mechanical plaque control
DESCRIPTION
Mechanical plaque control in periodonticsTRANSCRIPT
1. Introduction
2. Mechanical plaque control
(a) Toothbrush
(b) Dentifrice
(c) Interdental cleaning aids
- Dental floss
- Interdental brushes
- tooth pick
(d) Oral irrigation
(e) Salvadora persica
Mechanical plaque control, as measured by the oral hygiene effort of the individual patient, is the most important predictive factor in determining the overall prognosis of the treatment therapy.
Mechanical plaque control is the removal of microbial plaque and the prevention of accumulation on the teeth and adjacent gingival surface by the use of tooth brush and other mechanical hygiene aids.
It is very critical in every phase of therapy that plaque control must be maintained .
It is an effective way of treating and preventing gingivitis, periodontitis, .. ect.
The cause and effect relationship between supragingival plaque and gingivitis was demonstrated by Loe and his colleagues in 1965.
When plaque was allowed to accumulate, gingivitis
developed within 21 days. When plaque control was initiated, the gingivitis was reversed (by means of efficient plaque control, i.e., brushing and flossing) to clinical gingival health
The removal of microbial plaque leads to cessation of gingival inflammation, and cessation of plaque control measure leads to recurrence of inflammation
The removal of plaque also decreased the rate of formation of calculus. ( Sanders , 1962)
Thus eliminating the plaque is the key to prevent the occurrence of periodontal disease or halting the progression of the disease.
Masses of plaque first develop in Molar , Premolar areas , followed by proximal surfaces of the antrier teeth , and the facial surfaces of the molar and premolar( Lang,1973)
complete daily removal of dental plaque with a minimum of effort, time, and devices, using the simplest methods possible.
1. Mechanical plaque
control
(a) Toothbrush
(b) Dentifrice
(c) Interdental
cleaning aids
- dental floss
- toothpick
- interproximal brush
(d) Oral irrigation
(e) Salvadora persica
The bristle tooth brush
appeared about the year
of 1600 in China and later
was patented in America
in 1857.
Originally, they are varied
in size, length, hardness
of the bristle, and even in
the arrangement of the
bristle
- Generally toothbrushes very in size, design as well as in
length and arrangements of bristles hardness to overcome
this variation ADA given specification of toothbrushes.
- ----------------------------------------------------------
› Length : 1 to 1.25 inches
› Width : 5/16 to 3/8 inches
› Surface area : 2.54 to 3.2 cm
› No. of rows : 2 to 4 rows of brushes
› No. of tufts : 5 to 12 per row
› No. of bristles : 80 to 85 per tuft
Soft, nylon bristle toothbrush clean effectively ( when used properly),remain effective for a reasonable time , Soft bristle are more flexible, clean beneath the gingival margin, and reach farther into the proximal tooth surfaces.
soft toothbrush is utramatic , eliminates gingival recession, tooth surface abrasion (classical wedge shape defect in the cervical area of root surfaces), trauma to soft tissue.
The use of hard toothbrush , vigorous horizontal brushing, the use of extremely abrasive dentifrices may lead to cervical abrasion of teeth and recession of the gingiva.( Jepson ,1998)
Toothbrushs need to be replaced every 3 months
Today, there are three methods that are widely accepted:
the bass method, the modified stillman method( stillman
1932), and the charters method( Carter’s 1948) .
Controlled studied evaluating the most common brushing
technique have shown that no one method is superior
The method which is often recommended is Bass technique ,
because it emphasize sulcular placement of the bristles.
Dentist should be noted that a plaque control devices should
be tailored to the individual, similarly to his or her plaque
control program
Patient is instructed to start with molar region of one
arch around the opposite side than continue back
around the lingual or facial surfaces of the same arch
Last surface to be brush are occlusal.
Patient instructed to stroke each area ten time of spend
10 seconds per area then move on to next area.
Time : 2 minutes ( 30 sec per quadrent )
Method Bristle placement Motion Advantage/disadvantage
Scrub Horizontal on gingival margin Scrub in anterior position direction keeping brush horizontal
Easy to learn & best suited fro children
BASS Apical towards gingival into sulcus at 450 to tooth surface
Short back and forth vibratory motion while bristles remain in sulcus.
Cervical plaque removalEasily learned Good gingival stimulation
Charter's Coronally 45o, sides of bristles half on teeth and half of gingiva
Small circular motions with apical movements towards gingival margin
Hard to learn and position brush Clears inter proximalGingival stimulation
Fones Perpendicular to the tooth With teeth in occlusions, move brush in rotary motion over both arches and gingival margin
Easy to learn Inter proximal areas not cleaned May cause trauma
Roll Apically, parallel to tooth and then over tooth surface
On buccal and lingual inward pressure, then rolling of head to sweep bristle over gingiva & tooth
Doesn't clean sulcus area Easy to learn good gingival stimulation
Stillman's
On buccal and lingual, aplically at an ablique angle to long axis of tooth. Ends rest on gingiva and cervical part.
On buccal and lingual slight rotary motions with bristle ends stationary
Excellent gingival stimulationModerate dexterity required Moderate cleaning of interproximal area
Modified stillman's
Pointing apically at and angle of 45o to tooth surface
Apply pressure as in stillmans's method but vibrate brush and also move occlusally
Easy to master Gingival stimulation
Method Bristle placement Motion Advantage/disadvantage
Scrub Horizontal on gingival margin Scrub in anterior position direction keeping brush horizontal
Easy to learn & best suited fro children
BASS Apical towards gingival into sulcus at 450 to tooth surface
Short back and forth vibratory motion while bristles remain in sulcus.
Cervical plaque removalEasily learned Good gingival stimulation
Charter's Coronally 45o, sides of bristles half on teeth and half of gingiva
Small circular motions with apical movements towards gingival margin
Hard to learn and position brush Clears inter proximalGingival stimulation
Fones Perpendicular to the tooth With teeth in occlusions, move brush in rotary motion over both arches and gingival margin
Easy to learn Inter proximal areas not cleaned May cause trauma
Roll Apically, parallel to tooth and then over tooth surface
On buccal and lingual inward pressure, then rolling of head to sweep bristle over gingiva & tooth
Doesn't clean sulcus area Easy to learn good gingival stimulation
Stillman's On buccal and lingual, aplically at an ablique angle to long axis of tooth. Ends rest on gingiva and cervical part.
On buccal and lingual slight rotary motions with bristle ends stationary
Excellent gingival stimulationModerate dexterity required Moderate cleaning of interproximal area
Modified stillman's
Pointing apically at and angle of 45o to tooth surface
Apply pressure as in stillmans's method but vibrate brush and also move occlusally
Easy to master Gingival stimulation
Charters method
Bass method
O’Leary in 1970 studied the deposition of particlulate matter in the crevicular tissue by toothbrushing using the roll and the bass technique.
Brushes presoaked in solution containing carbon particle were used.
The result showed that no carbon particles were observed in the crevicular epithelium or underlying connective tissue of any test section on either technique.
However, the result of this study does not eliminate the possibility that bacteria can be introduced into the crevicular tissue since the bacteria is smaller in size than the carbon particle used in this study
Waerhaug 1981. reported on the effect of tooth brushing on subgingival plaque formation.
Results: during brushing, it could be noticed that the bristles penetrate as far as 0.9 mm below the gingival margin ( Bas technique)
MacGregor ( 1984) , conducted a study to determine whether smokers have more plaque than non-smokers , and whether it could be explained by dif. In brushing time, quality and frequency
Results:› In both genders, smokers have higher plaque scores.› No association btw tobacco consumption and frequency
of tooth brushing› Poorer oral cleanliness level in smokers both before and
after tooth brushing may be explained by their shorter brushing time.
• In 1939 powered tooth brush invented to make plaque control
easier.
• Its mainly recommended for
(a) Individual lacking motor skills
(b) Hospitalized patients whose teeth are cleaned by the caregivers.
(c) Special needs patient ( physical and mental disability)
(d) Patient with orthodontic applied
(e) Whosoever wants to use
There are many powered tooth brushes some with reciprocal of
back and back motions and some with combination of both some
are circular and elliptical motion.
Powered tooth cleaner resembles a dental prophylaxis and hand
piece with rotary rubber cap.
Patient should be lustrated for proper use.
No evidence of a statistically significant difference between powered and manual brushes. However, rotation oscillation powered brushes significantly reduce plaque and gingivitis in both the short and long-term
(C. Deery , et al 2003) electric toothbrush have not been shown to provide
benefits routinely for patients with RA, children who are well-motivated brushers , or patients with chronic periodontitis.
( Heasman, 1999)
Long and Killoy in 1985 evaluated the effectiveness of the electric toothbrush versus manual toothbrushing using modified Bass technique in 14 orthodontic patients.
The results showed the electric toothbrush is significantly better in toothbrusing efficiency.
Similar result was found in Youngblood et al. in 1985, when they examine the effectiveness of electric toothbrush compared to manual toothbrushing using modified Bass technique in removing subgingival and interproximal plaque
On the other hand, using electric tooth brush versus manual tooth brush had no significant difference in a group of 123 children in a two months period.
Crawford 1975
Any thooth brush , regardless of the brushing method, does not completely remove interdental plaque. Even for patients with wide-open dental embrassures. ( Gjermo, 1970, Schmid 1976).
The majority of dental and periodontal disease's originate in interproximal area, interdental plaque removal is necessary
Tissue distruction associated with perio. Disease often leave large ,open spaces, btween teeth and exposed roots with anatomic concavities and furcations which are difficult to clean and access with the toothbrush.
The purpose of Interdental cleaning aids is to remove plaque, not to dislogde food wedged btween teeth.
Dental floss is the most widely recommended mehtod for removing proximal plaque.
The floss is wrapped around each proximal surface and is activated with repeated up and down stroke.
Floss should pass gently through the contact area. Do not snap the floss pass the contact area as it may injure the interdental papilla.
Floss is available in many types: unwaxed, waxed, tape floss, ePTFE floss, and Superfloss. › Waxed floss contained wax to
facilitate passing the floss the floss through the contact and alleviate fraying.
› Tape floss contain criss-cross fiber and eliminate fraying.
› PTFE floss (Glide floss) is the teflon floss which allow passing through very tight contact easily without fraying.
› Superfloss is the web-like material which improved proximal cleaning efficiency.
There are no significat diffrence between various types of floss to remove dental plaque , they all work equally well ( Grossman 1979, Keller 1969).
Graves et al. in 1989 evaluated in a 2 week clinical trial the efficacy of unwaxed dental floss, dental tape, waxed floss, and tooth brushing alone in reduction of interproximal bleeding.
The result showed that the dental tape and dental floss were equally effective in reducing interproximal bleeding and twise effective as toothbrushing alone.
Lambert et al. in 1982 compare the waxed and unwaxed floss to determine the efficacy to remove plaque and their effect on gingival health during a home oral program.
The results showed there was no statistical difference between the types of floss in regards to their ability to remove plaque or prevent gingivitis.
Wunderlich et al. in 1982 reported there is no difference between wax and unwaxed floss in maintaining gingival health.
Wong and Wade study in 1985, which they compared the effectiveness of Super floss and waxed dental floss as proximal surface cleansing agent in 34 subject.
Superfloss was found to be superier (50%) to waxed dental floss(45%) in removing proximal plaquem but neither was 100% efffective.
Flossing can be made easier by using a floss holder –
Floss holder should have –
1. One or two fork that enough to keep the
floss tent even when its moved pass tight
contact area
2. An effective and simple mounting
mechanisms
Interdental brush are conical shape brushes made of bristles mounted on a handle, single tufted brushes, or small conical brushes.
They are suitable for cleaning large, irregular, or concave tooth surfaces adjacent to wide interdental spaces.
They are inserted interproximally and are activated with short back and forth strokes in between the teeth.
Waerhaug in 1976 evaluated the effec tof interdental brushes on 67 teeth which scheduled for extraction. › Teeth were cleaned prior to extraction and then stained
and examined after extraction. › The results indicated that plaque can be removed from
2 to 2.5mm subgingivally using the interdental brush
A comparision study between dental floss and interdental brush in patients with sever to moderate periodontitis , showed that interproximal brushs remove slightly more interproximal plaque and that the patients found them easier to use.
No diffrence was found in PD reduction and BI. ( Christou,1998)
Studies have been conducted to compare the efficacy of tooth pick, dental floss, and multi-tufted brush.
Dental floss removed more plaque at lingual interproximal surface than toothpicks.
Toothpicks combined with multi-tufted brush used on oral surfaces were as effective in removing interproximal plaque as dental floss.
The use of floss or tooth pick combined with single tufted brush may reduce the amount of plaque adhering to the proximal surfaces by an average of 50%
Oral irrigation device include the use of water picks.
The high pressure, pulsating stream of water through a nozzle is directed to the tooth surface and subgingivally, washing away debris and plaque containing bacteria.
They are helpful surrounding orhtodontic appliance, and when used as an adjucntive treatment in shallow pocket depth.
Patients reqiure antibiotic premidication should not use oral irrigation.
When used as adjuncts to toothbrushing , irrigation devises, can have a beneficial effect on periodontal health by reducing the accumulation of plaque and calculus and decreasing inflammation and pocket depth.
( Robinson and Hoover, 1971)
Eakle et al. in 1986 showed that the oral irrigator deliver an aqueous solution into the periodontal pocket and will penetrate an average to approximately half the depth of the periodontal pockets.
Penetration of 90 degree angle stream of water is about 70% for pocket less than 3mm, 44% for moderate pocket (4 to 7 mm) and 68% for deep pocket ( greater than 7mm).
For 45 degree angle, the result is 54%, 45%, and 58% respectively.
Ciancio in 1989 evaluate the efficacy of an antimicrobial rinse delivered by an oral irrigation device twice daily.
The results showed that irrigation with or without an antimicrobial agent was effective in reducing the plaque, suggesting that oral irrigation may be beneficial on oral health and the use of the chemotherapeutic agent will lead to greater reduction in plaque and gingival bleeding and to moderate decreases in total bacteria counts detected by phase contrast microscopy
Miswak (chewing stick) in the Islamic countries. Miswak use is as effective , tooth brushing for
reducing plaque and gingivitis. antimicrobial effect association with Islam, maximum benefits may
be achieved by encouraging optimum use of the miswak
Oral hygiene may be improved by complementing traditional miswak use with modern technological developments such as tooth brushing
Al-Otaibi 2004
A clinical trial study on Ethiopian schoolchildren comparing mefaka (Miswak) with conventional toothbrush, found Miswak to be as effective as the toothbrush in removing oral deposits.
In a clinical trial among adolescents in Nigeria, the- results showed that the Massularia acuminata
chewing stick was as effective in controlling and removing dental plaque as the toothbrush and paste
Danielsons, et al-showed that there was a reduction of plaque on the front teeth more than the posterior teeth and recommended Miswak as a tool for oral hygiene.
( Danielsons B, et al 1989)
Cross-sectional studies show conflicting results. A cross- sectional study in Ghana among adults revealed higher plaque and gingival bleeding in chewing stick users as compared with toothbrush users.
(Norman S , 1989)
Another retrospective study showed that Miswak users had deeper pockets and more prevalence of periodontal diseases
(Gazi M,1990)
Regardless the means to achieve the goal, mechanical plaque control is the key to the success of periodontal therapy and achieving dental health.
Good mechanical plaque control program should be included in the first phase of therapy and reinforced through the entire therapy.
The clinician must evaluated patient plaque control by means of gingival and plaque indices to motivate the patient toward the common goal, the optimal periodontal health.
Common devices to be recommended to the patient are soft bristle tooth brush, floss, interproximal brushes, and optional intraoral irrigation devices.
With good oralphysiotherapy, gingivitis can be prevented and periodontal disease with bacterial as the main etiological factor can be erradicated.
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Periodontology 33: 386, 1962. 3. O’Leary, Shafer W., Swenson H, Nesler D. Possible penetration of crevicular tissue from oral hygiene
procedure. Use of the toothbrush. J. Periodontology, 41:163, 1970 A. 4. Caranza, Newman. Textbook of clincal periodontology. Eighth edition. WB Saunders, 1996. 5. Grant, Stern, Listgarten. Textbook of Periodontics. Sixth Edition. The C.V. Mosby Company, 1988. 6. Genco, R., Goldman, H., Cohen, W. Contemporary Periodontics. The C.V. Mosby Company , 1990. 7. Killoy, W. Love J., Fedi, P. Tira, D. The effectiveness of a counterrotary action powered toothbrush and
conventional toothbrush on plaque removal and gingival bleeding. Journal of Periodontology, 60: 473, 1989. 8. Lamberts, D. Wunderlich, R. Caffesse, R. The effect of waxed and unwaxed dental floss on gingival
health. Part 1. Plaque removal and gingival response. Journal of Periodontology, 53: 393, 1982. 9. Graves, R. Disney J. Stamm J. Comparative effectiveness of flossing and brushing in reducing
interproximal bleeding. Journal of periodontology, 60: 243, 1989. 10. Ciancio, Mahter, Zambon, Reynolds, H. Effect of chemotherapeutic agent delivered by an oral irrigation
device on plaque, gingivitis, and subgingival microflora. Journal of Periodontology, 60: 310, 1989. 11. Eakle, W. Ford, C., Boyd, R. Depth of penetration in periodontal pockets with oral irrigation. Journal of
clinical Periodontology, 13: 39, 1986. 12. Danielsons B, Baelum V, Manji F and Fejerskov O. Chewing stick, toothpaste and plaque removal. Acta
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children. Comm Dent Oral Epidemiol 1989; 17:317-21. 14. . Gazi M, Saini T, Ashri N and Lambourne A. Meswak chewing stick versus conventional tooth- brush as
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