Not As Often As I Should

Creative Communication Can Lead To Greater Patient Compliance

By Erika Coleman, RDH

“Not as often as I should.” How many times do you hear that each day? If you have patients like I do, then you hear it more than you even realize. Those six small words make many a hygienist giggle, followed by a 10-minute lecture explaining the etiology of gingivitis and periodontal disease. A lot of us explain the importance of daily flossing as we scale their teeth and suction the blood from their mouths.

We explain that gingivitis is biofilm-induced, and that biofilm is, in essence, bacterial plaque. We show them in the patient mirror that their gingival margins are erythematous and that they have pockets due to the edema. We tell them that if they don’t take heed of what we’re saying, their condition will worsen and they will suffer connective tissue loss and the collagen fibers will become damaged, followed by loss of alveolar bone. Now listen closely as I lay my hand on the spinning record as it screeches on the needle. People, stop! You lost your patient way back at the word “biofilm.”

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I remember being a green hygienist and thinking I was going to make the world floss. I was like a bull in a china shop when I got my first job in a private practice. I had brand new scrubs and a brand new education to go with them. (Back then the pants had banded leg bottoms, not these cute flare bottoms that we all see these days. They will come back someday.)

I was determined and, as I found out, really naïve. These patients didn’t care about my fancy words and my scientific study knowledge. All they cared about was what flavor of prophy paste I would be using and if their insurance company would be paying for the recommended “extras.” How dare they refer to a fluoride treatment as an “extra”! I began leaving the office each day with my tail between my legs, wondering why I was failing. Failing miserably, I might add.

These patients were coming back for their routine cleanings as I had recommended. However, they still had floss left over from the sample I had given them over six months prior. This was my epiphany. I kept hearing it over and over again in my head. Me: “Here, Phoebe, here’s another sample of the floss I recommend you use.” Phoebe: “Oh no, sweetie, that’s okay. You keep it for someone else because I still have some left from the last one you gave me.” Me: “Oh, did you buy some other kind?” Phoebe: “No, honey, I just use the one you gave me,” and then she strolled out of my room with her freshly cleaned gums and shiny, white teeth.

I immediately retrieved a piece of scratch paper and started doing the math. I started talking to myself as I tried to solve this magical mystery. This woman had learned how to conserve floss! She had told me she was flossing. So my figures began rolling out onto the scratch paper. Let’s see, five yards in one sample box of floss. There’s 36 inches in a yard. Times five. That’s 180 inches. Everyone knows it takes 18 inches to floss 28 teeth. So that makes it 10 days! The woman is a genius. She figured out a way to make 10 days’ worth of floss last for 180 days. Pure genius.

Wrong. Pure fibber. I had been duped. The truth was that most of my patients were lying to me about their flossing habits just to avoid my 10-minute explanation of why they should floss. I was determined to be ready for Phoebe next time. I would have a new arsenal, and I only hoped she wouldn’t be expecting it.

When Phoebe returned, I hit her where she’d feel it and understand it – in the hair. Phoebe had a strikingly beautiful mane of blond that floated behind her like a cape as she walked into our office that sunny June day. I smiled at her like a snake about to strike her prey. I went through the usual motions; everything she was accustomed to. I even went so far as to ask how often she was flossing. Her response, of course, was “Not as often as I should.” She went on to say that she was flossing several times a week but that she had been really busy and distracted so I may notice some bleeding as I scaled. This was her way of justifying the bleeding that was about to commence. My inner snake commented, “Nice try.”

As I scaled, I pulled out a truckload of plaque from between Nos. 14 and 15. I pulled down my mask and had her inspect it herself. She pleaded innocent by blaming it on her lunch. I explained, “Unless you’re on a plaque diet, this is not your lunch.” Her eyes widened and she appeared horrified by my statement. It was the snake’s first strike.

I then took off my gloves and retrieved a small clear trash bag from my cabinet. I sat her up, continuing to smile at my inner snake. Some of you may wonder how I got her to do what she was about to do next. I often ask myself the same question, but with patients that are as curious as Phoebe, it was easy.

I gave her a brand new ponytail holder. I then asked her to take approximately 40% of her beautiful hair and place the ponytail holder around it. She was putty in my hands at this point. I then had her place the sectioned hair into the garbage bag. She did. I had her place a rubber band around the opening of the bag so that the hair was in the bag and it was hanging off the side of her head.

Now you, the reader, have the same look on your face as she did on hers. I began my trickery. “The only time that I want you to wash that hair that’s covered by the bag is on days that you floss all your teeth. You see, Phoebe, every time you don’t use the floss, you are leaving 40% of the bad stuff in your mouth. That would be like not washing 40% of your hair.” She got a look on her face as if she’d just expected a drink of tea and got whiskey instead.

I went on. “We, as a society, take better care of our hair than we do our teeth. The difference is that our hair can grow back. Our teeth can’t.” She smiled her sweet Southern smile and said, “Well, honey, now that you’ve explained it that way, I understand.” Ten years later, she is still not flossing daily. But from what I can gather, she is flossing at least five times a week. She no longer has gum tissue that matches her red lipstick and her visits with me are much more pleasant for both of us. I no longer lecture her, nor do I need to. The hair comparison was much more dead center in her mind than my using words like inflammation, loss of connective tissue, and loss of bone.

Now let’s talk about my patient, Billy. Billy is a personal trainer and I would bet has only about 1% of body fat. He preaches to me each time he comes in about daily exercise and eating properly; yet I cannot get him to floss. He always has the same answer to my flossing survey: “Not as often as I should.” One problem I was facing with Billy was that when he did floss, he wasn’t using floss that was the most effective for him. Billy has light contacts and was using very slick floss, which was resulting in debris and plaque being left behind. He wanted flossing to be easy, not necessarily effective.

At Billy’s last appointment, he had recommended a 90-day exercise program to me. For pure entertainment value, I said I’d give it a try. I did the program for a few days, and then thought to myself, “This is just too much resistance and burning muscle for me. I need something easier.” I had fallen into the same mindset that Billy had with flossing.

Six months later, Billy returned. He asked me if I had completed the program. I went on to explain to him that I had done it for a few days, but then realized it was much easier for me to sit on the couch, eat popcorn, and just watch the videos without actually participating. I told him that the program made my muscles burn, which isn’t a pleasant feeling for a woman like myself, who thoroughly enjoys muscle relaxation. He chuckled and began explaining to me that if I don’t feel the burn, then the exercise is not effective.

I replied, “Hmmm. Funny that you mention that, because you know how I’m always trying to get you to use different floss?” He nodded. “Well, I want you to start thinking about floss the same way you think about exercise. When you are flossing, if there is no resistance, it is not effective.” Bada-bing, bada-boom! Billy finally got it – and I returned the respect by removing the hanging clothes from my treadmill and using it four times a week.

You can’t force perfect habits on patients, but if you get creative, you sure can leave your mark on their memory. Find out what is important to your patients and use that as a tool for communication, resulting in education. If you can compare flossing to something that is important in their daily life, you will have a higher success rate and a much more captive audience. RDH

Erika Coleman, RDH, is a practicing hygienist in Illinois, She can be contacted at [email protected].