MECHANICAL PLAQUE CONTROL J E CBackground TMechanical plaque

MECHANICAL PLAQUE CONTROL

J E CBackground TMechanical plaque control (a) Toothbrush I (b) Dentifrice V (c) Interdental cleaning aids Dental floss E - Interdental brushes S - - tooth pik (d) Oral irrigation

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

Plaque as etiologic factor Experimental 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) FACIAL SURFACES OF THE MOLARS & PREMOLARS MOLAR & PREMOLAR AREAS PROXIMAL SURFACES OF THE ANTERIOR TEETH

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 v. OBJECTIVE: Complete Daily Removal Of Dental Plaque With A Minimum Of Effort, Time, And Devices, Using The Simplest Methods Possible.

Self-performed 1. Tooth brushing 2. 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 toothbrushing D. Toothbrush wear and replacement E. Electric toothbrushes of

The Toothbrush � First “toothbrush” 15 th 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 1960 s (Broxodent) � 1987 – first rotary action electric toothbrush •

The 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. -------------------------

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. 075 mm Hard: 0. 3 mm End shape Irregular Rounded Limitations Standardization not possible Wear: rapid & irregular Collection of debris & microorganisms due to hollow ends Cleaning, rinsing and maintenance easy Wear: Durable Repels debris: end rounded Resistant to accumulation of microraganisms

Bristle hardness v. Proportional to the square of the diameter and inversely proportional to the square of bristle length v. Soft brush: 0. 007 inch(0. 2 mm) v. Medium brush: 0. 012 inch(0. 3 mm) v. 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: v. The design of the brush v. The skill of the individual using the brush v. 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. 2. 3. 4. 5. 6. 7. 8. Horizontal brushing (scrub) Leonard method (vertical) Bass method (Sulcular cleaning) Modified Bass methods Stillman methos (vibratory) Modified Stillman method (roll) Charters method 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 removal Easily learned Good gingival stimulation Charter's Coronally 45 o, 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 proximal Gingival 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 stimulation Moderate dexterity required Moderate cleaning of interproximal area Modified stillman's Pointing apically at and angle of 45 o 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 removal Easily learned Good gingival stimulation Charter's Coronally 45 o, 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 proximal Gingival 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 stimulation Moderate dexterity required Moderate cleaning of interproximal area Modified stillman's Pointing apically at and angle of 45 o to tooth surface Apply pressure as in stillmans's method but vibrate brush and also move occlusally Easy to master Gingival stimulation

Bass method Charters 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

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 ü The bristles are placed at a 45 degree angle to the gingiva and moved in small circular motions. ü Strokes are repeated around 20 times, 3 teeth at a time. ü On the lingual aspect of the anterior teeth, the brush is pressed into the gingival sulci and proximal surfaces at a 45 angle. ü The bristles are then activated. ü 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 Toothbrush � 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 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 toothbrushes Invented 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 adolescents 2. Children with physical or mental disabilities 3. 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. •

DENTIFRICES Aids in cleaning and polishing tooth surfaces.

Composition: 1. Abrasives- silicon oxides, aluminum oxide 2. Humectants 3. Water 4. Soap or detergent 5. Flavoring and sweetening agents 6. Therapeutic agents such as fluorides and pyrophosphates 7. 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.

Dentifrices are marketed as Toothpowders Toothpastes Gels 55

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

• 1. 2. 3. • 1. Advantages: Long shelf life Maintained moisture content Nontoxic Disadvantages 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.

• 1. 2. 3. 4. Disadvantages of soaps: irritating to the mucous membrane flavor is difficult to mask often causes nausea 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: Stable Possesses some antibacterial properties Has a low surface tension which facilitates the flow of the dentifrice over the teeth 4. Active at a neutral ph 5. Flavor is easy to mask 6. Compatible with the current dentifrice ingredients • 1. 2. 3.

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 p. H, 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 (Na. F) at a level of 1, 100 ppm, • 0. 76% sodium monofluorophosphate (MFP) at a level of 1, 000 ppm, • 0. 4% stannous fluoride (Sn. F 2) 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 Na. F dentifrice. A recently introduced prescription dentifrice, Colgate Prevident 5, 000, contains 5, 000 -ppm

Stannous Salts • Stannous fluoride (Sn. F 2), specifically the stannous ion, has reported activity against caries, plaque, and gingivitis. • While Sn. F 2 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