Prevention of periodontal disease

Prevention of periodontal disease
Omar Karadsheh

Aims Aetiology Implications and importance of preventing periodontal disease Preventive methods Mechanical plaque removal Chemical plaque removal

Periodontal Disease Group of infections that affect the supporting structures of the teeth Gingivitis – inflammation restricted to the gingival marginal Periodontitis – resorption of the supporting connective tissue attachment and apical migration of the junctional epithelia Marginal and attached gingivae Periodontal ligament Alveolar bone Healthy oral epithelium is keratinized – areas of the epithelium are not keratinized (

What causes Periodontal Disease?
DENTAL PLAQUE Non mineralized, bacterial aggregation on the teeth and other solid structures in the mouth bacterial cells (70%) protein extracellular polysaccharides epithelial cells white blood cells Dental plaque is the major aetiological factor in periodontal disease pathogenesis It adheres tenaciously and resists removal by salivary flow or a gentle flow of water The exact structural, bacteriological and biochemical compostion of plaque is subject to great variation depending on Concentration of bacteria in saliva The site and duration of plaque formation The nautre of the resident flora Oxygen and nutrtient availability Composition o fthe diet Presence of perdiondontal disease

Dental Calculus? Result of mineralization within plaque
(70-90% inorganic content) Not in itself causative of periodontal disease provides a rough PLAQUE retaining surface distorts the gingival crevice and increases stagnation areas – allows greater bacterial proliferation within the crevice Inorganic content is 70-90%

Factors affecting PD Local factors Host factors

Local factors that increase plaque accumulation
Iatrogenic Rough surfaces Overhanging restorations Removable partial dentures Fixed orthodontic appliances Space maintainers (band and loop, etc.)

Host Factors modifying the immune response
Smoking Periodontitis is 2 – 5 times more severe amongst smokers compared to non-smokers Nicotine Diabetes (type 1 and 2) 2 - 3 fold increase risk of periodontitis related to degree of diabetic control, presence of complications and duration of the syndrome Host defense mechanism can be both protective and destructive Subtle changes in the ability of the host to deal with the bacterial challenge may caused an increased risk to periodontal disease Other: Reduction in the ability of neutrophils to adhere to capillary walls Production of cytokines Reduction in serum immunoglobulins The most recognized of these risk factors are smoking and diabetes Considerable research hs found that nictoine has wide effects on the host imune system

Aims Aetiology Implications and importance of prevention
Preventive methods Mechanical plaque removal Chemical plaque removal

Implications for prevention
Chronic gingivitis is reversible if effective plaque control is introduced GINGIVITIS and PERIODONTITIS can be prevented by adequate plaque control Preventive strategy should be customized for each individual – variation in susceptibility Since gingivitis is prerequisite for periodontitis, BOTH GINGIVITIS and PERIODONTITIS can be prevented by adequate plaque control

Why prevention is important?
Gingivitis is common in both children and adults Children - 26%- 63% (UK Children Dental Health Survey, 1993) Adults – almost 100% 1 mm attachment/bone loss Prevalence and severity of PD increases with age – more children with plaque and inflammation in 1993 than 1983, 1973 Tooth mortality caries and PD are the most common reasons for adult tooth extraction, PD is less important especially in populations with high caries risk

Why prevention is important (cont)
2. Important cause of tooth loss Scotland - 55% caries % PD 3. Time-consuming and difficult to treat 4. Potential source of systemic bacteraemia Infective Endocarditis, coronary heart disease Stroke Low-birth weight preterm infants Diabetes

Aims Aetiology Importance of preventing periodontal disease
Preventive methods Mechanical plaque removal Chemical plaque removal

Mechanical Plaque Control
Mechanical plaque control is the first choice in preventing periodontal disease as it removes the etiologic factors of gingivitis and periodontis – plaque and the pathogenic microlfora colonizing the tooth surfaces

Self Care Toothbrushing Interdental cleaning Professional Scaling/Root planing Polishing Studies in children and adults have shown that high quality plaque control can prevent and control gingivitis and periodontits (Axelsson, 1998)

Toothbrushes The first true bristled brush was invented in China in 1498 for the Emperor using animal hair (pigs) By the early 1800’s bristled brushes were in general use Nylon bristles were introduced around 1938 1960’s – development of power toothbrushes (electric) German Archaeologists have unearthed what they think may be the oldest known toothbrush in Europe. The toothbrush, which is ten centimetres long and carved out of animal bone, is thought to be 250 year’s old. Although the bristles have decomposed through the centuries and the find doesn’t quite compare to the colourful and varied toothbrushes we can buy today, it still shows that our ancestors had an interest in their The first true bristled toothbrush also originated in China at around 1600 AD. At around 1780, the first toothbrush was made by William Addis of Clerkenald, England. Addis, and later, his descendants, manufactured the finest English brushes, where the handles were carved out of the bone of cattle and the heads of the natural bristles were placed in the bored holes made in the bone and kept in place by thin wire. The natural bristles were obtained from the necks and shoulders of swine, especially from pigs living in colder climates like Siberia and China. By the early 1800s the bristled brushes were in general use in Europe and Japan. In 1857, H. N. Wadsworth was credited as the first American to receive a toothbrush patent as America entered the growing toothbrush market. In 1844, the first toothbrush was manufactured by hand and patented as a 3-row brush of serrated bristles with larger tufts by Dr. Meyer L. Rhein. In 1885, the Florence Manufacturing Company of Massachusetts, in association with Dr.Rhein, began producing the Pro-phy-lac-tic brush for mass marketing in the United States. As technology progressed, synthetic bristles replaced the natural swine bristles. Nylon was first applied to the toothbrush at around 1938 and by 1939, electric toothbrushes arrived in an attempt to offer the public a brush that could simulate the action of a manual brush but with better results and cleaning performance.

Requirements of a Satisfactory Toothbrush
Have good cleaning ability Cause minimal damage to soft and hard dental tissues Having a reasonable lifespan (good wear characteristics) Non-toxic

Manual toothbrushes Handle size appropriate to the user’s age and dexterity Head size appropriate for the user’s mouth Adult – 2.5 cm Child – 1.5 cm There are design variation in toothbrushes including dimensions of the head the length diameter and modulus of elasticity of filaments and their number distribution and angulation. Head size appropriate for the user’s mouth Adult – 2.5 cm Child – 1.5 cm Small enough to be used effectively everywhere in the mouth There is no clear evidence that one particular type of brush is superior to others with respect to plaque control Consensus favors compact arrange of send nylon filaments – hard-textured bursh has been linked to gingival recessions.

Hard brushes should never be recommended
Compact arrangement of soft, end rounded nylon filaments not larger than inches in diameter Hard brushes should never be recommended lacerate the gingiva, gingival recession and tooth abrasion Diameter is too large to enter the gingival crevice

Bristle patterns that enhance plaque removal in approximal spaces and along gum margin
Filaments arranged at different heights and angles significantly more effective at reducing plaque and gingivitis than flat trim brushes (Balanyk et al., 1993)

Requirements of a Satisfactory Brushing Technique
Technique should clean all tooth surfaces, especially interdental and gingival crevice Movement of the brush should not injure the soft or hard tissues Simple and easy to learn Well-organized so that each part of the dentition is brushed in turn and no area overlooked Well organized – the mouth can be divided into a number of sections depending on the size of the dental arch and the size of the toothbrush

Brushing Techniques Vertical Horizontal Roll Technique
Vibrating (Bass, Stillman, Charter) Circular Scrub Toothbrushing techniques are categorized accoriding to the direction of the brush stroke

Bass technique most recommended by dentists
Brushing Technique Bass technique most recommended by dentists Comparative studies have shown different results Bass technique is the most widely recommended by dentists as it seems to fulfill the requirement of the satisfactory burhsing technique More realistic to modify the patients existing method of burshing emphasize need to repeat the procedure on all tooth surfaces (especially on lignual surfaces which are neglected usually and other problem areas)

Brushing Technique aims to clean the gingival crevice
Bass technique aims to clean the gingival crevice brush held at 45° to the axis of the teeth so that the end pointing into the gingival crevice Involves placing the bristles at a 45 degree to the long azxis of the teeth and vibrating the brush in an anterior-posterior direction to remove plaque vibrating movement is done, not a displacement of the filaments, it is like if the filaments are moving without variation the position of the extreme end of the filaments. This movement is done approximately for 10 seconds in each group of 2 -3 teeth.

Brushing Techniques Research shows no particular method superior to any other Modify the patients method Emphasize need to repeat the procedure on all tooth surfaces British Dental Journal in 2003 did a systematic review of the literature about which brushing technique is superior and they concluded that there was no particular technique superior to any other The authors believe it is more realistic to modify the patients existing method of brushing emphasizing the need to repeat the procedure on all tooth surfaces More realistic modify the patients existing method of brushing A person can brush how he pleases as long as the dental plaque is removed without damaging the gums or the teeth, and as a dentist this should be respected since is very hard to change a person's brushing habits, even harder is to teach someone who has never brushed.

Powered toothbrushes Oscillating, rotating or counter-rotational movements Oscillating/rotating (Braun Oral B) more effective in removing plaque and reducing gingivitis than a manual toothbrush (2003) The most recent electric toothbrushes have rotating circular heads designed to clean each tooth surface separately. The head should be placed on each tooth surface in turn using an ordered process so that all facial and lingual surface are cleaned . If patient using this type of brush advice them to make sure that the most apical brushes are placed at the gingival margin so that the crevice is cleanred. Larger teeth like molars will have to be cleaned in two stages – distal and mesial. Pressure controls Timers Interplak brushes - These brushes are known as "counterrotational" toothbrushes. The brush head of these brushes looks similar to a standard manual toothbrush but each individual tuft of bristles in the brush head rotates, in opposite direction as its neighbor. Timers added to give idea of duration of brushing A recent Cochrane review found that powered toothbrushes with oscillating/rotating movement were more effective in removing plaque and reducing gingivitis than a manual toothbrush (2003) Professional advice given on their use - such as : Professional advice and instruction should be given on their use

Ultrasonic toothbrushes (Sonicare)
high frequency vibration (30,000 – 40,000 brush strokes/min) Two mechanisms of actions Conventional - scrubbing effect Vibratory motion – impact energy to oral fluid that surround the teeth – fluid pressure and shear forces A sonic toothbrush is easily identified by the high rate of speed at which its brush head vibrates. The brush head of a sonic toothbrush is capable of creating in excess of 30,000 brush strokes per minute (the newest models of sonic toothbrushes will typically create over 40,000 brush strokes per minute). It is the vibrational motion of these brushes that sets them apart from all previous generations of electric toothbrush design The cleaning action of a Sonicare ® toothbrush (or any other type of true "sonic toothbrush") is actually based on two separate mechanisms. One of the mechanisms is a conventional technology similar in nature to that employed by all other types of toothbrushes. The second cleaning action is based on a new technology that was first introduced by the Sonicare ® people and one that is entirely unique to sonic toothbrushes. The primary mode of cleaning produced by a sonic toothbrush is created by the scrubbing action of the brush's bristles on the surfaces of teeth. Of course this method of cleaning teeth is not new. All toothbrushes, both electric and manual, rely on this same principle for removing dental plaque. ( More... ) A secondary cleaning action is also produced by Sonicare ® toothbrushes and it is based on new technology developed by its creators. This cleaning action is founded in the intense speed at which the bristles of the sonic toothbrush vibrate. This vibratory motion is able to impart energy to the oral fluids that surround teeth (such as saliva). The motion of these agitated fluids is capable of dislodging dental plaque, even beyond where the bristles of the toothbrush actually touch. Only a sonic toothbrush can make this claim. The brush head of your sonic toothbrush has been designed to vibrate at over 30,000 brush strokes per minute. This high speed brushing motion is capable of creating movements in the fluids that surround your teeth, creating fluid pressure and shear forces. These fluid dynamics are capable of dislodging dental plaque in those hard to reach areas between teeth and below the gum line. The cleaning effect of these fluid forces has been measured to occur at distances of up to 4 millimeters (slightly more than 1/8th of an inch) beyond where the bristles of your sonic toothbrush actually touch.

?????? Which toothbrush????? Manual vs. Electric Which electric???
Athough evidence suggest that powered toothbrushes imporve plaque control this may be due to a ‘novelty’ effect of brushing with a new and exciting product

Manual vs. Electric Electric toothbrushes remove more plaque than manual toothbrushes Electric toothbrush is recommended for individuals who are unable to maintain effective plaque control Physical or learning disability Fixed orthodontic appliances Institutionalized patients depend upon care providers A manual toothbrush is appropriate for most people Subject control is more important than the appliance Short term ‘novelty’ effect of powered toothbrushes??

Which electric toothbrush?
Oscillating/rotating (Braun Oral B) performs better than Ultrasonic (Sonicare) (Strate et al., 2005) Whole mouth plaque was reduced by 88% versus 61% and approximal plaque by 97% versus 73% for the PCS and SE toothbrushes, respectively. There was no evidence of hard or soft tissue trauma after a single-use of either toothbrush. CONCLUSION: Based on the findings of this single-use clinical evaluation, the action of the oscillating/ pulsating power toothbrush is more effective at plaque removal than a high frequency power toothbrush. There is no consensus on which electric toothbrush is best Website sonic oral-b and philips sonicare..each claim its better

Brushing in Children Start brushing as soon as the first tooth erupts
Preschool children need help with brushing

Frequency and duration of brushing
Effective plaque removal every second day has been shown to prevent gingivitis (Lang et al., 1973) Twice daily brushing is consistent with maintaining good gingival health 2 - 3 minute duration is recommended Effective plaque removal every second day has been shown to prevent gingivitis (Lang et al., 1973) Few people clean their teeth so well at one time that all the plaque is removed Twice daily brushing is consistent with maintaining good gingival health Plaque forms continuously on tooth surfaces cannot be maintained in a plaque-free state by conventional mechanical means. The object of plaque control in prevention is therefore the periodic removal of accumulated plaque at intervals which are sufficient to preventy pathological effectsn arising from recurrent plaque accumulation Few people clean their teeth so well at one time that all the plaque is removed, therefore more frequent brushing is recommended Less frequent removal of plaque did not prevent or reduce gingivitis Individual susceptibility to gingivits and peridootntis may be another important facto to consider in selecting a suitable frequenty of tooth cleaning depends on the thoroughness of cleaning, the gingival condition and on individual susceptibility to PD The prevalence of visible plaque, calculus and carious lesions was found to be greater in those who brush once a daily or less than those who brushh twice daily (Adult Dental Health Survey, Oral Healthin the UK, 1998) Although no optimum frequency has been determined there is the consensus that twice daily brushing will maintain good gingival health There is no reason to alter this advice

Replacing toothbrush Splaying of the toothbrush is the most obvious sign of toothbrush wear Renewal is usually recommended after 3 months use This is influenced by the quality of the brush Replace it when the bristle tip is seen when the toothbrush is looked at from behind. Research has found that women tend to replace their brush more frequently than men

Interproximal Cleaning
Periodontal conditions are worst in interdental areas Toothbrush are less effective at removing proximal surface plaque Should be recommended in accordance with individual dexterity and interdental anatomy

Plaque Removal

Interproximal cleaners
Dental floss Interspace brush Interdental brush Wood points (toothpicks) Irrigation devices

Dental Floss Waxed/Unwaxed Tape Superfloss Flosette
Thread used to clean in between teeth Waxed and unwaxed floss are the most common. Some people prefer waxed floss because it slips between the teeth more easily than unwaxed floss and is less likely to break. Tape floss is flat rather than round and is typically thicker than regular floss. Tape takes less force to get in between your teeth than the regular round type so some people prefer it. There is little apparent difference between cleaning ability of waxed and unwaxed although some patients prefer waxed as it is easier to insert between the teeth There is no difference in their effectiveness at reducing interdental gingival bleeding Dental Floss is rounded, with or without wax. It is said that the wax allows a better penetration on the interdental gaps. Some manufactures also add flavor like mint and impregnated it with fluoride so it deposits on the teeth. Dental Thread is flat and harder to introduce interdentally but has the advantage of increasing the surface of performance therefore eliminating more bacterial plaque

Flossing technique?? take a length of the floss (about 45cm) and wrap it round the second finger of each hand, making sure that you leave a small piece (about 5cm) to use9 use your thumb and finger to place the floss between the teeth and wrap it around the side of one of your teeth pulling the floss tight, slide it up and down against your tooth surface and under your gumline repeat this action between each tooth making sure that you use a clean piece of floss for each one

Dental Floss Waxed/ Unwaxed Tape Superfloss Flosette
Super floss is used to clean under bridges. It has a thin piece of floss that you feed under the bridge which you then pull through until you reach a thicker piece. This thicker piece cleans under the bridge next to the gumline. Thread with nylon or foam (Floss), it has an initial hard section without nylon, that helps introducing it into the interdental gap. It eliminates a great amount of plaque and it is highly recommended to clean fixed prosthesis and implants. Since it is wider than the rest, when the interdental gap is small it is better to use any of the other two kinds of floss described above.

Dental Floss Waxed/Unwaxed Tape Superfloss Flosette
A flosette is a plastic handle that holds a length of floss. It can be held in one hand and can make it easier to direct where the floss is going than using your fingers.

Toothpicks Effective only when sufficient interdental space is available Triangular toothpicks are superior to round or rectangular Incorrect use may cause gingival lesions Wood toothpicks also made of synthetic materials sufficient interdental space is available to accommodate it

Interspace Brush Used for tipped, rotated or displaced teeth, teeth with gingival recession Limited value except for surfaces adjacent to an extraction space

Interdental brush Superior to floss for cleaning open spaces
May be used for cleaning around fixed orthodontic appliances

Irrigation Devices A steady or pulsating stream of water through a nozzle under pressure Eliminate food residue accumulated interdentally They are machines that project spurts of water with certain pressure, with the objective of eliminating food residue accumulated interdentally, in conventional fixed prosthesis, and in supported implants and in these cases they are highly recommended. Even though commercial brands state that they eliminate bacterial plaque, the amount of plaque reduced is very little, reason why it is not very useful for this, since there are better methods and systems like the ones described above. In patients with periodontal diseases, irrigators are very effective specially when to the water is added an anti - plaque substance like clorhexidina, sanguinari

Irrigation Device (cont.)
NOT A SUBSTITUTE FOR BRUSHING Time-consuming and messy Used to deliver chemical agents to the oral cavity Not very effective at removing plaque Sometimes an electric toothbrush will have a irrigation device attached

To floss or not to floss?

To floss or not to floss? Recommended by the federal government in When the federal government issued its latest dietary guidelines 2015, the flossing recommendation had been removed, without notice. In a letter to the AP, the government acknowledged the effectiveness of flossing had never been researched, as required.

Self Care Toothbrushing Interdental cleaning Professional Scaling/Root planing Polishing Dental plaque control is the first choise in preventing periodontal disease as it removes the etiologic factors of gingivitis and periodontis – plaque and the pathogenic microlfora colonizing the tooth surfaces Studies in children and adults have shown that high quality plaque control can prevent and control gingivitis and periodontits (Axelsson, 1998)

Scaling and Root Planing
Scaling sufficient to remove plaque and calculus from enamel leaving a smooth clean surface Root surfaces - Root planing calculus may be embedded in cemental irregularities Contamination of toxic substances in cementum – biologically unacceptable to gingival tissue Subgingival debridement should result in sufficient plaque free environment to allow renewal of junctional epithelium and the epithelial attachment. The degree of subgingival root sruface cleansing necessaru to achieve this is likely to vary from patient to patient and from site to site. Although it is well established that non-surgical instrumentation often fails to achieve complete removal of plaqu and calcculus, it may be still conpatible with periodontalhealth and sometimes failure fo complete plaqu removal will allow recolonization of the root surface and inflammation to persist OF course still need to maintain good supragingival plaque control to allow pocket healing

Recall intervals Aim Prevent recurrence and progression of PD
Prevent tooth loss Increase probability of diagnosing and treating in a timely manner other oral disease 1. Reinforcement of oral hygiene instruction 2. Supragingival scaling or root planing as necessary Frequency? 3 month recall is favoured by most clinical trials fFollowing periodontal treatment the long term stability of the peridontal tissues is achieved with a programme of supportaive peridontal or maintenance care Aim of supportive care 1prevent recurrence and progression of PD Prevent tooth loss Increase probability of diagnosing and treating in a timely manner other oral disease Tailored to individual Involves Reinforcement of oral hygience instruction Reintervention iwht scaling root planing or both Frequency of recalls – no clear evidence to indicate what gives the best longterm effects 3month recall is favoured in most clinical trials – again depends on the individual and the case….although cochrane Cochrane: Scale and polish for chronic periodontal disease. Elley K, Gold L, Burls A, Gray M Authors' conclusions In the reviewed studies, there was found to be some positive effect of dental scaling in most cases. However, the magnitude of differences between quarterly and annual scaling after one year were small and at levels which would not be clinically detectable with the equipment usually used for measuring them in primary dental care. The existing studies relate to specialist settings or groups which may not be representative of NHS General Dental Practice. Evidence confirming the above findings in the general dental population is required before a change in policy on dental scaling interval can be recommended Cochrane 2005: Authors' conclusions: The research evidence is of insufficient quality to reach any conclusions regarding the beneficial and adverse effects of routine scaling and polishing for periodontal health and regarding the effects of providing this intervention at different time intervals. High quality clinical trials are required to address the basic questions posed in this review.

Professional Cleaning - Polishing
Polishing enamel – reorientation of surface crystals to create a smoother surface Experimental studies shown polishing inhibits formation of pellicle, plaque and calculus No evidence that periodontal health improves Removal of fluoride from superficial layers of enamel is a significant drawback Experimental evidence suggest that polishing to a high gloss inhibits formation of pellicle, plaque and calculus May be beneficial fro cosmetic reasons – removing some extrinsic stains and psychological benefit of having cleaner teeth but has a significal drawback of removal of fluoride Tehrefore ther is no scientific ground of polishing as a routine unless there is evidence that surface roughness is iinhibiting plaque removal

Mechanical plaque control in special needs patients
Mental disability Physical disability

Denture brush and regular toothbrush handles enlarged using soft rubber balls to give improved hand grip

Double-headed brush for improved plaque control in people who would otherwise require assistance with toothbrushing

Double-headed brush with modified handle (using silicone putty) for ease of grip

TePe interdental brush showing handle for easy holding

Boy with Asperger’s syndrome using a large-handled electric toothbrush

Toothpaste pump and dispenser

Carer cleaning the teeth of a person with a disability such that they can no longer perform this task

Aims Aetiology Implications and importance of preventing periodontal disease Preventive methods Mechanical plaque removal Chemical plaque removal

Conclusion Mechanical plaque removal is the backbone of periodontal disease prevention

Reference Prevention of Oral Disease Murray, Nunn, Steele 4th Edition
2003

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Prevention of periodontal disease

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