MECHANICAL PLAQUE CONTROL

JYOTICA JOS3rd YEAR B.D.S

INTRODUCTION• Dental plaque is defined clinically as a

structured, resilient, yellow-grayish substance that adheres tenaciously to the intraoral hard surfaces including removable and fixed restoration.

PLAQUE

Supragingival plaque

Sub gingival plaque

COMPOSITION • Composed primarily of micro organisms• 1gm of plaque contains approximately 10¹¹bacteria• The number of bacteria in supragingival plaque on a

single tooth can exceed 10• More than 500 different species of microbes are

found in the plaque • One individual may harbor 150 or more different

species• Non-bacterial organisms in the plaque include

Mycoplasma species, yeasts, protozoa and viruses

CONTI..• Micro organisms are seen in intercellular matrix, that

also contain a few host cells such as epithelial cells, macrophages and leucocytes

• Health gingival crevice - 10³ bacteria

• Deep periodontal pocket – more than 108 bacteria

• Predominant species – streptococcus intermedius ,peptostrptococcus micros , porphyromonas gingivalis , prevotella intermedia , fusobacterium nucleatum , fannerella forsythia.

FORMATION OF PLAQUE

The three phases in the formation of plaque are:

Formation of pellicle on tooth surface

Initial adhesion and attachment of bacteria

Colonization and plaque maturation

PLAQUE CONTROL It is the regular removal of dental plaque and the

prevention of its accumulation on the teeth and adjacent gingival surface.

It is the major etiology of periodontal disease and is related to dental caries.

Good plaque control facilities the return of health for patients with gingival and periodontal diseases , prevent tooth decay and preserves oral health for a life time.

Two types of plaque control are : *MECHANICAL PLAQUE CONTROL *CHEMICAL PLAQUE CONTROL.

MECHANICAL PLAQUE CONTROL

• Manual tooth brushes• Powered tooth brushes• Sonic and ultra sonic• Ionic tooth brushes

Tooth brushes and Dentifrices

• Dental floss• Interdental brushes• Wooden or rubber tips

Interdental cleaning aids

• Gingival massage• Water irrigation devices

Aids for gingival

stimulationTongue

scrapers

A. TOOTH BRUSHES

• “The tooth brush is designed primarily to promote cleanliness of teeth and oral cavity”

• They are the most widely used oral hygiene aids ADA specification of tooth brush Brushing surface:• 1-1.25 inches in length• 5/16-3/8 inches in width• 2-4 rows of bristles• 5-12 tufts/row

HISTORY• Introduced in China as early as 1600 B.C (hog

bristles were used) and introduced the western world in 1640 and first patented in America in 1857

• William Addis introduced it in England in 1780• Nylon came into use in tooth brush construction in

1938• Powered toothbrush were actively promoted after

1960

TYPES OF TOOTH BRUSHES

Manual tooth

brushes

Powered tooth

brushes

Sonic and ultra

sonic

Ionic tooth

brushes

MANUAL TOOTH BRUSHES • Ideal characteristics of tooth brush are:

– Handle size should be appropriate to user age and dexterity so that the brush can easily and efficiently be manipulated

– Head size should be appropriate to the size of the individual patient’s requirements

– Use of end-rounded nylon or polyester filaments not larger than 0.23mm in diameter

– Use of soft filaments configurations as defined by the acceptable international industry standards (ISO)

– Should be readily cleaned and aerated and should be impervious to moisture

– Should be durable an inexpensive

• Tooth brush modifications : -- With long and contoured angle --Double angulations of head and neck --Concave surface of brushing plane -- Special indicator bands Tooth brush bristles can be• Hard or soft• Natural or synthetic• Multitufted or spacetufted

• Natural bristles: from the hair of hog or wild boar. They are tubular in form and are more susceptible in fraying, breaking and contamination with

microbial debris, softening and loss of elasticity.• Synthetic bristles: are made of nylon , uniform in size and elasticity, resistant

to fracture and do not get contaminated. • Bristle hardness• Proportional to the square of diameter and inversely proportional to the

square of bristle length.

PARTS OF BRUSHHandle - part grasp in hand during tooth

brushing

Working end -of tooth brush that holds the bristles or filaments

Tufts - clusters of bristles or filaments secured on to the head

Brushing plane - the surface formed by the free end of bristles or filaments

Shank - the section that connects head and handle

RECOMMENDATIONS• Soft , nylon bristle tooth brushes clean effectively

(when used properly) remain effective for reasonable time, and tend not to traumatize the gingival or root surfaces

• Tooth brush need to be replace in every 3 months• If patient perceive the benefit from a particular brush

design, they should used it• The amount of force used to brush is not critical for

effective plaque control. Vigorous brushing can lead to gingival recession bacteremia etc

POWERED TOOTH BRUSHES• In 1885, Fredrick Tomberg, a Swedish watchmaker

designed the first mechanical tooth brush which was followed by first powered tooth brush in 1939

• Also known as automatic , or mechanical or electrical tooth brushes

• Makes action faster and efficient• They work primarily by mechanical contact between

the bristles and the tooth to remove plaque• Perform the circular and elliptic motion

• Indications – Young children– Handicapped patients– Individual lacking manual dexterity– Patients with prosthodontic and endosseous

implants– Orthodontic patients– Patients on supportive periodontal therapy– Elderly people who depend on health care

workers

ADVANTAGES• Increase patient motivation resulting in better

patient compliance• Increased accessibility in inter-proximal and

lingual tooth surfaces• No specific brushing techniques required • Useless brushing force that the manual tooth

brushes• Brushing timer is incorporated in some

brushes to help the patient in brushing for required duration

SONIC & ULTRASONIC TOOTH BRUSHES

• Produce high frequency vibrations (1.6MHz) which leads to the phenomenon of cavitations or acoustic micro streaming

• Aids in stain removal and disruption of bacterial cell wall

IONIC TOOTH BRUSHES

• Change the surface charge of teeth by an influx of positively charged ions.

• Plaque with similar charge is repelled from the tooth surface and is attracted by the negatively charged bristles of toothbrush

B. DENTIFRICES

• Dentifrice is a substance used with toothbrush for the purpose of cleaning the accessible surface of the teeth.

• Functions ● Minimizing plaque buildup

● Anticaries action ● Removal of stains ● Mouth freshener

Amount needed

– pea sized dab on the top of half of toothbrush– preferably dispersed in between the bristles rather than on

the tips– children below 6 years of age – half amount of the dentifrices

as compared to that of an adult

Recent developments • Tooth paste for children• Natural toothpaste (herbal toothpaste)• Whitening toothpastes(as it contains highly abrasive silica particles, not

recommended for regular use)

Agents Material used FunctionsPolishing/abrasive agents Calcium carbonate

Dicalcium phosphate dehydrateAlumina Silica

They have a mild abrasive action, which aids in eliminating plaque and removing stains from the tooth surfaces

Binding/thickening agents Water soluble agents Alginate, sodium carboxymethyl celluloseWater insoluble agents Magnesium aluminum silicate Colloidal silicate

Agents which controls stability and consistency of the tooth paste

Detergents/surfactants Sodium lauryl sulphate Produces the foam which aids in the removal of food debris and also dispersion of the product in the mouth

Humectants Sorbitol, glycerin polyethylene glycol Aids in reducing the loss of moisture from the toothpaste

Flavoring agent Peppermint oil, spearmint oil, oil of winter green They render the product pleasant to use and leaves a fresh taste in the mouth after use

Sweeteners &coloring agent saccharin sweetener

Antibacterial agents Triclosan dedmopinolMetallic ions , zinc citrate trihydrate

Anticaries agents SodiummonoflurophosphteSodium fluorideStannous fluoride

Anti-calculus agents Pyrophosphates ,zinc citrate, zinc chloride , gantrez acid (a copolymer of methyl vinyl ether and maleic anhydride)

They are mostly designed to inhibit the mineralization of plaque They are also known as crystal growth inhibitors

Desensitizing agents Sodium fluoridePotassium nitrateStrontium chloride

COMPOSITION OF DENTIFRICES

TOOTH BRUSHING METHODS

Horizontal: Scrub technique

Vertical: Leonard technique

Circular: Fones technique

Vibratory: Stillman / Charters and Bass technique

Roll: Roll method / modified Stillman technique

According to the pattern of motion:-

ROLL TECHNIQUE• Also known as rolling stroke method/ADA method/sweep method.

Indications • Children • Adult patients with limited dexirity• Useful for preparatory instructionTechnique• The bristles are placed at 45° angle and lightly rolled across the toot surface

toward the occlusal surfaces Advantage • Provide gingival massage and stimulation Disadvantage• Brushing too high during initial placement can lacerate the alveolar mucosa.• Tendency to use quick, sweeping strokes resulting in on brushing for the cervical

third of the tooth.

MODIFIED STILLMAN’S TECHNIQUE

Indications• Dental plaque removal from cervical areas below the height of contour of

the enamel &from exposed proximal surfaces.• General application for cleaning tooth surfaces & massage of gingiva.Technique• Bristles are pointed apically with an oblique angle to long axis of tooth.• Bristles are positioned on the cervical aspect of teeth & partly on the

adjacent gingiva & are activated by short back &forth motions & simultaneously moved in a coronal direction.

• Following 20 strokes, the procedure is repeated systematically on adjacent teeth.

Disadvantage• Time consuming.• Improper brushing can damage epithelial attachment.

BASS METHOD / SULCUS CLEANING METHOD

Indications• Particularly adaptable for open interproximal areas ,cervical

areas, beneath the height of contour of enamel & exposed root surfaces

• Recommended for routine patients with /without periodontal involvement.

Technique• Place the tooth brush so that the bristles are angled

approximately 45 °from the tooth surface• Start at the most distal tooth in the arch & use a vibratory,

back and forth motion to brush.

CONT….

• Strokes are repeated around 20 times, 3 teeth at a time.• Occlusal surface are cleansed by pressing the bristles

firmly against the pits and fissure and then activating the bristles.

Advantages• Effective for plaque removal.• Provides good gingival stimulation• Easy to learn.Disadvantages• Time consuming.• Dexterity requirement is too high for certain patients.

MODIFIED BASS TECHNIQUE • The technique incorporates the vibratory and circular

movement of the bass technique with the sweeping motion of roll technique.

Advantages• Excellent sulcus cleaning• Good gingival stimulation• Good interproximal and gingival cleaning

Disadvantages • Dexterity to wrist is required

CHARTER’S METHOD

Indications• Individuals having open Interdental spaces with missing

papilla and exposed root surface.• Those wearing fixed partial dentures /orthodontic appliances• Patients who have had surgery Technique • Soft /medium Multitufted tooth brush is indicated• Bristles are placed at an angle of 45° to gingiva with the

bristles directed coronally &are activated by mild vibratory strokes with bristle ends lying inter proximally.

CONT…

Advantage• Massage & stimulation for marginal &Interdental

gingiva Disadvantage • Brush ends do not engage the gingival sulcus to

remove sub gingival bacterial accumulations • Requirement in digital dexirity are high

CIRCULAR METHOD

Indication • In young children• Physically or emotionally handicapped individuals• Patients who lack dexterity.

Technique• Arms are kept parallel to floor .then they are asked to

make big circles using the whole arm to draw circles in the air –reduced in diameter until very small circles are made in front of the mouth.

CONTI….

Advantages• Easy to learn • Shorter time is required. Disadvantages• Possible trauma to gingiva• Interdental areas are not properly cleaned

VERTICAL METHOD• Bristles placed 90 ° to the facial surface of the teeth.• Brush vigorsly, without great pressure, up and down with

a slight rotation or circular movement.

Advantage• Most convenient and effective for small children with

deciduous teeth Disadvantage• Interdental areas of permanent teeth of adults are not

properly cleaned.

SCRUB BRUSH TECHNIQUE

• Method of brushing requires vigorous horizontal ,vertical & circular motion

• Disadvantage• Not very effective of plaque removal• Tooth abrasion & gingival recession.

C. INTERDENTAL CLEANING AIDS

1. DENTAL FLOSS• Multifilament –twisted/ non-twisted• Bonded /non bonded• Thick /thin.• Waxed/ non-waxed

Disadvantages• Time consuming • Requires skill• Carries the risk of tissue if not used properly

Functions • Removal of adherent plaque and food debris from

the interproximal embrasure• Polishing of tooth surface during removal of plaque

&debris• Stimulating & massaging the Interdental papillae• Helping in locating

• Sub gingival calculus deposits• Overhanging margins of the restorations• Proximal carious lesion

• Techniques – Spool method– Circle or loop method

• Spool method• about 12-18 inches long loss is taken &about 4 inches

from each end is wound around the middle finger of each hand.

• in both hand, the last three fingers are folded and closed & both hands are moved apart.

• Circle/loop method• A loop /circle of the floss are made from about 12-18

inches long piece and both ends are tied securely with the three knots.

• All fingers except the thumb of both hands are placed within the loop and the floss is held tightly by both the hands having about 1- inches of floss between fingers of both the hands.

• The floss is then passed gently through each contact area with a firm back& forth motion. Once the floss is apical to the contact area, it is wrapped around the proximal surface of one tooth & slipped gently under the marginal gingiva. The floss is then moved firmly along the tooth up to the contact area & gently down in the sulcus again, repeating this stroke for 2-3 times .then move the floss across the Interdental gingiva &repeat the procedure on the adjacent tooth until the whole dentition is covered.

2. INTERDENTAL BRUSHES

• Cone shaped / cylindrical brushes made of bristle mounted on a handle

• Particularly suitable for cleaning large, irregular or concave tooth surfaces adjacent to wide Interdental spaces.

• They are inserted through interproximal spaces and moved back & forth between the teeth with short strokes.

3. WOODEN TIPS• Manufactured from orange wood & are triangular in

cross section.• Inserted into the gingival embrasures with the base of

the triangle oriented towards the gingiva.• They are repeatedly moved in& out of the embrasure,

thereby removing soft deposits from the teeth & also mechanically stimulating gingiva.

• Restricted to facial aspects of anterior teeth.• Rubber tips can be easily applied to interproximal spaces

& other defects throughout the mouth & are easily adaptable to lingual surface

D. GINGIVAL MASSAGE

• Mechanical stimulation of gingiva either by tooth brushing or Interdental cleansing with various aids or simple finger massage.

• It leads to :• Increased keratinization • Increased blood flow • Increased flow of gingival crevicular fluid within the

gingival sulcus.• This results in overall improvement of gingival health.

WATER IRRIGATION DEVICES (WATER PIK)

• Beneficial in the removal of unattached plaque & debris • Composed mainly of a built in pump and a reservoir • Also used to deliver antimicrobial agents.• They have a beneficial effect on periodontal health by

retarding plaque & calculus formation.• Oral irrigation Supragingival Subgingival• Daily sub gingival irrigation with a dilute antiseptic,

Chlorhexidine, for 6 months resulted in significant reduction in bleeding and gingivitis

• Sub gingival irrigation performed both in dental office & at home by the patient.

• It is called “lavage” or’flushing of the periodontal pocket”

E. TONGUE SCRAPERS• It is defined as process of removing debris from

the surface of tongue with some form of scraper designed for this purpose.

• Most of them are made of a soft flexible plastic • Metal scrapers are also available.• -It is placed toward the back of tongue on dorsal

surface, and then pulled forward with light pressure.

• A soft tooth brush may also be used for this purpose.

CHEMICAL PLAQUE CONTROL

Agents that could inhibit the development of plaque and its maturation are called chemical plaque control agentsThey act mainly by any of the following properties:• Anti adhesive • Anti pathogenic • Anti microbial • Plaque removal

Vehicles carrying these agents• Mouth rinses• Tooth paste• Gel• Irrigators chewing gums• Sprays

CLASSIFICATION– Antibiotics .Eg:- penicillin, spiromycin– Enzymes Eg:- dextrose, mutanase– Bisbiguanide antiseptics Eg:- Chlorhexidine– Phenol Eg: - thymol triclosan.– Metal salts. Eg: - tin, zinc copper.– Oxygenating agents .Eg:- hydrogen peroxide.– Detergents .Eg:- sodium lauryl sulphate

ADA has accepted two agents as plaque control agents• Prescription Chlorhexidine rinse.• Non-prescription essential oil rinse.

PRESCRIPTION CHLORHEXIDINE RINSE

• Chlorhexidine digluconate is a cationic Bisbiguanide which is effective against an array of microorganisms, including gram positive & gram negative organisms, fungi, yeasts& viruses.

• Exhibits both anti plaque & antibacterial properties.

• Chlorhexidine gluconate is a salt of Chlorhexidine & gluconic acid.

• It contains 0.12% Chlorhexidine gluconate.

Mechanism of action• The superior anti-plaque activity of

Chlorhexidine is due to its property of sustained availability –“substantivity”. This involves a reservoir of Chlorhexidine, slowly dissolving from all oral surfaces, resulting in “bacteriostatic milieu” in the oral cavity.

• Shows different effect in different concentrations

• It is bacteriostatic at low concentrations & bactericidal at high concentration, these vary between bacterial species.

Inhibits plaque by• Preventing pellicle formation by blocking

acidic groups on salivary glycoprotein thereby reducing glycoprotein adsorption onto the tooth surface.

• Preventing adsorption of bacterial cell wall onto the tooth surface by binding to bacteria.

• Preventing binding of mature plaque by precipitating agglutination Factors in the saliva& displacing calcium from the plaque matrix.

• Chlorhexidine shouldn’t be used before /immediately after using a tooth paste as interaction with anionic surfactants found within the formulations will reduce effective delivery of Chlorhexidine in active form.

• Tooth paste should be used prior to using Chlorhexidine and excess tooth paste rinsed away with water.

• Also Chlorhexidine has a bitter taste which may last for at least 4 hours .rinsing with water should be avoided after using mouthwash immediately because it increases the bitter taste of the rinse &also reduces the effect of the rinse

Adverse effects• Brownish staining of teeth on restoration .it is

reversible • Loss of taste sensation.• Rarely hypersensitivity to Chlorhexidine has been

reported • Stenosis of parotid duct has also been reported • Oral mucosal erosion• Enhanced supragingival calculus formation.• The preparation contains12% alcohol ,so regular

use of alcohol increases the risk of oropharyngeal cancer.

• DISCLOSING AGENTS• A disclosing agent is a preparation in liquid,

tablet / lozenge from which contains a dye or other coloring agent which is used for the identification of bacterial plaque, which might otherwise be invisible to naked eye.

• Solutions / wafers capable of staining bacterial deposits on the surface of teeth, tongue & gingiva.

Uses• Personalized patient instruction & motivation• Self evaluation by the patient.• To evaluate the effectiveness of oral hygiene

maintenances• In research studies with regard to

effectiveness of plaque control devices like tooth brushes &dentifrices etc.

Agents used a) Iodine preparations• skinners iodine solution• diluted tincture of iodine• b) Mercurochrome preparations• - Mercurochrome solutions 5%• -flavored mercurochrome disclosing

solution.• c) Bismark brown • d) Merbromin• e) Erythrosine: FD&C (federal food drug &

cosmetic act)

• f) Fast green: FD&C green no: 3• g) Fluorescein: FD&C yellow no: 8• h) Basic fuschin • i) Two tone solutions: FD&C blue no: 1 FD&C red no: 3 Mainly stains older plaque blue and newer plaque red

CONCLUSION

Periodontal disease accounts for a majority of missing teeth in adults in tremendous economic and burdens both in individual & society. Periodontal disease is so prevalent that the only possible solution to problem is prevention .to be effective, prevention requires responsible action on the part of the individuals themselves, government & society in general.

REFERENCES

• CARRANZA’S CLINICAL PERIODONTOLOGY 10th EDITION

• CLINICAL PERIODONTOLOGY AND IMPLANT DENTISTRY,5th EDITION-NIKLAUS P.LANG AND JAN LINDHE

• ESSENTIALS OF COMMUNITY DENTISTRY 3rd and 4th EDITION-SOBEN PETER