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Meet Ms. Floss and Mr. Periodontitis. They met by chance and had a whirlwind romance in the late 1800s. Back then, courtship was quick, and they married a month later. Ms. Floss wore a gown made from silk material and her groom wore a tailcoat with a blood red, ruffled cravat. Unfortunately, the union was not meant to be. The couple just didn’t seem to be able to communicate; they tried hard, but to no avail, and the marriage deteriorated rather quickly. These two people were as incompatible as oil and water. Water and oil don’t go well together, just as dental flossing isn’t a good match for patients who are diagnosed with periodontitis.
I’ve been communicating with a periodontitis patient by email for several months now and he’s asked me for self-care suggestions. He’s been seeing a periodontist every three months for a very long time, but his professional team has been unable to prevent further breakdown of the periodontium. To prevent further episodes of periodontitis and to reduce gingival inflammation, clinicians who are treating patients with periodontitis need to go beyond simple brushing/flossing/three-month periodontal maintenance thinking.
Active periodontal therapy includes oral hygiene instruction and it needs to be customized for patients with periodontitis.1 Dysbiotic biofilms, once established, are an invisible cloak that protects and hides biofilms from the body’s immune system and antimicrobial therapies. Periodontal pockets that remain in the inflammatory phase with bleeding on probing and exudate allow further proliferation of biofilms and deterioration of the periodontium. All too often, in general dental practices, patients who are diagnosed with periodontitis, are treated with a two hour (four quadrants) scaling and root planning procedure, with and without local anesthesia, and then dismissed with a powered toothbrush recommendation, a lecture on the importance of dental flossing/interdental cleaning and maybe a bottle of chlorhexidine to use twice a day until gone.
Periodontitis is a chronic inflammatory disorder that presents in individuals with an aberrant immune response, similar to that of asthma. Like asthma, its etiology is complex, and periodontitis is often an umbrella diagnosis, meaning that not all presentations are the same and responses to therapies vary based on risk factors. For example, patients with a smoking associated periodontitis or poorly controlled diabetes will more than likely continue to experience a breakdown in the periodontium in spite of excellent self-care. During a patient’s lifetime, risk factors may change. For example, older individuals experience an aging and frailty of the immune system (referred to as immune senescence), which leaves them more susceptible to conditions such as virus reactivation. Managing the subgingival microbiota in periodontitis patients in spite of other risk factors over a lifetime is a significant part of periodontitis management. A recent systematic review (SR) and meta-analysis of the association between oral hygiene and periodontitis reported that poor oral hygiene increases the risk of periodontitis in the general population by approximately two- to five-fold compared with good oral hygiene.2 According to the SR, mechanical plaque control by twice daily toothbrushing with a fluoride-containing dentifrice is an accepted recommendation. 2 Duration and technique sometimes need to be modified for periodontitis patients. The current scientific data showed that dental floss is an ineffective a tool for interdental plaque removal and requires specific skills in order to be effective. 2 The authors emphasized a recommendation for customizing interdental aids at the clinician’s discretion based on patient needs and dexterity and the characteristics of the patient’s interdental spaces. 2
Overview of Floss as an Interdental Cleaning Aid
In 2019, Ethan NG and Lum P. Lim published an overview of different interdental cleaning aids and their effectiveness. The authors emphasized that high-quality flossing is difficult to achieve, even for dental professionals, and their review found that the use of floss may not result in significant benefits over toothbrushing alone.3 A Cochrane review published in 2018 found weak and unreliable evidence that flossing or interdental brushes, in addition to toothbrushing, reduce gingivitis or plaque or both.4 Currently, available evidence for tooth cleaning sticks of various kinds and oral irrigators is limited and inconsistent study outcomes were mostly measured short term. In addition, participants in most studies had a low level of baseline gingival inflammation. The Cochrane report recommends that future research trials should report participant periodontal status according to current periodontal disease classification and the trial should last long enough to measure interproximal caries and periodontitis. 4
Research supporting interdental brushes may be unreliable to date, but they have become more popular in recent years and clinicians can customize the diameter of these brushes in removing plaque. A European Federation of Periodontology consensus workshop in 2015 reported, “…cleaning with interdental brushes is the most effective method for interproximal plaque removal, consistently associated with more plaque removal than flossing or wood sticks.”5 Size of the interdental brush matters.4 Studies have been done measuring color coded probes to determine best-fitting interdental brush for a proximal site. The color-coded probe was inserted horizontally until “snug” with the color on the probe corresponding to bleeding sites was attributed to appropriate size of brush diameter.4 There are still a lot of unknowns about interdental brush effectiveness including the brush head material and geometry of the interdental brush. There are straight and angled brushes, short and long handles, different shaped brush heads and another factor to consider is difficulty of accessing posterior spaces. 4
Oral irrigation research outcomes demonstrate that irrigators reduce gingival inflammation and favor improvement in gingival health compared to toothbrushing alone. 4 A Cochrane 2018 review states there is some research evidence that oral irrigation may be better than flossing for reducing gingivitis (but not plaque) in the short term.5
Variation in interdental spaces and customizing interdental aids for periodontitis patients is not often talked about or adequately studied. I was thinking about this topic earlier this week while I was teaching a 60-year-old patient with periodontitis how to use an interdental brush in a wide and deep embrasure. Dexterity is not always thought about by clinicians, and I’ve found myself using disclosing solution more often in older age groups with significant clinical attachment loss and less than ideal dexterity/vision. When vision is poor and dexterity is a problem, I almost always recommend oral irrigation with an antimicrobial rinse, and most of my recommendations for the use of antimicrobial solutions are based on trial and error (including clinical judgement and patient preferences), since there are so many factors to consider when making a recommendation. Chlorhexidine stains, so I don’t recommend it long term. However, it is an excellent antiplaque agent with substantivity. The use of CHX after implant and periodontal surgery showed in general significant reduction in plaque (means of 29–86 percent after one week) and bleeding (up to 73 percent) as compared to placebo.7
Patients with deep and wide embrasures created by episodes of periodontal disease activity-alveolar bone loss and attachment loss-need two-three months of periodontal maintenance and customized high-quality self-care. Modifying a patient’s self-care regimen can be a challenge for any periodontitis patient, but dedicated dental hygienists who are critical thinkers should welcome the opportunity to improve periodontal outcomes in susceptible patients. Don’t overlook the benefits of oral irrigation with medicaments in the water bath like essential oil mouth rinse, a diluted bleach, or povidone iodine solution. Get back to disclosing patients, too, and choose a combination of interdental aids that fit snugly in the embrasures where mature biofilm communities reside.