How important is floss to a perio
by Larry Burnett, DDS
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
havenít read the study (and Bill couldnít remember the reference),
but it sounds reasonable to me. Maybe even optimistic.
can send the patient home with a new toothbrush,
Proxabrushģ, floss, and Stimudentsģ. You can
tell him to go out and buy an irrigator. But the reality is, heíll
brush and do one other thing - And THATís if heís
The question is: Should that one other thing be
For normal patients, perhaps. But in my opinion,
there are better things than floss for perio patients.
definition, a patient suffering periodontitis is experiencing
attachment loss and pocket formation. Right?
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 thatís most in need of
cleaning, because thatís where further damage is most likely to
Hmmm. So far floss doesnít sound that great for this
patientís perio condition, does it?
Okay, suppose the coronal
gingiva has receded, so the patient can get the floss deeper. That
doesnít 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
And if all that remaining biofilm wasnít bad
enough, research suggests that the most damaging bacteria are those
that are free floating in the pocket, not attached to the root
surface heís flossing.
So letís 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 havenít even considered the possibility that
there may be bacteria on the soft tissue wall of the
How effective can a piece of string be in eliminating
these bacteria, or even disturbing them? If Billís study is true,
and most people will adopt only two homecare procedures, why in the
world would we keep emphasizing floss to our perio
The answer is simple. ďThatís how itís always been
done.Ē Itís what we were taught by teachers who were taught by their
teachers Ö and so on. Hey, I used to teach it myself.
misunderstand, Iím not anti-floss. I love Proxabrushes and Iím 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 Iíve mentioned many times
over the years, in the office I debride roots using an ultrasonic
scaler because studies suggest that itís more effective than hand
instruments in dislodging and destroying that hard-to-reach plaque.
The scaler tip doesnít 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 ďBetadine.Ē 10% Povidone Iodine is an
extraordinarily effective antimicrobial agent. Itís 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
And with the mixed infection weíre dealing
with, ďbroad spectrumĒ 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.
iodine/baking soda alone isnít enough. Brushing and rinsing with
this stuff will get it down 2mm into the pocket at most.
Furthermore, once theyíre 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 Iíve 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 theyíre more likely
to follow your instructions - and it emphasizes your personal
involvement in the technique.
Hereís 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 donít have a
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
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 canít see what
By the way, flossing isnít too good for the
buccaland lingual surfaces. What do floss fanatics use there for
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. Iíve found it extremely effective. In
fact, for many patients whoíve suffered years of chronic
periodontitis, this is the first thing that has really
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 ďAdvanced Ultrasonics in General PracticeĒ
Burnett also conducts hands-on courses for dentist and hygienists.