by Lynne H. Slim, RDH, BSDH, MSDH
I awoke at 4 a.m., made myself a cup of Costa Rican coffee (which I think is the best coffee in the world) and settled in front of the television to watch the royal wedding. Unlike the timeless British traditions which seem to have so much relevance, including a great attraction for so many people in the United Kingdom and around the world, some traditions ought to be abandoned or modified. The misguided habit of finger flossing is one that needs to be modified.
Only 10% to 40% of Americans floss on a daily basis.1 When a patient settles into a cushy operatory chair and a dental hygienist asks him that probing question about "between teeth" cleaning that generally results in a great deal of guilty embarrassment and fidgeting, maybe it's time to pose the question in a different way.
Consumers today are overwhelmed with "between teeth" cleaning devices, just as they are with toothbrushes. A weirdo nerd like me first wants to know how the range of interdental cleaning devices compare, including some of the newer ones, and that's no easy task.
Periodontal researchers don't doubt the benefit of self-care measures to disrupt proximal/interdental biofilm, but there are still unanswered questions about the role of personal plaque control in the pathogenesis of periodontitis in comparison with other risk factors.2 In addition to looking at outcomes such as improvement in gingival health and visible plaque removal from frequency of self-care measures, efficacy (how adept an individual is in removing quantity and quality of plaque) is another risk factor that's seldom taken into consideration.
Periodontitis is an inflammatory disease but it is induced by bacterial biofilms that set up residence in the gingival crevice. Gram negative periodontal pathogens (and maybe even viruses) in biofilm have numerous and very powerful "virulence" factors that neutralize host defenses and destroy periodontal tissues. Only a certain percentage of the population develops periodontitis (50% of the U.S. population)3 and it's the "impotence" or "aberrance" of the immune response in susceptible individuals (smokers and people with diabetes, for example) that permits the organization of mature biofilms where these pathogens flourish.
In other words, it's a complex, multi-factorial etiology related to an imbalance between the host and biofilm (parasite). As a practicing clinician who discloses patient plaque/biofilm on a regular basis, biofilm is always on my mind. Most of my patients get better with improved self-care and with more frequent recare. Biofilm removal with micro-ultrasonics on a low power setting is a lot of what I do in my operatory day in and day out. After periodontal maintenance, the professional disruption of hard-to-access biofilm almost always results in a reduction of red and orange complex pathogens and less inflammation with more frequent recare visits.4,5
Sonicare AirFloss is the new interdental kid on the block. It is an effective alternative to traditional flossing with microbursts of water and air. A rechargeable unit with an easy-to-grasp, ergonomic handle and thin, angled neck, this slick-looking device has special eye appeal. In the handle portion of the unit, there's an on/off button. There's also a reservoir for about two teaspoons of your favorite mouthwash or water, and I have found that it uses about one teaspoon of water/mouthwash per full mouth interproximal use. Maybe now we can now combine an OTC antimicrobial or fluoride mouthrinse to AirFloss and get more than one desirable outcome! It's easy to position between teeth and there's a mouse-like clicker that you press to activate the slim, slightly angled nozzle.
The feature I like most is the ability to point/click (with one hand), which means I'm free to walk around the house while AirFlossing! What research has shown so far (and it's still early in the research process because there are yet no completed clinical trials comparing AirFloss to other interdental devices) is that it improves gingival health by reducing gingival inflammation (independent of plaque/biofilm removal). But the company makes no claims about subgingival outcomes, nor does it make claims about removing clinically visible plaque/biofilm.
Marketing messages about oral irrigators often tout benefits over flossing. But there are still some unanswered questions about clinical outcomes for oral irrigation just as there are about string floss. In a systematic review** by Berchier et al., the efficacy of dental floss in addition to a toothbrush on plaque and clinical gingival inflammation of periodontal disease in adults was studied.6 Out of 187 studies, only 11 met the eligibility criteria established by the investigators. It may surprise some RDH readers that the routine instruction of flossing in gingivitis patients was not supported by scientific evidence in this particular review. Only three individual studies of a total of 11 studies showed a significant difference in favor of floss as an adjunct to toothbrushing. RDH readers should make a point of reading this important systematic review, especially the discussion section that covers patient compliance. (http://onlinelibrary.wiley.com/doi/10.1111/j.1601-5037.2008.00336.x/abstract)
A 2008 systematic review on the efficacy of oral irrigation in addition to toothbrushing on plaque and periodontal inflammation concluded that the oral irrigator does not have a beneficial effect in reducing visible plaque. The authors also reported a positive trend in favor of oral irrigation in improving gingival health over toothbrushing alone.7
In discussing the science behind Sonicare's AirFloss, Dr. Joerg Strate, vice president, Philips Oral Healthcare, Clinical and Scientific Affairs, still wants answers to the following research questions:
- Does AirFloss remove nonvisible biofilm?
- Does the use of AirFloss prevent maturation of non-visible biofilm?
- Does AirFloss detoxify nonvisible biofilm? Biofilm bacteria produce and secrete chemicals to break down surrounding tissue as a nutrient supply. Does this perhaps stimulate inflammation?
Could it be possible that daily AirFloss microburst flushing of the inflammatory infiltrate from the gingival tissue can help prevent tissue and alveolar bone destruction by stopping the activation of several pro-inflammatory cytokines? Is it the sheer air/fluid forces that detach biofilm fragments and/or is it possible that biofilm virulence factors, pyrogens, and other inflammatory toxins from the biofilm are diluted while leaving much of the biofilm bacteria inert? Future research may determine the answers to these questions.
AirFloss is also a great way to combine interdental cleaning and an antimicrobial or fluoride mouthrinse (undiluted). What a marriage with great potential! AirFloss as an interdental medicament delivery device is a great way for dental hygienists to customize medicaments for dental caries or gingival bleeding.
Floss is a generic term that refers to "between teeth" cleaning, but it doesn't define the technique. Instead of asking patients the nagging question, "Do you floss?" replace it with a question that reflects the variety of interdental products on the market. Customize your message and recommendations, and keep an open mind about string floss alternatives. Also, for periodontal patients, consider combining mechanical cleaning with an interdental device that reduces gingival inflammation.
**A systematic review has a high level of evidence and it is a systematic assessment of the available literature on the effects of healthcare interventions that are intended to help the professional in making evidence-based decisions.
Lynne Slim, RDH, BSDH, MSDH, is an award-winning writer who has published extensively in dental/dental hygiene journals. Lynne is the CEO of Perio C Dent, a dental practice management company that specializes in the incorporation of conservative periodontal therapy into the hygiene department of dental practices. Lynne is also the owner and moderator of the periotherapist yahoo group: www.yahoogroups.com/group/periotherapist. Lynne speaks on the topic of conservative periodontal therapy and other dental hygiene-related topics. She can be reached at [email protected] or www.periocdent.com.
- Asadoorian J. Flossing: Canadian Dental Hygienists Association position statement. Can J Dent Hyg. 2006; 40(3):1-10.
- Claydon NC. Current concepts in toothbrushing and interdental cleaning. Periodontol 2000. 2011; 48: 10-22.
- van der Weijden F, Slot DE. Oral hygiene in the prevention of periodontal diseases: the evidence. Periodontol 2000. 2011; 55: 109-123.
- Haffajee AD, Teles RP, Socransky SS. The effect of periodontal therapy on the composition of the subgingival microbiota. Periodontol 2000. 2006; 42: 219-258.
- Tan AES. Periodontal maintenance. Aus Dent J 2009: 54: (1 Suppl): S110-117.
- Berchier E, Slot DE, Haps S, Van der Heijden GA. The efficacy of dental floss in addition to a toothbrush on plaque and parameters of gingival inflammation: a systematic review. Int J of Dent Hyg. 2008; 6(4): 265-279.
- Husseini A, Slot DE, Van der Weijden GA. The efficacy of oral irrigaton in addition to a toothbrush on plaque and the clinical parameters of periodontal inflammation: a systematic review. Int J Dent Hyg. 2008;6(4): 301-14.
Clinical decision-making by dental hygienists requires a higher level of thinking (and constant rethinking!) based on new evidence and clinical experiences with patients. For example, in a recent online discussion www.yahoogroups.com/group/periotherapist), a participant named Lynn Gamarel, RDH, BA, issued some formidable challenges when discussing interdental cleaning and oral irrigation. Here's some of what she had to say:
"According to Dr. S.N. Bhaskar, periodontist, the efficacy of oral irrigation is attributed to Bernoulli's principle of fluid (and aero) dynamics. The intensity of the water stream which is directed horizontal to the long axis of teeth 'lifts' the biofilmfrom the sulcus. This reduces the population density of bacteria. I think it's that simple. Water alone is amazingly successful. I was taught years ago based on some studies from Columbia University dental school that it didn't remove plaque; therefore it was of no value. Not true! I have so much more reliable clinical success with oral irrigation (WaterPik) over a broader range of patients than anything else. It's really stunning to see the results.
"Dr. Bhaskar was a major general, U.S. Army, during the Vietnam War. During this time he said that the soldiers who were wounded during battle were sutured onsite and then sent for R&R (rest and recuperation). During R&R, the soldiers' wounds were reinfecting. According to Dr. Bhaskar, he was given the task to solve this problem, and he came up with lavage of the wounds prior to suturing. Voila...problem solved. He is a strong proponent of oral irrigation. He said the reason oral irrigation works is because the presentation of plaque subgingivally is a biofilm and easily disrupted, enough so to reduce the bacterial load. Another critical component is the ability of the water spray to reach the curves of root morphology as well as grooves or depressions missed by mechanical hygiene aids. The approach does not kill bacteria; it just flushes enough of it out of the sulci to prevent an inflammatory response. Practiced daily and regularly, it works."
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