How do we convert the unconvertible into the FAITHFUL FLOSSERS?

Nov. 1, 2004
A new generation of flossing products facilitate compliance.

by Sheri B. Doniger, DDS

How many of us went through dental hygiene 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 could conceivably 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, who stated, "How can you be so hypocritical as to teach dental flossing and not do it yourself?" After that fateful day, too many moons ago, I have been a faithful flosser. Yes, I do my Bass, 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 for every day. If we can't get ourselves to floss on a daily basis, how can we get our patients to do it?

It's the perpetual dilemma. How do we get patients to use the floss we give them? How do we motivate our patients into putting something more between their teeth than the corn they had 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 caries-free, we impress upon them the magnitude of maintaining oral health. As hygienists, we are truly 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 our 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. The first excuse is that they can't get the floss between their teeth. They used up the floss we gave them at 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 email.

Patients do try to 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 they have their preventive visit. Then, the habits slack off to non-existence. And, all of a sudden, when they receive the reminder notice of an impending dental maintenance appointment, they scrounge around and find the five-yard floss container we gave them six months ago and begin again, in earnest, to floss, causing their gums to bleed and generating not so nice thoughts about why they started flossing in the first place.

So, how to convert the inconvertible? How do we help them and try to decrease periodontal disease at the same time? We need to look at all the available floss and floss devices out there, attempting to match patients' personality with the best means for attacking their plaque.

Dental floss comes in all shapes and sizes. From unwaxed to waxed, from extra fine to tape, there are a variety of flosses to choose from. True unwaxed floss is an acquired taste. Sunstar Butler, POH and Johnson & Johnson offer unwaxed varieties. Flosses are now coated with materials other than wax to ease their way between the teeth. Glide floss was the innovator in the marketplace with polytetrafluoroethylene fibers, which slides between the teeth easier than the bulky waxed flosses. Glide has been available for about 14 years, historically a WL Gore company and now owned by Procter & Gamble.

Oral-B has responded with their Satin Floss, which is similar in capabilities to Glide, but made from nylon and Pebax, a different non-wax combination material. Johnson & Johnson's Clean Burst floss is a newer, shred-resistant floss that has individual bundles of filaments that appear to be exceptionally effective in plaque removal as well as ease of interproximal placement. Sunstar Butler's Expanding Floss is another alternative. Expanding Floss actually expands when exposed to moisture, thus creating a larger floss surface area to clean away more plaque.

There are also flavors for both adults and children to entice the patient to remove interproximal plaque. Johnson & Johnson offers a variety of waxed flosses, ranging from fluoride-incorporated floss to their newer Clean Burst, which offers a dynamic blast of flavor.

With all the varieties available, surely we must be able to find one that will suit each patient. So, what else can we do to make the patient understand the importance of flossing and motivate them to change their personal habits to incorporate this highly important oral health component into their daily lives?

As a purist, we would all like our patients to wind the floss around their middle fingers, grasp it between the thumb and first finger and gently guide it between the teeth, using a new portion of floss for each new tooth. As purists, we know that the floss needs to be configured or wrapped around the tooth, avoiding the col, for maximum coverage. Finally, as purists, we know that the tooth must sound "squeaky-clean" 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?

With all of these options, surely we will be able to find something to suit every patient's flossing needs at least some of the days of the week. Who knows? Maybe two or three days will become a week's worth of flossing habits.

We want patients to put us out of business. We want patients to comply with their oral hygiene instruction. We want them to have healthy hard and soft tissues. Because 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, and thereby eliminate some of the barriers to compliance.

The extra hands for flossing

Flossing has seen an explosion in adjunct products in recent years. Flossing aids assist the patient in guiding the floss between the teeth and removing some of the interproximal plaque. As electric or 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 the above-mentioned 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 the patient 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, such as the Flossmate by Sunstar Butler, which has been available to patients for over 30 years. Patients with rheumatoid arthritis or other physical disabilities that limited their 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 Johnson & Johnson, 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 the other. 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 is also placed on a bow shaped piece of plastic, which does not allow for ease in posterior placement. Both Johnson & Johnson and Oral-B offer these products geared to children. Due to their portability and single use, these are great for the occasional flossing need during a dining event, where an entire roll of dental floss is usually unavailable.

Two products, the Flosbrush (Sunstar Butler) and the 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 lies in the circumference of the handle. As 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 a push of a button.

Several newer products have recently emerged, some using a manual approach and others adding 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.

The 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. The Oral-B Hummingbird is another battery-operated product, but it incorporates two types of tips on a powered handle. A power flosser, which is similar to a floss bow, is inserted in the handle and gently vibrates interproximally as well as massages the interproximal area. The Hummingbird also has a flat, stimulator style flossing pick, which will also vibrate interproximally. Due to the size, it is quite portable for purse or briefcase.

J&J's Reach Access Daily Flosser is a floss aid that allows the patient all the maneuverability of a toothbrush, eliminating that "my fingers don't reach" excuse. The handle is shaped like a toothbrush, with a textured grip for easy, non-slip finger placement. The handle is also shaped to fit into a standard toothbrush holder. This is an excellent visual reminder to the patients to floss daily since it can be positioned next to the toothbrush. Additionally, the handle is long enough to reach the furthest distal tooth surface without many fingers entering the mouth. Disposable snap-on heads, containing shred-resistant floss, allow for easy replacement after plaque removal.

Author's note: Please forward flossing excuses to donigerdental@ 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.

Sheri B. Doniger, DDS, has been in the private practice of family and preventive dentistry for more than 20 years. A dental hygiene graduate of Loyola University, prior to receiving her dental degree, her current passion is focusing on women's health and well-being issues. She may be contacted at (847) 677-1101 or [email protected].