Opt out of floss: How to suggest other bathroom décor for oral care

June 12, 2015
Are you sick and tired of asking your patients if they use dental floss? Are you tired of nagging them about it? I stopped nagging a long time ago.

How to suggest other bathroom décor for oral care

Are you sick and tired of asking your patients if they use dental floss? Are you tired of nagging them about it? I stopped nagging a long time ago.

BY Kyle Isaacs, RDHEP, BHS

"You and your patients do not need to floss." I said it, and I will say it again and again if I need to.

What about when your patients ask you if you floss, do you feel uncomfortable in answering? Let's be honest, a recent ADA survey reveals that only 40% of people floss daily and 20% never floss. Even among dental professionals, the numbers are low.

I've asked other dental hygienists and dental hygiene educators what is currently being taught in the dental hygiene curriculum. Overwhelmingly, dental floss is still the first interproximal tool recommended to students for teaching oral hygiene to their patients. Most learn about and recommend the other oral aids, but it seems that dental floss is the standard of care. Some of my peers said that they always stress the use of dental floss even when using other aids. We all know that brushing alone is not sufficient in disrupting subgingival or interproximal biofilm. There are other ways to clean interproximally and subgingivally that are as effective and, in some studies, better than floss for decreasing inflammation, removing plaque, altering biofilm, and decreasing bleeding.


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It's easy to understand why dental professionals continue to push the use of dental floss on everyone. For 200 years, dental floss has been the go-to choice for cleaning interproximally. Dr. Levi Spear Parmly first introduced a silk thread in 1815, but there are some accounts that some sort of string was used in prehistoric times.

Statistics show that not many people floss and those who do, do not do it properly or effectively. Why is our profession continuing to be limiting about options for oral hygiene? Is it because it has been around for so long, and we feel most comfortable with it? Maybe it is because that is what was drilled into our heads when we were in dental hygiene school.

It is time for an open discussion within our profession about the effectiveness of floss vs. other tools. Dental floss is not the answer for everyone. Other interproximal aids are more effective for most people. For the majority who will not, can not, or just do not do a good job with floss, individual needs and abilities should determine what aids are used.

Here are some facts. In a 2010 survey published by Health Canada, of 6,000 people surveyed, only 28% floss five or more times each week.3 In another survey implemented in a New York periodontal practice, 307 patients were compared with 315 patients going to a dental clinic.6 There was an average of 13.5% who flossed daily; 29.5% who flossed one to six days per week; and 57% who did not floss at all. There were a greater number of people from the periodontal practice who flossed regularly, 19.3% vs. 7.9% than at the dental clinic. Even though the patients at the private periodontal practice flossed more on average, still the percentage is low; it might be expected that these patients have more dental knowledge than those going to a clinic.

Another survey targeted the habits of teenagers; 1% from Finland and 8% of those from England floss regularly.6 Most of us working clinically already know that the number of people who floss daily is low, and we also know that most of those who do make an attempt are not as effective as they should be.

It may be surprising to some, but dental professionals are not perfect when it comes to flossing either. Of the 201 periodontists Segelnick surveyed, 82% of the specialists admitted to flossing daily. Of the 79 general dentists he questioned, only 56.3% answered that they were flossing every day.6 In another survey, Imai and Hatzimanolakis (2011) found that daily use of dental floss falls between 11 and 30%. It would be safe to say that not many people are flossing.

Not being open to alternatives limits our ability as clinicians and health-care providers from being able to give our patients the tools necessary for optimum oral and systemic health. In my experience, asking patients if they floss and nagging them to do it only backfires, making them less likely to do it and do it regularly. Many times I have heard the ubiquitous, "I've been bad; I have not flossed much," even before they are seated in the chair. When people feel guilty for not flossing, sometimes they are less likely to come and see us for fear of being judged. The last thing I want my patients to feel is guilt! Why do we keep doing this? No one likes it; it's craziness in the making. It is my goal to help patients and colleagues learn that there is more than one way to skin the biofilm; that is, to effectively clean their teeth and gingiva with whatever tools work and do not harm.

Interdental Brushes

After greeting, seating, and updating pertinent information, I ask my patients what is their tool of choice for cleaning in between and under their gums. Most people are a little taken aback by my question. Some patients say that they floss on occasion; many do not use anything except their toothbrush. I explain why it is important to clean subgingivally daily, and then together we explore some of the possible options to do this.

One of the many options for cleaning interproximally are interdental brushes (IDBs). In a 2008 systematic review of 334 papers and abstracts, IDBs were found to be more effective at removing plaque and resulted in better pocket reduction than dental floss.7

IDBs are easy to use, come in many different diameters, and preferred more often than floss. People can carry them wherever they go and use them at will without requiring a trip to the bathroom; finding ways to make interproximal cleaning easy will increase use. When demonstrated to patients, most clinicians will agree that IDBs are better received; however, their use and recommendation has generally been only for bigger embrasures where the papilla is receded; that is, until the following study was done.

The study design included participants with gingivitis or early periodontitis and utilized 0.6 mm interdental brushes, the smallest diameter IDB available from Curaprox, a dental company based in Sweden.3 In the investigation, participants used the IDB only from the buccal aspect and slid it in and then out only once in each interproximal space being studied. There was a baseline scaling with hand and power instruments two weeks before the start of the experiment and each participant used dental floss on one side and the IDB on the other side of their mouth. For the first six weeks, the IDB sites resulted in less bleeding than the flossing sites, but from that point to the end of the study, the IDB and dental floss sites equally resulted in less bleeding. This most likely indicates that it took the subjects more time to master the technique for flossing. Both tools equally reduced plaque, and there was no evidence of any damage to papillae in either group.

In the past, interdental brushes were too big for people whose papilla filled the embrasure space, but now, with the emergence of the much smaller brushes, people with healthy gingiva can use interdental brushes instead of dental floss. This opens up more options for patients and, for many, a tool that is easier to use than dental floss, increasing the opportunity of more patients establishing a daily interproximal cleaning habit. This supports what I say while educating my patients: "I do not care what you do, as long as you do something to disturb the bacteria on a daily basis and that you do not hurt yourself."

Like IDBs, many patients like to use toothpicks because they are portable, require only one hand, and do not necessitate good dexterity. Recently, I had the opportunity to provide dental hygiene care for an elderly gentleman who has all of his teeth; he had very little plaque or bleeding, and no deep pockets. I was amazed! Many of my elderly patients have memory issues, diminished eyesight, and limited dexterity. Luckily, his wife was in the next chair, and I was able to ask his her what he was doing to maintain a healthy mouth. She shared with me that her husband was using toothpicks after each meal while watching television. This was not the first time I had treated a patient staying healthy by using only toothpicks and brushing - just my most recent.

If you don't believe me about toothpicks, here is a study that took place at the University of Tennessee, 55 people were split into two groups to compare dental floss to a holder with a toothpick.4 This study included people with gingivitis or early periodontitis between the ages of 18 and 50, and lasted three months. The results confirmed that both tools equally decreased plaque and bleeding.4 These results further strengthen the need to be aware of all the tools in our arsenal that are as effective or better than dental floss.

Oral Irrigation

Oral irrigating with water is another option and has been around since 1962. A four-week study with 108 participants compared the use of a water irrigator with dental floss use. At the end of the trial, those using irrigation had significantly less bleeding compared to the flossing group and both groups had the same amount of plaque reduction.5 After learning the basics, water irrigation is easy to perform even for those with big hands, small mouths, and a gag reflex. In a study comparing water irrigation to flossing with 105 participants, there was a significant difference with the irrigation groups over the flossing groups on bleeding reduction, and overall more plaque removal and better gingival index scores.1 ("The daily use of oral irrigation has been shown to reduce dental plaque, calculus, gingivitis, bleeding, probing depth, periodontal pathogens, and host inflammatory mediators.")1

Countless times I have heard from dental professionals that oral irrigators do not work; the results that I see with my patients as well as these studies prove that oral irrigators are optimum choices for interproximal cleaning.

Finding the best interproximal aid for patients should be on an individual basis; floss is not the only choice and not better than other tools. First, ask your patients what they are already using and build on that. What is important is to find what each patient will use on a daily basis in an effective manner, not what we think they should be using. Try the different brushes that are available, see what is in the stores, and learn about the ones that can be ordered only from specific companies. If you have healthy, filled embrasures, try the smallest interdental brushes or the water irrigators so that you know how to use them and can show your patients how to use them. Many companies make IDBs, some as small as 0.4 mm for healthy papilla. Some companies have instructional videos for using the water irrigators, which are great tools for patients when they get home with their new purchase.

Take the time to collaborate with your patients to find out what tools they realistically will use, reevaluate the effectiveness at subsequent appointments, be willing to offer different tools until they find the one that they will use with therapeutic success. It can be uncomfortable at first to start suggesting other tools instead of floss; when you do, you will most likely be surprised by both the reactions and the results you see. Start getting comfortable and enjoy all the benefits! RDH

Kyle Isaacs, RDHEP, BHS, lives near Corvallis, Oregon, where she works four days a week in a dental office. She also owns a company, Miles 2 Smiles LLC, and provides dental hygiene care in churches, private homes, and schools. Eventually, she hopes to provide care in nursing homes as well. She is a member of the American Dental Hygiene Association and serves on the board of her local component. She loves to volunteer and comes from a family with many dental professionals. She has been a dental hygienist for 32 years and loves educating patients and helping them to get and stay healthy - both in the mouth and systemically.


1. Barnes CM, Russell CM, Reinhardt RA, et al. Comparison of irrigation to floss as an adjunct to tooth brushing: Effect on bleeding, gingivitis, and supragingival plaque. The Journal of Clinical Dentistry. 2005;16:71-77.
2.Health Canada, www.hc-sc.gc.ca, 2010.
3. Imai PH, Hatzimanolakis PC. Interdental brush in type I embrasures: Examiner blinded randomized clinical trial of bleeding and plaque efficacy. Canadian Journal of Dental Hygiene. 2011;45(1):25-32.
4. Lewis MW, Selders RJ, Holder-Ballard C, et al. Comparison of the use of a toothpick in a toothpick holder to dental floss in improvement of gingival health. Journal of Dental Hygiene. 2005;79(4):1.
5. Rosema NA, Hennequin-Hoenderdos NL, Berchier CE, et al. The effect of different interdental cleaning devices on gingival bleeding. Journal of the International Academy of Periodontology. 2011;13(1):2-10.
6. Segelnick SL. A survey of floss frequency, habit, and technique in a hospital dental clinic and private periodontal practice. New York State Dental Journal. May/June 2004;28-33.
7. Slot D, Dorfer C, Van der Weijden G. The efficacy of interdental brushes on plaque and parameters of periodontal inflammation: A systemic review. International Journal of Dental Hygiene. 2008;6(4):253-264.