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TOOTH BRUSHING TECHNIQUES BY: AYUSHI AGRAWAL III rd yr BDS , INDIA

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DETAILS OF TOOHTHBRUSHES & METHODS OF TOOTHBRUSHING & FLOSSING EXPLAINED IN DETAIL.

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TOOTH BRUSHING

TECHNIQUES

BY: AYUSHI AGRAWAL III rd yr BDS , INDIA

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TOOTH BRUSHES

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TOOTH BRUSHESToothbrushes are most widely used oral

hygiene aids for plaque controlAcc. to ADA council

“ The toothbrush is designed primarily to promote cleanliness of teeth & oral cavity”

Adult Toothbrush length: 15 to 19 cm ( 6 to 7.5 inch)

Length of brushing plane: 25.4 to 31.8 mmWidth of brushing plane: 7.9 to 9.5 mmBristle & filament height: 11mm

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Parts of Toothbrush1. HANDLE 2. HEAD3. TUFTS4. BRUSHING PLANE5. SHANK

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I. HANDLE :• That part which is grasped in hand

during tooth brushing. • Composition is single type of plastic or

a combination of polymers.• A handle of larger diameter may be

useful for the patient with limited dexterity such as children, aging patient & those of any age with disability.

• Straight handles are more common. Handles with contra-angle provide better sense of touch

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II. HEAD• The working end of the toothbrush

that holds the bristles or filaments. • It should be small enough for max.

maneuverability in oral cavity.• Length of brush head: 5-12 tufts• Width of brush head: 3-4 rows

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III. TUFTS • Cluster of bristles or filaments secured in

head • Toothbrush BRISTLES

Hard , soft NaturalMedium Multitufted & synthetic & space tufted

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Natural bristles Synthetic bristlesSource Hair of hog or wild bear Mainly NYLON but also of

synthetic plastic material

Uniformity No uniformity in texture Uniformity controlled of size & elasticity

Diameter Varies depending on portion of bristle taken, age & life of animal

Range from extra soft at 0.075mm (0.003inch) to hard at 0.3mm(0.012inch)

End shape Deficient, irregular, frequently open-ended

End rounded to ensure fewer trauma

Advantage, Disadvantage

1) Cannot be standardized2) Wear rapidly & irregularly3) Hollow ends allow micro-

organisms & debris to collect inside.

1) Rinse , clean, dry rapidly.2) Durable & maintain longer.3) End rounded & closed, repel

debris & water.4) More resistant to accumulate

micro-organisms

Comparison of Natural & Synthetic bristles

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IV. BRUSHING PLANE• The surface formed by the free ends of the

bristles or filaments• Length: Range from filaments of equal length

(flat plane) to those variable length.• There are variously shaped filament profile like

flat, rippled, dome, multilevel, angled etc.• Brushing plane is commonly soft and rounded

for safety to oral soft tissues & tooth structure.• ADA specification of toothbrush brushing

surface:- length: 1-1.2 inch, width: 7.9-9.5 mm, 2 – 4 rows of bristles, 5 – 12 tufts/row.

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V. SHANK The section that connects head and

handle.

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Types of Toothbrushes

MANUAL IONIC POWERED SONIC & ULTRASONIC

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I. MANUAL TOOTHBRUSH The ideal characteristics for a manual

toothbrush can be listed as follows:a. Should confirm individual patient

requirement in size, shape & texture.b. Be easily& effectively manipulatedc. Be readily cleaned & aerated.d. Be impervious to moisture.e. Durable& inexpensive.f. Designed for utility efficiency &

cleanliness.

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II. POWERED TOOTHBRUSH• Also known as Automatic, Mechanical

or Electric toothbrush.• The powered toothbrush was first

designed in 1885 by Fredrick Tonberg & first made in 1939.

• PRINCIPLE: The head of toothbrush oscillate in a side to side motion or in rotary motion. The frequency of oscillation is around 40 Hz.

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• INDICATIONS FOR POWERED TOOTHBRUSH:-1. Young children2. Handicapped patient3. Individuals lacking manual dexterity4. Patient with prosthodontic or endosseus

implants.5. Orthodontic patient.6. Institutionalized patient including the elderly

who are dependent on care providers.7. Patient on supportive periodontal therapy.

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• ADVANTAGES OF POWERED TOOTHBRUSH:-1. It increases patient motivation resulting in better

patient compliance.2. Increased accessibility in the interproximal &

lingual tooth surface.3. No specific brushing technique required.4. Uses less brushing force than manual

toothbrush.5. Brushing timer is incorporated in

some brushes to help the patient in brushing for required duration.

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III. SONIC AND ULTRASONIC TOOTHBRUSH

• PRINCIPLE: These types of toothbrushes

produce high frequency vibration(1.6MHz) .

• ADVANTAGE: This phenomenon aids in stain removal

as well as disruption of bacteria cell wall.

• DISADVANTAGE: It leads to cavitation & acoustic

streaming.

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IV. IONIC TOOTHBRUSH• They change the charge of a tooth by an

influx of positively charged ions.• The plaque with similar charge is thus

repelled from the tooth surface & is attracted by negatively charged bristles have to be carried out to prove the efficacy of these type of toothbrushes.

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TOOTH BRUSHING

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OBJECTIVES OF TOOTHBRUSHING1) To clean teeth & interdental spaces of

food remnant debris & stain.

2) To prevent plaque formation.

3) To disturb & remove plaque.

4) To stimulate & massage gingival tissue.

5) To clean tongue.

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TOOTH BRUSHING

IN CHILD IN & ADOLESCENT ADULT (0 to19 yrs) (19 yrs & above)

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Tooth brushing in Child & AdolescentVarious methods of removal of plaque in child & adolescent are :-

1) TOOTHBRUSH• Synthetic(nylon) manual toothbrush is the most

commonly used. • Soft brushes are most preferred in pedodontics due

to decreased chances of gingival tissue trauma & increased interproximal cleaning ability.

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• Round type of bristles is of choice because it is associated with lower incidence of gingival tissue irritation.•Toothbrush shd also have smaller head & thicker handle to aid access to oral cavity & facilitate better child grip.

2) FLOSS• Interproximal removal of plaque beyond tooth

brushing is necessary which is done by interdental brushes, floss holders & floss & end tuft brushes.

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• Nylon & Teflon floss are available. Teflon has advantage that it has lower coefficient of friction than nylon, this floss also does not shred & slides easily between tight contacts. • Unwaxed nylon filament floss has generally been considered as floss of choice as it has an ease of passing b/w the tight junctions ,lack of wax residue, increased surface contact & greater plaque removal.• In pedodontics, flavored wax floss may be most effective. Floss-holder devices are also used.

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• For orthodontic patient super floss or floss threader is helpful.

3) DENTRIFRICES• Dentifrices are used as:-a) Plaque removing agents abrasives and b) Stain removing agents surfactantsc) Tartar control properties pyrophosphatesd) Anticaries property e) Desensitizing property fluoride

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• The child dentifrices should contain fluoride, rank low in abrasives & carry ADA seal of acceptance.• The caries preventive efficacy of fluoride toothpastes in children has been good but these fluoride toothpaste has an adverse effect on the child by increasing the total fluoride intake. • The use of much of toothpaste may lead to ingestion of fluoride which is a substantial source of systemic fluoride for children at risk of dental fluorosis.

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•To reduce chance of dental fluorosis children:a) Manufacturers shd market low fluoride

toothpaste for infants or reduce diameter of tube orifice.

b) Shd advice to use a fluoride dentifrice in a child older 36months.

c) To use small, pea sized quantity toothpaste.• The manufacture shd state that it shd be non

abrasive, non foaming, without fluoride,safe for infants & ideal for babies 4mth -3yr. It contain mild surfactant, is sugar-free & comes in vanilla & fruit flavor.

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4) DISCLOSING AGENT• A disclosing agent is a preparation

in liquid, tablet or lozenges form that contains dye or other coloring agent.

• The bacterial plaque is usually colorless & after the use of disclosing agents it picks up color of the agent where as dye is rinsed off easily from plaque free areas.

• Use:a) Personalized patient instruction in

location of soft deposits and techniques for removal.

b) Self evaluation of patient on daily basis.

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c) Continuing evaluation of the effectiveness of the instructions for the patient to determine need for revisions of plaque control procedures.

d) Preparation of plaque index.e) To gain new information about the incidence

& formation of deposits on the teeth.• Method of application:The patient chews the tablet moves it around

for 30-60 seconds rinse it completely.

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5) CHEMOTHERAPEUTIC PLAQUE CONTROL

• Chemicals interfere at various stages of development of plaque:-

a) Micro- org. for plaque formation may be reduced or eliminated in number.

b) The formation of bacterial & salivary products which constitute the intermicrobial substance in plaque is inhibited.

c) Established plaques may be dissolved.d) Calcification of plaque may be counteracted.e) Colonization of bacteria on the tooth surface may be

inhibited. f) Pathogenicity of plaque may be reduced by interference

with metabolisation of plaque bacteria.

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Chemotherapeutic plaque control agentsANTISEPTIC AGENTS: Positively charged org. molecules:- quaternary ammonium compds- cetylpyridinium chloride, pyrimidines- hexatidine bisguinides- CHLORHEXIDINE,alexidineNoncharged phenolic agents:- LISTERINE, triclosan, phenol & thymol.Oxygenating agents:- peroxides & perborate.Bis- pyridines:- octenidineHalogens :-iodine, idophores & fluoridesHeavy metal salts:- silver, mercury, zinc, copper & tin.

ANTIBIOTICS:Niddamycin, kanamycin sulfate, tetracycline hydrochloride,& vancomycin hydrochloride.

ENZYMES:Mucinases, pancreatin, fungal enzymes & protease.

SUGAR SUBSTITUTES:Xylitol, mannitol.

PLAQUE ATTACHMENT INTERFERANCE AGENTS:Sodium polyvinyl phosphonic acid, perfluoroalkyl.

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6) TOOTH BRUSHING TECHNIQUE• There are predominantly 4 main tooth brushing

technique that is described by Anaise, for children of 11 to 14 yrs old:

a) ROLL METHOD • The brush is placed in vestibule, the bristle ends

directed apically with the sides of bristles touching the gingival tissue.

• The patient exerts lateral pressure with sides of bristles & brush is moved occlusally.

• The brush is placed again high in the vestibule & the rolling motion is repeated.

• lingual surface same manner with 2 teeth 2gether.

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b) CHARTERS METHOD • The bristles are placed in contact with

enamel of teeth & gingiva.• The bristles are placed at 45- degree

angle towards plane of occlusion.• A lateral downward pressure is then

placed on the brush & the brush is then vibrated gently back and forth a mm or so.

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c) MODIFIED STILLMAN METHOD

• This method combines a vibratory action of bristles with stroke movement of brush in long axis of teeth

• The brush is placed at mucogingival line, with bristles pointed away from the crown, & moved with stroking motion along the gingiva & tooth surface.

• The handle is rotated toward the crown & vibrated as brush is moved.

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d) HORIZONTAL SCRUBBING METHOD

• The brush is placed horizontally on buccal & lingual surfaces

• Then brush is moved back & forth with a scrubbing motion.

• Anaise concluded that horizontal scrubbing method exhibited a more significant plaque removing

effect than the roll, charters & modified stillmans. • As this method removes more of plaque as compared to

other techniques and it is most naturally adopted by children so the HORIZONTAL SCRUBBING TECHNIQUE is the MOST RECOMMENDED brushing technique for CHILDREN.

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7) FLOSSING TECHNIQUE

1. A 18-24 inch length of floss is obtained & ends are wrapped around the fingers.

2. Thumb & index fingers are used to guide the floss b/w the 2 teeth to be cleaned.

3. Care shd be taken not to snap the floss down thru the interproximal contacts

to avoid gingival trauma.

4. Floss is then manipulated into “c”- shape around each teeth individually & moved cervical-occlusal reciprocating motion until the plaque is removed.

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AGE – SPECIFIC INSTRUCTIONSI. INFANTS (0 TO 1 yr)• The plaque removal activities should

begin on eruption of the first primary tooth.• There shd be cleaning & massaging of gums

before eruption of teeth to help establishing a healthy oral flora & to aid teething. This shd be done totally by the parent. Tooth brush can also be used if parent feel comfortable.

• This cleaning and massaging of gums can be done by wrapping a moistened gauze square or washcloth around the finger and gently massaging the teeth and gingival tissue.

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•While massaging the child can be placed in numerous ways, but ARM- CRADLING POSITION is the simplest & provides the infant more security. In this the child is cradled with one arm while massaging is done with the other. This procedure shd be practiced once daily.•Nonflouridated tooth & gum cleanser may be used.•The child's first visit todentist shd be during thisperiod.•Dentifrice is not advised to be used becoz the foaming action of the paste is objectionable.

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II. TODDLERS(1 TO 3 yr old)• Introduction of moistened, soft–bristled, child or

infant sized TOOTH BRUSH into plaque removing procedure.

• Only a non-fluoridated dentifrice shd be used.• Positioning of child and parent is again important

in this case. several positions can be used by the parent but LAP TO LAP POSITION is most common & allows one adult to control child's movements while the other adult brushes the teeth.

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III. PRESCHOOLERS (3 TO 6 yrs old)• The parents shd continue to brush the

teeth for the child.• A fluoride dentifrice can be introduced at 3 yrs of age.

Only pea sized amount of toothpaste shd be used.• Flossing is also started in this age. In the primary

dentition , posterior contacts are the only areas where flossing is needed.

• In this age the position can be such that the parent stands behind the child and both face the same direction. The child rests his or her head back in parents non- dominant arm. With the hand of this arm the cheeks can be retracted& the other hand is used for brushing . This position is also appropriate for flossing.

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IV. SCHOOL-AGED CHILDREN(6-12yr)• Most of children can provide their basic oral hygiene i.e.

brushing & flossing under active supervision by parents.• Parents can check the cleanliness of child’s teeth by use of disclosing agent. after the child has brushed, flossed & used disclosing agent, the parent can easily visualize the

remaining plaque & assist the child to remove it.• Use of fluoridated dentifrices is essential & fluoridated

gels & rinses used in children at risk for caries.• Early T/t of malocclusion in this age group.• This age is at high risk of caries & periodontal disease

so increased frequency and adequacy of brushing & flossing becomes necessary. Use chemotherapeutic agents & oral irrigators in higher risk patients.

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V. ADOLESCENT(12-19yr old)• At this age the patient has developed adequate

skills for oral hygiene procedures but compliance is major problem at this age.

• Motivating an adolescent to assume responsibility for personal oral hygiene may lead to rebellious rxns.• These patients are at a risk for caries & gingival

inflammation bcoz of poor dietary habits, pubertal hormonal changes & poor plaque control habits due to increase in self-esteem.

• Increasing adolescents knowledge regarding plaque control & oral diseases, as well as appealing to their appearance, may also help in motivating these patients.

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Tooth Brushing In Adults

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I. TOOTHBRUSHESA. TOOTH BRUSHING

TECHNIQUES1. The Bass method or Sulcus cleaning

method2. Modified bass method3. Modified Stillman’s method4. Charter’s method5. Scrub brush method6. The Roll technique7. Fones method or Circular scrub method

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I. BASS/SULCUS CLEANING METHOD

Most widely accepted & most effective method for dental plaque removal, adjacent & directly beneath the gingival margin.

INDICATIONS:a. For all patients for dental plaque removal

adjacent to & directly beneath gingival margin.b. Particularly adaptable for open interproximal

areas, cervical areas beneath the height of contour of enamel& exposed surfaces

c. For routine patients with or without periodontal involvement.

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1. Place the brush at a 45 angle against the tooth, making certain that the bristles are at gingival margin. Gently brush the surface of each tooth using a short, gentle vibratory back & forth motion.

2. Brush the outer surfaces of each tooth, upper & lower , keeping the bristles against the gingival margin . Repeat the same method on the inner surface of the teeth as well.

3. To clean the inside surfaces of the front teeth , tilt the brush vertically & make several gentle up and down strokes using the front half of brush.

4. Scrub the chewing surfaces of the teeth using a short back & forth movement. Brushing the tongue will remove bacteria & freshen your breath.

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ADVANTAGES:a. Effective method for subgingival cleansing.b. Provides good gingival stimulation.c. Easy to learn.d. Recommended for routine patients with or

without periodontal involvement.

DISADVANTAGE:a. Time consuming b. Dexterity requirement is too high

in some patients.

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II. MODIFIED BASS TECHNIQUE INDICATIONS:a. As a routine oral hygiene measure.b. Intrasulcular cleaning.

TECHNIQUE:a. The toothbrush is held such that the bristles are at

a 45- degree angle at gingiva.b. Bristles are gently vibrated back & forth motion

i.e. vibratory horizontal motion.c. In a single motion, the bristles are then swept

vertically over the sides of teeth towards their occlusal surfaces.

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ADVANTAGES:a. Excellent sulcus cleaning.b. Good interproximal & supragingival

cleaning.c. Good gingival stimulation.

DISADVANTAGES:a. Moderate dexterity of wrist is required.

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III. MODIFIED STILLMANS TECHNIQUE

INDICATIONS:a. Dental plaque removal from cervical areas

below the height of contour of enamel & from exposed proximal surfaces.

b. General application for cleaning tooth surfaces and massage of the gingiva.

c. Recommended for cleaning in areas with progressing gingival recession & root exposure to prevent abrasive tissue destruction.

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TECHNIQUE:a. Place the toothbrush at 45 degree angle

partly on gingiva & partly on cervix of teeth.b. The bristles are gently moved with a

vibratory pulsating motion& gently swept occlusally over sides of teeth.

ADVANTAGE:a. Helps in supragingival cleaning. DISADVANTAGE:a. Time consuming.b. Improper brushing can damage the

epithelial attachment.

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IV. CHARTERS METHOD

INDICATIONS:a. Indications having open inter dental spaces with missing papilla & exposed root surfaces.b. Those wearing FPD or orthodontic appliances.c. For patients who have had periodontal surgery.d. Patients with moderate gingival recession

particularly interproximally.e. Massage & stimulation for marginal &

interdental gingiva.

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IV. TECHNIQUE:a. The bristles are placed at a 90 degree angle to the tooth.b. The bristles are then moved in a circular vibratory

motion. ADVANTAGE:a. Gingival stimulation.

b. Interproximal cleansing. DISADVANTAGE:a. Brushing ends do not engage the gingival sulcus to

remove subgingival bacterial accumulation.b. In some areas the correct brush placement is limited or

impossible, therefore modifications become necessary which add to the complexity of the procedure.

c. Requirements in digital dexterity are high.

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V. SCRUB BRUSH METHOD TECHNIQUE:a. The brush is kept in 90 degree angle to the

tooth.b. The bristles are moved in horizontal

strokes. ADVANTAGE:a. Supragingival cleansing. DISADVANTAGE :a. Ineffective at plaque removal.b. Tooth abrasion & gingival recession.c. Detrimental to general oral health.

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VI. THE ROLL TECHNIQUE In patients with anatomically normal gingiva Indications:a. Children & adult patients with limited dexterity.b. Patients required gingival massage &

stimulation.c. Cleaning gingiva & removal of plaque, material

alba & food debris from the teeth without emphasis on gingival sulcus.

d. For general cleaning in conjunction with the use of vibratory technique.

e. Used as a preparatory instruction for modified stillmans technique.

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TECHNIQUE:a. Bristles are placed at a 45 degree angle to tooth

surface.b. Bristles are lightly rolled across the tooth surface

towards the occlusal surfaces. DISADVANTAGE:a. Brushing too high during initial placement can

lacerate the alveolar mucosa.b. Tendency to use quick, sweeping strokes

resulting in no brushing for the cervical third of tooth & the interproximal area.

c. Replacing the brush with filament tips directed into the gingiva may produce punctuate lesions.

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VII.FONES METHOD INDICATION: Indicated for young patients who want to

do brushing, but do not have the muscle development for techniques which requires more co-ordinations.

TECHNIQUE: a. The child is used to make big circles in air

which are then reduced in diameter very small circles are made in front of mouth

b. The brush is placed in 90 degree angle to the tooth & then bristles are moved in horizontal direction.

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ADVANTAGES:a. This technique has equal or better potential than bass

technique for plaque removal & prevention of gingivitis.b. It is easy to learn.c. Shorter timed. Physically or emotionally, handicapped individuals.e. Patients who lack dexterity for a more technical

brushing method.f. Gingiva is provided with good stimulation.

DISADVANTAGE:a. Possible trauma to gingiva.b. Interdental areas are not properly cleaned.c. This technique may cause harm to adults especially who

use the brush vigorously.

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TECHNIQUE BRISTLES POSITION

BRUSHINGMOTION

EFFECT CLAIMED

BASS 45 degree to tooth Vibratory horizontal

Subgingival cleansing, gingival stimulation

MODIFIED BASS 45 degree in sulcus Sweep occlusally Supragingival cleansing

CHARTERS 90 degree to tooth Circular vibratory

Gingival stimulation, interproximal cleaning

MODIFIED CHARTERS

90 degree to tooth Sweep occlusally Supragingival cleansing.

TOOTH BRUSHING METHODS

CONTINUED…….

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TECHNIQUE BRISTLES POSITIONING

BRUSHINGMOTION

EFFECT CLAIMED

STILLMAN 45 degree to apex; part on gingiva & part on cervix tooth

Vibratory pulsing Gingival stimulation

MODIFIED STILLMAN

45 degree to apex; part on gingiva & part on cervix tooth

Sweep occlusally Supragingival cleansing

HORIZONTAL SCRUB

90 degree to tooth Horizontal strokes Supragingival cleansing

FONES 90 degree to tooth

Large circles over tooth & gingiva

Supragingival cleansing

ROLLING 45 degree to tooth Rolled towards occlusal surface

Gingival stimulation

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MOTIONS USED METHODS

Horizontal Scrub method

Vibratory BassStillmansCharter

Vertical Sweeping Rolling strokeModified bassModified stillmanModified charter

Rotary Fones

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B. EFFECTS OF IMPROPER TOOTH BRUSHING

I. Toothbrush trauma: gingival alterations Acute alteration Chronic alteration

a. ACUTE ALTERATION(LACERATIONS)1. Scuffled epithelial border with denuded underlying connective

tissue.2. Punctate lesions that occur as red pinpoint spot.3. Diffuse redness && denuded attached gingiva.PRECIPITATING FACTORS:4. Horizontal or vertical scrubbing tooth brushing method with

pressure (either manual or powered)

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2. Over vigorous placement & application of toothbrush.3. Penetration of gingiva by filament ends.4. Use of toothbrush with frayed , broken bristles or filaments.5. Application of filaments beyond attached gingiva.

b. CHRONIC ULCERATIONS1. Usually appear on the facial gingiva becoz of the vigor with which

toothbrush is used.2. Areas most commonly involved are around canines or teeth in labio-

or bucco- version.

• RECESSION1. Appearance: margin of the gingiva has receded towards the apex &

cementum is exposed.2. Predisposing anatomic factorsi. Malposition of teeth.ii. Narrow band of attached gingiva cannot withstand pressures of

brushing

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• CHANGES IN GINGIVAL CONTOUR1. Rolled, bulbous, hard firm marginal gingiva in ‘piled up’ or festoon

shape.2. Gingival cleft.PRECIPITATING FACTORS3. Repeated use of vigorous rotary, vertical or horizontal tooth brushing

techniques over a long period of time.4. Use of long, brisk strokes with excessive pressure over a long period

of time.5. Habitual prolonged brushing in one area.6. Excessive pressure applied with worn out non-resilient brush.

Suggested corrective measures• Use of softer toothbrush.• Demonstration of proper brushing technique.

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II. Abrasion of teethDEF: Abrasion is loss of tooth substance produced by mechanical wear

other than by mastication, or it may be defined as pathologic wearing away of tooth substance through some abnormal mechanical process.

CONTRIBUTING FACTORSi. Hard toothbrush.ii. Horizontal brushingiii. Excessive pressure during brushing.iv. Abrasive agent in the dentifrice.v. Prominence of tooth surface labially or bucally.

LOCATION OF ABRADED AREASvi. Facial surfaces of canine, premolars & first molars or any tooth in

bucco- or labio version.vii. Most abraded area cervical areas of exposed root surface.

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APPEARANCESaucer shaped or wedge shaped indentations with smooth shiny

surfaces

CORRECTIVE MEASURESi. Advise a specific brush with soft textured bristles or filaments.ii. Change the tooth brushing technique.iii. Recommend a less abrasive dentifrice.iv. Use a smaller amount of dentifrice.

C. MAINTAINENCE OF TOOTHBRUSH• As toothbrushes are vehicle in breeding & transmitting various

organisms so advised cleaning with antiseptic mouthwash.• Store in dry areas as wet areas may allow bacterial proliferation.• Toothbrush shd be kept in open air with head in upright position

with no contact with other brushes.• Toothbrush has an avg. lifespan of 3 to 6 months.

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II. INTERDENTAL CLEANING AIDS• The toothbrush is not adequate for interproximal

cleaning.

A. DENTAL FLOSS Dental floss is available in forms:• Multifilament – twisted / non twisted• Bonded / non bonded• Thick / thin• Waxed / non waxed Unwaxed dental floss is better than waxed bcoz:i. Small diameter & pass easily thru tight interproximal

contact.ii. Under tension it flattens on tooth surface.iii. Unwaxed floss makes a squeaking noise & this can be

used to monitor performance.

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• Interproximal / Interdental brushes• Powered interdental brushes

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CLASSIFICATION OF FLOSS ON BASIS OF GINGIVAL EMBRASURES

TYPES OF EMBRASURE

CONDITION OF GINGIVA IN EMBRASURES

CLEANING AIDS RECOMMENDED

TYPE 1 Embrasures are completely occupied by healthy interdental papilla

Superfine & thin dental floss, used only for cleaning sulcus.

TYPE 2 About 75% of embrasure occupied by gingiva

Medium or coarse & thick dental floss.(wooden tips)

TYPE 3 About 50% of embrasure is occupied by gingiva

Thin fine pointed small spiral interdental brushes (unitufted)

TYPE 4 About 25% of embrasure is occupied by gingiva.

Thick spiral interdental brushes & fine bristle ended unitufted brushes.

TYPE 5 Complete loss of interdental papilla & gingiva from the embrasure. The level of the gingiva in the interdental space is same as the buccal & lingual gingiva on the teeth.

Bristle ended unitufted brushes & thick spiral interdental brushes.

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III. TONGUE SCRAPING• The process of removing debris from surface of tongue

with some form of scraper designed for this purpose.• Most tongue scrapers are made of soft flexible plastic. TECHNIQUES:1. BRUSHINGa. Place sides of the brush on the dorsum of the tongue

with the tip directed towards the throat.b. Apply light pressure & move the brush forward & out,

repeat to cover the entire surface.2. TONGUE CLEANING DEVICESa. Device is placed towards the back of tongue on the

dorsal surface, the pulled forward with light pressure.b. Used in patient with elongated papilla, deep fissures or

surface coating.

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IV. IRRIGATION DEVICES• Valuable in removing the unattached plaque & debris.• Mainly composed of a pump & a reservoir • These devices are used to deliver antimicrobial agents

eg:chlorhexidine.

V. CHEMICAL PLAQUE CONTROL• Ideal adjunct to mechanical plaque control specially in

individuals with a defective host defence mechanism, mentally or physically handicapped & in patients who have undergone surgical procedures postoperatively.

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REFRENCES:-1. SOBEN PETER2. JOSEPH JOHN3. CARRENZA4. Textbook of periodontology- WILKINS5. Textbook of child & adolescent-

MCDONALD.

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THANK YOU