1. MECHANICAL
PLAQUE CONTROL

2. OBJECTIVES Background Mechanical plaque control (a) Toothbrush
(b) Dentifrice
(c) Interdental cleaning aids
- Dental floss
- Interdental brushes
- tooth pik
(d) Oral irrigation

3. IMPORTANT CHAPTER
CLINICALLY VERY RELEVANT
REQUIREMENT FOR PATIENT TEACHING

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

6. 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

7. The removal of plaque also decreased the rate of formation of calculus
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.

8. Masses of plaque first develop ( Lang,1973)
MOLAR & PREMOLAR AREAS
PROXIMAL SURFACES OF THE ANTERIOR TEETH
FACIAL SURFACES OF THE MOLARS & PREMOLARS

9. 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

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

12. Self-performed Tooth brushing Interdental aids Adjunctive aids
Dental floss and tape
Toothpicks
Interproximal brushes
Single-tufted brush
Adjunctive aids
Dental irrigation devices
Tongue scrapers
Dentifrices

13. TOOTH BRUSH Toothbrush Design Methods of toothbrushing
Frequency and effectiveness of toothbrushing
Toothbrush wear and replacement
Electric toothbrushes

14. The Toothbrush First “toothbrush” -15th Century in China
First modern toothbrush - England in 1780 by William Addis – mass produced

15. The Toothbrush Nylon toothbrush bristles - 1938 in USA (Du Pont)
First electric toothbrush -1960s (Broxodent)
1987 – first rotary action electric toothbrush

16. 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.

17. 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

18. Toothbrush bristles
Natural: hog
Artificial filaments: nylon

19. NATURAL ARTIFICIAL Source Uniformity Diameter End shape Limitations
Hair of hog/ wild boar
Synthetic, plastic material mainly nylon
Uniformity
Non uniform
Uniform
Diameter
Varies
Extra soft: 0.075mm
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

20. Bristle hardness
Proportional to the square of the diameter and inversely proportional to the square of bristle length
Soft brush: inch(0.2 mm)
Medium brush: inch(0.3 mm)
Hard brush: inch(0.4 mm)

21. 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.

22. 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.

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

24. Effects and sequel of the incorrect use of toothbrush
REASON
Gingival erosion
Toothbrush stiffness
Gingival recession
Method of brushing
Gingival abrasion
Brushing frequency

25. Toothbrushing methods
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

26. 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 )

27. 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 45o, 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
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 45o to tooth surface
Apply pressure as in stillmans's method but vibrate brush and also move occlusally
Easy to master

28. 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 45o, 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
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 45o to tooth surface
Apply pressure as in stillmans's method but vibrate brush and also move occlusally
Easy to master

29. Bass method
Charters method

30. 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 emphasize sulcular placement of the bristles.
Plaque control devices should be tailored according to individual plaque control needs.

31. 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.

32. TECHNIQUE
The bristles are placed at a 45 degree angle to the gingiva and moved in small circular motions.
Strokes are repeated around 20 times,3 teeth at a time.
On the lingual aspect of the anterior teeth, the brush is pressed into the gingival sulci and proximal surfaces at a 45 angle.
The bristles are then activated.
Occlusal surfaces are cleaned by pressing the bristles firmly and then activating the bristles.

33. Bass method

34. ADVANTAGES DISADVANTAGES Effective method for removing plaque.
Provides good gingival stimulation.
DISADVANTAGES
Injury to the gingival margin.
Time consuming.
Dexterity.

35. MODIFIED BASS TECHNIQUE
INDICATION:
As a routine oral hygiene measure
Intrasulcular cleansing.

36. 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.

37. ADVANTAGES DISADVATAGES EXCELLENT SULCUS CLEANING.
GOOD INTER PROXIMAL AND GINGIVAL CLEANING.
GOOD GINGIVAL STIMULATION
DISADVATAGES
DEXTERITY

38. MODIFIED STILLMAN’S TECHNIQUE
INDICATIONS
DENTAL PLAQUE REMOVAL
CLEANING TOOTH SURFACES AND GINGIVAL MASSAGE .
DISADVANTAGE
TIME CONSUMING
DAMAGE EPITHELIAL ATTACHMENT.

39. 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.

40. CHARTER’S METHOD INDICATIONS: Persons having :-
Missing papilla and exposed root surfaces.
FPD and Orthodontic appliances.
Periodontal surgery.
Interproximal gingival recession.

41. 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.

42. ADVANTAGES DISADVANTAGES Massage and stimulation of gingiva.
Poor removal of subgingival bacterial accumulations.
Limited brush placement.
Requirements in digital dexterity are high.

43. 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

44. 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.

45. Lecture II

46. Col area

47. 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

48. Powered toothbrushes Invented in 1939. Motions: Back and forth
Circular
Elliptic
Combinations

49. Cleaning action by:
Mechanical contact between the bristles and the tooth
Low-frequency acoustic energy generates dynamic fluid movement and provides cleaning slightly away from the bristle tips.

50. INDICATIONS: Children and adolescents
Children with physical or mental disabilities
Hospitalized patients, including older adults who need to have their teeth cleaned by caregivers
Patients with fixed orthodontic appliances.

51. 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.

52. DENTIFRICES
Aids in cleaning and polishing tooth surfaces.

53. Composition:
Abrasives- silicon oxides, aluminum oxide
Humectants
Water
Soap or detergent
Flavoring and sweetening agents
Therapeutic agents such as fluorides and pyrophosphates
Coloring agents and preservatives.

54. The term dentifrice is derived from dens (tooth) and fricare (to rub)
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.

55. Dentifrices are marketed as Toothpowders Toothpastes Gels

56. Original purpose: Pleasant taste Cosmetic effect
Remove extrinsic stains

57. Abrasives Degree of abrasive hardness depends on:
inherent hardness of the abrasive
size of the abrasive particle
shape of the particle

58. Other variables:
the brushing technique
pressure on the brush
the hardness of the bristles
the direction of the strokes
number of strokes

59. Abrasives used: Calcium carbonate calcium phosphate
baking soda (sodium bicarbonate)
Silicas
silicon oxides
aluminum oxides

60. 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.

61. To solve this problem, humectants were added to maintain the moisture.
Commonly used humectants are:
Sorbitol,
Mannitol,
Propylene glycol

62. Advantages:
Long shelf life
Maintained moisture content
Nontoxic
Disadvantages
Mold or bacterial growth can occur in their presence

63. 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.

64. 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.

65. Detergents Substitute to soaps
sodium lauryl sulfate (SLS) is the most widely used detergent

66. Advantages of SLS:
Stable
Possesses some antibacterial properties
Has a low surface tension which facilitates the flow of the dentifrice over the teeth
Active at a neutral ph
Flavor is easy to mask
Compatible with the current dentifrice ingredients

67. 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

68. Synthetic flavors are blended to provide the desired taste.
Spearmint,
peppermint,
wintergreen,
cinnamon,
other flavors give toothpaste a pleasant taste, aroma, and refreshing aftertaste

69. Sweetening Agents
In early toothpaste formulations, sugar, honey, and other sweeteners were used.
DISADVANTAGE: these materials can be broken down in the mouth to produce acids and lower plaque pH, they may increase caries RISK.

70. Replaced with:
Saccharin,
Cyclamate,
Sorbitol,
Mannitol

71. 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.

72. SPECIFIC DENTIFRICES:

73. 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

74. 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.

75. Therapeutic toothpastes, dispensed on prescription, could contain up to 260 mg of fluoride in a tube.

76. OTC safe levels:
0.22% sodium fluoride (NaF) at a level of 1,100 ppm,
0.76% sodium monofluorophosphate (MFP) at a level of 1,000 ppm,
0.4% stannous fluoride (SnF2) at a level of 1,000 ppm.

77. Fluoride levels were increased to 1,500 ppm sodium monofluorophosphate in "Extra Strength Aim," marketed OTC.
In published studies, this product was 10% more effective than an 1,100 ppm NaF dentifrice.
A recently introduced prescription dentifrice, Colgate Prevident contains 5,000-ppm

78. Stannous Salts
Stannous fluoride (SnF2), specifically the stannous ion, has reported activity against caries, plaque, and gingivitis.
While SnF2 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.

79. 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
Triclosan can be considered safe for use in dentifrice and mouth rinse products.

80. 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.

81. Antihypersensitivity Dentifrices
Active agents such as:
potassium nitrate,
strontium chloride,
sodium citrate

82. Whiteners Controversial
These dentifrices control stain via physical methods (abrasives) and chemical mechanisms (surface active agents or bleaching/oxidizing agents).

83. LECTURE 3

84. Interdental cleaning aids
Dental floss
Interdental brushes
Wooden or rubber tips

85. Gingival embrasure space: a small triangular open space
V-shaped spillway next to the contact area of adjacent teeth
Gingival embrasure space evaluation is critical in determining which aid will provide the most accurate biofilm control.

86. TYPE I Embrasure is filled completely by interdental papilla.
Dental floss is effective

87. TYPE II The height of interdental papilla is reduced.
Interdental brushes and wooden toothpicks are effective.

88. TYPE III The interdental papilla is missing.
Interdental brushes and end-tuft brushes are effective.

90. PLANNING INTERDENTAL CARE
PATIENT HISTORY OF ORAL HYGIENE
DENTAL AND GINGIVAL ANATOMY
PLAQUE SCORES
SELECTION OF INTERDENTAL AIDS

91. DENTAL FLOSS Levi Spear Parmly REMOVES DENTAL BIOFILM
REDUCES INTERPROXIMAL BLEEDING
EFFICIENT IN TYPE I EMBRASURES

92. TYPES OF DENTAL FLOSS Multifilament vs. monofilament
Twisted vs. untwisted
Bonded vs. unbonded
Waxed vs. unwaxed

93. Monofilament: resists breakage or shredding when passed over irregular tooth surfaces, restorations or calculus deposits.
Waxed: gives strength and durability during application.
Shredding and breakage is rare

94. Materials: Silk: loosely twisted, waxed
Nylon: multifilaments, waxed/ unwaxed
circular (floss) or flat (dental tape)
Expanded PTFE: monofilament, waxed

95. Floss Available
Flattened floss is designed to increase the contact surface with the tooth.
Ultra floss is spongy and soft.
Round floss is relatively thinner.
Superfloss contains segments of stiffened-end threader, spongy floss and regular floss.

96. Stiffened-end threader can make it easier to slide the superfloss through the gap between the teeth and fixed orthodontic appliances.
Spongy floss cleans around the appliances and between wide spaces or to floss underneath the bridge.
Regular floss removes plaque from the adjacent tooth surfaces.

98. How to Floss: Firmly grasp the dental floss with index fingers.
Gently slide the floss in between both sides of teeth and repeat until finished.
Using 18 inches of dental floss, wrap it lightly around middle fingers.
Forming a C-shape, carefully slide the floss up and down between tooth and gum line.

99. Common Mistakes:
Not placing the floss under the gum line - Not placing dental floss carefully under the gum line, the area where plaque accumulation occurs most, will not be as effective in the prevention of dental decay and periodontal disease.
Rushing when flossing the teeth - One cannot perform proper flossing when rushing through the procedure of removing plaque. One should take at least 2-3 minutes when flossing.

100. Misconception:
Flossing is not just supposed to remove food particles from between teeth.
The primary function of dental floss is to remove the invisible film of bacteria that constantly forms between teeth i.e. plaque. Flossing should be performed between each tooth.

101. INTERDENTAL BRUSH
Open embrasure spaces
Type II & III
Root concavities

102. Root Concavities They are trenchlike depression in the root surface.
In health, root concavities are covered with alveolar bone.
In periodontitis, junctional epithelium migrates apically with bone and tissue destruction, exposing the root concavity to the oral environment.

103. Interdental brush

104. Steps for Use of the Interdental Brush
Hold brush handle between the thumb and the index finger
Gently insert between teeth
Maintain brush at a 90-degree angle to the long axis of the tooth
Use slight pressure to adapt brush

105. Slide brush in and out of the space
Adapt brush to the mesial surface of the first premolar
For posterior areas, advise the patient to close his or her mouth slightly to relax the cheek.
It is helpful to bend the brush to facilitate insertion.

106. Single tufted brush
A single tuft or group of small tufts, may be 3-6 mm in diameter
Flat or tapered
Handle : straight or contra- angled

107. Indications: Type II embrasures Fixed dental prosthesis
For difficult to reach areas

108. INTERDENTAL TIP
Conical or pyramidal flexible rubber tip attached to the end of the handle of a toothbrush.
Soft, pliable rubber tip: adapted to the interdental area and below gingival margin
Does not cause damage to epithelial lining.

109. INDICATIONS: Interdental embrasure type II
Plaque removal at or just below the gingival margin.

110. WOODEN TIP Wooden cleaner is a 2 inch long device Made of: basswood
birch wood
It is triangular in cross section
Indication: type III embrasure

111. GINGIVAL MASSAGE Advantages: Epithelial thickening,
increased keratinization,
increased mitotic activity in epithelium and connective tissue
alteration or removal of plaque

112. Oral irrigation devices
Supragingival irrigation
Subgingival irrigation

113. Supragingival vs. Subgingival Irrigation
The objective of supragingival irrigation is to diminish gingival inflammation by disrupting biofilms coronal to the gingival margin. The goal of subgingival irrigation is to reduce the number of bacteria in the periodontal pocket space.

114. Dental Water Jet
Device that delivers pulsed irrigation of water or other solution supragingivally and subgingivally
Also known as dental water irrigator, home irrigator, water flosser

115. Mechanism of Action
Delivers a pulsating fluid that incorporates a compression and decompression phase
This creates two zones of fluid movement called hydrokinetic activity.
Impact zone—initial fluid contact with an area of the mouth Flushing zone—depth of fluid penetration within a subgingival sulcus or periodontal pocket

116. Benefits of Home Irrigation
Biofilm removal
Bleeding reduction
Gingival inflammation reduction
Periodontal pathogens reduction
Reduction in inflammatory and destructive host response

117. Indications for Recommendation
Individuals on periodontal maintenance
Individuals who are noncompliant with dental floss
Individuals with special needs
Individuals with dental implants
Individuals with diabetes
Individuals with orthodontic appliances
Individuals with prosthetic bridgework and crowns

118. Precautions:
Incidence of bacteremia is similar to other oral healthcare devices.
Before recommending a water jet to a patient who is at high risk for infective endocarditis, dental healthcare providers should consider both the patient's overall medical and oral health status.
Consultation with a physician is advisable for patients at high risk for infective endocarditis.

119. Irrigating Solutions Water
Antimicrobial solutions Chlorhexidine Essential oils Other solutions

120. TONGUE CLEANING
Daily tongue cleaning removes pathogenic bacteria on the dorsum surface.
Reduces bacteria in the saliva
Improves taste sensation
Reduces halitosis
Removes volatile sulfur compounds, which are gases that cause halitosis

121. Manual tongue cleaners come in a variety of styles
Manual tongue cleaners come in a variety of styles. Toothbrush with a thin head Tongue scrapers All types are designed to allow patients to reach the back of the tongue.

122. Any QUESTIONS????