How important is floss to a perio patient?

by Larry Burnett, DDS

Bill Landers (President of Oratec) recently told me about a study that strongly suggested most patients will use two and only two dental homecare techniques. That means just one besides the toothbrush. I haven’t read the study (and Bill couldn’t remember the reference), but it sounds reasonable to me. Maybe even optimistic.

You can send the patient home with a new toothbrush, Proxabrush^®, floss, and Stimudents^®. You can tell him to go out and buy an irrigator. But the reality is, he’ll brush and do one other thing - And THAT’s if he’s motivated!

The question is: Should that “one other thing” be flossing?

For normal patients, perhaps. But in my opinion, there are better things than floss for perio patients.

By definition, a patient suffering periodontitis is experiencing attachment loss and pocket formation. Right?

Consider a typical 6mm pocket on the interproximal of a lower molar. The patient slides the floss through the contact and begins rubbing it along the root surface as we have taught since the beginning of time. But the surface gum tissue will anatomically limit its depth. The deepest the floss will slide is usually about 4mm. So it leaves at least 2mm of completely untouched apical bacterial plaque. And unfortunately, it is the bottom 2 mm that’s most in need of cleaning, because that’s where further damage is most likely to occur.

Hmmm. So far floss doesn’t sound that great for this patient’s perio condition, does it?

Okay, suppose the coronal gingiva has receded, so the patient can get the floss deeper. That doesn’t really solve the access problem because the further he goes down the root, the more likely he is to encounter fluted areas (anatomical indentations of the root surface). No matter how enthusiastically he flosses those indented areas will never be touched by the string. Bacterial plaque in those flutes will remain undisturbed.

And if all that remaining biofilm wasn’t bad enough, research suggests that the most damaging bacteria are those that are free floating in the pocket, not attached to the root surface he’s flossing.

So let’s recap. After the patient has finished brushing and flossing, there are areas of that 6mm pocket still covered with biofilm. Free-floating bacteria are still floating freely. And we haven’t even considered the possibility that there may be bacteria on the soft tissue wall of the pocket.

How effective can a piece of string be in eliminating these bacteria, or even disturbing them? If Bill’s study is true, and most people will adopt only two homecare procedures, why in the world would we keep emphasizing floss to our perio patients?

The answer is simple. “That’s how it’s always been done.” It’s what we were taught by teachers who were taught by their teachers … and so on. Hey, I used to teach it myself.

Don’t misunderstand, I’m not anti-floss. I love Proxabrushes and I’m crazy about Stimudents. Just not for perio patients! In my opinion these tools are effective primarily in fighting supragingival plaque and preventing decay, not periodontitis.

Our patients are paying us for good advice, and telling them to floss away their periodontitis is bad advice.

As I’ve mentioned many times over the years, in the office I debride roots using an ultrasonic scaler because studies suggest that it’s more effective than hand instruments in dislodging and destroying that hard-to-reach plaque. The scaler tip doesn’t actually have to touch the beasts to dislodge them. And I often run an antimicrobial agent through my scaler, to kill those free-swimming beasts.

I apply the same philosophy to homecare. I want a regimen that at least stands some chance of disrupting the biofilm lurking at the bottom of the pocket and in concavities along the root. I also want something to kill the motile monsters that are the most dangerous.

One of my favorites is a paste the patient can make by mixing baking soda (right out of the grocery store) and 10% Povidone Iodine, which can be found over the counter in any drugstore as “Betadine.” 10% Povidone Iodine is an extraordinarily effective antimicrobial agent. It’s what surgeons scrub with before surgery. Matter of fact, it has the broadest spectrum of activity of any product that can be safely used on mucous membranes
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And with the mixed infection we’re dealing with, “broad spectrum” is what we want. This stuff kills Gram-positive bacteria, Gram-negative bacteria, aerobic bacteria, anaerobic bacteria, viruses and even yeasts, which are responsible for some of our most resistant periodontal infections.

But iodine/baking soda alone isn’t enough. Brushing and rinsing with this stuff will get it down 2mm into the pocket at most. Furthermore, once they’re hunkered in a biofilm, pathogens are highly resistant to antimicrobial agents. You need a delivery system that not only delivers the iodine, but also will also physically disrupt the biofilm.

The best devices I’ve found to deliver the baking soda/iodine paste is the Butler Rubber Tip Stimulator or Proxabrush. Your patient can buy them in any drug store, but I suggest you hand it out in the office. That way they’re more likely to follow your instructions - and it emphasizes your personal involvement in the technique.

Here’s the routine I follow with the patient. I give the patient a hand mirror and have them observe one of their pockets bleeding as I probe it. I explain that this bleeding is caused by bad kinds of bacteria. At this point I use my microscope with TV monitor to show them what the iodine does to their bacteria. (I know most practices don’t have a microscope.)

I let the patient observe with their hand-mirror as I demonstrate how to use the Butler Rubber Stimulator to carry the paste into the pocket and rub it around, actual touching the surfaces. I do this on an anterior so they can see the tip disappear deeply into the pocket. Believe it or not, for many patients this will be their first real awareness of the all-important sub-gingival area.

This tip is soft and comfortable, and they will easily be able to reach the bottom of the pocket solely by feel. This is important because on the buccal and lingual they can’t see what they’re doing.

By the way, flossing isn’t too good for the buccaland lingual surfaces. What do floss fanatics use there for pocket decontamination?

If after he brushes, your perio patient is just going to use one other hygiene tool, do you really want him fooling around with floss?

Try this little iodine/baking soda approach. I’ve found it extremely effective. In fact, for many patients who’ve suffered years of chronic periodontitis, this is the first thing that has really worked.

And believe me, these people will always remember it was you who really helped them.

About the author ...

A graduate of the Medical College of Virginia School of Dentistry, Dr. Burnett has authored numerous articles and lectured extensively on conservative periodontal therapy throughout the US and Canada. A frequent speaker at both the ADA annual scienific session (1995, 1996, 1997, 1998) and AGD meetings (1994, 1995), he is featured in the new video-based program “Advanced Ultrasonics in General Practice”

Dr. Burnett also conducts hands-on courses for dentist and hygienists.