MECHANICAL PLAQUE CONTROL

JYOTICA JOS 3rd 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 10bacteria 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 - 10 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

Tooth brushes and Dentifrices
Interdental cleaning aids Aids for gingival stimulation Tongue scrapers
Manual tooth brushes Powered tooth brushes Sonic and ultra sonic Ionic tooth brushes

Dental floss Interdental brushes Wooden or rubber tips

Gingival massage Water irrigation devices

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 patients 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 BRUSH
Handle - 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)

COMPOSITION OF DENTIFRICES
Agents Polishing/abrasive agents Material used Calcium carbonate Dicalcium phosphate dehydrate Alumina Silica Water soluble agents Alginate, sodium carboxymethyl cellulose Water insoluble agents Magnesium aluminum silicate Colloidal silicate Sodium lauryl sulphate Functions They have a mild abrasive action, which aids in eliminating plaque and removing stains from the tooth surfaces Agents which controls stability and consistency of the tooth paste

Binding/thickening agents

Detergents/surfactants

Humectants Flavoring agent

Sorbitol, glycerin polyethylene glycol Peppermint oil, spearmint oil, oil of winter green

Produces the foam which aids in the removal of food debris and also dispersion of the product in the mouth Aids in reducing the loss of moisture from the toothpaste They render the product pleasant to use and leaves a fresh taste in the mouth after use sweetener

Sweeteners &coloring agent Antibacterial agents Anticaries agents

saccharin Triclosan dedmopinol Metallic ions , zinc citrate trihydrate Sodiummonoflurophosphte Sodium fluoride Stannous fluoride Pyrophosphates ,zinc citrate, zinc chloride , gantrez acid (a copolymer of methyl vinyl ether and maleic anhydride)

Anti-calculus agents

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

Desensitizing agents

Sodium fluoride Potassium nitrate Strontium chloride

TOOTH BRUSHING METHODS

According to the pattern of motion:Roll: Roll method / modified Stillman technique

Vibratory: Stillman / Charters and Bass technique

Circular: Fones technique

Vertical: Leonard technique

Horizontal: Scrub technique

ROLL TECHNIQUE
Also known as rolling stroke method/ADA method/sweep method. Indications Children Adult patients with limited dexirity Useful for preparatory instruction Technique 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 STILLMANS 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

CHARTERS 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 orflushing 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 agents They 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 shouldnt 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
CARRANZAS 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