MECHANICAL

PLAQUE
 Background
CT

ES
IV
JE

Mechanical plaque control

(a) Toothbrush
(b) Dentifrice
(c) Interdental cleaning aids
- Dental floss
- Interdental brushes
- tooth pik
(d) Oral irrigation
•
IMPORTANT CHAPTER
•
CLINICALLY VERY RELEVANT
•
REQUIREMENT FOR PATIENT TEACHING
Plaque as etiologic factor
Experimental gingivitis study (1965 Löe et al. )

The cause and effect relationship between
supragingival plaque and gingivitis was
demonstrated by Loe et al (1965).


When plaque was allowed to accumulate, gingivitis
developed within 21 days. When plaque control was
initiated, the gingivitis was reversed (by means of
efficient plaque control, i.e., brushing and flossing)
to clinical gingival health


The removal of microbial plaque leads to cessation
of gingival inflammation, and cessation of plaque
control measure leads to recurrence of
inflammation

The removal of plaque also decreased the
rate of formation of calculus. ( Sanders ,
1962)

Thus eliminating plaque is the key to prevent
the occurrence of periodontal disease or
halting the progression of the disease.
Masses of plaque first develop
( Lang,1973)
FACIAL
MOLAR & SURFACES OF
PREMOLAR THE MOLARS &
AREAS PREMOLARS

PROXIMAL
SURFACES OF
THE ANTERIOR
TEETH
 PLAQUE CONTROL

Plaque control: The removal of dental plaque on
a regular basis and the prevention of its
accumulation on the teeth and adjacent gingival
surfaces.


Position: supra- & sub-gingival plaque control


Methods: mechanical & chemical
 MECHANICAL PLAQUE CONTROL

OBJECTIVE:
Complete Daily Removal Of Dental Plaque
With A Minimum Of
Effort,
Time,
And Devices,
Using The Simplest Methods Possible.
 Self-performed
1. Tooth brushing
2. Interdental aids
Dental floss and tape
–

Toothpicks
–

Interproximal brushes
–

Single-tufted brush
–

3. Adjunctive aids
Dental irrigation devices
–

Tongue scrapers
–

Dentifrices
–
 TOOTH BRUSH
A. Toothbrush Design
B. Methods of toothbrushing
C. Frequency and effectiveness of
toothbrushing
D. Toothbrush wear and replacement
E. Electric toothbrushes
 The Toothbrush

First “toothbrush”
-15th Century in China

First modern
toothbrush - England in
1780 by William Addis
– mass produced
 The Toothbrush

Nylon toothbrush bristles -
1938 in USA (Du Pont)

First electric toothbrush
-1960s (Broxodent)

1987 – first rotary action
electric toothbrush
•
 
 The Toothbrush
-
Generally toothbrushes vary in
size, design as well as in length
and arrangements of bristles
hardness.
-
To overcome this variation ADA
given specification of
toothbrushes.
-------------------------------------------------
 Toothbrush design
American Dental Association (ADA)
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
 NATURAL ARTIFICIAL
Source Hair of hog/ wild boar Synthetic, plastic material
mainly nylon

Uniformity Non uniform Uniform

Diameter Varies Extra soft: 0.075mm

Hard: 0.3 mm

End shape Irregular Rounded

Limitations Standardization not Cleaning, rinsing and

possible maintenance easy
Wear: rapid & irregular Wear: Durable
Collection of debris & Repels debris: end rounded
microorganisms due to Resistant to accumulation
hollow ends of microraganisms
 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)
 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.
 TOOTH BRUSHING
TECHNIQUES
•
Various toothbrushing technique have
achieved acceptance by the dental profession.
•
Each technique has been designed to achieve
a definite goal.

•
Depending on the individual cases, the
techniques of toothbrusing may have to be
altered to achieve the maximum beneficial
effects.
 The efficacy of brushing with regard to plaque
removal is dictated by three main factors:


The design of the brush

The skill of the individual using the brush

The frequency and duration of use

1986 Frandsen
Effects and sequel of the incorrect
use of toothbrush
SEQUEL REASON
Gingival erosion Toothbrush
stiffness

Gingival Method of
recession brushing
Gingival Brushing
abrasion frequency
 Toothbrushing methods
1. Horizontal brushing (scrub)
2. Leonard method (vertical)
3. Bass method (Sulcular cleaning)
4. Modified Bass methods
5. Stillman methos (vibratory)
6. Modified Stillman method (roll)
7. Charters method
8. Methods of cleaning with powered toothbrushes
 How to brush?

Patient is instructed to start with molar region of one arch
around the opposite side than continue back around the
lingual or facial surfaces of the same arch

Last surface to be brushed are occlusal.

Patient instructed to stroke each area ten time or spend 10
seconds per area then move on to next area.

Time : 2 minutes ( 30 sec per quadrant )
 Method Bristle placement Motion Advantage/
disadvantage
Scrub Horizontal on gingival margin Scrub in anterior position direction Easy to learn & best suited
keeping brush horizontal for children

BASS Apical towards gingival into sulcus Short back and forth vibratory Cervical plaque removal
at 450 to tooth surface motion while bristles remain in Easily learned
sulcus. Good gingival stimulation

Charter's Coronally 45o, sides of bristles half Small circular motions with apical Hard to learn and position
on teeth and half of gingiva movements towards gingival brush
margin Clears inter proximal
Gingival stimulation

Fones Perpendicular to the tooth With teeth in occlusions, move Easy to learn
brush in rotary motion over both Inter proximal areas not
arches and gingival margin cleaned
May cause trauma

Roll Apically, parallel to tooth and then On buccal and lingual inward Doesn't clean sulcus area
over tooth surface pressure, then rolling of head to Easy to learn
sweep bristle over gingiva & tooth good gingival stimulation

Stillman' On buccal and lingual, aplically at On buccal and lingual slight rotary Excellent gingival
s an ablique angle to long axis of motions with bristle ends stimulation
tooth. Ends rest on gingiva and stationary Moderate dexterity
cervical part. required
Moderate cleaning of
interproximal area

Modified Pointing apically at and angle of 45 o Apply pressure as in stillmans's Easy to master
stillman's to tooth surface method but vibrate brush and also Gingival stimulation
move occlusally
 Method Bristle placement Motion Advantage/
disadvantage
Scrub Horizontal on gingival margin Scrub in anterior position direction Easy to learn & best suited
keeping brush horizontal for children

BASS Apical towards gingival into sulcus Short back and forth vibratory Cervical plaque removal
at 450 to tooth surface motion while bristles remain in Easily learned
sulcus. Good gingival stimulation
Charter's Coronally 45o, sides of bristles half Small circular motions with apical Hard to learn and
on teeth and half of gingiva movements towards gingival position brush
margin Clears inter proximal
Gingival stimulation
Fones Perpendicular to the tooth With teeth in occlusions, move Easy to learn
brush in rotary motion over both Inter proximal areas not
arches and gingival margin cleaned
May cause trauma

Roll Apically, parallel to tooth and then On buccal and lingual inward Doesn't clean sulcus area
over tooth surface pressure, then rolling of head to Easy to learn
sweep bristle over gingiva & tooth good gingival stimulation
Stillman's On buccal and lingual, aplically at an On buccal and lingual slight rotary Excellent gingival
ablique angle to long axis of tooth. motions with bristle ends stimulation
Ends rest on gingiva and cervical stationary Moderate dexterity
part. required
Moderate cleaning of
interproximal area
Modified Pointing apically at and angle of Apply pressure as in stillmans's Easy to master
stillman's 45o to tooth surface method but vibrate brush and Gingival stimulation
also move occlusally
Bass method

Charters method
 Tooth Brushing

Three methods widely accepted: the modified bass
method, the modified stillman method( stillman 1932),
and the charters method( Carter’s 1948) .

Controlled studied evaluating the most common brushing
technique have shown that no one method is superior

Recommended is Bass technique , because it emphasize
sulcular placement of the bristles.

Plaque control devices should be tailored according to
individual plaque control needs.
 BASS OR SULCUS CLEANING
METHOD
Most accepted and effective method for the
removal of dental plaque present adjacent to and
underneath the gingival margin.
•
INDICATIONS

interproximal areas

cervical areas beneath the height of contour of
enamel.

exposed root surfaces.
 TECHNIQUE

The bristles are placed at a 45 degree angle to the
gingiva and moved in small circular motions.

Strokes are repeated around 20 times,3 teeth at a
time.

On the lingual aspect of the anterior teeth, the
brush is pressed into the gingival sulci and
proximal surfaces at a 45 angle.

The bristles are then activated.

Occlusal surfaces are cleaned by pressing the
bristles firmly and then activating the bristles.
Bass method
ADVANTAGES
•
Effective method for removing plaque.
•
Provides good gingival stimulation.
DISADVANTAGES
•
Injury to the gingival margin.
•
Time consuming.
•
Dexterity.
 MODIFIED BASS TECHNIQUE
•
INDICATION:
•
As a routine oral hygiene measure
•
Intrasulcular cleansing.
 TECHINIQUE
•
Vibratary and circular movements with
sweeping motion
•
Bristles are at 45 to the gingiva
•
Bristles are swept over the sides of the teeth
towards their occlusal surfaces in a single
stroke.
 ADVANTAGES
•
EXCELLENT SULCUS CLEANING.
•
GOOD INTER PROXIMAL AND GINGIVAL
CLEANING.
•
GOOD GINGIVAL STIMULATION

DISADVATAGES
•
DEXTERITY
MODIFIED STILLMAN’S TECHNIQUE

INDICATIONS
•
DENTAL PLAQUE REMOVAL
•
CLEANING TOOTH SURFACES AND GINGIVAL
MASSAGE .

DISADVANTAGE
•
TIME CONSUMING
•
DAMAGE EPITHELIAL ATTACHMENT.
 TECHNIQUE
•
Bristles are pointed apically with an oblique
angle to the long axis of the tooth
•
Bristles placed on the cervical aspect of the
teeth
•
Short back and forth motion moved in a
coronal direction.
 CHARTER’S METHOD
INDICATIONS:
•
Persons having :-
•
Missing papilla and exposed root surfaces.
•
FPD and Orthodontic appliances.
•
Periodontal surgery.
•
Interproximal gingival recession.
 TECHNIQUE
•
A soft/medium multi-tufted tooth brush
taken
•
Bristles are placed 45 to the gingiva with
bristles directed coronally.
•
Mild vibratory strokes required with bristles
ends lying interproximally.
 ADVANTAGES
•
Massage and stimulation of gingiva.

DISADVANTAGES
•
Poor removal of subgingival bacterial
accumulations.
•
Limited brush placement.
•
Requirements in digital dexterity are high.
 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
 The Toothbrush
Soft, nylon bristle toothbrush
•
clean effectively (when used properly),
•
remain effective for a reasonable time ,
•
Soft bristle are more flexible and atraumatic
•
clean beneath the gingival margin,
•
reach farther into the proximal tooth surfaces.
Lecture II
Col area
 EMBRASURE
•
V-shaped spillway next
to the contact area of
adjacent teeth;
•
Narrowest at the
contact and widening
toward the facial,
lingual, and occlusal
contacts
 Powered toothbrushes
Invented in 1939.

Motions:
Back and forth
Circular
Elliptic
Combinations
 Cleaning action by:

1. Mechanical contact between the

bristles and the tooth
2. Low-frequency acoustic energy
generates dynamic fluid movement and
provides cleaning slightly away from
the bristle tips.
 INDICATIONS:
1. Children and adolescents
2. Children with physical or mental disabilities
3. Hospitalized patients, including older adults
who need to have their teeth cleaned by
caregivers
4. Patients with fixed orthodontic appliances.
•
Patients who can develop the ability to
use a toothbrush properly usually do
equally well with a manual or a powered
toothbrush.
•
Less diligent brushers do better with
powered tooth brushes, which generate
stroke motions automatically and require
less operator effort.
 DENTIFRICES
Aids in cleaning and polishing
tooth surfaces.
Composition:
1. Abrasives- silicon oxides, aluminum oxide
2. Humectants
3. Water
4. Soap or detergent
5. Flavoring and sweetening agents
6. Therapeutic agents such as fluorides and
pyrophosphates
7. Coloring agents and preservatives.
 The term dentifrice is derived
from dens (tooth) and fricare (to
rub).
A simple, contemporary
definition of a dentifrice is a
mixture used on the tooth in
conjunction with a toothbrush.
Dentifrices are marketed as
Toothpowders
Toothpastes
Gels

55
 Original purpose:
•
Pleasant taste
•
Cosmetic effect
•
Remove extrinsic stains
 Abrasives

Degree of abrasive hardness depends

on:
•
inherent hardness of the abrasive
•
size of the abrasive particle
•
shape of the particle
Other variables:
•
the brushing technique
•
pressure on the brush
•
the hardness of the bristles
•
the direction of the strokes
•
number of strokes
 Abrasives used:
•
Calcium carbonate
•
calcium phosphate
•
baking soda (sodium bicarbonate)
•
Silicas
•
silicon oxides
•
aluminum oxides
 Humectants
•
Toothpaste consisting only of a toothpowder
and water results in a product with several
undesirable properties.
•
Over time, the solids in the paste tend to
settle out of solution and the water
evaporates.
•
This may result in caking of the remaining
dentifrice.
•
To solve this problem, humectants were
added to maintain the moisture.
•
Commonly used humectants are:
•
Sorbitol,
•
Mannitol,
•
Propylene glycol
•
Advantages:
1. Long shelf life
2. Maintained moisture content
3. Nontoxic
•
Disadvantages
1. Mold or bacterial growth can occur in their
presence
 Soaps
•
Logical cleansing agent.
•
The toothbrush bristles dislodge food
debris and plaque
•
The foaming action of the soap aids in
the removal of the loosened material.
•
Disadvantages of soaps:
1. irritating to the mucous membrane
2. flavor is difficult to mask
3. often causes nausea
4. soaps are incompatible with other
ingredients, such as calcium.
 Detergents
•
Substitute to soaps
•
sodium lauryl sulfate (SLS) is the most widely
used detergent
•
Advantages of SLS:
1. Stable
2. Possesses some antibacterial properties
3. Has a low surface tension which facilitates the
flow of the dentifrice over the teeth
4. Active at a neutral ph
5. Flavor is easy to mask
6. Compatible with the current dentifrice ingredients
 Flavoring and Sweetening
Agents
•
Flavor, along with smell, color, and
consistency of a product, are important
characteristics that lead to public acceptance
of a dentifrice.
•
The flavor must be:
pleasant,
provide an immediate taste sensation,
relatively long-lasting
•
Synthetic flavors are blended to provide the
desired taste.
•
Spearmint,
•
peppermint,
•
wintergreen,
•
cinnamon,
•
other flavors give toothpaste a pleasant taste,
aroma, and refreshing aftertaste
 Sweetening Agents
•
In early toothpaste formulations, sugar,
honey, and other sweeteners were used.

•
DISADAVNTAGE: these materials can be
broken down in the mouth to produce acids
and lower plaque pH, they may increase
caries RISK.
•
Replaced with:
Saccharin,
Cyclamate,
Sorbitol,
Mannitol
•
Sorbitol and mannitol serve a dual role as
sweetening agents and humectants.
•
Glycerin also serves as a humectant, adds to
the sweet taste.
•
A new sweetener in some dentifrices is xylitol.
SPECIFIC DENTIFRICES:
 Essential-Oil Dentifrices

•
The essential-oil ingredients found in
Listerine mouth rinse are also available in a
dentifrice formulation.
•
The clinical and laboratory data suggest a
benefit to gingival health and plaque
reduction
•
This product does not carry the ADA Seal of
Acceptance
 Therapeutic Dentifrices

•
The most commonly used therapeutic agent
added to dentifrices is fluoride, which aids in the
control of caries.
•
OTC: The original level of fluoride -restricted to
1,000 to 1,100 ppm fluoride
•
total of no more than 120 mg of fluoride in the
tube
•
Requirement that the package include a safety
closure.
•
Therapeutic toothpastes, dispensed on
prescription, could contain up to 260 mg of
fluoride in a tube.
•
OTC safe levels:
•
0.22% sodium fluoride (NaF) at a level of
1,100 ppm,
•
0.76% sodium monofluorophosphate (MFP) at
a level of 1,000 ppm,
•
0.4% stannous fluoride (SnF2) at a level of
1,000 ppm.
•
Fluoride levels were increased to 1,500 ppm
sodium monofluorophosphate in "Extra
Strength Aim," marketed OTC. In published
studies,17,18 this product was 10% more
effective than an 1,100 ppm NaF dentifrice. A
recently introduced prescription dentifrice,
Colgate Prevident 5,000, contains 5,000-ppm
 Stannous Salts

•
Stannous fluoride (SnF2), specifically the
stannous ion, has reported activity against
caries, plaque, and gingivitis.
•
While SnF2 has a long record as an anticaries
agent, long-term stability in dentifrices and
mouthrinses has been questioned since
clinical antimicrobial activity has only been
demonstrated in anhydrous state.
 Triclosan

•
Triclosan is a broad-spectrum antibacterial
agent
•
It is effective against wide variety of bacteria
•
A review of the available pharmacological and
toxicological information concluded
•
Triclosan can be considered safe for use in
dentifrice and mouth rinse products.
 Anticalculus Dentifrices

•
Interrupt the process of mineralization of
plaque to calculus.
•
Plaque has a bacterial matrix that mineralizes
due to the super saturation of saliva with
calcium and phosphate ions.
•
Crystal growth inhibitors may be added to
dentifrices to provide a reduction in calculus
formation.
 Antihypersensitivity Dentifrices

Active agents such as:

•
potassium nitrate,
•
strontium chloride,
•
sodium citrate
 Whiteners

•
Controversial

•
These dentifrices control stain via physical
methods (abrasives) and chemical
mechanisms (surface active agents or
bleaching/oxidizing agents).
To be continued in next lecture
 Interdental cleaning aids
•
Dental floss

•
Interdental brushes

•
Wooden or rubber tips
 Dental floss
•
Multifilament vs. monofilament
•
Twisted vs. untwisted
•
Bonded vs. unbonded
•
Waxed vs. unwaxed
•
12-18 inches for use
•
Stretch: thumb and forefinger
•
Up-and-down stroke
Interdental brush
 Gingival massage
•
Epithelial thickening, increased
keratinization, and increased mitotic
activity in epithelium and connective tissue

•
Emphasizing the importance of altering or
removing plaque rather than stimulating or
thickening the keratinized surface in the
plaque control program
 Oral irrigation devices
•
Supragingival
irrigation

•
Subgingival irrigation
 Chemical plaque control
•
Antiadhesive
•
Antimicrobial
•
Plaque removal
•
Antipathogenic