value of a positive result, and the perceived cost of taking the action (for example, the humiliation in case of failure). His model is applicable only when an individual knows that his effort will be evaluated, by himself or others, in terms of success or failure. Therefore, proper training for caregivers must take these variables into account and include a method of evaluation, perhaps a disclosing agent to detect plaque after cleaning or evaluation of tissue condition by a trained family member or hygienist. After home care techniques are presented, hygienists should initially follow up within a month to see that the appropriate care is provided, lengthening the time between visits once plaque accumulation is under control.


At Camp Liddlespot Bigmess, relatively small dental conditions create big problems for patients who need to maintain them. These conditions include implants and some bridgework. Patients in this camp often find these dental conditions challenging even if they floss the rest of their teeth with ease. Many will reach one side of the restoration, but skip the other because they cannot see well enough to insert the device or because it is too bulky to fit.

Cone-shaped interdental brushes and yarn-like floss are available for isolated areas such as implants and bridgework. Hygienists typically needed to keep re-training or motivating patients who abandon them. The power-assisted interdental cleaner deserves consideration for accessing these spaces.

Though floss has traditionally been the method of choice for removing interproximal plaque, dental professionals must accept the reality that some patients are unwilling or unable to use floss between their teeth. Hygienists have a responsibility to work with patients to find an acceptable alternative. As summed up by Warren et al. in The Journal of Clinical Dentistry, OIf a patient finds a particular method or device easy to use or even enjoyable to use, then long-term compliance becomes an achievable goal.O

Cindy Quinn, RDH, BS, is president of CreativAtions in Tucson, Ariz., which provides marketing services to dental manufacturers. Her 20-year career in dentistry includes seven years in corporate management.