Mechanical plaque control

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1. MECHANICAL PLAQUE CONTROL

2. Plaque Control The regular removal of microbial plaque and the prevention of its accumulation on the teeth and adjacent gingival surfaces. The level of plaque which maintains a healthy gingiva and doesn’t progress into gingivitis. In Periodontal Therapy, It is very critical in every phase that plaque control must be maintained .

3. Classic Study In 1965, Loe and his colleagues demonstrated The cause and effect relationship between microbial plaque accumulation and development of experimental gingivitis Summary: When plaque was allowed to accumulate, gingivitis developed within 7 to 21 days. When plaque control was initiated, the gingivitis was reversed to clinical gingival health within 1 week.

4. Mechanical Plaque Control Toothbrushes - Tooth brushing techniques -Powered toothbrush Dentifrices Interdental Cleaning Aids - Dental floss - Interdental brush - Wooden / Rubber tips

5. Toothbrushes • 1600 - Bristle toothbrush appear in China • 1857 - H.N. Wadsworth patented the first American toothbrush History:

6. TYPES OF TOOTH BRUSH ACCORDING TO USE : • Manual • Electrical • Interdental TYPE OF HANDLE : • Non slip grip - straight • Flexible neck SHAPE OF HEAD • Tapered • Rectangular STYLE OF BRISTLE • Rippled • Flat • Dome shaped BRISTLES • Soft • Medium • Hard

7. Bristles It is either natural or artificial Natural bristles from hogs Artificial filaments made of nylon are Superior They are grouped in tufts which are arranged in 2-4 rows The brush is either unitufted or multitufted Soft bristles are more flexible, clean beneath gingival margin and can reach farther onto proximal surfaces

8. Bristles….. Bristle hardness is proportional to square of diameter Diameter of bristle • Soft brush = 0.2 mm • Medium brush = 0.3 mm • Hard brush = 0.4 mm • Ultra soft = 0.075 mm

9. Toothbrush specification American Dental Association (ADA) • Brush length: 1-1.25 inches • Brush width: 5/16 - 3/8 inches • 2-4 rows • 5-12 tufts per row • Surface area : 25.4 to 31.6 mm long

10. Recommendations: Soft, nylon bristle toothbrush clean effectively when used properly ,remain effective for a reasonable time and tends not to traumatize the gingiva or root Toothbrushes need to be replaced every 3-4 months Importantly, There is no need for excessive force / vigorous brushing as it can lead to gingival recession, wedge-shaped defects of cervical areas and painful ulcerations

11. Toothbrushes Toothbrushing methods: Classification given by Greene J.C (1966) Roll: Modified Stillman technique Vibratory : Stillman , Charters and Bass technique Circular : Fones technique Vertical : Leonard technique Horizontal : Scrub technique

12. Bass Technique • Most often recommended – Emphasizes sulcular placement of bristles, adapting the bristle tips to gingival margin to reach supragingival plaque and accessing subgingival plaque to possible extent. Technique Place the head of a soft brush parallel with the occlusal plane Place the bristles at the gingival margin, establishing an angle of 45 degrees to the long axis of the teeth Exert gentle vibratory pressure, using short back and-forth motions without dislodging the tips of the bristles Reposition to next group of teeth.

13. MODIFIED BASS TECHNIQUE This method differs from bass technique in that it has sweeping motion from cervical to incisal or occlusal surface. INDICATION : As a routine oral hygiene measure. Intrasulcular cleansing . ADAVANTAGE: Excellent sulcus cleaning. Good inter proximal and Gingival cleaning. Good gingival stimulation. DISADVANTAGE : Dexterity of wrist is required.

14. MODIFIED BASS TECHNIQUE   Toothbrush positioned on facial and maxilloproximal surfaces of maxillary molars . Palatal position on molars and pre molars. • This technique combines the vibratory & circular movements of the Bass technique with the sweeping motion of the Roll technique . The toothbrush is held in such a way that the bristles are at 45° to the gingiva. • Bristles are gently vibrated by moving the brush handle in a back & forth motion. • The bristles are then swept over the sides of the teeth towards their occlusal surfaces in a single motion. Brush position on the occlusal surface used with Bass, Stillman , Charter's method. Palatal position on incisors. Intrasulcular position of the brush at 45º angle to the long axis of the tooth.

15. Bass Method

16. Stillman Technique Same stroke as bass . Same angle 45 dgree . Filaments are placed half in sulcus and half on gingiva. INDICATIONS : Gingival recession to clean large embrasures remove plaque from cervical regions

17. Charters Technique The bristles be pressed against the sides of the teeth and gingiva, the brush is moved with short circular or back-and-forth strokes. Indications: - Individual’s having open inter-dental spaces with missing papilla & exposed root surfaces - For patients who have had periodontal surgery

18. Toothbrushes Powered Toothbrushes - invented in 1939 Its mainly recommended for: Individual lacking motor skills Can be used in children . Hospitalized patients whose teeth are cleaned by caregivers Special needs patient(physical & mental disability) Patient with orthodontic applied.

19. Mimics back and forth tooth brushing technique Removes plaque in shorter duration. Has better plaque removal efficiency. Variations: Reciprocal of Back and Back motions Circular and Eliptical motions Combination of both

20. Sonic Powered toothbrush These types of toothbrushes produce high frequency vibrations (1.6MHz)which leads to the phenomenon of cavitation and acoustic microstreaming This phenomenon aids in stain removal as well as disruption of the bacterial cell wall (bactericidal)

21. Dentifrices They aid in cleaning and polishing tooth surfaces Appear in forms of paste, powder and gel. Contents Abrasive: silica, aluminium , dicalcium phosphate and calcium carbonate Detergent : sodium lauryl sulphate Thickeners: silica and gum Sweeteners: saccharine Humectants : glycerin and sorbitol Flavors: mint & peppermint Actives: flourides,triclosan , stannous fluoride

22. Detergent – 1.2%Sodium lauryl sulphate • Use – To lower surface tension -Penetrate and loosen surface deposits and strains • Emulsify debris for easy removal by toothbrush Contribute to the foaming action 2. Cleaning and polishing agents - 20-40% Calcium carbonate, calcium pyrophosphate bicalcium phosphate • Uses– Act as abrasive agents for cleaning and polishing objectives. • Polishing agent is used to produce a smooth shining tooth surface that resists discoloration, bacterial accumulation and retention 3. Binders – 1.2%Organic hydrophilic colloids, alginates, magnesium aluminium silicate, colloidal silica • Use – To prevent separation of the solid & liquid ingredients during storage

23. 4. Humectants : 20-40%Glycerin : Sorbitol • Use – Added to retain moisture • Prevent hardening on exposure to air. • To stabilize preparation 5. Preservatives - Alcohol, formaldehyde ; dichlorinated phenols Use – To prevent bacterial growth and to prolong shelf life 6. Sweetener : 2-3%Sorbitol ,sodium saccharin, sorbitol, xylitol Use – To import a pleasant flavor for patient acceptance 7. Flavoring agent : 1-15%Peppermint : cinnamon, menthol • Use – To make the dentifrices desirable To make other ingredients that may have less pleasant flavor 8. Therapeutic agent 1-2 %Fluoride • Use – For medical value 9. Coloring agent 2-3% -Added for all activeness 10. Water 20-40%Main transport medium

24. Interdental cleaning The toothbrush does not reach the approximal surfaces of teeth as efficiently as it does for the facial, lingual, and ooclusal aspects nor does it reach into the interproximal area between adjacent teeth • Therefore measures for interdental plaque control should be selected to complement plaque control by toothbrushing

25. DENTAL FLOSS • FREQUENTLY RECOMMENDED TECHNIQUE • LEVI SPEAR PARMLY from New Orleans , dentist inventor of modern dental floss. • Unwaxed dental floss recommended for patients with normal tooth contacts • Waxed dental floss - tight tooth contact • Powered floss - with special handle - No significant difference in plauqe removal but preferred by patients due to ease of use.

26. Take a 20-25cm long floss Hold the ends of the floss together Spool method of flossing also called the finger-wrap  method ).

27. Make a small loop around the tip of the forefinger Pass the ends of the floss thrugh the loop Make a knot

28. Use thumb and forefinger of both hands to hold the floss. use sawing motion to slide into the interdental space. Wrap around one tooth , make C shape , gently pull down to the deepest part of the gingival sulcus Slide it up and down

29. Wrap around the adjacent tooth and repeat up and down motion Clean adjacent teeth surfaces in similar way

30. Spool method ( also called the finger-wrap method) Cut off a piece of floss about18 to 20 inches long. Lightly wrap each side of the piece of floss several times around each middle finger. Next, carefully move the floss in between the teeth with your index fingers and thumbs in an up and down, not side-to-side, motion. Bring the floss up and down, making sure to go below the gum line. Bend it to form a C on the side of each tooth

31. PURPOSE To remove plaque and food lodged between teeth . For ideal plaque control , brushing should be supplemented with aids that assist in cleaning interproximal surfaces

32. INTERDENTAL BRUSHES • Introduced in 1960s , alternative to woodsticks • effective in plaque removal from proximal tooth surfaces. • Recommended ideally for periodontitis patients. • Uncomfort for sensitive root surfaces • INDICATIONS proximal tooth surfaces , orthodontic appliances fixed prosthesis , periodontal splints Exposed class IV

33. SINGLE TUFTED BRUSH • Designed with smaller brush heads • Tuft is 3-6mm diameter • Handle is straight or contra angled. • Angulated handles are more easier to access palatal and lingual surfaces. • Filaments are directed into the required area and activated with rotation motion . • Their design permits access to even tipped , rotated or displaced tooth. Also effectively cleans Fixed dentures , orthodontic appliances .

34. WOOD STICKS • Earliest habit – toothpicks • Triangular wedge sticks are more superior in plaque removal • Unlike floss , they can be used on concave surface of tooth root

35. INTERDENTAL TIP • Conical or pyramidal flexible rubber tip attached to handle. • Trace along the gingival margin (1-2mm) below • Indicated for biofilm removal at or just below gingival margin • For clearing debris from interdental areas.

36. Interdental cleaning methods recommended for particular situations in the mouth Situation • Intact interdental papillae; narrow interdental space • Moderate papillary recession; slightly open interdental space • Complete loss of papilla; wide open interdental space • Wide embrasure space; diastema, extraction diastema, furcation or posterior surface of most distal molar, root concavities or grooves Interdental cleaning method • Dental floss or small woodstick • Dental floss, woodstick or small interdental brush • Interdental brush • Single-tufted/end-tufted brush or gauze strip