Dental plaque part2

PLAQUE CONTROLPRESENTED BY :ROSHNI MAURYA,2ND YEAR PGTDept. Of pedodontics , gnidsr

CONTENTS• Introduction• Plaque control: mechanical ; chemical• Mechanical plaque control

introduction• The emergence of a new philosophy and dentistry based on

prevention rather than repair and replacement has been one of the most significant developments in the history of dentistry. Due to this preventive philosophy ,the dentistry for children now focuses to a very extent on inculcating sound dental practices in each child patient for a healthy dentition to last for life.In order to realize this goal the home oral hygiene and plaque control become the most important aspects of patient and parent education which a pedodontists can provide.In this presentation,this aspect of preventive dentistry is being highlighted in particular reference to a child patient.

Plaque control• It is the regular removal of dental plaque and the prevention of

its accumulation on the teeth and adjacent gingival surfaces.• It is the key to prevention and successful treatment of

periodontal disease.

• although 100% plaque control is not possible , the tolerance of some inflammation suggests that the host response can effectively handle a degree of inflammation.• Under certain conditions that are not evident, however,some

periodontal site undergo tissue destruction and loss.therefore, the patient and the therapist must constantly be diligent and persistent in plaque removal.this includes continuing education and motivation using a variety of devices and tecniques.

Goals of plaque control• 2 broad goals are:• A) use of mechanical and chemical agents on a personal

day to day basis to eliminate supragingival plaque along with dietary control to prevent the onset of dental caries.

• B) mechanical removal of subgingival plaque through professional means periodically so as to maintain predominantly gram-positive flora associated with gingival health.

Mechanical plaque controla)Gauze piece for use in infantsb)Manual toothbrush & dentifricesc)Electronic & powered toothbrush d) Dental floss e) Disclosing

agent f) Tongue

scrapers g) oral

irrigators

GAUZE PIECE FOR USE IN INFANTS

A moist gauze piece wrapped around the finger can be ideal for cleaning gumpads in children

Toothbrush

• Most widely used oral hygiene aids

• Principal instruments in general use for accomplishing the goals of plaque control.

• Has been described as “the most classic and principal method employed in oral hygiene.”

• Acc. To ADA’s council on Dental therapeutics “the toothbrush is designed primarily to promote cleanliness of teeth and oral cavity”.

Toothbrush development timeline3000BC Egyptians use small branches with frayed ends to clean teeth1400AD Chinese invent bristle toothbrush, made of Siberian wild boar hair fixed to a bamboo or bone handle.

1600AD European travelers to china bring back toothbrush, replace wild boar hair with softer horse hair.1885AD Companies began to mass produce manual toothbrushes.

1938 First nylon bristles introduced 1950 Nylon bristles were made softer 1960 1ST electric toothbrush introduced in U.S. 1987 1ST rotary action electric toothbrush for home used introduced. 2000 Low-price power toothbrushes become popular.

Parts o f a toothbrush• Handle: part grasped in the hand during tooth brushing• Head : working end of a toothbrush that holds the bristles or filaments• Tufts : clusters of bristles or filaments secured into head • Brushing plane : the surface formed by the free ends of the bristles/filaments.• Shank : the section that connects head and handle

Toothbrushes should be able to reach and effectively clean most areas of teeth. Type of brush is a matter of individual preferences.2 kinds of bristle material use: natural bristles from logs ; artificial filaments of nylon, both types remove plaque but nylon filament are superior in homogenicity of material, uniformity of bristle size; # resistances ; repulsion of water and debris.

- Generally toothbrushes very in size, design as well as in length and arrangements of bristles hardness, to overcome this variation ADA given specification of toothbrushes.

- ----------------------------------------------------------› 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› Diamt. for soft brushes: .007 inch; for medium brushes- .12 inch ;› for hard brushes - .014 inch

Toothbrush

• For a pediatric usage it is preferable to use a toothbrush with a head size fitting conveniently the oral cavity of child.

• Brush handle should be of length appro. Enough to be held by child, angulation of head be such that child can carry the brush to his posterior teeth easily.

• Acc. To Bass recommendation, smaller brush with thinner Diamt.-0.005 inch/0.1 m; shorter length: 0.344 inch/8.7m

• Oral B cross action toothbrush has the most superior properties among all manual brushes.

• The ideal time to replace a toothbrush is 3 months or moment when bristles appear worn out

Frequency and duration of brushing• Generally, adults take not more than 45 secs to brush; children

even less.• It is recommended to clean the teeth for at least 1-2 mins.• Brushing twice is recommended.• If only once brushing is practiced, best to do it before going to

sleep.• Use of disclosing solution to check the thoroughness of brushing

is recommended in children.

• Jenkins suggested that tooth brushing before a meal is optimal. Brushing of teeth 5 or more mins after eating may remove remineralizing effects of saliva.

Powered toothbrush• Level of oral hygiene achieved by an individual is dependent on

technique, motivations, dexterity and perseverance. Since the behavioral practices can’t be modified, the greatest potential for improving oral hygiene will come from advancements of brush design that enhance plaque removal .

• So, powered toothbrushes were devised in 1939.they have 3 motions back and forth , circular and elliptical and are mostly recommended for:• Individual lacking motor skill• Handicapped patients• Patients who have orthodontic appliances • Whosoever wants to use

Manual and powered toothbrushes

• Characteristic manual powered• Brushing duration 20-40 sec 1-3min• Teeth brushed at a time multiple one/multiple• Brush head motion cross & multiple minimal• Brush head strokes 40-100/min 10-40/min• Brush head load 150-1000grams 50-250 grams• Brush head speed zero 1000s/min

Electric toothbrushes are still the most effective in visually disabled grp. however ,becoz of cheaper cost ,easier availability ,use, the oral B cross action toothbrush with criss - cross bristles could be a suitable alternative.

( Asmita Sharma,et al 2012)

No evidence of a statistically significant difference between powered and manual brushes. However, rotation oscillation powered brushes significantly reduce plaque and gingivitis in both the short and long-term

(C. Deery , et al 2003)

Electric toothbrush have not been shown to provide benefits routinely for children who are well-motivated brushers , or patients with chronic periodontitis.

( Heasman, 1999)

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.

Easily learned Good gingival stimulation Cervical and sulcus plaque removal

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 proximalGingival 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 Easy to learn good gingival stimulation

Stillman's On buccal and lingual, aplically at an oblique 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 stimulationModerate 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 Gingival stimulation

Charters method

Bass method

1- The bristles are placed onto the attached

gingiva & cervix of teeth at 45 degrees to

the long tooth axis.

2- Apply pressure & activate the brush

coronally with 20 short back-&-forth mov.

Modified Stillman’s Technique

Bristle tips effectively clean embrasure areas as well

as the facial tooth surface .

BRUSHING TECHNIQUE USED COMMONLY IN CHILDREN• FONE’S TECHNIQUE

•HORIZONTAL SCRUB TECHNIQUE

•BASS METHOD

dentifrices

• A substance used with a toothbrush or other applicator to remove the DP, material alba , debris, stains from teeth, tongue and gingiva for cosmetic, therapeutic or preventive purposes

Component % Added Use Example

Detergent 1.2%• To lower surface tension• Penetrate and loosen surface deposits and strain• Emulsify debris for easy removal by the toothbrush• Contribute to the foaming action

Sodium lauryl sulphate

Cleaning and polishing

20 to 40 %• A dentifrice may have a combination of agents in

abrasive system to accommodate both cleaning and polishing objective

• Abrasive is used to clean• A polishing agent is used to produce a smooth, shining

tooth surface that resists discoloration, bacteria accumulation and retention

Calcium carbonate, calcium pyrophosphate, bicalcium phosphate

Binders 1 to 2 %• To prevent separation of the solid and liquid

ingredients during storage• Contribute to the stability and consistency of the

toothpaste

Organic hydrophilic colloids, alginates, magnesium aluminium silicate, colloidal silica

Humectants 20 to 40 %• These are added to retain moisture• Prevent hardening on exposure to air • To stabilize the preparation

Glycerin, Sorbitol

Component % Added Uses Example

Preservatives • To prevent bacterial growth and to prolong shelf

lifeAlcohols, formaldehyde and dichlorinated phenols

Sweetener 2 to 3 %• To impart a pleasant flavor for patient’s

acceptanceSorbitol and glycerin

Flavoring agent 1 to 15 %• To make the dentifrices desirable • To mask other ingredients that may have less

pleasant flavor

Peppermint, cinnamon, menthol

Therapeutic agent

1 to 2 %• For medicinal value Fluoride

Coloring agent 2 to 3 %• Added for attractiveness

Water 20 to 30 %• Main transport medium

fluoride dentifrices

• Recommendations for use of fluoridated dentifrices in children• Age type of dentifrice frequency of brushing• 6 months non-fluoridated twice daily in morning or at night; in

to 3 yrs. very young child brushing without denti.is also acceptable 3-7 yrs. non-fluoridated once daily every morning fluoridated once daily at night before going to bed. >7 yrs. fluoridated twice daily brushing

• For pediatric use it is best to select fluoridated toothpaste for any child above 36 months of age, having low abrasive content, is flavored , accepted by ADA.

• No fluoridated toothpaste should be used till 36 months of age due to incr. risk of systemic ingestion in children.

• Till child is 7 yrs. of age only pea size quantity of dentifrice should be dispensed for brushing.

• Parents should be counseled on their child’s caries risk, frequency & supervision of tooth- brushing.

• Among the individual methods of fluoride delivery (fluoride toothpastes and rinses), the use of fluoride toothpastes is by far the most important because it combines the use of fluoride with the mechanical removal of the biofilm. There is unequivocal evidence that fluoride toothpastes are efficient to control caries and have played an important role in the caries decline observed in both developed19 and developing countries. (Fluoride: its role in dentistry§ ;Braz Oral Res. 2010;24(Spec Iss 1):9-17)

• Toothpastes containing 1,000-1,500 ppm F (also named conventional fluoride toothpastes) have proven highly effective to control caries, by many high-quality, randomized and controlled studies conducted in the last decades.(source: same as above)• Toothpastes with increased fluoride concentration(e.g. 5,000 ppm F) have

been launched aiming to control root caries, considering that dentine is more caries-prone than enamel. There is some evidence that these toothpastes are more effective than the conventional ones in such cases, but a review of the literature on this subject is still lacking.(same as above)

• F toothpastes are not able to control caries under a high cariogenic challenge (biofilm accumulation and exposure to sucrose 8 times/day). The lower fluoride availability in the biofilm fluid and solids, either soon after or 10 to 12 hours after the use of a low fluoride toothpaste, may explain these results. (Low-fluoride toothpaste and deciduous enamel demineralization under biofilm accumulation and sucrose exposure. Eur J Oral Sci. 2010 Aug;118(4):370-375. )

• A recent systematic review of the literature confirmed that the effectiveness of fluoride toothpastes is proven in conventional strength formulations, but not in low fluoride ones. (Fluoride toothpastes of different concentrations for preventing dental caries in children and adolescents. Cochrane Database Syst Rev. 2010 Jan 20;(1):CD007868)• Brushing with F dentifrice at night to remineralize daily mineral losses appears to

be more effective than brushing in the morning to inhibit the demineralizing episodes of the day. It is possible that use at night may reduce F clearance and increase its availability, causing lower mineral loss.(Timing of fluoride toothpaste use and enamel-dentin demineralization ;Braz Oral Res. 2011 Sep-Oct;25(5):383-7 )

• The best recommendation on the use of fluoride toothpastes by young children, considering the balance of benefits and risks, is that a small amount of dentifrice should be used. For example, by recommending the use of 0.3 g of toothpaste per brushing (similar to the size of a pea), the amount of fluoride ingested would still fall within the safe limit considering fluorosis risk involving aesthetic issues. {Fluoride intake by Brazilian children from two communities with fluoridated water. Community Dent Oral Epidemiol. 2003;31(3):184-91.}

• In fact, since the anticaries effect of fluoride is concentration-dependent (the concentration of free fluoride in the mouth), and the fluorosis risk is dose-dependent (the dose of fluoride circulating in the blood according to the child’s weight), a reduction in the amount of toothpaste used by young children would reduce the risk of dental fluorosis without significantly affecting its anticaries benefit. It is thus a recommendation that can be made for all children, irrespective of their social or caries-risk status.{How much toothpaste should a child under the age of 6 years use? Eur Arch Paediatr Dent. 2009Sep;10(3):168-74.}

interdental cleaning aids Any tooth brush , regardless of the brushing method, does not completely

remove interdental plaque. Even for patients with wide-open dental embrassures. ( Gjermo, 1970, Schmid 1976).

The majority of dental and periodontal disease's originate in interproximal area, interdental plaque removal is necessary

Tissue destruction associated with perio. Disease often leave large open spaces, between teeth and exposed roots with anatomic concavities and furcations which are difficult to clean and access with the toothbrush.

The purpose of Interdental cleaning aids is to remove plaque, not to dislogde food wedged between teeth.

Interdental brush (proxy brush): Interdental brush are conical shape

brushes made of bristles mounted on a handle, single tufted brushes, or small conical brushes.

They are suitable for cleaning large, irregular, or concave tooth surfaces adjacent to wide interdental spaces.

They are inserted interproximally and are activated with short back and forth strokes in between the teeth.

• They are used with back and forth strokes between teeth.

• For most efficient cleaning, the diameter of the brush must be slightly larger than the embrasures to be cleaned.

• Single tufted brushes are slightly effective on lingual surface of mand. Molar & PM; regular toothbrush is often impeded by tongue.

Waerhaug in 1976 evaluated the effect of interdental brushes on 67 teeth which scheduled for extraction. › Teeth were cleaned prior to extraction and then stained and examined

after extraction. › The results indicated that plaque can be removed from 2 to 2.5mm

subgingivally using the interdental brush

Wooden tips• Are used either with / without a handle.

• Soft triang. W.t like stim-u- dent are placed in interdental space in gingiva,slide with contact the proximal tooth surface.

• Repeatedly moved in & out of embras., removing soft deposit for teeth and mechanically stimulating the gingiva.

• Use is limited to facial surfaces.

Dental floss: (df)• 1st paper on DF was published by PARMLY in 1819.

• In 1882, CODMAN AND SHURTUFF made 1st commercial floss of silk.

• In 1948, BASS recommended nylon floss is superior to silk.

• Size of DF: 300-1500 D(denier)

• Floss is constructed with help of individual filaments 2 -3D thick

Dental floss: Dental floss is the most widely

recommended method for removing proximal plaque.

The floss is wrapped around each proximal surface and is activated with repeated up and down stroke.

Floss should pass gently through the contact area. Do not snap the floss pass the contact area as it may injure the interdental papilla.

Dental floss :types • 1) twisted & non-twisted• 2) bonded & non- bonded• 3) thin & thick• 4) microfilament & multifilament• Acc to ADA specification:• Type I- unbonded dental floss composed of yarn having no additives.• Type II- Bonded DF composed of yarn having no additives other

than binding agent or agent for cosmetic performance.• Type III- Bonded or unbonded having drug for therapeutic usage.

Dental floss :types • unwaxed, waxed, tape floss,, and

Superfloss.

• Waxed floss contained wax to facilitate passing the floss through the contact and alleviate fraying.

• Tape floss contain criss-cross fiber and eliminate fraying.• • Superfloss is the web-like material

which improved proximal cleaning efficiency.

• Flossing can be made easier by using a floss holder –

• Floss holder should have –

1. One or two fork that enough to keep the floss tent even when

its moved pass tight contact area

2.An effective and simple mounting mechanisms

There are no significant difference between various types of floss to remove dental plaque , they all work equally well ( Grossman 1979, Keller 1969).

Graves et al. in 1989 evaluated in a 2 week clinical trial the efficacy of unwaxed dental floss, dental tape, waxed floss, and tooth brushing alone in reduction of interproximal bleeding.

The result showed that the dental tape and dental floss were equally effective in reducing interproximal bleeding and twice effective as tooth brushing alone.

Lambert et al. in 1982 compare the waxed and unwaxed floss to determine the efficacy to remove plaque and their effect on gingival health during a home oral program.

The results showed there was no statistical difference between the types of floss in regards to their ability to remove plaque or prevent gingivitis. Wunderlich et al. in 1982 reported there is no difference between wax and

unwaxed floss in maintaining gingival health.

A comparsion study between dental floss and interdental brush in patients with sever to moderate periodontitis , showed that interproximal brushes remove slightly more interproximal plaque and that the patients found them easier to use. (Christou,1998)

Wong and Wade study in 1985, which they compared the effectiveness of Super floss and waxed dental floss as proximal surface cleansing agent in 34 subject.

Superfloss was found to be superior (50%) to waxed dental floss(45%) in removing proximal plaque but neither was 100% efffective.

Flossing for children• Not all children can floss effectively.

• Ability to floss is a function of age & manual dexterity.

• Ability to manipulate floss and remove plaque is highly dependent on hand & eye coordination and age.

APPLICATIONHold floss firmly in a diagonal or oblique position

Guide the floss past contact area with a gentle motion

Control floss to prevent snapping through the contact area onto the gingival tissue

Pass the floss between the gingival margin, curve to adapt the floss around the tooth, press, and side up and down over the tooth surface

DISCLOSING AGENTS• A disclosing agent is a preparation in

liquid, tablet or lozenge from which contains a dye or other coloring agents• A disclosing agent is used for

identifying bacterial plaque• When applied to the teeth, the agents

imparts its colour to soft deposits but can be rinsed easily from clean tooth surface

IDEAL PROPERTIES

• Intensity of colour• Duration of intensity• Taste• Irritation to mucous membrane• Diffusibility• Astringent and antiseptic property

Agents used for disclosing plaquea. Iodine preparations

• Skinners iodine solution• Diluted tincture of iodine

b. Mercurochrome preparations• Mercurochrome soln 5• Flavored mercurochrome disclosing solution

c. Bismark brownd. Mebromine. Erythrosinef. Fast greeng. Fluoresinh. Two tone solutionsi. Basic fuschin

Oral irrigation • Oral irrigation device include the use of water

picks. • The high pressure, pulsating stream of water

through a nozzle is directed to the tooth surface and subgingivally, washing away debris and plaque containing bacteria.

• They are helpful surrounding orthodontic appliance, and when used as an adjucntive treatment in shallow pocket depth.

• Patients reqiure antibiotic premedication should not use oral irrigation.

• Not commonly recommended for pediatric usage.

• Eakle et al. in 1986 showed that the oral irrigator deliver an aqueous solution into the periodontal pocket and will penetrate an average to approximately half the depth of the periodontal pockets.

• Penetration of 90 degree angle stream of water is about 70% for pocket less than 3mm, 44% for moderate pocket (4 to 7 mm) and 68% for deep pocket ( greater than 7mm).

• For 45 degree angle, the result is 54%, 45%, and 58% respectively.

• When used as adjuncts to toothbrushing , irrigation devises, can have a beneficial effect on periodontal health by reducing the accumulation of plaque and calculus and decreasing inflammation and pocket depth.

• ( Robinson and Hoover, 1971)

Ciancio in 1989 evaluate the efficacy of an antimicrobial rinse delivered by an oral irrigation device twice daily.

The results showed that irrigation with or without an antimicrobial agent was effective in reducing the plaque, suggesting that oral irrigation may be beneficial on oral health and the use of the chemotherapeutic agent will lead to greater reduction in plaque and gingival bleeding and to moderate decreases in total bacteria counts detected by phase contrast microscopy

Tongue scrapers

• May be flat ,flexible ,plastic sticks which help in cleaning the rough dorsal surface of tongue.

• Additionally, gauze piece can also be used as tongue scraper.

• It should be routinely recommended for all the patients.

Toothette

• It is a swab of sponge attached to a stick .

• Used in oral cleaning in hospitals and in patients having extremely fragile tender gingiva or mucosal lesions.

• Also helps to deliver moisture and swab cleaning of the oral cavity.