Wave Goodbye to Floss?

The Yahoo periotherapist group is near and dear to my heart. We discuss everything from lasers in the treatment of periodontal diseases to the disastrous marketing of sugar-laden cereals as a snack to children. I try very hard to be objective when discussing every topic and use an evidence-based approach to clinical problem-solving. Research in health care continues to verify that using evidence-based clinical guidelines in practice improves patient outcomes. 1

BY LYNNE SLIM, RDH, BSDH, MSDH

The Yahoo periotherapist group is near and dear to my heart. We discuss everything from lasers in the treatment of periodontal diseases to the disastrous marketing of sugar-laden cereals as a snack to children. I try very hard to be objective when discussing every topic and use an evidence-based approach to clinical problem-solving. Research in health care continues to verify that using evidence-based clinical guidelines in practice improves patient outcomes. 1

Sometimes research needs to be evaluated before applying it in clinical practice. The application of research requires critical thinking and good clinical judgment. There are many gray areas; research findings are sometimes mixed or even conflicting, requiring clinicians to select the best scientific evidence relevant to particular patients. None of it is easy, and sometimes it involves intuition and reasoning over time.

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Other articles by Lynne Slim

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Over the last few months, several members of the periotherapist group (yahoogroups/periotherapist) have been discussing self-flossing for periodontal patients. We've discussed it many times before, and I thought it would be an interesting exercise for me to dedicate a column to this topic.

Should we wave goodbye to flossing instructions for patients with diagnosed periodontal disease? I'm not so sure, but let's examine this question. For this particular topic, I'm going to divide the subject into the following components: scientific evidence for and against, clinical expertise, and unique patient features.

Scientific evidence behind flossing for patients with periodontal diseases

In reviewing evidence, it's always important to search for the highest level of research you can find - in this case, systematic reviews (SR) such as the Cochrane database. I found one SR that evaluated the effects of flossing in addition to tooth brushing - as compared to brushing alone - in the management of periodontal diseases and dental caries in adults. 2 The SR (582 subjects) included 12 trials, seven of which were considered at unclear risk of bias and five at high risk of bias.

Researchers discovered that flossing plus brushing showed a statistically significant benefit when compared to brushing alone at three time points: one month, three months, and six months in reducing gingivitis, not periodontitis or clinical attachment loss. There is weak, very unreliable evidence suggesting that the addition of flossing may be associated with a small reduction in plaque at one or three months.

None of the studies reported the effectiveness of flossing plus brushing as a caries-preventive method.

Clinical expertise

The proximal and interdental areas have a high risk of developing periodontal lesions, which appear to be attributed to the formation of subgingival biofilms that stimulate a cascade of chronic inflammatory reactions by the affected tissue. Manual brushing alone removes biofilm primarily on flat surfaces of teeth. Powered toothbrushes offer a greater reduction in plaque/biofilm that may include the interproximal area. 3

An astute clinician will customize an interdental biofilm disruption method for a particular patient, according to the size and shape of each interdental and proximal space. This may include a powered toothbrush, simple floss or tape, wood sticks, interdental brushes, oral irrigation, or some of the newer electric interdental cleaning devices.

For periodontal patients, the efficacy of any device, even oral irrigation or interdental brushes over flossing is inconclusive. 4,5

Many studies are thrown out when researchers look at study errors. Some readers may wonder why some studies on these devices are thrown out by researchers during the process of designing a systematic review of the literature. The answer has to do with individual study error, and these errors are called extraneous or confounding variables. An extraneous variable bias can affect what's called the internal validity of a study, and they need to be controlled in the study design. If extraneous variables aren't controlled, the study is thrown out.

In addition, some types of studies are better suited than others. For example, if we are studying biofilm reduction in posterior sextants, using extracted teeth (in vitro study) may show that biofilm can be reduced but what happens when the root is placed in bone with a ligament in a posterior sextant of a live human with questionable dexterity?

I recently read a Gallup Youth Survey that found that only 13% of teenagers floss their teeth, and 44% say they rarely or never floss.

I'm not sure we know for certain how many of our adult periodontal patients comply with our self-care recommendations, and the flossing percentages are probably similar to those of teenagers.

Many periodontal patients have significant clinical attachment loss, and a lot of daily biofilm cleaning (disruption) needs to take place apical to the contact.6 A good starting point in educating patients is to order a good quality periodontal typodont model that shows advanced periodontitis, clinical attachment loss, and the typical wider lingual embrasures. These patients need an arsenal of appropriate biofilm disruption tools that include customizing color-coded interdental brushes according to the size of the interdental space and end-tufted toothbrushes to clean furcations and tipped or rotated molars.

According to the scientific evidence to date, none of the interdental cleaning devices offers a clear advantage, so select those items that you are excited about and demonstrate each of them on the typodont. Make good use of that intraoral camera, and capture some images of that biofilm along the CEJ where the patient needs to do better. Pay close attention to localized areas of inflammation that need supplementary aids, and long handles are sometimes needed for interdental brush access and efficiency, especially in posterior sextants.

Unique patient features

Habitual tooth cleaning is not needs-related, and patients mainly brush tooth surfaces with the least disease activity.6 Behavioral training and customizing an action plan are like potty training a toddler. Not all toddlers are created equal, just as not all adults with periodontal disease are identical. One patient may have aggressive periodontitis that is particularly destructive because of smoking. In this particular case, focusing on self-care isn't going to do much good if the patient hasn't decided to fight his addiction and dedicate himself to whatever is necessary to save his periodontium.

A geriatric patient with dementia and severe chronic periodontitis isn't going to arrest periodontitis if her caregiver is unwilling to assist and follow a customized treatment plan.

Have your patient disclose a few teeth in a posterior sextant, and then give them customized choices for interdental biofilm removal. Together, study the biofilm and explain that biofilm prefers warm, moist areas.

Whatever you do, have fun with it, and show your patient how passionate you are about biofilm disruption. Neither should you throw out the baby with the bathwater. In other words, if self-flossing is something your periodontal patient enjoys doing, keep it as part of their routine but show them on the anatomy of a posterior tooth how even tape is going to glide right by biofilm in concavities/furcations and wider embrasures. RDH

References

1. http://www.aaos.org/news/bulletin/janfeb07/research4.asp

2. Sambunjak D, Nickerson JW, Poklepovic T, Johnson TM, Imai P, Tugwell P, Worthington HV. Flossing for the management of periodontal diseases and dental caries in adults. Cochrane Database of Syst Rev. 2011, Issue 12. Art. No.: CD008829. DOI:10.1002/14651858.CD008829.pub 2.

3. Yaacob M, Worthington HV, Deacon SA, Deery C, Walmsley AC, Robinson PG, Glenny AM. Editorial Group: Cochrane Oral Health Group. Powered versus manual toothbrushing for oral health. Published online: 17 JUN 2014. DOI: 10. 1002/14651858.CD002281.pub 3.

4. Poklepovic T, Worthington HV, Johnson TM, Sambunjak D, Imai P, Clarkson JE, Tugwell P. Interdental brushing for the prevention and control of periodontal diseases and dental caries in adults. Cochrane Database Syst Rev. 2013 Dec 18; 12:CD009857. doi: 10.1002/14651858.CD009857.pub 2.

5. Husseini A, Slot DE, Van der Weijden GA. The efficacy of oral irrigation in addition to a toothbrush on plaque and the clinical parameters of periodontal inflammation: a systematic review. Int J Dent Hyg. 2008 Nov; 6(4): 304-14.

6. Claydon NC. Current concepts in toothbrushing and interdental cleaning. Periodontol 2000, Vol. 48, 10-22.


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 Evidence-Based Dental Hygiene Group (EBDH) on LinkedIn. Evidence-based periodontal therapy will be part of the group's focus, and Lynne enjoys mentoring dental hygienists in EBDH. She can be reached at periocdent@mindspring.com or www.periocdent.com.

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