Get Teeth Clean, Especially In-Between

If we had a nickel for every patient who sat in our dental hygiene chair and announced that they don’t floss “as often as they should” we would all have a lot of nickels. It is almost as if they are asking for forgiveness and expecting penance while confessing their dental health shortcomings.

While confession is good for the soul, it is time to revisit flossing and figure out a way to make it easier and more effective, as well as rewarding and enjoyable. All from a little piece of string. What if we could make flossing fun? That’s a tall order, but it can be done.

Why Floss?

As dental health professionals, we know why we want people to incorporate flossing into their daily dental health routines: prevent tooth decay, keep the biofilm disrupted, maintain healthy teeth and gums, and prevent recession. Our goal behind flossing in between teeth is to disrupt and remove the plaque biofilm that grows there. What has gotten lost in our homecare instructions is the critical role floss plays. We know that folks who floss have healthier mouths.¹ Flossing is actually more important than brushing. Dental disease starts between the teeth and underneath the gumline where colonies of bacteria, fungi, parasites, and viruses can live comfortably undisturbed. They repopulate and grow, creating an entire microbial pathogenic world that elbows out our good microbes. Dental plaque has been identified as a “biofilm.”²

Biofilms are everywhere. They are sticky, tenacious, and hard to remove. As a dental biofilm matures, it becomes more anaerobic and creates a shell of extracellular polysaccharide matrix that protects it and allows it to live undisturbed.³

These pathogens are very sophisticated. As I tell my school-age students, they had texting before we did; the pathogens communicate via quorum sensing. They excrete toxins, enzymes, and other harmful molecules that create a chronic inflammatory response in the body. Within a week, the immune system recognizes the presence of these toxins and activates our defense system.²

Two key immune defense players:

• Interleukin-I which plays a crucial role in inflammation. It promotes the migration of immune cells to the site of infection. It activates osteoclast production which destroys bone and collagenase which breaks down collagen.⁴
• C-reactive protein binds to bacterial cell walls marking them for destruction by the immune cells.⁵

This is the beginning of the destruction of the jawbone. As the biofilm matures, the immune system escalates its response.

What happens in the mouth doesn’t stay in the mouth. These pathogens and their endotoxins enter the broken-down inflamed gum tissues with free passage into the bloodstream, or are swallowed or inhaled, and are then translocated within the body. They have found oral pathogens in the heart, lungs, brain, and synovial fluid of joints. They have been linked to 57 different systemic conditions.⁶ Flossing and its role in biofilm disruption are critical in stopping dental diseases and a pivotal role in systemic health.

What Patients Think

Patients think that since they have an electric toothbrush or “brush really well” they are in the clear. They do not understand the role floss plays. They think flossing is all about food removal. They have no concept of microbes. Instead, they floss to remove food debris. And if they can’t see food, they think they are good to go.

Also, of note, is the fact most folks are self-taught. They think that by sliding the floss in and out quickly, they are in fact “flossing”. Flossing is actually very technique-sensitive. Proper flossing requires dexterity, and one-on-one coaching to learn how to curl the floss, hug the tooth surface, rub the tooth enough to remove the sticky biofilm, and go underneath the gumline without causing floss cuts. This takes patient education and coaching time in the dental hygiene chair as well as practice by the patient.

Disclosing solutions or tablets are one of the tools that can show the patient quickly and easily how to slip the floss in between the teeth (because, as they have told you, they have tight teeth) and effectively disrupt and rub the plaque biofilm off the teeth.

Most folks just pop the floss between the contacts, slam the floss into the papilla, and end up cutting their gums. Flossing is not fun when it hurts. They didn’t grow up flossing so it’s not yet a true habit and part of their self-care routine. Until age 9, children do not have the fine motor skills and dexterity needed to manage proper and safe flossing.⁷ And, children learn by example, so if parents aren’t flossing, then children are not going to grow up to floss either. Compounding the problem can be the lack of other role models, and even television commercials and advertising demonstrate improper flossing techniques. It’s a wonder anyone flosses at all.

Brushing

We all “remember to brush our teeth” and would never leave the house without doing that. Brushing, at its best, removes 50-60% of the biofilm on the smooth flat teeth surfaces but leaves behind the microbes in all the nooks and crannies as well as underneath the gumline.⁸ The toothbrush cannot access these areas. As I tell my patients, if I get a grade of 60% on a test, that means I fail. Brushing is important but only 1 part of the home care process.

Most people still use a manual toothbrush, and research shows they brush until the toothpaste foams, and then they spit and rinse. That takes approximately 45 seconds.⁹ They think the toothpaste and its foam are the keys to removing plaque biofilm. Little do they realize it is the action of the brush on the tooth surface that is the key to removing the plaque biofilm.If my patients prefer a manual toothbrush, then I strongly suggest following Trisha O’Hehir’s dry brushing recommendations- no toothpaste or water- until their teeth feel and taste clean. Toothpaste often numbs the tongue so they cannot tell if the biofilm is properly removed. (It can take upwards of 15 minutes to properly and thoroughly remove all the plaque on the flat surfaces of the teeth. Most folks won’t manually brush that long.)

Brushing in a mindful pattern is also important. Most folks have a haphazard style, missing the same exact areas with each brushing. Once the teeth are thoroughly clean, then apply a pea-sized dab of toothpaste, brush, spit, and don’t rinse. And of course, don’t scrub and see-saw back and forth, like you are cleaning grout. Gentle strokes, on the teeth, the gums, tongue, cheeks, and palate. Plaque biofilm is everywhere in the mouth and removing it will reduce volatile sulfur compounds that contribute to bad breath.¹⁰

Since this is the twenty-first century, we have much better oral health tools. Electric toothbrushes can do the job more quickly and effectively as they use fluid dynamics that create waves that forcefully expand and contract to disrupt the biofilms. Electric brushes do require water to be effective.¹¹ Most folks can remove the biofilm in 2 to f4 minutes. I always suggest they still jiggle the brush into the nooks, crannies, and gumline, doing little tiny circles while the brush is oscillating. Jiggling the brush helps break up the biofilm.

Toxic Floss Ingredients

A patient recently brought to my attention that slippery flosses that easily slides into those tight contacts are flosses made with Teflon, and may be quite toxic. Those flosses contain an ingredient called Polytetrafluoroethylene (PTFE)^.12 Also related are Perfluoroalkyl substances and a chemical called Perfluorooctanoic Acid (PFOA). They are used to make substances water and grease-proof. Unfortunately, they remain in the body and environment forever. It is an ingredient within the wax used on waxed flosses.

To date, there is no established link to dental floss causing thrush or hormonal conditions. Since we know these products can cause health issues, and we do not know how little it takes to cause a tripwire, we can wisely select other flosses that are less risk to our well-being.

That being said, we are coming to learn that these chemicals, collectively referred to as PFAS affect hormone systems, suppress the antibody response, diminish the immune system’s ability to fight infections, and are a likely risk for neurotoxicity, interfering with the neurotransmission of dopamine, especially in young brains.^{13, 14}

PFAS exposure is associated with ADHD in children, and research is also connecting exposure to PFAS accumulation in the central nervous system with Alzheimer’s and dementia.^{15, 16} We look forward to seeing more research on this topic. Slippery, easy-sliding floss is everyone’s favorite type of floss so ensuring its safety is important.

Nylon flosses, while not toxic, do not biodegrade and may be a poor environmental choice. Charcoal flosses are either nylon or polyester-based (petroleum). Reading labels, even for floss can be beneficial. Knowing ingredients is important because chemicals can be

absorbed into the oral mucosa within a few minutes and it takes most people 1 to 2 minutes to floss.¹⁶

These ingredients might be a good reason not to floss but, thankfully, we do have “safe” flosses. Safe floss is silk which is a natural and biodegradable product. Be sure your floss has natural flavors as well.

To Floss or Not to Floss

People do “forget” to floss. Though it’s incredible to think that they wouldn’t “remember” to clean the other 40% of their teeth.

Maybe they are in a rush and think they will do it later. It could also be because many people have an aversion to getting their fingers wet, putting their hands in their mouths, or even lack the confidence, ability, or dexterity to floss. Too often, in their zeal to be “good flossers," they floss too aggressively, cutting their gums, or amputating their papillae. That hurts.

Flossing is hard to do. It takes time and proper technique, and instructions can feel extensive. It requires us to teach our patients to use the middle fingers to hold the floss, use a small section to tease the floss at a slant between the contacts, curl and hug the teeth, complete 10 up-and-down strokes to ensure they have thoroughly disrupted the plaque biofilm, then up and out of the embrasure and rotate to a clean section of floss and repeat with the goal of squeaky clean teeth.

All in all, flossing is hard to do and it certainly has gotten a bad rap, and the bottom line is most people don’t like flossing so they don’t want to do it.

Making Flossing Fun

Flossing tools can make all the difference. Just as electric brushes have made tooth brushing so much more efficient, flossing tools can do the same. (And, no surprise, but men prefer flossing tools.) Let’s save string floss for those who love it. For the folks that find flossing hard, or “don’t floss as often as they should”, let’s offer them a truly remarkable tool to make flossing easy and quick.

The Slate Flosser offers 3 devices in one flossing power tool. It flosses gently, stimulates the gum tissues, and also contains a tongue cleaner. Slate runs on 2 AA batteries, vibrates 12,000 times per minute, and uses 450 strands of high-grade woven floss free of wax, toxins, or Teflon (so, no PFAs or PTFEs). They even have special heads that can be used underneath wired braces.

The magic of the Slate flosser, or as they like to call it, their “secret sauce,” is contained in the “gum sweeps.” These little rubber bumpers on each side of the floss allow you to effectively clean interproximally while not cutting the gum tissues. Move the flosser from front to back and up and down while hugging the tooth. The gum sweeps stimulate and clean the tissues while vibrating. The tongue cleaner on the reverse side gently cleans the tongue while also vibrating all of the plaque and food debris out of the tongue follicles. Tongue cleaning is an important part of oral care. Having one tool makes it easy and quick to do both. Clean the teeth, flip it over, and clean the tongue.

The flosser is easy to use and the floss is reusable. Slant the floss, tease it between the contacts, and work it gently down between the teeth. The gum sweeps and vibration do the rest of the work. The best part may be that this can be done one-handed.

Creating That Flossing Habit

People are often motivated to do things to avoid pain or get a reward. Adding the Slate Flosser to your oral hygiene suggestion list may just change your patients' views of flossing. Using a one-handed tool frees them up to floss in unconventional places.

Flossing has no obvious, tangible “reward”. As dental health professionals, we know it is critical to oral health as well as the role it plays in systemic wellness. The best thing we can do for our patients is to make flossing easy and painless. Once they notice how great their teeth feel – 100 % clean and no longer fuzzy– they will realize the reward and appreciate the feeling of silky-smooth teeth.

Just as electric toothbrushes revolutionized toothbrushing, this little amazing vibrating string on this fun tool just might turn your patients into daily flossers. Let’s save those nickels and stop the guilt. Dental operatories don’t need to be confessionals but rather a place where our patients thrive and look forward to seeing us.

References

1. Marchesan JT, Byrd KM, Moss K, et al. Flossing Is Associated with Improved Oral Health in Older Adults. J Dent Res. 2020;99(9):1047-1053. doi:10.1177/0022034520916151
2. Marsh PD. Dental plaque as a biofilm and a microbial community - implications for health and disease. BMC Oral Health. 2006;6 Suppl 1(Suppl 1):S14. Published 2006 Jun 15. doi:10.1186/1472-6831-6-S1-S14
3. Flemming HC, Neu TR, Wozniak DJ. The EPS matrix: the "house of biofilm cells". J Bacteriol. 2007 Nov;189(22):7945-7. doi: 10.1128/JB.00858-07. Epub 2007 Aug 3. PMID: 17675377; PMCID: PMC2168682.
4. Takayanagi H. Osteoimmunology: shared mechanisms and crosstalk between the immune and bone systems. Nat Rev Immunol. 2007;7(4):292-304. doi:10.1038/nri2062
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6. Rice A. Do You Really Know What Oral-Systemic Means? Registered Dental Hygienists. Published August 2, 2023. Accessed March 14, 2024. www.rdhmag.com/patient-care/article/14275130/do-you-really-know-what-oral-systemic-means
7. Flossing and Children. Stanford Medicine Children’s Health. Accessed March 14, 2024. www.stanfordchildrens.org/en/topic/default?id=flossing-and-children-90-P01852
8. Petker W, Weik U, Margraf-Stiksrud J, Deinzer R. Oral cleanliness in daily users of powered vs. manual toothbrushes - a cross-sectional study. BMC Oral Health. 2019;19(1):96. Published 2019 May 29. doi:10.1186/s12903-019-0790-9
9. O’Hehir T. The Toothpaste Secret. Published March 17, 2015. Accessed March 14, 2024. www.onlineoralhealth.com/the-toothpaste-secret/
10. Mogilnicka I, Bogucki P, Ufnal M. Microbiota and Malodor-Etiology and Management. Int J Mol Sci. 2020;21(8):2886. Published 2020 Apr 20. doi:10.3390/ijms21082886
11. Ng C, Tsoi JKH, Lo ECM, Matinlinna AJP. Safety and Design Aspects of Powered Toothbrush-A Narrative Review. Dent J (Basel). 2020;8(1):15. Published 2020 Feb 5. doi:10.3390/dj8010015
12. Dental Flossing and Other Behaviors Linked with Higher Levels of PFAS in the Body. Silent Spring Institute. Accessed March 14, 2024. silentspring.org/news/dental-flossing-and-other-behaviors-linked-higher-levels-pfas-body
13. PFAS Chemicals in Dental Floss. ConsumerLab.Com. Published February 29, 2024. Accessed March 14, 2024. www.consumerlab.com/answers/toxic-pfas-chemicals-in-dental-floss/pfas-dental-floss/
14. Risks of PFASs Known Decades before Research Revealed, Says Expert. Published August 1, 20118. Accessed March 14, 2024.hsph.harvard.edu/news/hsph-in-the-news/pfas-health-risks-grandjean
15. Forns J, Verner MA, Iszatt N, et al. Early Life Exposure to Perfluoroalkyl Substances (PFAS) and ADHD: A Meta-Analysis of Nine European Population-Based Studies. Environ Health Perspect. 2020;128(5):57002. doi:10.1289/EHP5444
16. Starnes HM, Rock KD, Jackson TW, Belcher SM. A Critical Review and Meta-Analysis of Impacts of Per- and Polyfluorinated Substances on the Brain and Behavior. Front Toxicol. 2022;4:881584. Published 2022 Apr 11. doi:10.3389/ftox.2022.881584