The appeal of sticks

June 1, 2002
Lamar, my friendly bank teller, noticed the RDH after my name on my deposit slip yesterday and said, "RDH ... I know I've asked you before what that means, but I can't remember." I told him again, and he quickly responded, "I'm going to my hygienist next week, and she's really going to be mad at me because I haven't flossed for months. I just hate to floss!"

Lamar, my friendly bank teller, noticed the RDH after my name on my deposit slip yesterday and said, "RDH ... I know I've asked you before what that means, but I can't remember." I told him again, and he quickly responded, "I'm going to my hygienist next week, and she's really going to be mad at me because I haven't flossed for months. I just hate to floss!"

Sound familiar? He said he doesn't have time to floss, because he already brushes his teeth for eight minutes now, including his tongue and the roof of his mouth and just about every place except between his teeth. From an unpublished study done by Northern Arizona University dental hygiene students, we know that people don't even spend half as much time brushing as they think they do - that makes it four minutes or less for Lamar.

When I mentioned that he was still missing nearly half the tooth surfaces by not cleaning between the teeth, he was quick to suggest that his rinsing with ListerineRegistered would take care of that, because he rinsed vigorously! The current advertising for Listerine does give that idea, so I could not fault him on his reasoning. But the Listerine message is, "brush, floss and rinse" - it's not just rinsing. If rinsing were enough to reach between the teeth, surely it would be even better on facial and lingual surfaces and then we wouldn't need to brush at all! I haven't heard that message yet.

How well does a rinse or any interproximal tool work between the teeth? Unless we extract every other tooth, or surgically excise each papilla, we can't really see the interproximal area to evaluate effectiveness. This is especially true in posterior areas, where the interproximal sites are wide and inaccessible. Chew up a handful of nuts and then brush your teeth with the best toothbrush around. Now all you need to do is use a WaterpikRegistered to see how much food remains between the teeth, untouched by the brush. If the food is still there, how much plaque is there?

This raises two more questions. What is our goal - plaque removal or food removal? Your answer will lead to the next question - should we clean our teeth before or after eating? What does the research say?

Plaque bacteria, in contact with fermentable carbohydrates, produce acid within seconds. Knowing that, it no longer makes sense to wait until after eating to clean the teeth. Removing plaque bacteria before eating will prevent the acid production that begins while we're eating. Waiting until after a meal to clean the teeth will remove both plaque and food, but only after allowing acid production during the time spent eating - before getting around to brushing and cleaning between the teeth.

Brushing has been around longer than flossing or other interdental tools, so it naturally gets more attention. What do you teach patients first? Brushing or flossing? If time is limited, which should you focus on, brushing or cleaning between the teeth? Would Lamar, my friendly bank teller, be better off skipping brushing and focusing between the teeth? What does the research say about this?

I cannot find a study that compares just brushing to just cleaning between the teeth, but it is an intriguing question. What we do know is that dental decay begins between the teeth and on occlusal surfaces, where toothbrush bristles often are too large to reach into grooves and fissures, thus the importance of pit and fissure sealants. Brushing surfaces are not the likely areas for decay to begin. It begins between the teeth.

We also know that periodontal disease starts between the teeth, where tissue in the col area is not keratinized and, thus, more susceptible to bacterial endotoxins. Research that visually measures gingivitis and plaque misses the interproximal area entirely, unless there are large diastemas or lots of missing teeth.

A dramatic effort by researchers at the Eastman Dental Center in Rochester, N.Y., to measure interproximal inflammation resulted in removal of papilla for microscopic evaluation. I know that sounds a bit radical, but they selected patients who were already scheduled for periodontal surgery who were willing to donate a papilla to science. Before removing the papilla, they used a triangular wooden toothpick to test for interdental bleeding. This is called the EIBI (Eastman Interdental Bleeding Index). A toothpick is placed into the interdental area from the facial aspect. While keeping the toothpick perpendicular to the long axis of the tooth, it is rubbed in and out four times. Bleeding within 15 seconds is your indication of infection. Microscopic evaluation of the tissue samples confirmed a correlation between bleeding and inflammation. The sites that bled with the toothpick also had significant inflammatory infiltrate visible microscopically. Those that didn't bleed, appeared histologically healthy.

So, based on science, the toothpick test is a good way for both you and your patients to check the health of tissue between the teeth. If you can get your patients to do this self-test every day, they also will be effectively removing plaque between the teeth and soon will have a bleeding score of zero!

Our choices for interdental wooden sticks have been extremely limited in the past. You all know Stim-U-Dents by Johnson & Johnson. The best sticks come from Scandinavia, in matchbook-like packs or double-ended loose sticks in plastic containers. You can even get them with fluoride. One brand is Jordan Sticks, available from Pearson Dental. Go-Betweenstrademark Picks, from Butler, are the newest toothpicks on the market. These are available at many drug and discount stores right now. If you cannot find them in your area, ask the store to order them, or better yet, have them available in your office for patients to purchase.

There are several plastic picks on the market, but no research is available on these. Pro-DentecRegistered makes Rota-Points and Prophy Perfect now carries a very nice one called Dentastix.

Most hygienists aren't toothpick fans, but my years in Switzerland showed me that people are more likely to use sticks than floss. They can be used while reading, watching TV, or riding in the car. They don't have to be in the bathroom. When used regularly, the results are fantastic. Do a little research yourself. Get some Go-Betweenstrademark Picks for your patients who won't floss. It won't take long for the patients to sing your praises for showing them such an easy alternative to floss.

Trisha E. O'Hehir, RDH, BS, is a senior consulting editor of RDH. She also is editor of Perio Reports, a newsletter for dental professionals that addresses periodontics. The Web site for Perio Reports is She can be reached by phone at (800) 374-4290 and by e-mail at [email protected].