PLAQUE CONTROL

PLAQUE CONTROL

Prof. N. D. Gupta

PLAQUE

DENTAL PLAQUE “is a specific

but highly variable structural entity,

resulting from sequential

colonization of microorganisms on

tooth surfaces, restorations & other

parts of oral cavity, composed of

salivary components like mucin,

desquamated epithelial cells, debris

& microorganisms, all embedded in

extracellular gelatinous matrix.”

WHO-1961

Plaque Control

It is defined as the

removal of microbial

plaque &

prevention of its

accumulation on the

teeth & adjacent

gingival tissue.

MEANS OF PLAQUE CONTROL Mechanical

Chemical

MECHANICAL PLAQUE CONTROL

Introduction

Mechanical plaque control is the removal of microbial plaque and the prevention of accumulation on the teeth and adjacent gingival surface by the use of tooth brush and other mechanical hygiene aids.

It is an effective way of treating and preventing gingivitis & Periodontitis.

The objective of mechanical plaque control

complete daily removal of dental plaque with a minimum of effort, time, and devices, using the simplest methods possible.

Mechanical plaque control

1. Mechanical plaque control

(a) Toothbrush

(b) Dentifrice

(c) Interdental cleaning

aids

- dental floss

- toothpick

- inter-proximal brush

(d) Oral irrigation

The Toothbrush The bristle toothbrush

appeared about the year of

1600 in China and later was

patented in America in 1857.

Originally, they are varied in

size, length, hardness of the

bristle, and even in the

arrangement of the bristle

The Toothbrush- 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.

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› 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

Toothbrush bristles Natural: hog

Artificial filaments: nylon

The Toothbrush Soft, nylon bristle toothbrush clean effectively ( when

used properly),remain effective for a reasonable time , Soft bristles are more flexible, clean beneath the gingival margin, and reach farther into the proximal tooth surfaces.

soft toothbrush is atraumatic , no tooth surface abrasion (classical wedge shape defect in the cervical area of root surfaces), trauma to soft tissue.

Bristle hardness Proportional to the square of the diameter and

inversely proportional to the square of bristle length

Soft brush: 0.007 inch(0.2 mm)

Medium brush: 0.012 inch(0.3 mm)

Hard brush: 0.014 inch(0.4 mm)

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

Tooth Brushing Today, there are three methods that are widely accepted:

the bass method, the modified stillman method( stillman

1932), and the charters method( Charter’s 1948) .

The method which is often recommended is Bass

technique , because it emphasize sulcular placement of

the bristles.

Dentist should note that a plaque control devices should

be tailored to the individual, similarly to his or her plaque

control program

Bass techniquesoft brush

Straight handle Nylon bristle 0.007 inch(0.2 mm) in diameter 0.406 inch(10.3 mm) in length Rounded ends 3 rows of tufts 6 evenly spaced tufts per row 80-86 bristles per tuft

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.

Charters method

Bass method

Electric toothbrush ( powered)• In 1939 powered toothbrush invented to make plaque control easier.

• Its mainly recommended for

(a) Individual lacking motor skills

(b) Hospitalized patients whose teeth are cleaned by the caregivers.

(c) Special needs patient ( physical and mental disability)

(d) Patient with orthodontic appliance

▪ There are many powered toothbrushes some with reciprocal of back

and back motions, some with circular motion and some are

combination of circular and elliptical motion.

▪ Powered tooth cleaner resembles a dental prophylaxis and hand piece

with rotary rubber cap.

Interdental cleaning aids Any toothbrush , regardless of the brushing method,

does not completely remove inter-dental plaque. Even for patients with wide-open gingival embrasures. ( Gjermo, 1970, Schmid 1976).

The majority of dental and periodontal diseases originate in inter-proximal area, inter-dental plaque removal is necessary

Interdental cleaning aids Dental floss

Interdental brushes

Unitufted brushes

Dental floss Multifilament

Twisted vs. untwisted

Bonded vs. unbonded

Waxed vs. unwaxed

12-18 inches for use

Stretch: thumb and forefinger

Up-and-down stroke

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.

FYI

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

Interdental brush

Gingival massage Epithelial thickening, increased keratinization, and

increased mitotic activity in epithelium and connective tissue

Oral irrigation devices Supragingival

irrigation

Subgingival irrigation

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 sub-gingivally, washing away debris and plaque containing bacteria.

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

Patients require antibiotic premedication should not use oral irrigation.

When used as adjuncts to tooth brushing , 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)

DENTIFRICESDentifrice is a substance used with a

toothbrush for the purpose of cleaning the accessible surfaces of the tooth

It contains

therapeutic agent such as fluoride to inhibit caries

Antimicrobial agents-chlorhexidine, cetrimide

Anticalculus agent - Zn-chloride

COMPOSITION1. Polishing/ abrasive agents

• Ca carbonate

• Dicalcium phosphate dihydrate

• Alumina

• Silica

Functions

➢ Mild abrasive action aids in eliminating plaque

➢ Removes stained pellicle, restores natural luster,

enhances enamel whiteness

2.Binding/ thickening agents

a. Water soluble agents

• Alginates, Sodium carboxy methyl cellulose etc

b. Water insoluble agents

• Colloidal silica, Magnesium, Aluminium salts etc

Functions

➢ Controls stability & consistency of toothpaste

3.Detergents/ surfactants

• Sodium lauryl sulfate

Functions

➢ Produces foam & removes food debris

➢ Antimicrobial property

4. Humectants

Sorbitol, glycerin, polyethylene glycol

Function

➢ reduces the loss of moisture from toothpaste

5. Flavoring agents

Peppermint oil, spearmint oil

Function

➢ Render the product pleasant to use & leaves a

fresh taste in mouth after use

6. Sweeteners and colouring agents

7. Anti bacterial agents Triclosan, delmopinol, metallic ions & Zn-citrate trihydrate

8. Anticaries agents Na fluoride, stannous fluoride

9. Active agents-fluoride

10. Anticalculus agents(crystal growth inhibitors) Pyrophosphate, Zn citrate, Zn chloride

11. Desensitizing agents Sodium fluoride, potassium nitrate

Recent developments in dentifrices

Tooth paste for children

Natural toothpaste (herbal)

Whitening toothpaste

Breath freshening toothpaste

CHEMICAL PLAQUE CONTROL

Ideal requisites

Should decrease plaque & gingivitis

Prevent pathogenic growth

Should prevent development of resistant bacteria

Should be biocompatible

Should not stain teeth or alter taste

Should have good retentive properties

Should be economic

CLASSIFICATIONCHEMICAL

PLAQUE CONTROL AGENTS

FIRST GENERATIONEg: antibiotics, phenol,quarternary ammonium

compounds & sanguinarine

SECOND GENERATIONEg: Bisbiguanides,(chlorhexidine)

THIRD GENERATIONEg: delmopinol

FIRST GENERATION AGENTS

TRICLOSAN

Phenol derivative

Is synthetic and ionic

Used as a topical antimicrobial agent

Broad spectrum of action including both gram positive and gram negative bacterias

It also includes mycobacterium spores and Candida species

MECHANISM OF ACTION

TRICLOSAN

ACT ON CYTOPLASMIC MEMBRANE

INDUCE LEAKAGE OF CELLULAR CONSTITUENTS

BACTERIOLYSIS

Triclosan is included in tooth paste to reduce plaque

formation

Used along with Zinc citrate or co-polymer Gantrez to

enhance its retention within the oral cavity

Triclosan delay plaque formation

It inhibits formation of prostaglandins & leukotrienes

there by reduces the chance of inflammation

2. METALLIC IONS

eg: Zn & Cu ions

MECHANISM OF ACTION

It reduces the glycolytic activity in bacteria &delays

bacterial growth

3.QUARTERNARY AMMONIUM

COMPOUNDS

Cationic antiseptics & surface active agents

Effective against gram positive organisms

MECHANISM OF ACTION

Positively charged molecule reacts with negatively

charged cell membrane phosphates and thereby

disrupts the bacterial cell wall structure

Eg: Benzanthonium chloride, Benzalleonium

chloride and cetylpyredinium

4.SANGUINARINE

It is a benzophenanthredine alkaloid

It is most effective against gram –ve organisms

Used in mouth rinse

ANTIBIOTICS

Vancomycin, erythromycin, and Kanamycin

Due to bacterial resistance problems the use of

antibiotics has been reduced

BISBIGUANIDES

CHLORHEXIDINE

GLUCONATE(0.2%)

It is a cationic

bisbiguanide

Effective against gram

+ve, gram –ve organisms,

fungi, yeasts and viruses

Exhibit antiplaque &

antibacterial properties

MECHANISM OF ACTION

Antiplaque action of chlorhexidine

1. Prevents pellicle formation by blocking acidic

groups on salivary glycoproteins thereby reducing

glycoprotein adsorption on to the tooth surface

2. Prevents adsorption of bacterial cell wall on to the

tooth surface

3. Prevents binding of mature plaques

Antibacterial action of chlorhexidine

It shows two actions

1. Bacteriostatic at low concentrations

Bacterial cell wall(-ve charge)

Reacts with +ve charged chlorhexidine molecule

Integrity of cell membrane altered

CHX binds to inner membrane phospholipids & increase permeability

Vital elements leak out & this effect is reversible

2. Bacteriocidal action

increased concentration of chlorhexidine

Progressive greater damage to membrane

Larger molecular weight compounds lost

Coagulation and precipitation of cytoplasm

Free CHX molecule enter the cell & coagulates proteins

Vital cell activity ceases

cell death

ADVERSE EFFECTS OF CHLORHEXIDINE

1. Brownish staining of tooth or restorations

2. Loss of taste sensation

3. Rarely hypersensitivity to chlorhexidine has been

reported

4. Stenosis of parotid duct has also been reported

ENZYMES

Enzymes has been used as active agents in antiplaque

preparations

It is due to the fact that enzymes would be able to

breakdown already formed matrix in some plaques

and calculus

Some are proteolytic and have bactericidal action

eg:Mucinase, mutanase, dextranase etc

DELMOPINOL Inhibits plaque growth and reduces

gingivitis

Mechanism of action

Interfere with plaque matrix formation & also reduces bacterial adherence

It causes weak binding of plaque to tooth, thus aiding in easy removal of plaque by mechanical procedures

It is therefore indicated as a pre brushing mouth rinse

Adverse effect of delmopinol

1. Staining of tooth & tongue

2. Taste disturbances

3. Mucosal soreness & erosion