MECHANICAL

PLAQUE

CONTROL

OB JE CT IV ES

Background

Mechanical plaque control

(a) Toothbrush

(b) Dentifrice

(c) Interdental cleaning aids

- Dental floss

- Interdental brushes

- tooth pik

(d) Oral irrigation

• IMPORTANT CHAPTER• CLINICALLY VERY RELEVANT• REQUIREMENT FOR PATIENT TEACHING

Plaque as etiologic factorExperimental gingivitis study (1965 Löe et al. )

The cause and effect relationship between supragingival plaque and gingivitis was demonstrated by Loe et al (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 plaque is the key to prevent the occurrence of periodontal disease or halting the progression of the disease.

Masses of plaque first develop ( Lang,1973)

MOLAR & PREMOLAR

AREAS

PROXIMAL SURFACES OF

THE ANTERIOR TEETH

FACIAL SURFACES OF

THE MOLARS & PREMOLARS

PLAQUE CONTROL Plaque control: The removal of dental plaque on

a regular basis and the prevention of its accumulation on the teeth and adjacent gingival surfaces.

Position: supra- & sub-gingival plaque control

Methods: mechanical & chemical

MECHANICAL PLAQUE CONTROL

OBJECTIVE:Complete Daily Removal Of Dental Plaque

With A Minimum OfEffort,

Time, And Devices,

Using The Simplest Methods Possible.

Self-performed

1. Tooth brushing2. Interdental aids

–Dental floss and tape–Toothpicks–Interproximal brushes–Single-tufted brush

3. Adjunctive aids–Dental irrigation devices–Tongue scrapers–Dentifrices

TOOTH BRUSH

A. Toothbrush Design

B. Methods of toothbrushing

C. Frequency and effectiveness of toothbrushing

D. Toothbrush wear and replacement

E. Electric toothbrushes

The Toothbrush

First “toothbrush” -

15th Century in China

First modern

toothbrush - England in

1780 by William Addis

– mass produced

The Toothbrush

Nylon toothbrush bristles -

1938 in USA (Du Pont)

First electric toothbrush -

1960s (Broxodent)

1987 – first rotary action

electric toothbrush•

- Generally toothbrushes vary in

size, design as well as in length

and arrangements of bristles

hardness.

- To overcome this variation ADA

given specification of

toothbrushes.

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The Toothbrush

Toothbrush design

American Dental Association (ADA)›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

Toothbrush bristles

• Natural: hog

• Artificial filaments: nylon

NATURAL ARTIFICIAL

Source Hair of hog/ wild boar Synthetic, plastic material mainly nylon

Uniformity Non uniform Uniform

Diameter Varies Extra soft: 0.075mmHard: 0.3 mm

End shape Irregular Rounded

Limitations Standardization not possibleWear: rapid & irregularCollection of debris & microorganisms due to hollow ends

Cleaning, rinsing and maintenance easyWear: DurableRepels debris: end roundedResistant to accumulation of microraganisms

Bristle hardness

Proportional to the square of the diameter and inversely proportional to the square of bristle length

Soft brush: 0.007 inch(0.2 mm) Medium brush: 0.012 inch(0.3 mm) Hard brush: 0.014 inch(0.4 mm)

For most patients:

short-headed brushes with straight-cut, round-ended, soft to medium nylon bristles arranged in three or four rows of

tufts ARE RECOMMENDED.

TOOTH BRUSHING TECHNIQUES

• Various toothbrushing technique have achieved acceptance by the dental profession.

• Each technique has been designed to achieve a definite goal.

• Depending on the individual cases, the techniques of toothbrusing may have to be altered to achieve the maximum beneficial effects.

The efficacy of brushing with regard to plaque removal is dictated by three main factors:

The design of the brush The skill of the individual using the brush The frequency and duration of use

1986 Frandsen

Effects and sequel of the incorrect use of toothbrush

SEQUEL REASON

Gingival erosion

Toothbrush stiffness

Gingival recession

Method of brushing

Gingival abrasion

Brushing frequency

Toothbrushing methods

1. Horizontal brushing (scrub)2. Leonard method (vertical)3. Bass method (Sulcular cleaning)4. Modified Bass methods5. Stillman methos (vibratory)6. Modified Stillman method (roll)7. Charters method8. Methods of cleaning with powered

toothbrushes

How to brush?

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 brushed are occlusal.

Patient instructed to stroke each area ten time or spend 10

seconds per area then move on to next area.

Time : 2 minutes ( 30 sec per quadrant )

Method Bristle placement Motion Advantage/disadvantage

Scrub Horizontal on gingival margin Scrub in anterior position direction keeping brush horizontal

Easy to learn & best suited for 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 for 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

Tooth Brushing Three methods widely accepted: the modified 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

Recommended is Bass technique , because it emphasize sulcular placement of the bristles.

Plaque control devices should be tailored according to individual plaque control needs.

BASS OR SULCUS CLEANING METHOD

Most accepted and effective method for the removal of dental plaque present adjacent to and underneath the gingival margin.

• INDICATIONS interproximal areas cervical areas beneath the height of

contour of enamel. exposed root surfaces.

TECHNIQUE The bristles are placed at a 45 degree angle to

the gingiva and moved in small circular motions. Strokes are repeated around 20 times,3 teeth at

a time. On the lingual aspect of the anterior teeth, the

brush is pressed into the gingival sulci and proximal surfaces at a 45 angle.

The bristles are then activated. Occlusal surfaces are cleaned by pressing the

bristles firmly and then activating the bristles.

Bass method

ADVANTAGES• Effective method for removing plaque.• Provides good gingival stimulation.

DISADVANTAGES• Injury to the gingival margin.• Time consuming.• Dexterity.

MODIFIED BASS TECHNIQUE

• INDICATION:• As a routine oral hygiene measure• Intrasulcular cleansing.

TECHINIQUE• Vibratary and circular movements with

sweeping motion• Bristles are at 45 to the gingiva• Bristles are swept over the sides of the

teeth towards their occlusal surfaces in a single stroke.

ADVANTAGES• EXCELLENT SULCUS CLEANING.• GOOD INTER PROXIMAL AND GINGIVAL

CLEANING.• GOOD GINGIVAL STIMULATION

DISADVATAGES• DEXTERITY

MODIFIED STILLMAN’S TECHNIQUE

INDICATIONS• DENTAL PLAQUE REMOVAL• CLEANING TOOTH SURFACES AND GINGIVAL

MASSAGE .

DISADVANTAGE• TIME CONSUMING• DAMAGE EPITHELIAL ATTACHMENT.

TECHNIQUE• Bristles are pointed apically with an

oblique angle to the long axis of the tooth• Bristles placed on the cervical aspect of

the teeth• Short back and forth motion moved in a

coronal direction.

CHARTER’S METHOD

INDICATIONS:• Persons having :-• Missing papilla and exposed root surfaces.• FPD and Orthodontic appliances.• Periodontal surgery.• Interproximal gingival recession.

TECHNIQUE• A soft/medium multi-tufted tooth brush

taken• Bristles are placed 45 to the gingiva with

bristles directed coronally.• Mild vibratory strokes required with

bristles ends lying interproximally.

ADVANTAGES• Massage and stimulation of gingiva.

DISADVANTAGES • Poor removal of subgingival bacterial

accumulations.• Limited brush placement.• Requirements in digital dexterity are high.

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)

Toothbrushes need to be replaced every 3 months

The Toothbrush

The Toothbrush

Soft, nylon bristle toothbrush • clean effectively (when used properly),• remain effective for a reasonable time , • Soft bristle are more flexible and atraumatic• clean beneath the gingival margin, • reach farther into the proximal tooth surfaces.

Lecture II

Col area

EMBRASURE• V-shaped spillway next

to the contact area of adjacent teeth;

• Narrowest at the contact and widening toward the facial, lingual, and occlusal contacts

Powered toothbrushesInvented in 1939.

Motions: Back and forth

Circular Elliptic Combinations

Cleaning action by:

1. Mechanical contact between the bristles and the tooth

2. Low-frequency acoustic energy generates dynamic fluid movement and provides cleaning slightly away from the bristle tips.

INDICATIONS:

1. Children and adolescents2. Children with physical or mental disabilities3. Hospitalized patients, including older adults

who need to have their teeth cleaned by caregivers

4. Patients with fixed orthodontic appliances.

• Patients who can develop the ability to use a toothbrush properly usually do equally well with a manual or a powered toothbrush.

• Less diligent brushers do better with powered tooth brushes, which generate stroke motions automatically and require less operator effort.

DENTIFRICESAids in cleaning and polishing

tooth surfaces.

Composition:1. Abrasives- silicon oxides, aluminum oxide2. Humectants3. Water4. Soap or detergent5. Flavoring and sweetening agents6. Therapeutic agents such as fluorides and

pyrophosphates7. Coloring agents and preservatives.

The term dentifrice is derived from dens (tooth) and fricare (to

rub). A simple, contemporary

definition of a dentifrice is a mixture used on the tooth in

conjunction with a toothbrush.

55

Dentifrices are marketed asToothpowders

Toothpastes Gels

Original purpose:

• Pleasant taste• Cosmetic effect• Remove extrinsic stains

Abrasives

Degree of abrasive hardness depends on:

• inherent hardness of the abrasive

• size of the abrasive particle• shape of the particle

Other variables:• the brushing technique• pressure on the brush• the hardness of the bristles• the direction of the strokes• number of strokes

Abrasives used:

• Calcium carbonate • calcium phosphate• baking soda (sodium bicarbonate)• Silicas• silicon oxides• aluminum oxides

Humectants• Toothpaste consisting only of a

toothpowder and water results in a product with several undesirable properties.

• Over time, the solids in the paste tend to settle out of solution and the water evaporates.

• This may result in caking of the remaining dentifrice.

• To solve this problem, humectants were added to maintain the moisture.

• Commonly used humectants are:• Sorbitol, • Mannitol, • Propylene glycol

• Advantages:1. Long shelf life2. Maintained moisture content3. Nontoxic• Disadvantages1. Mold or bacterial growth can occur

in their presence

Soaps• Logical cleansing agent. • The toothbrush bristles dislodge

food debris and plaque• The foaming action of the soap

aids in the removal of the loosened material.

• Disadvantages of soaps:1. irritating to the mucous membrane2. flavor is difficult to mask3. often causes nausea4. soaps are incompatible with other

ingredients, such as calcium.

Detergents• Substitute to soaps• sodium lauryl sulfate (SLS) is the

most widely used detergent

• Advantages of SLS:1. Stable2. Possesses some antibacterial properties3. Has a low surface tension which facilitates

the flow of the dentifrice over the teeth4. Active at a neutral ph5. Flavor is easy to mask6. Compatible with the current dentifrice

ingredients

Flavoring and Sweetening Agents

• Flavor, along with smell, color, and consistency of a product, are important characteristics that lead to public acceptance of a dentifrice.

• The flavor must be: pleasant, provide an immediate taste sensation, relatively long-lasting

• Synthetic flavors are blended to provide the desired taste.

• Spearmint, • peppermint, • wintergreen, • cinnamon, • other flavors give toothpaste a pleasant

taste, aroma, and refreshing aftertaste

Sweetening Agents

• In early toothpaste formulations, sugar, honey, and other sweeteners were used.

• DISADAVNTAGE: these materials can be broken down in the mouth to produce acids and lower plaque pH, they may increase caries RISK.

• Replaced with: Saccharin, Cyclamate, Sorbitol, Mannitol

• Sorbitol and mannitol serve a dual role as sweetening agents and humectants.

• Glycerin also serves as a humectant, adds to the sweet taste.

• A new sweetener in some dentifrices is xylitol.

SPECIFIC DENTIFRICES:

Essential-Oil Dentifrices

• The essential-oil ingredients found in Listerine mouth rinse are also available in a dentifrice formulation.

• The clinical and laboratory data suggest a benefit to gingival health and plaque reduction

• This product does not carry the ADA Seal of Acceptance

Therapeutic Dentifrices

• The most commonly used therapeutic agent added to dentifrices is fluoride, which aids in the control of caries.

• OTC: The original level of fluoride -restricted to 1,000 to 1,100 ppm fluoride

• total of no more than 120 mg of fluoride in the tube

• Requirement that the package include a safety closure.

• Therapeutic toothpastes, dispensed on prescription, could contain up to 260 mg of fluoride in a tube.

• OTC safe levels:• 0.22% sodium fluoride (NaF) at a level of

1,100 ppm, • 0.76% sodium monofluorophosphate (MFP) at

a level of 1,000 ppm, • 0.4% stannous fluoride (SnF2) at a level of

1,000 ppm.

• Fluoride levels were increased to 1,500 ppm sodium monofluorophosphate in "Extra Strength Aim," marketed OTC. In published studies,17,18 this product was 10% more effective than an 1,100 ppm NaF dentifrice. A recently introduced prescription dentifrice, Colgate Prevident 5,000, contains 5,000-ppm

Stannous Salts

• Stannous fluoride (SnF2), specifically the stannous ion, has reported activity against caries, plaque, and gingivitis.

• While SnF2 has a long record as an anticaries agent, long-term stability in dentifrices and mouthrinses has been questioned since clinical antimicrobial activity has only been demonstrated in anhydrous state.

Triclosan

• Triclosan is a broad-spectrum antibacterial agent

• It is effective against wide variety of bacteria

• A review of the available pharmacological and toxicological information concluded

• Triclosan can be considered safe for use in dentifrice and mouth rinse products.

Anticalculus Dentifrices

• Interrupt the process of mineralization of plaque to calculus.

• Plaque has a bacterial matrix that mineralizes due to the super saturation of saliva with calcium and phosphate ions.

• Crystal growth inhibitors may be added to dentifrices to provide a reduction in calculus formation.

Antihypersensitivity Dentifrices

Active agents such as:• potassium nitrate, • strontium chloride, • sodium citrate

Whiteners

• Controversial

• These dentifrices control stain via physical methods (abrasives) and chemical mechanisms (surface active agents or bleaching/oxidizing agents).

To be continued in next lecture

Interdental cleaning aids

• Dental floss

• Interdental brushes

• Wooden or rubber tips

Dental floss

• Multifilament vs. monofilament• Twisted vs. untwisted• Bonded vs. unbonded• Waxed vs. unwaxed• 12-18 inches for use• Stretch: thumb and forefinger• Up-and-down stroke

Interdental brush

Gingival massage

• Epithelial thickening, increased keratinization, and increased mitotic activity in epithelium and connective tissue

• Emphasizing the importance of altering or removing plaque rather than stimulating or thickening the keratinized surface in the plaque control program

Oral irrigation devices

• Supragingival irrigation

• Subgingival irrigation

Chemical plaque control

• Antiadhesive • Antimicrobial• Plaque removal • Antipathogenic