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Dental professionals understand that to prevent disease and achieve optimal oral health, regular interdental cleaning is required. Generally, floss is the most common interdental recommendation, yet reports show few adults (32.9%) use floss or other types of interdental cleaning on a daily basis.1 Moreover, patients who do not floss are often not honest about it with their dental provider.2
In August 2016 an Associated Press report surprisingly posited that the medical benefits of flossing are unproven.3 Many dental professionals were outraged, as experience and observation have shown that flossing works, even if it has not been proven scientifically.
The apparent gap between experience and research is most likely due to human nature. Lang et al found that only slightly more than 20% of people are able to floss correctly.4 A 2008 systematic review on flossing included 11 studies with 559 adult subjects. The investigators found three studies supporting better plaque removal, one study showing a greater reduction in bleeding, and one supporting greater reductions in gingivitis.4 Despite the acknowledgment of weak evidence, the researchers did not recommend abandoning flossing altogether. Instead, they recommended that dental professionals determine on an individual basis whether effective flossing is an achievable goal and then make a well-considered decision about what to advise the patient.4
Numerous alternative interdental cleaning products besides floss are available to clinicians for recommendation to their patients. The aim of this article is to provide the dental team with the basic knowledge and skill set required to elicit effective behavior change in patients, particularly in the area of interdental cleaning.
The Challenge of Behavior Change
The traditional approach to patient education has been the "tell, show, do" method. "Telling" involves explaining to the patient why the recommendation is being made (ie, plaque accumulation leads to gingivitis). Next, "showing" the patient what to do includes, for example, demonstrating the use of dental floss. Finally, the "do" component entails the patient demonstrating the use of the product. Unfortunately, this approach rarely works for dental professionals and other healthcare providers, as patients often are unwilling to invest the necessary time and fail to comply with the provider's recommendations. On the medical side, patient nonadherence to prevention and disease management has been shown to range from 25% to 50%.5 A meta-analysis of 106 correlation studies and 21 experimental interventions found that physician communication was significantly positively correlated with patient adherence.6 The ability to ask effective questions, express empathy and concern, and provide opportunities for participatory decision-making were identified as communication skills that can enhance compliance. The investigators concluded that improving communication skills can help practitioners identify and personalize patient interventions that improve adherence and outcomes.6
Tailoring the message to the patient is the first step in influencing patient behavior. Patients are people. They have different personalities, styles of learning, experiences, and generational and cultural influences. All of these aspects impact a patient's interest in particular products or regimens.
The Complexity of Behavior Change
It is logical to think that giving patients information about their condition will motivate them to adopt healthy behaviors. However, although knowledge is a necessary component of behavior change, it is not the only factor needed for long-term change. Many factors and complexities influence change; some are within a clinician's control and others are not.7
For example, consider weight loss or smoking cessation. It is widely established that maintaining a healthy weight and abstaining from smoking are two of the best ways to avoid preventable disease, disability, and death. Yet losing weight and quitting smoking are extraordinarily difficult to accomplish. Nicotine is addictive, and sugar tastes pleasurable. Both can make a person feel good-at least temporarily-and may be hard to resist. Although people know these habits are detrimental to their overall health, their emotions often rule their decision-making. Only when the mind and heart align can one begin the process to lose weight or stop smoking.
Regarding self-care, a study by Tedesco et al found that most people understood that flossing was an important and beneficial activity.8 The investigators also found that people rated their confidence low in being able to floss effectively and as a result stated they often "forgot" to floss. This research falls in line with Lang et al, who found that people had difficulty holding the floss correctly, easing it through the contact point, and gliding it up, down, and around the teeth.4
Just as it is human nature to gravitate to things that make a person feel good, it is also normal to avoid discomfort, whether genuine pain or the pain of struggling. The pain or discomfort can be alleviated, however, by creating a path to success.9 Practitioners cannot control their patients' emotions, but they can make their path easier.9
One way for practitioners to do this, though it may feel like an abandonment of principles, is to stop recommending floss to patients who have difficulty flossing. In other words, flossing may not be for everyone. Practitioners can approach this change by having the patient view flossing as a technical or physical skill he or she lacks rather than a character failing. Acknowledging that everyone has different skill levels is essential. Flossing requires a level of skill that may not be attainable by all people. Lang et al found that nearly 80% of adults were not able to correctly floss.4
Science and Interdental Alternatives
Practitioners may consider alternative interdental aids to be less effective than traditional floss. However, science says differently. Numerous products, including floss holders,10,11 interdental brushes,12,13 and water flossers,14-18 have been shown to work as well as or, in some cases, better than floss.
For people who struggle to manipulate floss and have a normal embrasure and contact area, a floss holder can be a good recommendation. Many different types are available, including floss holders for single use. Floss holders have been found to remove plaque and reduce gingivitis as effectively as flossing by hand, and, moreover, when given a choice, study subjects preferred a floss holder to traditional floss.10,11
Popular in Europe, the interdental brush (IDB) is a favored recommendation in the United States for patients with open/wide embrasures and periodontal pockets. Interdental brushes can be conical or cylindrical in shape and come in a wide variety of sizes, including products with elastomeric fingers that are suitable for patients with healthy tissue. To maximize effectiveness and avoid trauma, the size of the IDB must be compatible with the embrasure size.
A 2013 systematic review of seven studies with 354 subjects found insufficient evidence to determine whether IDBs removed more plaque than flossing. There was low-quality evidence indicating that IDB may provide better gingivitis reduction than flossing.12 Cylindrically shaped brushes have been shown to be more effective than conical brushes.19 A traditional IDB and an IDB with elastomeric fingers have been compared with conventional floss and floss in a holder; all products provided similar results for plaque and bleeding reductions.20
The first water flosser was introduced in 1962. Since that time, 70 clinical studies have been conducted on the product, demonstrating safety and efficacy. In 2017, a water flosser product earned the American Dental Association (ADA) Seal of Acceptance for removing plaque along the gingival margin and between teeth and for helping to prevent and reduce gingivitis. It was the first and only powered interdental cleaner to earn this Seal.
Products that earn the ADA Seal of Acceptance must have met ADA criteria for safety and effectiveness and be backed by clinical or laboratory studies that demonstrate these qualities. The submitted evidence is reviewed by the ADA Council on Scientific Affairs. The ADA may, through its own facilities, conduct additional evaluations and physical tests on the product before granting the Seal.21
Five studies have compared the water flosser with conventional floss. In the first study, conducted in 2005 at the University of Nebraska, the investigators found that the water flosser was up to 93% better at reducing bleeding and up to 52% better at reducing gingivitis than floss.14 Rosema et al confirmed these results by showing the water flosser was twice as effective as traditional floss at reducing bleeding.16 Subsequent studies have demonstrated the water flosser significantly more effective than floss at improving gingiva health for people with orthodontic appliances15 and implants.18 The water flosser was also compared with an IDB regimen and was found to be 56% more effective at reducing bleeding.22
A 2009 study at the University of Southern California School of Dentistry Center for Biofilms investigated the biofilm-removing ability of the water flosser. The investigators found that the shear hydraulic forces produced by the combination of pulsation and pressure used at the 7 (70 psi) setting and applied to the treated area for 3 seconds removed 99.9% of biofilm.23 A single-use plaque study where subjects abstained from oral hygiene for at least 23 hours and then used either a water flosser or traditional floss found the water flosser removed 29% more plaque.17 When compared with IDB, a single-use plaque study found the water flosser 20% more effective at plaque removal.24
A new entry to the self-care market is a multifunctional device that allows the user to brush and "water floss" with the same handle. The device features a sonic toothbrush with a water-flossing tip embedded into the brush head. The user can brush and water floss separately or brush and water floss simultaneously, enabling the fast, easy, and effective incorporation of interdental cleaning.
A 4-week clinical study found that 2 minutes of sonic toothbrushing followed by 1 minute of water flossing was twice as effective as traditional brushing and flossing for removing plaque and reducing bleeding and gingivitis.25 This multifunction device was also found to be more effective than sonic toothbrushing for removing plaque and improving gingival health.26
Getting patients to comply with interdental cleaning can be an exercise in frustration for practitioners. The traditional "tell, show, do" approach typically falls short; only about one-third of patients floss on a regular basis. Moving beyond traditional flossing for all recommendations is one way practitioners may be able to help patients find a better path to interdental cleaning. Many types of interdental aids have been shown to work as well as or better than traditional flossing, including floss holders, interdental brushes, and water flossers. A new entrant to the market, a combination sonic toothbrush with water flossing device, may enhance both patient success and compliance.
About the Author
Carol A. Jahn, RDH, MS
Director of Professional Relations and Education, Water Pik, Inc.,
Fort Collins, Colorado
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