Plaque control for the prevention of oral diseases

D Caroline Mohamed 1

Plaque control for the prevention of oral diseases

Libyan International Medical University 2nd Year First SemesterD Caroline Mohamed


At the end of this topic you should be able to explain and describe:

Mechanical plaque control by: Self-care Professional mechanical tooth cleaning

Objectives


Remember……..!!!Plaque:• Plaque is a white, sticky substance that builds up every day around your teeth and gums, and on dental appliances.• Plaque can be removed with daily brushing, flossing, and rinsing with an antiseptic mouthwash.• If plaque is not removed it hardens into calculus.Calculus:• Once plaque has been allowed to remain it calcifies. Only a dental professional can then remove calculus.


The objective of mechanical plaque control

Complete daily removal of dental plaque with a minimum of effort, time, and devices, using the simplest methods possible.

Primary role in removal of soft deposits on teeth and gingival tissue.

Helps in increasingly gingival tone, surface keratinization, gingival vascularity and gingival circulation.


What can we use to clean our teeth?


1. Mechanical plaque control Self Care(a) Toothbrush

manual electrical ionic sonic and ultrassonic

(b) Dentifrice (c) Interdental cleaning aids dental floss tooth pick

interdental brushes gauze strips pipe cleaner yarns


(d) Aids for gingival stimulation Rubber tip stimulator (e) Oral irrigation (f) Salvadora persica –Miswak (g) Aids for Completely or Partially Edentulous Patients Denture & Partial Clasp Brushes/Cleansing Solutions


The efficacy of brushing with regards to plaque removal depends upon 3 main factors:

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

The dental cleaning instrument most used: The toothbrush


To clean teeth of food, stains and debris, To disturb and remove plaque formation, To stimulate and message the gingival tissue, To aply fluoride dentifrice. Cleaning of tongue and palate.

Objectives of toothbrushing


Ideals requisites of a toothbrush

Handle size appropriate to user age and dexterity. Head size appropriate to the size of the patients mouth. Use of end-rounded nylon or polyester filaments not larger than 0.009

inches in diameter. Bristles should be of even lengh, so that, they can function

simultaneously. Use of soft bristle configuration as defined by the international

industries standards. Bristle pattern which enhances plaque removal in the approximal

spaces and along gum line. Causing minimum damage to soft and hard dental tissue. The brush should be easy to keep and clean. Should be nontoxic. Having a reasonable lifespan.


Morphology of a ToothbrushComponents/DimensionsStructurally, the toothbrush has four components � the body, the neck, the head and the bristles.


- 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.- ---------------------------------------------------

› Length : 1,5 child to 12,5 cm adults› 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

The Toothbrush


Lateral profile of a toothbrushFlat, rippled, dome, multilevel.


Baby´s Toothbrush


Polyester or nylon• Nylon wear less and is more hygienic- antistatics

Classified: Soft 0.15-0.18 mm Medium 0.18-0.23mm Hard/Extra hard 0.230.28mm

Bristles


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)

If you think the economy has been in a recession, just look what can happen to your gum tissue!


Toothbrushes need to be replaced every 3 months, when the bristles flare or you have an infective high respiratory disease.


Electric toothbrush ( powered)• Its mainly recommended for :

(a) Individual lacking motor skills ( Aged persons, arthritic patients)

(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 back and forth, rotating, oscillating-pulsating motions . Some are circular and elliptical motion. Round head.

Powered tooth cleaner resembles a dental prophylaxis and hand piece with rotary rubber cap.

Patient should be oriented for proper use. Care if the bristles are not soft.


Electric Toothbrush Manual ToothbrushMinimal skill level needed to brush

Requires manual dexterity and diligence

Individual lacking motor skills Not helpful in such scenarioTend to brush longer as minimum effort is needed. It can lead to better removal of dental plaque

Efforts needed can cause the person to limit the amount of time spent on brushing

Smaller brush head that is easier to reach all areas of the mouth without causing discomfort

Not always true

Less brushing force required More force required

Less like to cause damage to tooth enamel and gums because the majority of them have pressure sensors

Incorrect techniques can often cause damage

Electrical toothbrush X Manual toothbrush


Electric Toothbrush Manual Toothbrush

Allow to regulate the brushing time and pressure applied using a built-in-timer and pressure control

Manual regulation required

Recommended for those who wear braces as it may reach crevices between braces and teeth that are not easily cleaned

Comparative, cleaning can be a cumbersome task for those who have braces

Hard toothbrushes can erode teeth tissues

Old fashionable power TB can


Sonic Toothbrush The motion of these agitated fluid is capable of dislodging

dental laque, even beyond where the bristles of the toothbrush actually touch. Only a sonic toohbrush can make this claim.


Ionic Toothbrush


Both sonic and ionic toothbrushes are capable of removing plaque and reducing gingivitis and bleeding effectively.

The results show that the sonic toothbrush showed better results as compared with the ionic toothbrush, though the difference was statistically insignificant.

Guljot Singh, D. S. Mehta,1 Shruti Chopra, and Manish Khatri.Comparison of sonic and ionic toothbrush in reduction in plaque and gingivitisJ Indian Soc Periodontol. 2011 Jul-Sep; 15(3):

210–214.

Sonic X Ionic

http://www.ncbi.nlm.nih.gov/pubmed/?term=Singh%20G%5Bauth%5D


http://www.ncbi.nlm.nih.gov/pubmed/?term=Mehta%20DS%5Bauth%5D

http://www.ncbi.nlm.nih.gov/pubmed/?term=Chopra%20S%5Bauth%5D


http://www.ncbi.nlm.nih.gov/pubmed/?term=Khatri%20M%5Bauth%5D



Soladey ionic with light activated titanium rod (semicondutor)


No significant difference in dental plaque removal between a conventional toothbrush and the Soladey-2.

Soladey toothbrush had significant reduction in plaque over a conventional toothbrush in the front portions of the mouth, but the removal effects on other areas were similar in comparison.

Niwa et al. Clinical study on the control of dental plaque using a photo energy conversion toothbrush equipped with a TiO2 semiconductor. Shigaku Vol. 77 No 2, 1989.


Some problems with the children’s electric toothbrush have been reported, including cut lips, battery burns and bristles that fell off and lodged in the child’s tonsils.

Should change the toothbrush’s head every three months – or sooner, especially if the head is loose.

"Extended usage, loose parts or excessive wear could lead to brush head breakage, generation of small parts and possible choking hazard," according to the website. "Inspect brush for loose parts before use."Read more: http://www.foxnews.com/health/2012/02/17/some-electric-toothbrushes-causing-health-problems-fda-says/#ixzz2JNjfiK14

Take care with your power brush

http://www.foxnews.com/health/2012/02/17/some-electric-toothbrushes-causing-health-problems-fda-says/

http://www.foxnews.com/health/2012/02/17/some-electric-toothbrushes-causing-health-problems-fda-says/


Tooth Brushing Techniques

1. Vertical (Leonard´n method)

2. Horizontal

3. Roll technique (Modified Stillman// rolling stroke)

4. Vibrating technique (Charter´s/Stillman and Bass)

5. Circular technique (Fones method)

6. Physiological technique (Smiths method)

7. Scrub Brush method


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

Rolling stroke

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


The technique should clean all tooth surfaces specially the area of gingival crevice and the interdental region.

The movment of the brush should not injure the soft or hard tissues. Certain methods, e.g. Vertical and horizontal scrubbing methods can produce gingival recession and tooth abrasion.

The technique should be simple to use and simple to learn.

The method most be well organized so that, each part of the dentition is brushed in turn and no area over looked.

Requirement of a satisfactory Method of tooth brushing

D Caroline Mohamed 35Charters method

Bass method


Charter[s enphasizes bristle action in the interproximal area


Stillman method provides better gingival stimulation


Abutment teeth cleaning: Charter´s techn. along with floss threaders.


Be sure:Use disclosing solutions!

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It is clean, isn

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Dentist should be noted that a plaque control devices should be tailored to the individual, similarly to his or her plaque control program.

Controlled studied evaluating the most common brushing technique have shown that no one method is superior.


Handicapped patient Toothbrush adaptations The most common tool for effective mechanical control

of dental plaque is a toothbrush. The presence of physical and/or cognitive disabilities can create difficulties both in holding and manipulating a toothbrush.

http://www.nature.com/bdj/journal/v205/n3/fig_tab/sj.bdj.2008.652_F8.html


Grasp, manipulation and control Grasp – for people who cannot grasp and hold,

the objective is to fasten the brush handle to the hand. velcro strap with a pocket on the palm side into which the toothbrush can be inserted.

Fixed fingers – for a patient with fingers permanently flexed or fixed in a fist. The handle of some brushes can be modified by immersion in hot water.

no spill beaker'



Limited hand closure or reduced manual dexterity – here, the objective is to enlarge the diameter of the brush handle to fit the hand.

Plastazote tubing and silicone putty the use of sponges plastazote tubing bicycle handlebar grips wrapping the handle of the brush in tape or pushing it into a soft rubber





Carers


Adjunts to toothbrushingInterdental cleaning aids

Any tooth brush, regardless of the brushing method, does not completely remove interdental plaque. Even for patients with wide-open dental embrasures. ( Gjermo, 1970, Schmid 1976).

The majority of dental and periodontal disease's originate in interproximal area, interdental plaque removal is necessary.


Tissue destruction associated with periodontal disease often leave large, open spaces, between 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 dislodge food wedged between teeth.


Remove plaque and debris that adhere to the teeth; restorations, orthodontic

appliances, fixed prostheses and pontics, gingiva in the interproximal embrasures; and around implants.

Polish the surfaces as it removes the debris. Massage the interdental papillae Aids in identifying the presence of subgingival

calculus deposits, over –hanging restorations, or interproximal carious lesions.

Reduces gingival bleeding and control of halitoses. May be used as a vehicle for the application of

polishing or chemotherapeutic agents to interproximal and subgingival areas.

Objectives:


Dental Floss


Dental floss Types: unwaxed, waxed, tape floss, EPTFE floss, and Superfloss.

◦ Waxed floss contained wax to facilitate passing 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.


Best done before brushing. There are no significant difference between

various types of floss to remove dental plaque, they all work equally well.

( Grossman 1979, Keller 1969). Super floss X Waxed dental floss Superfloss superior (50%)


Type of embrasure Dental Floss

Type I: The interdental papilla fills up the embrasure

Dental floss

Type II: Moderate papillary recession is seen

Miniature interdental

Type III:There is complete loss of papillae

Unitufed brushes


More time consuming. Unable to mantain the tension of the floss. Must be rethreaded when the floss becomes soiled or frayed. Need to set fulcrum to avoid floss cuts. Incorrect use may cause: wearing down of papillae, cuts,

abrasion, can force bacteria or debris into gingival attachment , Opening of embrasure.

Disadvantages:


Interdental brush (proxy brush):

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.


-Type II and Type III embrasures,-Diastemas,-Exposed root furcations, -Orthodontic and fixed appliances,-Application of fluoride, antimicrobial or desensitizing agents.

Indications


Cleaning implants


Toothpick 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.

Tooth picks may erode teeth.


Oral irrigation use in the lowest level, do not direct subgingivally 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 orthodontic appliance, and when used as an adjunctive treatment in shallow pocket depth.

Contra indicated: Patients require antibiotic premedication. (patients that

had bone marrow transplants, history of endocardites, rheumatic fever, and congenital heart disease, cardiac pacemakers, cardiovascular prosthesis…


Adjuncts to toothbrushing Do not use in full strength! ( Robinson and Hoover, 1971)

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

Miswak

66D Caroline Mohamed


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)


The patient preference for particular hygiene device should

always be considered.

Professional Care Dental Health Education Objectives: Change in behavior Prevente the initiation and progression of

dental caries and periodontal disease and make the patient as much as possible, independent of professional support.

Chair side Self educational program Self exam

Instruction manual

Motivated by the health

profissional

Advice on

Dental Hygiene and oral habits Self exam Diet influencing the plaque formation, e.g.

dietary sugars, natural cleansers such as fruits and vegetables, etc.

Smoking cessation.

The responsability thus would be thus : To provide information about the dental

health To provide information and guidence about

methods and techniques of plaque control Motivate the patient to bring about a

change in his behaviour; which promotes dental helth.

Age, culture, mental and physical capacity

Informative leaflet


Go deeper in this issue by the informative paper


Professional mechanical tooth cleaning

Scaling and root planning Removal of infected deposits- plaques & calculus,

and stains from surfaces of teeth. Simple procedure by a dentist to keep your gums

healthy and firm.


Polishing Removal of extrinsic tooth stains for cosmetic

reasons and psychological effect of having clean teeth maybe are the principal effects of polishing.

Maybe indicated in when plaque removal is inhibited by surface roughness.


Step 1. Supragingival cleaning

Step 2. Subgingival cleaning

Step 3. Polishing

Steps in Oral Prophylaxis


Refrences 1. Loe, H. Theilade, E., Jensen, SB. Experimental Gingivitis in Man. Journal of Periodontology, 36: 177, 1965. 2. Sanders, WE. Robinson, HBG. The effect of toothbrushing on deposition of calculus. Journal of 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 Odontol Scand

1989; 47:121-25 13. Norman S and Mosha HJ. Relationship between habits and dental health among rural Tanzanian children. Comm Dent

Oral Epidemiol 1989; 17:317-21. 14. . Gazi M, Saini T, Ashri N and Lambourne A. Meswak chewing stick versus conventional toothbrush as an oral

hygiene aid. Clin Preventive Dent 1990; 12: 19-23. Griffiths J, Boyle S. Holistic oral care – a guide for health professionals. Sections 2–3. London: Stephen Hancocks

Ltd, 2005. Guljot Singh, D. S. Mehta,1 Shruti Chopra, and Manish Khatri.Comparison of sonic and ionic toothbrush in

reduction in plaque and gingivitisJ Indian Soc Periodontol. 2011 Jul-Sep; 15(3): 210–214.



http://www.ncbi.nlm.nih.gov/pubmed/?term=Mehta%20DS%5Bauth%5D






Highly recommended reading http://www.nature.com/bdj/journal/v205/n3/f

ull/sj.bdj.2008.652.html

http://www.nature.com/bdj/journal/v205/n3/full/sj.bdj.2008.652.html

http://www.nature.com/bdj/journal/v205/n3/full/sj.bdj.2008.652.html


Please, Buy and use 3 different type of tooth brushes

and a power brush. Next class bring a report comparing the

advantages and disadvantages of the different characteristics of each tooth brush in relation to design (handle and head shape), bristle type (soft, medium), cleaning ability, prices and general satisfaction with it.

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Plaque control for the prevention of oral diseases

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