Plaque Control Periodontium Dental plaque A biofilm consists

Plaque Control

Periodontium

Dental plaque • A biofilm consists of complex communities of bacterial species that reside on tooth surfaces or soft tissues • 400 -1000 species • Etiology of gingivitis and periodontitis

Biofilm concept matrix-enclosed bacterial populations adherent to each other and/or to surfaces of interfaces

Plaque as etiologic factor • Experimental gingivitis study (1965 Löe et al. )

Plaque as etiologic factor • Oral hygiene study (1973 Lang et al. )

3 hypothesis in etiology of periodontal disease • Non-specific plaque hypothesis • Ecological plaque hypothesis • Specific plaque hypothesis

Non-specific plaque hypothesis (1986 Theilade) • The bacterial dental plaque that accumulates to around teeth is a relatively homogenous mass that causes periodontal disease when it accumulates to the point of overwhelming the host’s defense mechanisms • A result of the overall interaction of the microflora with the host • 從量的角度

Non-specific plaque hypothesis • Experimental gingivitis • Effect of mechanical removal of plaque

Ecological plaque hypothesis (1994 Marsh) • Change in a key environmental factor will trigger a shift in the balance of the resident plaque microflora and that this change might predispose a site to disease • 從微生態環境的角度

Ecological plaque hypothesis

Specific plaque hypothesis (1976 Loesche) • The diverse collection of microorganisms constituting the resident plaque microflora, only a very limited number are actively involved in causing disease • Meet Koch’s postulate(modification) • 從專一致病菌的角度

Current suspected pathogens of destructive periodontal diseases • • • Actinobacillus actinomycetemcomitans Porphyromonas gingivalis Bacteroides forsythus 1996 American Academy of Periodontology Spirochetes Prevotella intermedia Fusobacterium nucleatum Campylobacter rectus Eikenella corrodens Peptostreptococcus micros Eubacterium species Selenomonas species Others

Definition • 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

Experimental gingivitis • Dental plaque was allowed to accumulate in the absence of any plaque control procedures, resulting in the development of gingivitis in all subjects within 7 -21 days. 1965 L Öe

Self-performed plaque control • Brushing • Interdental cleaning

Brushing • Toothbrush • Methods of toothbrushing • Frequency and effectiveness of toothbrushing • Toothbrush wear and replacement • Electric toothbrushes

Interdental cleaning • • Dental floss and tape Toothpicks Interproximal brushes Single-tufted brush

Adjunctive aids • Dental irrigation devices • Tongue scrapers • Dentifrices

Effects and sequelae of the incorrect use of mechanical plaque removal devices • Gingival erosion • Gingival recession • Cervical abrasion • Toothbrush stiffness • Method of brushing • Brushing frequency

Mechanical plaque control • • The toothbrush Powered toothbrushes Dentifrices Toothbrushing methods Interdental cleaning aids Gingival massage Oral irrigation devices

Toothbrush American Dental Association (ADA) • Brush length: 1 -1. 25 inches • Brush width: 5/16 -3/8 inches • 2 -4 rows • 5 -12 tufts per row

Toothbrush bristles • Natural: hog • Artificial filaments: nylon

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)

Bass soft brush • • Straight handle Nylon bristle 0. 007 inch(0. 2 mm) in diameter 0. 406 inch(10. 3 mm) in length Rounded ends 3 rows of tufts 6 evenly spaced tufts per row 80 -86 bristles per tuft

• 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.

Powered toothbrushes • Powered toothbrushes are not generally superior to manual ones • Powered toothbrushes have been shown to improve oral health: Ø Children and adolescents Ø Children with physical or mental disabilities Ø Hospitalized patients Ø Patients with fixed orthodontic appliances

Dentifrices • Dentifrices aid in cleaning and polishing tooth surfaces • Paste, powder and gel

Dentifrices • Abrasive: silica, alumina, dicalcium phosphate, and calcium carbonate • Detergent: sodium lauryl sulfate • Thickeners: silica and gums • Sweeteners: saccharine • Humectants: glycerine and sorbitol • Flavors: mint, peppermint • Actives: fluorides, triclosan and stannous fluoride

Abrasion • • Upper arch > lower arch Left side > right side Abrasive: powder > paste, gel (5 times) Cementum > dentin > enamel 35 25 1

Toothbrushing methods • • Horizontal brushing (scrub) Leonard method (vertical) Bass method Modified Bass methods Stillman methos (vibratory) Modified Stillman method (roll) Charters method Methods of cleaning with powered toothbrushes

Bass method

The efficacy of brushing with regard to plaque removal is dictated by three main factors: Ø The design of the brush Ø The skill of the individual using the brush Ø The frequency and duration of use 1986 Frandsen

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

Caries control for the periodontal patient • Periodontal patients require appropriate use of topical fluorides in the daily plaque control regimen to protect and remineralize both exposed root surfaces and coronal surfaces of teeth

Chemical plaque control • • Antiadhesive Antimicrobial Plaque removal Antipathogenic

Vehicles for the delivery of chemical agents • • • Toothpaste Mouthrinses Spray Irrigators Chewing gum Varnishes

Mouthrinse • ADA has accepted two agents for treatment of gingivitis: Ø Prescription solutions of chlorhexidine digluconate mouthrinse Ø Nonprescription essential oil mouthrinse

• Chlorhexidine: plaque reduction 45 -61%, gingivitis reduction 27 -67% • Essential oil mouthrinse: plaque reduction 20 -35%, gingivitis reduction 25 -35%

Chlorhexidine • In the US: 0. 12 % solution • In Europe: 0. 2 % solution

Chlorhexidine-side effects • • • Brown discoloration Taste perturbation Oral mucosal erosion Parotid swelling Enhanced supragingival calculus formation 1971 Flotra

Disclosing agents • Solutions or wafer capable of staining bacterial deposits on the surfaces of teeth, tongue, and gingiva • Erythrosine, fuchsin • Fluoresceincontaining dye

Frequency of plaque removal • Cleaning once a day with all necessary tools is sufficient if it is performed meticulously. • Emphasis must be placed on the efficiency of complete plaque removal at least once per day, rather than the frequency of brushing alone

Plaque control instruction • • • Motivation for effective plaque control Education Instruction Encouragement Reinforcement

Plaque control • Mechanical plaque control is necessary and not replaceable by chemical plaque control • Mechanical plaque control >>>>>> chemical plaque control