Common Problems, Uncommon Solutions

July 1, 2009
Sunstar Americas hosts a roundable discussion about that nagging issue of patient compliance

Sunstar Americas hosts a roundable discussion about that nagging issue of patient compliance

During the Chicago Dental Society Midwinter Meeting last February, Sunstar Americas hosted a roundtable discussion of oral health issues. The Chicago company, which produces the Butler GUM home-care and professional products, hosted five hygienists — Dawn Kasper, Tricia Osuna, Susan Ranno, Donna Grzego-rek, and Sharon Zastrow — to offer their viewpoints on patient care.

Kristine Hodsdon, the director of RDH eVillage, moderated the discussion. RDH eVillage is an electronic newspaper published by PennWell.


Hodsdon: On the subject of interproximal health, patients just don’t want to floss. We face a challenge even if they say they floss; you know they’re probably not flossing, perhaps not doing it effectively. So what have you found as far as reasons why certain clients or patients avoid flossing?

• I think as a profession we set the standards so high for flossing that patients feel that they can’t excel and so they tend to drop out. So I set the bar a little lower for them. I tell patients, “I don’t care if you stand on your head and use yarn between your teeth in the shower, you are being effective, we’ll make it work.” So I think I’ve lowered the bar from the perspective of once a day, make sure you’re going back and forth, make sure you’re wrapping, make sure you’re using this floss. I’ve just set more of a realistic expectation for them. And then, as I’ve introduced new products for in-between-the-teeth cleaning, they’ve been more accepting. So I’ve actually seen an increase in flossing in my practice, because I don’t hold them to such a high standard. And then, as they start to improve, they raise their own standard and ask more questions and then perfect their own technique.

• I find that if you bring it to their level, based on their lifestyle, they’ll come in and go, “You know, I thought about it. I started.” I don’t ever say, “You have to floss.” I say, “What can we do to clean between your teeth?” And I add, “This is why. You’re doing two surfaces wonderfully, but you’re missing two surfaces, and gum disease and cavities, they don’t really care.” I talk at their level and say, “What can we work into your lifestyle?” It really does depend on whether they are running around with four kids, or if they are traveling out of town all the time. Many of them don’t think about it. So I never say, “Think about it at night,” or “Think about it first thing in the morning. Can we do something in the car? What can we do that’s easy on your way home when you’re stuck on the train half the time?” Just kind of bringing it to their level. I’ve actually seen in the last year a turnaround because of that. Because I don’t just say that you have to floss, the way we were trained to do and the way we all started. So bringing it down to that, really just without even trying, just doing it for them, really has made a difference.

• I think that if they understand what they’re removing, I find that is an incentive. They have a good understanding of the bacteria and plaque. It’s not complicated, but they just really don’t realize what they’re doing and what effect they have on their general health too, especially with men. I have written a couple of articles about strokes, and the articles are geared toward men. I use that as a handout, and it really gets their attention. They understand what they are removing, that it’s an infection, that it’s bacteria, and that makes them want to floss more. I find the interproximal GUM Go-Betweens work better, especially in the back. Some of them are resistant, so I’ll hand them floss, I’ll say, “Do the front and use the GUM Go-Betweens in the back, and then it’s not such a big chore.” So little things like that.

Home-Care Education

Hodsdon: We need to teach about the symmetry between periodontal health and adverse reactions. I teach my patients that a “pocket that bleeds is a pocket that needs.” They later come in and they tell me, “Now I’m bleeding up here; you’re not going to be happy.” So at least they are thinking about it. How do you address talking with them about periodontal health?

• I do teach them that a pocket that bleeds is a pocket that needs. And so, then the question is how to get the patient to focus on that. Your point is educating why the bleeding is occurring, so let’s figure out how we can solve the problem. The GUM Soft-Picks are an example. I compare that product with American Express. I never leave home without them. I tell my patients to put them in their car or purse. I carry them, because as a hygienist I’m comfortable flossing anywhere. My husband would tell you I’ve embarrassed him several times. But GUM Soft-Picks are easy. Pull those out and use them at a stoplight. People can find ways to fit it into their busy lives. Because of the economy being the way it is, we have more bruxers now. We have more people breaking teeth because of crunching and grinding. We have more TMJ issues. We have more immune suppression. We have more bleeding. As a result of that, even the patients have noticed that they need to turn up their home care a notch. Everyone is brushing; we pretty much have gotten most of our patients to brush at least once a day. But as far as interproximal cleaning, we haven’t seen a lot of that. And I think it’s because as hygienists we’ve gotten on our soapbox about flossing, and people have tuned out that message. So we have to find a different way to spin the message. So for me it’s a pocket that bleeds is a pocket that needs.

• When I have patients that say they don’t floss, I let it go. That’s like a confessional to say you don’t floss. And I’ll go on and work into the appointment, “Why don’t you floss?” And usually they say they don’t like it, they don’t know how, or it’s just too difficult, and I never discuss flossing with them again. They pretty much said, “I’m not going to floss.” They just don’t like to put their fingers in their mouths, the wet string, and they’re not going to do it. So I don’t talk about it again. I give them all the education on the subject throughout the appointment. At the end of the appointment, if I do polishing, cause that’s what they all want, I don’t also floss. Which is like a mortal sin for a dental hygienist, not to floss. And they call it on you too. “Aren’t you going to floss?” “No, no. Cause I pretty much went in there, and I rinsed everything out and I blasted everything out with my little water gun here, and it looks good. You’re not going to floss? Well, I really want you to.” And I give them the floss. “Show me what the problem is that you have with floss.” Now they know that I’m not going to do it for them. And they start flossing and I just look at them and smile. So I pretty much put it back to them to do that. I joke with them a lot. “You know how to floss; it’s not rocket science. You can floss.” People are just lazy. I don’t beat them up about the flossing. If they’re not going to do it, I just take a different direction and give them different tools to use. I’ll be more productive, accepted, and positive with them. When you give them the floss at the end of the appointment and tell them to show me how you can’t do it.

Home-Care Options

Hodsdon: Can I back up for a second? A client or patient has indicated to you that they’re not going to floss. So you kind of went through a laundry list of products. Do you kind of go through the laundry list verbally with them, or do you kind of play it off in your head to what would be site specific?

• I play it off in my head and then I offer them, depending on their lifestyle and their motivation, if they are motivated, and most aren’t. You look at them, and you can just tell in a minute. As they’re talking during their medical history to start the appointment, that sets it off right there as to what is going to happen. Are they someone who bleeds? Are they taking medications? Are they diabetic? As the appointment goes on, we talk about their family, their lifestyle, and their history. Do they have 5 millimeter pockets regularly? Or are they somebody who’s all two threes, two threes? It all plays a difference in the products. I have my little drawer there with the supplies based on what I hear. But I almost always offer them a choice — at least two things. “Here’s the GUM Go-Between. This actually might be a little too large for you in the front; here’s a GUM Soft-Pick. Try this. They’re both brushes; you can throw them in the car or put them in your pocket.” I would say at least nine times out of ten, there’s success with that. And if there isn’t, it sets off a conversation the next time they come in. “You know, I tried those GUM Go-Betweens; they were great. But they were a little too big. I did start them, but I’m now flossing in the front and doing the GUM Go-Betweens in the back. So it actually starts off the motivation. Those are the same patients who a year or two years ago would not have done anything. So it’s like opening a new doorway to them. There are new products now. Dentistry has progressed a long way. But I don’t harp on it because if they’re going to tell you right from the start they’re not going to do it, they’re not going to do it. And it’s that simple. So you kind of listen and you don’t approach it for a while. You have to wait until the appointment has been going along before you bring it up.

• If they say they’re not going to floss I say, “Well, I’m not going to tell you that you have to floss.” Their mouth just drops. You can feel the mandible just open up. I’m saying, “Well, there are other things you can do. You don’t have to floss.” At the end of the visit, I always put floss in their bag. They’ll always get floss and then I’ll give them two or three different options, such as GUM Go-Betweens. I ask, “Which one do you think would be most appropriate for you?” Many of them will ask for my professional opinion. Then some will say, “I’d like to try all three.” I’ll give the three free to them to let them try what they want to try.

• What we’re talking about is experience — what we’ve learned and how to deal with patients. When you get out of school, there is a mandate of what you’re going to do and what you’re going to tell the patient. The longer you practice, you learn that regimen doesn’t work. My situation is somewhat unique because I’ve spent 20-plus years in a geriatric practice. Probably more than half of my patients don’t floss. But they have reached 70 or 80 years of age, and they still have their teeth. They didn’t floss the entire time. So I’ve switched them to vertical brushing. It’s amazing they can clean as much of the interproximal space way more than they can. In school, you learned a way to teach techniques. Until you get experience, it’s the only way you can teach.

The Recall Appointment

Hodsdon: What results, on the positive side, do you see if a patient comes in that you’ve had a conversation with about initiating some kind of interproximal health plan? What do you see when they come back?

• A world of difference if they do it right. Less plaque, firmer tissue. They feel better. It tastes better. It’s cleaner. And they look in the mirror. That’s my big thing. I call it the Lifesaver look. If the tissue is red and rolled like the Lifesaver and it’s bleeding, you know you have gum disease going on here. Then I show them their healthy papillae, nice pink between the teeth. You can show them the difference that they never noticed. So when you show them that they’re using the irrigating device correctly, or if they’re using the electric toothbrush correctly, suddenly there’s more pink papillae; there’s less of that Lifesaver look, and they know they’ve been successful. I give them that pat on the back. Make sure they know, “You’re doing a great job. You really are. Whatever it is, keep doing it. What did we do last time that made the difference? Let’s keep doing it and can we add to it this time with one more thing?”

• I think it depends on the device. I personally haven’t seen a huge improvement in tissue with people who use oral irrigators. People who will use an interdental device as opposed to flossing, I’ve noticed that there’s improvement. But still, there’s areas they can’t access. There’s always a little bit of irritation presence, so I don’t think there’s a be-all-end-all. I don’t think there’s one thing that any one person can use that’s going to be 100% effective. So I think just based on our experience and what we’ve learned, we figure out how to customize to that particular person, and in some cases it will be nothing.

• I quantify my patients — a trickler vs. a spurter. There’s more infection in the pocket if there’s a spurter, and I’m pretty melodramatic when I do my charting. If there’s a spurter, I’ll wear a white lab coat. I’ll say “Whoa,” and back up a little bit. They’re holding the mirror, so they can see the difference. If you go from a spurter to a trickler, they see that change if they’re engaged. If anybody opened their eyes and looks, they’re going to see those changes. So you have to have that person who’s ready to do that. They’re ready to buy in, because they now have a gastric ulcer that they think may have been caused due to the perio-systemic link, so now all of a sudden their radar is up a little bit more. They’re willing to see the changes.


Hodsdon: Patient care and communication involves more than just lecturing and recommending floss. When communicating with our patients, our attitude, speech patterns, the words we use, tone of voice, body language, and sometimes even silence, coupled with appropriate self-care devices, research and techniques all play a role in how successful we are with patient care.

I would like to thank Sunstar Americas for providing this opportunity and bringing passionate registered dental hygienists together to personally share their patient care messages, products and strategies.