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Tips for Patients Who Refuse to Floss

Most of the patients I see either outright refuse to floss or lie about it. What are some good alternatives to recommend?


The fact that our patients lie to us about flossing is not surprising. According to data from the National Health and Nutrition Examination Survey 2011 to 2014, approximately 32% of United States adults age 30 and older floss daily, while 68% reported flossing at least once per week.1 A 2019 study that looked at knowledge, attitudes, and behaviors of patients concerning interdental cleaning reported the most common reasons for floss avoidance were: “inconvenience, discomfort, and irritation.”2 The same report found patients had a “lack of motivation” due to little understanding about the benefits of interdental care. 

Oral health professionals know that regular interdental cleaning every 12 hours to 24 hours leads to optimal gingival health.3 A systematic review determined that all interdental cleaning aids other than floss were effective at removing proximal biofilm at varying degrees.4 Additionally, when patients feel as though they have control over their behavior and intrinsic motivation, oral self-care behaviors increase.5 As such, the key to compliance may not be only the additional interdental cleaning aids we recommend, but also how we educate our patients about the importance of using them and allowing them the autonomy to decide which interdental cleaners are best for their needs. 

When recommending interdental aids, patients’ embrasure types, their motivation for oral health, and their hand dexterity must be considered.6 Liang et al6 created an elegant decision tree to help clinicians make evidence-based recommendations. The authors split the decision tree into types of interdental spaces and patient cohorts. When working with motivated patients who have open embrasures—regardless of dexterity—an appropriately sized interdental brush with a wide, long handle will suffice. For patients with closed embrasures and good dexterity but lack of motivation, easy flossers or floss picks are a good option. If the patient lacks dexterity, an oral irrigator in conjunction with brushing will be most effective. The use of an oral irrigator may offer additional benefits for all cohorts, such as disrupting bacteria in periodontal pockets and changing the composition of plaque, decreasing the invasiveness of the most harmful bacteria.7 Regardless of what is recommended, dental hygienists need to use a teach-back technique and a handheld mirror to educate the patient on how to correctly and effectively use the aid. Additionally, increasing the patient’s oral health literacy through education on the benefits of interproximal plaque removal will improve results.2 By recommending evidence-based interdental aids, education on how to use them, and benefits of why to use them into the care plan, oral health professionals will likely find improved patient compliance and decreased risk for periodontitis.


  1. Fleming EB, Nguyen D, Afful J, Carroll MD, Woods PD. Prevalence of daily flossing among adults by selected risk factors for periodontal disease-United States, 2011-2014J J Periodontol. 2018;89:933–939. 
  2. Smith AJ, Moretti AJ, Brame J, Wilder RS. Knowledge, attitudes and behaviours of patients regarding interdental deplaquing devices: A mixedmethods study. Int J Dent Hyg. 2019;17:369–380.
  3. de Freitas GC, Pinto T, Grellmann AP, et al. Effect of selfperformed mechanical plaque control frequency on gingival inflammation revisited: a randomized clinical trial. J Clin Periodontol. 2016;43:354358.
  4. Sälzer S, Slot DE, Van der Weijden FA, Dörfer CE. Efficacy of interdental mechanical plaque control in managing gingivitis—a metareview. J Clin Periodontol. 2015;42(Suppl 16):S92S105.
  5. Staunton L, Gellert P, Knittle K, Sniehotta FF. Perceived control and intrinsic vs. extrinsic motivation for oral selfcare: a full factorial experimental test of theorybased persuasive messages. Ann Behav Med. 2015;49:258268.
  6. Liang P, Ye S, McComas M, Kwon T, Wang CW. Evidence-based strategies for interdental cleaning: a practical decision tree and review of the literature. Quintessence Int. 2021;52:84–95.
  7. Cutler CW, Stanford TW, Abraham C, Cederberg RA, Boardman TJ, Ross C. Clinical benefits of oral irrigation for periodontitis are related to reduction of proinflammatory cytokine levels and plaque. J Clin Periodontol. 2000;27:134–143.
The Ask the Expert column features answers to your most pressing clinical questions provided by Dimensions of Dental Hygiene’s online panel of key opinion leaders, including: Jacqueline J. Freudenthal, RDH, MHE, on anesthesia; Nancy K. Mann, RDH, MSEd, on cultural competency; Claudia Turcotte, CDA, RDH, MSDH, MSOSH, on ergonomics; Van B. Haywood, DMD, and Erin S. Boyleston, RDH, MS, on esthetic dentistry; Michele Carr, RDH, MA, on ethics and risk management; Erin Relich, RDH, BSDH, MSA, on fluoride use; Kandis V. Garland, RDH, MS, on infection control; Mary Kaye Scaramucci, RDH, MS, on instrument sharpen­ing; Stacy A. Matsuda, RDH, BS, MS, on instrumentation; Karen Davis, RDH, BSDH, on insurance coding; Cynthia Stegeman, EdD, RDH, RD, LD, CDE, on nutrition; Olga A.C. Ibsen, RDH, MS, on oral pathology; Jessica Y. Lee, DDS, MPH, PhD, on pediatric dentistry; Timothy J. Hempton, DDS, on periodontal therapy; Ann Eshenaur Spolarich, RDH, PhD, on pharmacology; and Caren M. Barnes, RDH, MS, on polishing. Log on to to submit your question.

From Dimensions of Dental Hygiene. August 2021;19(8):46.

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