I’ve been a refrigerator hygienist for many years. This nickname was given to nurses years ago and refers to nurses who go to work simply to pay for a specific item or a vacation. They work to provide for their families, and if the family doesn’t need the extra cash, then they stay home. Refrigerator nursing is now considered demeaning in health care circles and instead refers to part-time employment.
However, refrigerator hygiene (part-time employment) has been good to me and my immediate family. It’s provided me adequate time to write, which is an ongoing passion, and it’s given my life the much needed balance I’ve come to appreciate.
For me, one of the disadvantages of working part-time has been the lack of participation in the selection of self-care items that are dispensed to patients in “goody” bags, but I’ve noticed a trend toward “less is more” in a lot of dental practices, especially in PPO practices with discounted fees. Most patients don’t use the floss sample since less than a quarter of patients floss and the evidence to date to support dental flossing to reduce plaque at one and three months (from 10 studies) is weak.1 No studies report the effectiveness of flossing plus toothbrushing as a dental caries-preventive measure. Experience in the tooth and gum trenches has taught me to focus not on the flossing message but on encouraging changes in diet and oral hygiene and explaining their effect on oral health and biofilm. As most dental professionals already know, biofilm composition changes with poor oral hygiene, lifestyle and diet.2
Freaky facts about biofilm
In addition to being a refrigerator hygienist, I’ve labeled myself a biofilm freakazoid! Since 2002, when I read the first publication on biofilm titled “Emerging Trends in Oral Care: The Biofilm Revolution” by Scientific American, Inc. and Philips Electronics, I have been mesmerized by the topic and have poured over every magazine article and book I could find.
I do whatever I can to engage my adult patients, especially boomers who need to ramp up their oral hygiene efforts. Most boomers I encounter have exposed roots and these surfaces, along with the cemento-enamel junction (CEJ), are biofilm magnets. Along the way, I’ve discovered a way to attract the attention of millennials, too. Here’s a sampling of a customized script that I’ve used before:
Bacteria either live within a sticky slime or carry a bit of it around them like Spider-Man’s cape! With this protection, they can move around from place to place like Spider-Man. Think of them as cobwebs or silky strands, and while you’re here with me over the next hour, I’ll scrape and polish them off your teeth. Just as a spider uses its web to catch prey or make cocoons for their eggs, bacteria don’t survive without biofilm. Just as you would take a broom and disrupt a cobweb on the ceiling of your house, you need to thoroughly disrupt all the biofilm around your teeth, including the exposed roots. Biofilm likes to live where it’s moist and the gumline is the best building lot in the neighborhood. Toothbrushing, when done properly, will easily remove biofilm, but there’s a big space called an embrasure that houses a lot of it. For these areas, as with toothbrushing, I will customize what works best to eliminate those silky strands.
Just like a spider’s silky strands, biofilm, once formed, secretes a matrix (web) early. The matrix material incites inflammation of the host and it does so to mop up the exudate that comes out of capillaries. Bacteria even attach themselves to epithelial cells in chronic wounds like a spider latching onto its prey. I learn a lot about the periodontal pocket environment by reading about the management of chronic wounds.
Clinicians and patients need to know that these silky strands of biofilm are boundaries to substances that try to diffuse through them. They are extremely resistant to antimicrobial agents and even the host’s immune response. Therefore, swishing away with antimicrobial mouthrinses at home as a substitute for disrupting biofilm doesn’t accomplish much except mask mouth odor!
Thorough debridement of silky strands by hygienist and patient alike reduces inflammation. As an individual ages, the interdental embrasure deepens and widens around posterior teeth and biofilm loves to settle in these luxurious suites. I arm many patients, especially boomers and those who present with periodontal disease, with a wide array of biofilm disruption tools. I especially like high-end powered toothbrushes. Customizing interdental brushes for posterior embrasures is important and color-coded proximal brushes are widely available. For boomers who accumulate a lot of biofilm along the CEJ and around and into furcations, an end-tufted or sulcus pocket brush is very helpful in removing silky strands and clumps of biofilm.
Lack of research evidence doesn’t mean that flossing doesn’t make a difference -- it simply means that there’s inadequate research to firmly establish its effectiveness. There is some evidence that dental flossing in addition to toothbrushing reduces gingivitis compared to toothbrushing alone, so I wouldn’t dismiss it all together.1
Teaching and sharing your expertise with patients should be fun. Be creative and use metaphors like Spider-Man to get your point across about the importance of disrupting biofilm. Spider-Man, like biofilm, can dodge physical attacks, laser blasts and even explosions unless, of course, a talented RDH and a dedicated patient disrupts his webshooters!
1. Sambunjak D, Nickerson JW, Poklepovic T, Johnson TM, Imai P, Tugwell P, Worthington HV. Flossing for the management of periodontal diseases and dental caries in adults. Cochrane Database of Systematic Reviews 2011, Issue 12. Art. No.: CD008829. DOI: 10.1002/14651858.CD008829.pub
2. Al-Ahmad A1, Roth D, Wolkewitz M, Wiedmann-Al-Ahmad M, Follo M, Ratka-Krüger P, Deimling D, Hellwig E, Hannig C. Change in diet and oral hygiene over an 8-week period: effects on oral health and oral biofilm.Clin Oral Investig. 2010 Aug;14(4):391-6. doi: 10.1007/s00784-009-0318-9. Epub 2009 Jul 22.