1. Plaque Control Measures Dr Hidayathulla Shaikh

2. objectives At the end of the lecture student should know Define plaque Discuss disclosing agents Discuss different types of mechanical plaque control methods Tooth brushes and dentifrices Inter dental aids Aids for gingival stimulants Discuss different types of chemical plaque control methods. Explain different types of brushing techniques.

3. DEFINITION Plaque is defined as the soft deposits that form the biofilm adhering to the tooth surface or other hard surfaces in the oral cavity including removable and fixed restorations. It has got a definite internal feature. It plays the major role in development and maintaining gingival and periodontal diseases. Calculus is formed when the plaque is calcified. So it is very important to remove and prevent formation of the plaque.

4. WHAT IS PLAQUE CONTROL? The procedure of removal of the microbial plaque and prevention of its accumulation on the teeth & adjacent gingival surface is called plaque control. AIMS OF PLAQUE CONTROL To prevent Dental Caries. To prevent Periodontal Disease. To prevent Gingivitis. Maintenance of oral hygiene. Prevention of halitosis. Esthetic appearance. Provide favorable environment for healing. MODE OF CONTROL Mainly by two ways 1.Oral Prophylaxis 2.Oral Hygiene Professionals perform oral prophylaxis by scaling, root planning etc.

5. Maintenance of oral hygiene by the patient can be done in two ways:- (I) Mechanical aids. (II) Chemical agents.

6. (I) Mechanical aids 1.Tooth brushes. (a) Manual (b) Electrical 2.Interdental aids (a)Dental Floss (b)Triangular Toothpicks -Handheld Triangular Toothpicks -Proxapic (c)Interdental Brushes -Proxabrush System -Bottle Brushes -Single Tufted Brushes (d)Yarn (e)Superfloss (f)Perio-aid 3.Aids for gingival stimulation (a)Rubber Tip Stimulator (b)Balsa wood edge 4.Others (a)Gauze Strips (b)Pipe Cleansers (c)Water Irrigation Devices 5.Aids for edentulous or partially edentulous patients (a)Denture and partial clasp brushes (b)Cleansing solution

7. (II) Chemical agents: These can be broadly classified in to 3 generations.  First generation (antibiotics, quaternary ammonic compounds, phenolic compound, sanguanarine etc.)  Second generation (chlorhexidine or bisguanines)  Third generation (delmopinol)

8. Tooth Brush One of most commonly used mechanical aids in plaque control is toothbrush. The tooth brush should have the following characteristics:-  Its size shape & texture should be comfortable to the patient  It should be readily cleaned.  It should be durable and inexpensive.  It should have round end bristle.

9. ADA SPECIFICATION OF A TOOTHBRUSH Brushing Surface 1 to 1.25 inches in length 5/16 to 3/8 inches in width 2.54 to 3.2 cm surface area 2 to 4 rows of bristles 5 to 12 tufts per row

10. Selection of tooth brush :- Patient’s mental ability, motivation, willingness to use tooth brush. Status of gingival and periodontal health. Malocclusion (Crowding, spacing etc.) Shape of the tooth, exposed root surface. Personal preference.

11. TOOTH BRUSHING TECHNIQUES The Roll Technique: Modified Stillman The Vibratory technique: Stillman, Charters & Bass Method The circular technique: Fones Method The vertical technique: Leonard’s Method The Horizontal technique: Scrub Brush method The Physiological Technique Smiths method

12. BRUSHING METHODS BASS METHOD Technique : The bristles are placed at a 45 0 angle to the gingivae and moved in small circular motions. Strokes are repeated around 20 times, 3 teeth at a time. On the lingual aspect of anterior teeth the brush is inserted vertically. The bristle are then activated. Occlusal surfaces are cleansed by pressing the bristles firmly against the pits and fissures and then activating the bristles. Advantages: Effective method for removing plaque Easy to learn Recommended for routine patient with or without periodontal involvement Disadvantages Time consuming Overzealous brushing may convert the very short stokes into a scrub brush technique and cause injury to the gingiva

13. Modified Stillman method Technique: The bristles are pointed apically with an oblique angle to the long axis of the tooth. The bristles are positioned partly on the cervical aspects of teeth and partly on the adjacent gingiva. The bristles are activated by short back and forth motions and simultaneously moved in a coronal direction. Following 20 strokes, the procedure is repeated. Disadvantages Time consuming Improper brushing can damage the epithelial attachment.

14. Charter’s Method Technique :- A soft/medium multitufted tooth brush is indicated for this technique. Bristles are placed at an angle of 45 0 to the gingiva with the bristles directed coronally. The bristles are activated by mild vibratory strokes with the bristle ends lying interproximally Disadvantage :- Brush ends do not engage the gingival sulcus. In some areas the correct brush placement is limited or impossible.

15. SCRUB BRUSH METHOD This method of brushing requires vigorous horizontal, vertical and circular motions.It is the virtual freestyle of the brushing scene. Disadvantages 1.Ineffective at plaque removal 2.Tooth abrasion and gingival recession 3.Detrimental to general oral health

16. Powered tooth brushes :- This kind of tooth brushes are recommended for :- Patient lacking fine motor skills. Small children. Handicapped patient. Hospitalized patient. Patient with orthodontic appliances. Patient who prefer them.

17. INTERDENTAL CLEANING AIDS Dental floss : It is thread used as an inter-dental cleaning aid which functions through frictional force. It can be made of silk, nylon, Teflon type material etc. Type : It can be thick, medium, thin and extra thin. It can be twisted and untwisted or waxed and unwaxed. Selection of floss depends on :- Tightness of the contact area of the two teeth. Roughness of the tooth surface. Patient’s mental ability. Indication :- It is recommended for cleaning the inter-proximal embrasure area where recession of inter-dental papillae has not taken place.

18. Limitations : Care recommended for cleaning the inter-dental tissue. Time consuming procedure. Irregular or concave tooth surfaces & furcation areas cannot be cleaned. Method of using dental floss : There are two methods – 1. Spool method 2. Circle or Loop method

20. INTERDENTAL BRUSHES Dental floss cannot effectively clean the concave root surface of furcation areas when there is recession of gingival. So special type of aids are recommended for cleaning these areas. Miniature bottle or spiral brushes are recommended for cleaning the narrow space between teeth where there is minimal or moderate degree of gingival recession These also can be useful in cleaning the bridges, orthodontic appliances or for application of medication in narrow space between teeth

21. TOOTH PICKS These are pieces of soft wood of 5-7.5cm lengths. They are triangular in cross section. The base of the triangle should rest on the gingiva and the sides should make contact with the proximal areas of the tooth surface. It moves in and out of the embrasure. It is recommended for cleaning the inter-dental area where recession has taken place. In normal healthy condition it should be avoided as it may damage the inter-dental papilla. It should be moistened with water or saliva before use. It should be advised to those patient who follow the instruction of their dentist. Improper use by uncooperative patient may damage the gingiva.

22. Mouthrinsing : Ideally the patient should brush his teeth after every meal. But when this is not possible patient can at least rinse his mouth after taking some food. This will help in removal of loose food debris and thus retard the formation of plaque.

23. Dentifrices : Dorland described it as a preparation for cleaning and polishing the teeth. A dentifrice contains : Abrasive (15 - 45%) = CaCo3, Ca. phosphate etc Detergents (1 - 5% foaming agents) = Sodium Lauryl sulphate etc Anticariogenic agent = Sodium Fluoride, Stannous fluoride Desensitising agent = Strontium Chloride, Sodium Fluoride Humectant (20 - 45%) = Glycol, sorbitol Flavoring agent (1%)= Mint Sweetening agent (2%) = Sorbitol, Saccharine Coloring agent (.5%) as per manufacturers choice Preservative (.5%) Benzoic acid Dentifrice contain fluoride and according to ADA the flouride content should be 800-1100 ppm.

24. CHEMICAL METHOD According to Glemo (1974) an antiplaque agent should have the following properties:- Inhibit plaque formation Elimination of exiting plaque. Inhibition of calcification of plaque. According to Bral & Brountein (1988) an antiplaque agent should have the following properties. Eliminate pathogenic bacteria and prevent development of resistant bacteria. Should be safe for oral cavity. They should reduce plaque and gingivitis and prevent mineralization of plaque to calculus. Should not stain the tooth and alter the taste. Easy to use Inexpensive

25. Chemicals used as antiplaque agent can be divided in to three generation. A.First Generation :- 1.Antibiotics 2.Phenolic Compound 3.Fluorides 4.Peroxide 5.Sanguanarine B.Second Generation agents :- 1.Chlorhexidine C. Third generation drug:- 1.Delmopinol

26. Mechanism of Action of chlorhexidine: 1.Antiplaque action of Chlorhexidine a)prevents pellicle formation b)prevents adsorption of bacterial cell wall onto the tooth surface by binding to the bacteria. c)prevents binding of mature plaque by precipitating agglutination factors in the saliva and displacing calcium from the plaque matrix. 2.Antibactrial action : Chlorhexidine shown different effects at different concentrations i.e. a)Bacterio static at low concentrations b)bacteriocidal at high concentrations. Pin cushion effect: One charged end of chlorhexidine molecule binds to the tooth surface and the other remains available to initiate the interaction with the bacterial membrane as the microorganism approaches the tooth surface.

27. Disclosing Agents A disclosing agent is a preparation in liquid tablet or lozenge from which contains a dye of other coloring agent.

28. Agents used for disclosing plaque 1.Iodine preparations 2.Mercurochrome preparations 3.Bismark brown (Easlick’s disclosing solution 4.Merbromin 5.Erythrosine 6.Fast green 7.Fluorescin 8.Two tone solutions FD & C green No. 3 FD & c red No 9.Basic Fuchsin

29. Recommendation for plaque control instruction  For a successful long-term Plaque control patients active cooperation is very important. Patients education, motivation play very important role in this regard.  Daily mechanical removal of plaque and use of chemical agents are most important practical means for improving oral hygiene.  This process require motivation on the part of the patient, education and instruction followed by encouragement and reinforcement. Motivation Motivation for effective plaque control is one of the most important element for long term success. Change the habit of life time – it is required to adopt successful self determined daily plaque control regimes. Behavioral changes- required to adjust the hierarchy of one’s belief, practice and value.