At a loss about floss? Expand the interproximal repertoire for patients

Nov. 15, 2016
In regard to floss, JoAnn Gurenlian, RDH, writes that dental professionals "need to stop giving incorrect messages to our patients. We must evaluate each person and customize a program of interdental biofilm management that's appropriate to their needs and skill level."

By JoAnn Gurenlian, RDH, PhD

One year ago I wrote a column about floss and how the latest research showed weak and unreliable evidence supporting its use for reducing inflammation in patients with periodontal disease. At that time the evidence indicated that interdental brushes were more effective in biofilm management when these brushes fit between the proximal spaces.

Flash forward to August 2. Nightly News with Lester Holt broadcast a story about flossing. During the segment, the Associated Press noted that they reviewed 25 studies and found little to no evidence that flossing works. It was reported that the government removed flossing from its oral health guidelines. However, the American Dental Association (ADA) still recommends flossing. The segment featured Dr. Wayne Aldredge representing the American Academy of Periodontology, who stated, "If you want to keep your teeth, keep flossing. ... If dentists do it, we do it because it is the right thing."

So, what is the right thing to recommend for our patients? Do we still tell our patients to "floss only the teeth they want to keep" and "floss or die"? Do we keep the plaques with those alarming mottos on the walls of our dental offices? Do we continue to recommend string floss to every patient as the ADA and AAP suggest? Can we bear to give up the flossing message we were taught in dental hygiene school?

In a year's time, the science about flossing has not changed. In fact, we've known this evidence for almost a decade. However, if it has been a while since you've familiarized yourself with this literature, the Cochrane review is a good place to start.1

What we are building toward is a case of acceptance not among our patients, but among dental health professionals. Our patients have been honest for quite some time. Many do not like to floss or they feel inadequate in their technique. They ask for alternatives for interdental biofilm management. They're frustrated when we show them only the flossing way. Some of our patients are quite skilled at flossing and happy to continue to use string floss. They have healthy mouths and appropriate embrasure spaces to manage flossing well. They're motivated and we should encourage them to maintain their oral health-care regimen.

For those patients who need alternatives for interproximal cleansing, they exist. Use your preventive expertise and recommend interdental brushes or mechanical devices, such as the Sonicare AirFloss Pro or the Waterpik Water Flosser. In some cases, the best device is the one a patient will use daily.

Most importantly, oral health professionals need to stop giving incorrect messages to our patients. We must evaluate each person and customize a program of interdental biofilm management that's appropriate to their needs and skill level. To say that one must keep flossing to keep one's teeth is the wrong message. It's not based on science. What it does represent is a longstanding need to cling to tradition.

For those who just can't stand to leave string floss behind, the good news is that you don't need to give it up completely. But it is time to expand the interproximal repertoire. More importantly, it is also time for the media to use oral health professionals who have the expertise to properly educate patients based on current science-dental hygienists. Let's hope that next time Nightly News or some other series airs a story about oral health, they will consult preventive oral health specialists who can provide a more accurate perspective about these issues. RDH


Sambunjak D, Nickerson JW, Poklepovic T, et al. Flossing for the management of periodontal diseases and dental caries in adults. Cochrane Database Syst Rev.2011Dec 7;12:CD0088209.

JOANN R. GURENLIAN, RDH, PhD, is president of Gurenlian & Associates, and provides consulting services and continuing education programs to health-care providers. She is a professor and dental hygiene graduate program director at Idaho State University, and past president of the International Federation of Dental Hygienists.