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PLAQUE CONTROL

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INTRODUCTION

Plaque Control

Accomplished by Professional plaque removal Patient performed oral hygiene Chemical plaque control

Interferes with initiation, development and progression of periodontal disease.

Plaque control is the removal of microbial plaque & the prevention of its accumulation on the teeth & adjacent gingival tissues. It also deals with the prevention of calculus formation.

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RATIONALE FOR PLAQUE CONTROL

Plaque – Gingivitis

Gingivitis doesn’t always progress to Periodontitis

Inflammatory changes in Gingivitis provides an ecological niche for pathogenic changes of plaque

Facilitates Subgingival colonization that could lead to periodontal destruction

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METHODS OF PLAQUE CONTROL

MechanicalPerformed in officePerformed at home

Chemical Dentrifice Mouthwash Pre brush rinse

Combined

MECHANICAL PLAQUE CONTROL AIDS:• The various aids used for mechanical plaque control can be listed as

follows:Tooth brushes

Manual tooth brushPowered toothbrushesSonic and ultrasonic toothbrushes

Ionic toothbrushes

Interdental aids• Dental Floss• Triangular tooth picks–Hand held tooth picks–proxapic

– Interdental brushes • Proxabrush system• Bottle brushes• Single tufted brushes (Flat or Tapered)

– Yarn– Superfloss– Perio-aid

• Aids for Gingival stimulation– Rubber tip stimulator– Balsa wood edge

• Others– Gauze strips– Pipe cleansers– Water Irrigation device

• Aids for edentulous or partially edentulous patients– Denture & partial clasp brushes– Cleansing solutions

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PERFORMED IN OFFICE

HAND SCALING

ULTRASONIC SCALING

ORAL IRRIGATION

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PERFORMED AT HOME

Tooth brushing Tooth brush Dentrifices Brushing techniques

Interdental cleaning Dental floss Other Interdental aids

Oral irrigation Supragingival Subgingival

TOOTHBRUSH

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HISTORY

• Twigs of lenstick wood and aromatic twigs

• Gold tooth picks -- 3000 B.C.

• Chinese fabricated toothbrushes made with bone or ivory fitted with

natural hog bristles. 1600 A.D.

– Natural bristles made from hog's hair are usually very sharp and unkind to soft

tissues.

– These are expensive, very hard, sharp, and abrasive to both cervical root

surfaces and gingival tissues.

• Present day -- nylon bristles of varying quality, end rounded by a

polishing process, affixed to plastic handles of diverse designs.

Types Of Tooth Brushes:

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Manual toothbrushesPowered toothbrushesSonic and ultrasonic toothbrushesIonic toothbrushes

Manual toothbrush:

Ideal characteristics of toothbrush are –1.Should conform patient requirement in size , shape and texture1.Easily and effectively manipulated2.Readily cleaned and aerated3.Durable and inexpensive4.Designed for efficiency and cleanliness

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Parts of toothbrush:

HANDLE

HEAD

SHANK

TUFTS

HandleThe part grasped in the hand during tooth brushing

HeadThe working end of a tooth brush that holds the bristles or filaments

TuftsClusters of bristles or filaments secured into head

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Parts of toothbrush:

HANDLE

HEAD

SHANK

TUFTS

Brushing PlaneThe surface formed by the free ends of the bristles or filaments

ShankThe section that connects head & handle

TOOTH BRUSH BRISTLES• Hard & soft• Natural & synthetic• Multi-tufted & space tufted

1. Natural Bristles– Obtained from hair of hog or wild boar. The bristles are tubular in form &

are more susceptible to fraying, breaking, Contamination with microbial debris, Softening & loss of elasticity

2. Synthetic Bristles– Nylon bristles which are uniform in size & elasticity,

resistant to fracture & doesn’t get contaminated

The stiffness of bristles vary based on the following factors• Diameter of bristles α Stiffness (Diameter of bristle for soft brushes - 0.2mm

for medium brushes - 0.3mm for hard brushes - 0.4mm)

• Length of bristle α 1/stiffness

• Number of filaments in tuft α stiffness

• Curvature of filaments – Curved filaments may be highly flexible & less stiff than straight filaments

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TOOTHBRUSH DIMENSIONS

•Total length: 6.0-7.5 inches

•Length of brushing plane: 1-1.25 inches

•Width of brushing plane: 5/16-3/8 inch

•Filament height: 7/16 inch

•Rows of bristles: 2-4

•Tufts per row : 5 to 12

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WHATEVER MAY BE THE DESIGN OF THE TOOTHBRUSH, THE FACT IS THAT THE USER IS THE ONLY ONE RESPONSIBLE FOR USING ANY TOOTHBRUSH MOST EFFICIENTLY.

• TOOTHBRUSH MODIFICATIONS:

Long & contoured handles Double angulation of the & neck

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TOOTHBROSH HEAD MODIFICATION:

Concave Surface

Deep Grooved Surface Special Indicator Bands

Conventional Flat Multitufted

POWERED TOOTHBRUSHES

• Three basic types of tooth brushing actions:

1) Rotation in a arc of about 60o so that the bristles brush the teeth in a sweeping action similar to the roll method,

2) Back and forth horizontal action as used in the horizontal scrub method, and

3) An elliptic movement that combines oscillating with the back and forth movements.11/04/23 20

Electrically powered toothbrushes were invented in 1939.

All powered toothbrushes rely on mechanical contact between the bristles and the tooth to remove plaque.

INDICATIONS

• Young children • Handicapped patients• Patients with prosthodontic or endosseous implants• Orthodontic patients• Elderly patients dependant on care providers• Patients on supportive periodontal therapy

SONIC AND ULTRASONIC TOOTHBRUSHES:

• Produce high frequency vibrations (1-6 MHz) ,which leads to the phenomenon of cavitation and acoustic micro streaming.

• This aids in stain removal as well as disruption of the bacterial cell wall.

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IONIC TOOTHBRUSHES:

• Change the surface charge of a tooth by influx of positively charged ions.

• Plaque with a similar charge is thus repelled from the tooth surface .

• It is attracted by the negatively charged bristles of the toothbrush

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DENTIFRICES Aid in cleaning & polishing the tooth surface

Pastes /Powders/Gels

Proper use of dentifrice can enhance the cleaning action of tooth brush up to 40 times

Can also be used as vehicles to deliver chemotherapeutic agents to inhibit plaque / calculus /root hypersensitivity

Fluoridated tooth pastes – role in caries prevention11/04/23 24

• Ingredients • 1. Abrasives:

Eliminates plaque, polishing of tooth surface e.g. Calcium Carbonate, Alumina, Silica

• 2. Surfactant agent: Provides foam and removes debris e.g. Sodium Lauryl Sulphates

• 3. Flavouring Agents: Helps individual to get liking for brushing e.g. Spearmint oil, Peppermint oil, Wintergreen

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• Humectants:Helps to reduce the loss of moisture from the pastee.g. Glycerine, Sorbitol, Polyethyl Glycerol

• Binders:Control stability and consistency of toothpastee.g. Alginates, Carrageenates and Sodium

Carboxymwthyl Cellulose or water insoluble substances like Magnasium Alluminium Silicate

• Therapeutic Agents:Excellent vehicle for delivery of anti-plaque agents,

antitarter agents, desensitizing agents and whitening agents

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TECHNIQUES OF TOOTHBRUSHING

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Methods of tooth brushing can be categorized primarily according to the pattern of motion when brushing :

BASS TECHNIQUE• Placement of the toothbrush

bristles at a 45° angle to the long axis of the teeth

• Gently pressing the ends of the bristles into the gingival sulcus and interproximal areas while the brush is vibrated in a back and forth short stroking motion.

• 2-4 teeth and their interproximal

spaces cleansed at one time. • Occlusal surfaces brushed using

short antero posterior strokes.

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MODIFIED BASS TECHNIQUE

• This technique combines the vibratory and circular movements of the bass technique with the sweeping movement of Roll technique.

• The two methods are performed separately rather combining them.

• So the difference in Bass and modified Bass is that roll technique being added in the later.

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CIRCULAR SCRUB / FONES TECHNIQUE• Bristles at 90°, and the entire brush head is moved in a

circular scrubbing motion using light pressure. The spherical pathway is limited to the mucobuccal space.

• No deliberate attempts at intra sulcular cleansing is made. This technique is said to be effective for young children with minimal manual dexterity.

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MODIFIED STILLMANS' TECHNIQUE

• Placement of the bristles at 45° to the long axis of the teeth on the gingival margin.

• The brush is vibrated mesiodistally as the brush head is rotated toward the coronal surface.

• Technique stresses interproximal cleansing and the massaging effects of the bristles on the gingival tissues.11/04/23 33

CHARTER'S TECHNIQUE• Starts with bristles placed at a

45° angle to the teeth, but they are firmly pushed into the interproximal spaces with a slight rotary and vibratory action.

• Main action depends on the massaging effects of the sides of the bristles.

• Occlusal surfaces are brushed using a rotary movement.

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INTERDENTAL CLEANING AIDS

Special efforts have to be made & special devices have to be used for the removal of the plaque from the inter-dental areas esp. of posteriar molars

• Factors in selection of an inter dental cleaning aid– Type of gingival embrasures– Alignment of teeth– Fixed prosthesis/ orthodontic appliances– Open furcation areas– Contact areas

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I II III

Types of embrasure Condition of gingiva in embrasure

Cleaning aid recommended

Type I Embrasure occupied by completely healthy gingiva

Superfine and thin dental floss

Type II Slight to moderate recession of gingiva

Medium or coarse , thick dental floss /Spiral interdental brushes

Type III Extensive recession or complete loss of gingiva

Bristle ended unitufted brushes

DENTAL FLOSSIndicated to remove plaque from inter-proximal surfaces with type 1 gingival embrasures

• Dental floss may be available in various forms– Multifilament – twisted /non twisted– Bonded/ non bonded– Thick/thin– Waxed/non waxed

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FUNCTIONS OF DENTAL FLOSS:

• Removal of adherent plaque & food debris from the inter-proximal embrasure & under the pontics of FPD

• Polishing of the tooth surface during removal of the plaque & debris

• Stimulating &massaging the inter-dental papillae• Helping in locating the following– Sub gingival calculus deposits– Overhanging margins of the restorations

• Improving oral hygiene• Reducing gingival bleeding• Vehicle for application of polishing or therapeutic agents to

inter-proximal & sub gingival area11/04/23 38

Flossing Technique:

1. Spool method

Requires manual dexterity.

a. Take a floss 12-18 inches long.

b. Wrap around the right middle finger 2-3 times and then around left middle finger.

c. Maxillary: Grasp floss firmly with thumb and index finger of each hand (1/2” btw fingers) Mandibular: Direct floss down with the index fingers.11/04/23

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Grasp for maxillary arch

Grasp for mandibular arch

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d. Fulcrum on the cheek or in the mouth.

e. Pass through contact using a gentle seesaw motion.

f. Pass floss below the gingival margin.

g. Wrap it tightly around the tooth in a “C” shape.

h. Move the floss up and down, 3 or 4 strokes.

i. Remove floss using a seesaw motion.

2.Circle or Loop method

• In this method a loop or circle of the floss is made from about 45 cm (18inch) long piece

• both ends are tied securely with the three knots. • All the fingers except the thumbs of both the hands are

placed within the loop

• the floss is held by both the hands having 2.5cms (1 inch) floss between fingers of both the hands.

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• Flossing can be made easier by using a floss holder.• They are helpful for the patients lacking manual dexterity.• A floss holder should posses following features : 1) one or two rigid forks 2) an effective and simple mounting mechanism

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• Powered flossing devices are also available.

• These devices have a single bristle that moves in a single motion.

• The devices have been shown to be safe and effective

• but no better at plaque removalthan finger flossing

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INTER INTERDENTAL BRUSHES:• In case of type 2 gingival embrasure inter-dental brushes have

proven to be the best choice for plaque removal from inter proximal tooth surfaces

• Their design is similar to that of a bottle brush, which may be mounted on to specifically designed handles to make its use in the post. areas of the mouth more comfortable

• They may also be used to clean furcation areas & root concavities

Unitufted brushes

• Employed in the type 3 gingival embrasures• Also used to carry antimicrobial agents (Chlorhexidine) into

the inter proximal areas

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EFFECTS OF IMPROPER TOOTH BRUSHING

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GINGIVAL ALTERATION

• Acute alterations (Lacerations)» Scuffled epithelial surface with denuded underlying

C.T.» Punctate lesions that appear as red pinpoint spots

– Precipitating factors» Horizontal or vertical scrubbing tooth brushing

method with pressure» Over vigorous placement and application of tooth

brush» Penetration of gingiva by filament ends » Use of tooth brush with frayed, broken bristles of

filaments

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• Chronic alterations»Usually appear on the facial gingiva

because of the vigour »Area most commonly involved are

around canines or teeth in labio or bucco version11/04/23 50

GINGIVAL ULCERATION

• Recession» Appearance : margin of the gingiva has receded

towards the apex and the cementum is exposed» Predisposing anatomic factors

Malposition of teethNarrow Band of attached

gingiva can’t withstand pressures of brushing

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Precipitating factors :Repeated use of vigorous rotary, vertical or horizontal tooth brushing techniques over a long period of timeUse of long brisk strokes with excessive pressure over a long period of timeHabitual prolonged brushing in one area

RECESSION

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Abrasion of the teeth

– It is defined as the pathologic wearing away of tooth substance through some abnormal mechanical process • Contributing factors– Hard tooth brush– Horizontal brushingExcessive pressure during

brushing – Abrasive agent in the dentifrice

• Appearance– Saucer shaped or wedge shaped indentation with

smooth shiny surfaces

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ABRASION OF TEETH

Wooden Tips:• These devices are manufactured from orange wood & are

triangular in cross section. They are inserted into the gingival embrasures with base of the triangle oriented towards the gingiva

• The wooden tip then may be repeatedly moved in & out of the embrasure ,there by removing soft deposits from the teeth & also mechanically stimulating the gingiva

Gauze Strip:

• Indications for use:

-for proximal surfaces of widely spaced teeth -for surfaces of teeth next to edentulous areas -distal and mesial surfaces of abutment teeth -distal portion of denture supported implants

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Gingival Massage• Gingival massage leads to -improved circulation, -increased keratinization and -epithelial thickening.• Improved gingival health due to plaque removal.• Also used to recontour gingival papilla following periodontal

therapy.• Accomplished by -rubber tip -tooth brushing - interdental cleaning or - simple finger mssaging

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TO BE CONTINUED…

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