Stringing along: Find an alternative to string flossing to boost compliance

March 13, 2015
Find an alternative to string flossing to boost compliance

Find an alternative to string flossing to boost compliance

BY Susan Clark, RDH, BS, OM

"Dental school educators are key gatekeepers of information and influence to their students. Their actions and opinions count, because students are sensitive to what teachers do and say" (Frazier, 2007). Students amass information verbatim from their instructors. One example is the emphasis placed on string flossing as the primary source for plaque biofilm removal from between the teeth. As a student of traditional teaching, where a teacher lectures and students memorize information, followed by examination, one might not grasp the concept of critical thinking, where gathering information, analyzing, and evaluating could be applied to life and career.

This traditional-style curriculum does not lend itself to application and understanding of facts through individualized discovery. Information is simply learned to pass a test. This restricts one's mindset, limits one's thought process, and is not conducive to reflective critical thinking or action. Reflecting upon learned knowledge, experiences, and life lessons over the course of a lifetime will lead one's mind to a more advanced way of learning and living. It also can reward an individual with a more empowering career.

Learning to evaluate, analyze, and incorporate information learned in the classroom and making more informed decisions rather than taking information verbatim can enhance your life and career. Gone are the days of living within a structured format. A common expression is, "Insanity is doing the same thing over and over and expecting different results." We cannot solve a problem if the mindset or process is not altered to reach a different conclusion.

The notion of dental floss is not new. For centuries people have been using a variety of implements, such as grass stalks as toothpicks and silk fibers to clean between their teeth. Dr. Levi Spear Parmly, a New Orleans dentist, invented floss in 1815. He advised his patients to use a thin silk thread to clean between their teeth. String flossing is considered the most effective tool for cleaning between the teeth. But if patients are not compliant, why, as hygienists, do we continue to sound like a broken record, emphasizing the use and benefits of string flossing during each recare appointment? Is it because we learned the repetition principle that states, "If something is enforced often enough, it will eventually be persuaded, and through repetition it will create familiarity and lead to understanding"? (Changing As Dr. Phil McGraw, a psychologist, life strategist, and popular American television host would say, "How's that working for you?"

"The Cochrane Oral Health Group is an international, nonprofit organization that networks in a way that helps clinicians, researchers, consumers, and patients make decisions about oral health care based on up-to-date, reliable, and accurate information" (Riley, 2013). Data extracted from 12 randomized controlled trials reported in the Cochrane Oral Health Group states that there is evidence that flossing reduces gum disease. According to the American Dental Association, however, "Only about 12% of Americans floss daily, 39% floss less than daily, and 49% don't floss at all" (American Dental Association, 2008).

It is a challenge to get patients to add flossing to their daily regime. When patients are asked why they do not floss, excuses range from dexterity issues, lack of time, or that flossing is too hard to do. Others mentioned they do not place any significant value on flossing, do not like their fingers in their mouth, or that flossing hurts.

Focusing on prevention to help patients avoid gum disease is a primary goal of dental hygienists. One key to prevention is finding delivery systems and techniques that patients will feel comfortable performing on a daily basis. It becomes a win-win situation for the dental hygienist and dental patient when they work together as a team to find solutions for improved home care. Since oral health is linked to general health and well-being, actively involving patients in the decision-making process by offering alternative methods to aid in home-care compliance is essential.


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Everyone has a different tolerance to change. One way you can understand where your patients are coming from is to listen to them. Listen to understand what they want, and not what you know they need. If you want to be understood, you first have to be understanding of others.

Assess your patients by asking open-ended questions to find out what initiatives you could take and resources you could offer to help them reach their oral health wants and needs. Involving them in the decision-making process for improved oral care will enhance your professional relationship and create greater patient compliance.

The Water Flosser is one such practical alternative that is effective for non-string-flossing patients, and it takes only one minute to do. There have been numerous studies conducted by universities and clinical research facilities, independent of any Waterpik studies, comparing string flossing to the Waterpik Water Flosser. In 2005, a report from the American Academy of Periodontology noted that the Waterpik Water Flosser "continues to play a role in the treatment of gingivitis and maintenance of periodontal pockets." (Greenstein 2005) In 2006, the "Canadian Dental Hygienists' Association recommended the home irrigator as one viable option to finger flossing." (Asadoorian 2006) A study conducted at BioSci Research Canada, Ltd. in Mississauga, Ontario, showed that "the Waterpik Water Flosser was significantly more effective than string floss for removing plaque." (Goyal et al. 2013) These are just a few of the many clinical research articles available to indicate the benefits of the Waterpik Water Flosser as a viable alternative to string flossing.

Dentistry is a business, and dental hygienists are its most valued assets. They educate, motivate, and inspire change for their patients. Offering options to assist patients in making well-informed decisions promotes trust and goodwill. Patients may be more willing to return for treatment and refer others to the dental practice. Making patients a part of the reasoning process connected with their own treatment may just be the answer to greater compliance.

Waterpik also has an informative lunch-and-learn educational program where dental teams can learn more about the benefits of water flossing. For more information, you can visit or call 800-525-2020 to invite an independent Waterpik Product Educator to come to your office. RDH

Susan Clark, RDH, BS, OM, is an oral myologist, independent consultant, professional educator on behalf of Waterpik, key opinion leader, public speaker, self-published author of "Exploring Dental Hygiene, Finding the Hidden Rewards," past president of the SDCDHS, and delegate to the California House of Delegates. She is a 2013 recipient of the Sunstar/RDH Award of Distinction. To contact Susan to schedule a Waterpik lunch-and-learn in the Southern California area, email [email protected].


1. Repetition Principles. (Riley, 2013)

2. Asadoorian J. 2006. Canadian Dental Hygienists' Association Position Statement: Flossing. CJDH, Volume 40, pp. 40:1-10.

3. Frazier PJ. Public Health Education and Promotion for Caries Prevention. Vol43 Issue1 John /Wiley & Son.

4. Goyal C et al. 2013. Evaluation of the Plaque Removal Efficacy of a Water Flosser Compared to String Floss in Adults After a Single Use. J. Clin Dent, Volume 24 (2), pp 37-42.

5. Greenstein G. 2005. Research, Science, and Therapy. Committee of the American Academy of Periodontology position paper: Role of Supra- and Subgingival Irrigation in the Treatment of Periodontal Diseases. J. Periodontal 2005; 76:2015-2027.

6. Roper GFK, 2008. A Collaboration Between the American Dental Association (ADA), Crest, and Oral-B. Conducted by GFK Roper Public Affairs and Media. October 2008.