Plaque Control Notes

Plaque Control

• Periodontal disease is initiated by bacterial plaque.
• Organic acids, end products of bacterial metabolism in plaque, cause dental caries.
• Caries is theoretically preventable with regular oral hygiene to remove plaque.
• Plaque is defined as a soft, non-mineralized bacterial deposit on inadequately cleaned teeth.
• Plaque accumulates on tooth surfaces away from cheeks, lips, tongue and food friction, varying in composition by location.
• Plaque immediately begins to rebuild after removal, as it consists of salivary residues, bacteria, and their end products.
• Plaque control requires a continuous, daily commitment.

Definition of Plaque Control

• Plaque control is the elimination of microbial plaque and prevention of its accumulation on teeth and adjacent gingival surfaces.

Responsibilities in Plaque Control

• Individuals play the major role in plaque control.
• Professional personnel responsibilities include:
  • Providing information about dental health.
  • Providing information and guidance on plaque control techniques.
  • Motivating the patient by changing their evaluation of dental health.

Guidelines for Acceptance of Chemotherapeutic Products

• Council on Dental Therapeutics has guidelines for chemotherapeutic products controlling supragingival dental plaque and gingivitis.
• Clinical studies should include:
  • Active product compared with placebo or active control in a normal regimen.
  • Acceptable crossover or parallel designed studies.
  • Minimum study duration of 6 months.
  • Two studies conducted by independent investigators.
  • Microbiological sampling to estimate plaque qualitatively plus indices to measure plaque quantitatively.
  • Plaque & gingivitis scoring, and microbiological sampling at baseline, 6 months, and an intermediate period.
  • Microbiological profile showing no development of pathogenic or opportunistic microorganisms.
  • Toxicological profile including carcinogenicity and mutagenicity assays.

Approaches in Plaque Control

1. Mechanical:
   • Individual.
   • Professional: Subgingival plaque control (scaling, polishing, root planing).
2. Chemical.

Mechanical Plaque Control

1. Toothbrush
   • Manual
   • Electrical
   • Ionic toothbrushes
   • Sonic and ultrasonic
2. Interdental oral hygiene aids
   • Dental floss
   • Dental floss holder
   • Toothpicks and toothpick holder
   • Interproximal brushes
   • Single tuft brushes
   • Knitting yarn
   • Gauze strip
   • Pipe cleaner
   • Wedge stimulators
3. Adjunctive aids
   • Irrigation devices (water-pik)

Ideal Requisites of a Toothbrush

1. Handle size appropriate to user age and dexterity.
2. Head size appropriate to the size of the patient's mouth.
3. End-rounded nylon or polyester filaments not larger than 0.009 inches in diameter.
4. Soft bristle configuration as defined by international industry standards.
5. Bristle pattern which enhances plaque removal in the approximal spaces and along the gum line.
6. Causing minimum damage to soft and hard dental tissue.
7. The brush should be easy to keep and clean.
8. Should be nontoxic.
9. Having a reasonable lifespan.

Adjunctive Aids

• Irrigation devices (water-pik)
• Tongue cleaner
• Dentifrices
• Mouth rinses (mouthwash)
• Rubber tip stimulator
• Denture brush

Chemical Plaque Control

1. Antibiotics
2. Enzymes
3. Phenolic compounds and essential oils
4. Quaternary ammonium compounds
5. Bisguanides
6. Natural products
7. Metal salts
8. Amine alcohols
9. Oxygenating agents
10. Fluorides

Toothbrushes

• The conventional toothbrush is most frequently used to remove dental plaque.
• Efficacy depends on:
  • Design of the brush.
  • Skill of the user.
  • Frequency and duration of use.

Objectives of Toothbrushing

1. To clean teeth of food, stains, and debris.
2. To disturb and remove plaque formation.
3. To stimulate and massage the gingival tissue.
4. To apply fluoride dentifrice.
5. Cleaning of tongue.

Manual Toothbrushes - History

• First brush made of hog's hair was mentioned in early Chinese literature.
• Early nineteenth century, European craftsmen made handles of gold and ivory with replaceable brush heads.
• First patent for toothbrush in USA was issued to HN. Wadsworth in the middle of the nineteenth century.
• Nylon came into use in toothbrush construction in 1938.
• World War II prevented Chinese export of wild boar bristles and synthetic materials were substituted for natural bristles.

Parts of a Toothbrush

• Total brush length: about 15 to 19 cm (6 to 7.5 inches).
  • Junior brushes for children may be shorter in size.
• The Head
  • The working end that consists of tufts of bristles or filaments and the stock where the tufts are secured.
  • The brush head must be small enough to be manipulated effectively everywhere in the mouth.
  • Length of about 2.5 cm for an adult and 1.5 cm for a child is satisfactory.
  • A brush head may be 5-12 tufts in 3-4 rows wide.
  • Tufts may be flat or may vary (rippled, dome, multilevel).
• The Handle
  • The part which is grasped in hand during tooth brushing.
  • Made of materials such as acrylic and polypropylene.
  • Its flexibility, size and shape must be convenient for manual use in the mouth.
  • The handle must be comfortable and rest securely in the hand.
  • It should be thick enough to allow a firm grip and good control.
• Shank
  • The part that connects the head and the handle.
• Tufts
  • Bristles when bunched together are known as tufts.
• The Filaments (Bristles)
  • Made of either polyester or nylon.
  • These are polymers with good chemical resistance and are inert.
  • Nylon wears less rapidly than polyester and is more hygienic due to its antistatic properties.

Bristles

• Bristles are classified into three depending upon the diameter of the filaments:
  1. Soft: 0.15-0.18 mm (0.006"- 0.007")
  2. Medium: 0.18-0.23 mm (0.007"- 0.009")
  3. Hard/Extra hard: 0.23-0.28 mm (0.009"- 0.11")
• Bristle stiffness also depends upon the length of the filament, its elasticity, whether the brush is used dry or wet and the temperature of the water.
• Nylon loses approximately 30 percent of its stiffness when wet.
• The bristles of children's brushes should always be soft (0.1-0.15 mm).
• Hard brushes can lacerate the gingival, encourage gingival recession and cause tooth abrasion.
• Their bristle diameter is too large to reach gingival crevice and hence should never be recommended.

Powered Toothbrushes

• Also called automatic, mechanical or electric toothbrushes.
• Introduced to the market more than 50 years ago.
• They are potentially faster than manual tooth brushes at cleaning tooth surfaces.
• New ones apply rotary and oscillating-pulsating movements with bristles moving at high frequencies.
• Rotating-oscillating-pulsating toothbrushes:
  • Small round head with stationary tufts that move in a 60-degree counter-rotational motion with approximately 7600 strokes per minute.
  • There are brushes that have three dimensional movements that add a pulsating action of 20,000 to 40,000 movements per minute.
• Rotating-oscillating and rotating-oscillating-pulsating powered toothbrushes are distinctive in that the brush head is meant to be moved from tooth to tooth instead of using it in manner like a manual toothbrush.

Types of Power Toothbrushes

• The electrical toothbrush designs are categorized by the type of the brush head's shape and movement:
  • The first generation of power toothbrushes had a head looking like the one of manual toothbrushes, and moving back and forth to simulate manual brushing.
  • Only few low cost power toothbrushes use this not efficient mode today.
  • Rotary toothbrushes: The next generation moved to a design with a circular head that is rotating in one direction.
  • Counter-rotational toothbrushes with different tufts of bristles rotating in opposite directions.
  • Rotating-oscillating toothbrushes in which a circular head spins back and forth in quick bursts.
  • Oscillating-pulsating toothbrushes have in addition a pulsating motion to enhance the cleaning action.
• Brush heads of powered toothbrushes tend to be more compact than manual toothbrushes.
• The bundle of bristles is arranged either in circular pattern or in rows which are mounted in a round head.
• The bristles are arranged as more compact single tuft, facilitating interproximal cleaning and brushing in less accessible areas of mouth.

Electric Toothbrush vs. Manual Toothbrush

Indications for Electric Toothbrushes

1. Those with physical or learning disability
2. Fixed orthodontic appliances
3. Young children
4. Aged persons
5. Institutionalized patients who depend upon care providers for brushing
6. Arthritic patients
7. Individuals with poor dexterity
8. Poorly motivated patients.

Sonic and Ultrasonic Toothbrushes

• Cleaning action is based on two separate mechanisms:
  1. Scrubbing action of its brush head's bristles on the surface of the user's teeth (conventional).
  2. New technology: intense speed at which the bristles vibrate.
• Sonic toothbrushes can produce a secondary cleaning action based on the intense speed at which the bristles of the sonic toothbrush vibrate.
• This vibratory motion is able to impart energy to the fluids that surround teeth (such as saliva).
• The motion of these agitated fluids dislodges dental plaque, even beyond where the bristles of the toothbrush actually touch.
• The brush head vibrates at more than 30,000 brush strokes per minute.
• This creates turbulent fluid dynamics near the tips of its bristles.
• The result is the creation of waves of pressure and shear forces in the liquids that surround your teeth, and also the creation of minute bubbles that are propelled forcefully against surfaces where plaque resides.
• The combination of these various fluid dynamics results in forces that are capable of dislodging dental plaque in those hard to reach areas such as between teeth and below the gum line.
• The cleaning effect of these fluid forces has been measured to occur at distances of up to 4 millimeters (slightly more than 1/8th of an inch) beyond where the bristles of sonic toothbrush actually touch.

Ionic Toothbrushes

• Principle
  1. The bonding between the pellicles and bacteria is mediated by Ca^{2+} bridge formation.
  2. The anions, supplied by the lithium battery inhibit the bonding between the bacteria and Ca^{2+} and prevent the bacteria from absorbing to the pellicles.
  3. Plaque accumulation is reduced: the above mentioned anions continuously supplied from the tips of the bristles of the ionic toothbrushes prevent the mild electrostatic bonding between the bacteria per se.
     Instead of using friction or sound (sonic) waves to try to blast apart' this bond, ionic technology changes the polarity of tooth surfaces from -ve to +ve.
• As brushing is done, plaque material is actively repelled by teeth and drawn to the negatively charged bristles, even in hard-to-reach areas of the mouth.

Bionic Toothbrush - Soladey

• Soladey was invented in Japan by Dr Yoshinori Nakagawa.
• The name originates from the words 'Solar' and 'Dental'.
• Mechanism of Action
  • There is a light-activated titanium rod (semiconductor) inside the handle.
  • When exposed to any good light source the photo-sensitive titanium rod inside Soladey converts light into negatively-charged ions (electrons) which attract the positive ions in the acids in dental plaque.
  • The rod releases these ions, which blend with saliva to attract positive (hydrogen) ions from

Modified Bass Technique

• The tooth brush is held with bristles at 45 degree to the gingival.
• Gentle pressure is exerted using short back and forth motion without dislodging the tips of the bristles.
• The bristles are then swept downwards over the tooth surface occlusally.

Stillman's Method

• Indications
  • As the bristle ends are not directed into sulcus, this method can recommended for individuals with progressive gingival recession.
• Technique
  • This method was originally developed to provide gingival stimulation.
  • The brush is positioned with bristles inclined at a 45 degree angle to the long axis of the tooth, with the bristles placed partly on the gingiva and partly on the cervical portion of the tooth.
  • The strokes are activated in a short back and forth (vibratory) motion, with slight pressure to stimulate the gingiva.
  • Approximately 5 to 10 strokes are completed in each region, and the brush is moved to the next

Interdental Oral Hygiene

• As the interdental region is the most common retention and the most inaccessible to the toothbrush, special methods of cleaning are needed.
• Removal of plaque without injuring the soft tissue should be the aim.

Definitions

• Approximal (proximal) areas are the visible spaces between teeth that are not under the contact area'.
• Interproximal and interdental may be used interchangeably and refer to the area under and related to the contact point.
• Tooth brushing alone cannot effectively control interproximal plaque, and the adjunctive methods of cleaning are to remove from these hard to reach sites.
• A number of interdental cleaning methods have been used for this purpose, ranging from floss to the recently introduced electrically powered cleaning aids.
• However, not all interdental cleaning devices suit all patients or all types of dentition.

Factors Effecting Selection of Interdental Aids

1. Contour and consistency of gingival tissue.
2. Probing depth.
3. The size of the interproximal embrasure.
4. Tooth position and alignment.
5. Ability and motivation of the patient.
6. Condition and type of restorative work present.
7. Susceptibility of the person to disease.

Dental Floss

• Although, flossing requires more digital skills and is more time consuming than toothpick, but there appears to be no alternative for using a floss or tape (a type of broader dental floss) in cleaning proximal surfaces when a normal healthy papilla fills the interdental space.
• Uses of Dental Floss
  1. Removes plaque and debris adherent to the teeth, restorations, orthodontic appliances, fixed prosthesis and gingival in the interproximal embrasure.
  2. It polishes the surfaces as it removes the plaque.
  3. Massaging of the interdental papilla.
  4. Helps to identify the presence of subgingival calculus deposits, overhanging restorations and interproximal carious lesions.
  5. Maintenance of general oral hygiene and control of halitosis.
  6. Reduces gingival bleeding.
• Disadvantages of Dental Floss
  1. Not easy to perform specially in posterior areas.
  2. Requires good manual dexterity.
  3. Time consuming.
  4. Risk of frequent shredding when passing through contact point.
  5. Risk of tissue damage if improperly used.
• Types of Dental Floss
  1. Twisted or nontwisted.
  2. Bonded or nonbonded.
  3. Waxed or unwaxed.
  4. Thin or thick.
• Methods of Using Dental Floss
  1. Spool method.
  2. Loop or circle method.
• Spool Method
  • It is recommended for teenagers and adults who have acquired the required the level of neuromuscular coordination and mental maturity to use floss correctly.

Loop Method

• This method is particularly suited for children as well as adults with less nimble hands or handicaps such as poor muscular coordination or arthritis.
• To be effective the floss should be pulled around the tooth curvature so that, close contact with tooth surface is made.
• Patients with tight contact areas need thin unwaxed floss that can be slipped easily between the contact areas, whereas in patients with crowded teeth, heavy calculus deposits, or defective and overhanging restorations, a bonded unwaxed floss or waxed floss is the dental floss of choice because they do not fray as easily as unwaxed floss.
• Dental tape is recommended when there is considerable interdental space resulting from gingival recession and bone loss.

Unwaxed versus Waxed Floss

• Studies have shown no difference in the effectiveness of unwaxed versus waxed dental floss.
• Unwaxed dental floss is usually recommended for individuals with normal tooth contacts because it slides through the contact areas easily.
• Waxed dental floss is recommended for individuals with tight proximal tooth contacts, moderate to heavy calculus deposits, crowded teeth or defective and overhanging restorations.
• It is preferred because of its ability to slide through tight contacts and resist fraying.
• Dental tape or ribbon is a waxed dental floss that is wider and flatter than conventional dental floss.
• The flat-sided surface of dental tape is preferred by some, particularly when the surface area to be flossed is large.

Floss Threader

• It is another device designed to assist individuals with flossing.
• In case of fixed partial dentures, floss cannot be passed through the interdental contacts because this is closed.
• A floss threader assists in introducing floss into an area such as between an abutment tooth used for support of a fixed bridge and a pontic end of the floss threader is passed under the pontic or fixed partial denture connector from the facial aspect.

Super Floss

• It is a type of floss that incorporates a rigid plastic portion that can be introduced under fixed bridge.
• Distal to rigid plastic portion is a spongy region that is ideal for plaque removal.
• The terminal portion of superfloss is similar to standard dental floss.
• The rigid portion is passed into the embrasure space between the retainer and the pontic and pulled through to the lingual aspect.
• The spongy region is then used in apico-coronal stroke along the interproximal surfaces of the abutment teeth and along the intaglio surface of the pontic.

Floss Holder

• Indications
  1. Patient with physical disabilities.
  2. Patient lacking manual dexterity.
  3. Individuals with large hands.
  4. Individuals with strong gag reflex.
  5. Caregivers.
  6. Type I embrasures.
• Floss holder is a flossing aid.
• The majority of floss holders consist of a device with a handle with two prongs in Y shape or C shape.
• The floss is tightly secured between the two prongs.
• The patient holds the handle of the device to guide it during use.
• Disadvantages
  1. More time consuming.
  2. Unable to maintain tension of floss.
  3. Must be rethreaded when the floss becomes soiled or frayed.
  4. Need to set fulcrum to avoid floss cuts.

Toothpicks

• Toothpicks are usually made of softwood and have a triangular, round or rectangular shape.
• Triangular are said to be superior to the rest as they are ineffective on lingual aspect of proximal surfaces.
• Indications
  1. Type II and Type III embrasures from facial aspect only.
  2. Accessible furcations.
  3. Small root concavities.
  4. Interproximal open spaces.
• Contraindications
  1. Type I embrasures.
  2. Healthy gingiva.
• Disadvantages
  1. Wearing down of papilla and marginal tissues from incorrect usage.
  2. Wood ends may cause tissue trauma/ cuts or abrasion.
  3. Enamel abrasion from incorrect use.
  4. Can force bacteria or debris into gingival attachment if used improperly.
  5. May cause opening of the embrasure.

Toothpick Holder

• It is also called as periodontal aid.
• It is an instrument designed to increase patient's application of the traditional toothpick by holding it securely at the proper angle.
• Indications
  1. Plaque removal along the gingival margin.
  2. Type II and Type III embrasures from facial or lingual aspect.
  3. Accessible furcations.
  4. Concave surfaces in interproximal areas.
  5. Fixed prosthetic and orthodontic appliances.
  6. Sulcular cleansing in areas of shallow pocketing.
  7. Application of fluoride, antimicrobials and desensitizing agents.

Interproximal Brushes

• Also called as interdental brushes, proxa brush.
• They are available in various sizes and shapes.
• The most common are conical or tapered and designed to be inserted into a plastic or metal reusable handle that is angled to facilitate interproximal adaptation
• Studies have shown that they are equal to or more effective than floss for plaque removal and for reducing gingival inflammation in Type II and Type III embrasures and exposed furcations areas.
• Indications
  1. Type II and Type III embrasures.
  2. Diastemas.
  3. Exposed root furcations.
  4. Orthodontic and fixed appliances.
  5. Application of fluoride, antimicrobial or desensitizing agents.
• Technique
  • Inserted interproximally and activated with short back and forth strokes in between the teeth.
• Disadvantages
  1. Different types may be needed to fit different open interproximal spaces.
  2. Trauma to tooth or gingiva from sharp wire center of some.

Single Tuft Brushes

• Single tuft or end tuft brushes are small brushes with nylon bristles that are attached to a plastic handle.
• There are variations in the shape of the tufts and the width and length of the handles.
• Single tuft brushes are indicated in open embrasure areas where there is little or no papilla.
• They are used by placing the brush in the interdental area.
• The brush is then jiggled in a small circular motion and/or use a sweeping motion away from the gingiva.
• Indications
  1. The single tuft brush is for patients who prefer a longer handle.
  2. Patients who are not able to change the refills of the interproximal brush.
  3. Patients who cannot control the interproximal brush due to manual dexterity or disabilities.