D Caroline Mohamed1 Libyan International Medical University 2nd Year First Semester D Caroline Mohamed

 At the end of this topic you should be able to explain and describe:  Mechanical plaque control by: Self-care  Professional mechanical tooth cleaning D Caroline Mohamed2

Remember……..!!! Plaque: Plaque is a white, sticky substance that builds up every day around your teeth and gums, and on dental appliances. Plaque can be removed with daily brushing, flossing, and rinsing with an antiseptic mouthwash. If plaque is not removed it hardens into calculus. Calculus: Once plaque has been allowed to remain it calcifies. Only a dental professional can then remove calculus. D Caroline Mohamed3

 Complete daily removal of dental plaque with a minimum of effort, time, and devices, using the simplest methods possible.  Primary role in removal of soft deposits on teeth and gingival tissue.  Helps in increasingly gingival tone, surface keratinization, gingival vascularity and gingival circulation. 4D Caroline Mohamed

 What can we use to clean our teeth? D Caroline Mohamed5

1. Mechanical plaque control Self Care (a) Toothbrush manual electrical ionic sonic and ultrassonic (b) Dentifrice (c) Interdental cleaning aids dental floss tooth pick interdental brushes gauze strips pipe cleaner yarns 6D Caroline Mohamed

(d) Aids for gingival stimulation Rubber tip stimulator (e) Oral irrigation (f) Salvadora persica –Miswak (g) Aids for Completely or Partially Edentulous Patients Denture & Partial Clasp Brushes/Cleansing Solutions D Caroline Mohamed7

 The efficacy of brushing with regards to plaque removal depends upon 3 main factors: The design of the brush. The skill of individual using the brush. The frequency and duration of use. D Caroline Mohamed8

 To clean teeth of food, stains and debris,  To disturb and remove plaque formation,  To stimulate and message the gingival tissue,  To aply fluoride dentifrice.  Cleaning of tongue and palate. D Caroline Mohamed9

 Handle size appropriate to user age and dexterity.  Head size appropriate to the size of the patients mouth.  Use of end-rounded nylon or polyester filaments not larger than inches in diameter.  Bristles should be of even lengh, so that, they can function simultaneously.  Use of soft bristle configuration as defined by the international industries standards.  Bristle pattern which enhances plaque removal in the approximal spaces and along gum line.  Causing minimum damage to soft and hard dental tissue.  The brush should be easy to keep and clean.  Should be nontoxic.  Having a reasonable lifespan. 10D Caroline Mohamed

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- 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 › Length: 1,5 child to 12,5 cm adults › 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 12D Caroline Mohamed

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Polyester or nylon Nylon wear less and is more hygienic- antistatics Classified:  Soft mm  Medium mm  Hard/Extra hard mm D Caroline Mohamed15

D Caroline Mohamed16 If you think the economy has been in a recession, just look what can happen to your gum tissue!

 Toothbrushes need to be replaced every 3 months, when the bristles flare or you have an infective high respiratory disease. D Caroline Mohamed17

Its mainly recommended for : (a) Individual lacking motor skills ( Aged persons, arthritic patients) (b)Hospitalized patients whose teeth are cleaned by the caregivers. (c)Special needs patient ( physical and mental disability) (d) Patient with orthodontic applied (e) Whosoever wants to use 18D Caroline Mohamed

 There are many powered tooth brushes some with back and forth, rotating, oscillating- pulsating motions. Some are circular and elliptical motion. Round head.  Powered tooth cleaner resembles a dental prophylaxis and hand piece with rotary rubber cap.  Patient should be oriented for proper use. Care if the bristles are not soft. D Caroline Mohamed19

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Electric ToothbrushManual Toothbrush Minimal skill level needed to brushRequires manual dexterity and diligence Individual lacking motor skillsNot helpful in such scenario Tend to brush longer as minimum effort is needed. It can lead to better removal of dental plaque Efforts needed can cause the person to limit the amount of time spent on brushing Smaller brush head that is easier to reach all areas of the mouth without causing discomfort Not always true Less brushing force requiredMore force required Less like to cause damage to tooth enamel and gums because the majority of them have pressure sensors Incorrect techniques can often cause damage D Caroline Mohamed21

D Caroline Mohamed22 Electric ToothbrushManual Toothbrush Allow to regulate the brushing time and pressure applied using a built-in-timer and pressure control Manual regulation required Recommended for those who wear braces as it may reach crevices between braces and teeth that are not easily cleaned Comparative, cleaning can be a cumbersome task for those who have braces Hard toothbrushes can erode teeth tissues Old fashionable power TB can

D Caroline Mohamed23  The motion of these agitated fluid is capable of dislodging dental laque, even beyond where the bristles of the toothbrush actually touch. Only a sonic toohbrush can make this claim.

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 Both sonic and ionic toothbrushes are capable of removing plaque and reducing gingivitis and bleeding effectively.  The results show that the sonic toothbrush showed better results as compared with the ionic toothbrush, though the difference was statistically insignificant.  Guljot Singh, D. S. Mehta, 1 Shruti Chopra, and Manish Khatri.Comparison of sonic and ionic toothbrush in reduction in plaque and gingivitisJ Indian Soc Periodontol Jul-Sep; 15(3): 210–214. Guljot SinghD. S. MehtaShruti ChopraManish Khatri D Caroline Mohamed28

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 No significant difference in dental plaque removal between a conventional toothbrush and the Soladey- 2.  Soladey toothbrush had significant reduction in plaque over a conventional toothbrush in the front portions of the mouth, but the removal effects on other areas were similar in comparison. Niwa et al. Clinical study on the control of dental plaque using a photo energy conversion toothbrush equipped with a TiO2 semiconductor. Shigaku Vol. 77 No 2, D Caroline Mohamed30

 Some problems with the children’s electric toothbrush have been reported, including cut lips, battery burns and bristles that fell off and lodged in the child’s tonsils.  Should change the toothbrush’s head every three months – or sooner, especially if the head is loose.  "Extended usage, loose parts or excessive wear could lead to brush head breakage, generation of small parts and possible choking hazard," according to the website. "Inspect brush for loose parts before use." Read more: electric-toothbrushes-causing-health-problems-fda- says/#ixzz2JNjfiK14http:// electric-toothbrushes-causing-health-problems-fda- says/#ixzz2JNjfiK14 D Caroline Mohamed31

1. Vertical (Leonard´n method) 2. Horizontal 3. Roll technique (Modified Stillman// rolling stroke) 4. Vibrating technique (Charter´s/Stillman and Bass) 5. Circular technique (Fones method) 6. Physiological technique (Smiths method) 7. Scrub Brush method 32D Caroline Mohamed

MethodBristle placementMotionAdvantage/ disadvantage ScrubHorizontal on gingival margin Scrub in anterior position direction keeping brush horizontal Easy to learn & best suited for children BASS Apical towards gingival into sulcus at 45 0 to tooth surface Short back and forth vibratory motion while bristles remain in sulcus. Cervical plaque removal Easily learned Good gingival stimulation Charter's Coronally 45 o, sides of bristles half on teeth and half of gingiva Small circular motions with apical movements towards gingival margin Hard to learn and position brush Clears inter proximal Gingival stimulation FonesPerpendicular to the tooth With teeth in occlusions, move brush in rotary motion over both arches and gingival margin Easy to learn Inter proximal areas not cleaned May cause trauma Rolling stroke Apically, parallel to tooth and then over tooth surface On buccal and lingual inward pressure, then rolling of head to sweep bristle over gingiva & tooth Doesn't clean sulcus area Easy to learn good gingival stimulation Stillman's On buccal and lingual, aplically at an ablique angle to long axis of tooth. Ends rest on gingiva and cervical part. On buccal and lingual slight rotary motions with bristle ends stationary Excellent gingival stimulation Moderate dexterity required Moderate cleaning of interproximal area Modified stillman's Pointing apically at and angle of 45 o to tooth surface Apply pressure as in stillmans's method but vibrate brush and also move occlusally Easy to master Gingival stimulation 33D Caroline Mohamed

The technique should clean all tooth surfaces specially the area of gingival crevice and the interdental region. The movment of the brush should not injure the soft or hard tissues. Certain methods, e.g. Vertical and horizontal scrubbing methods can produce gingival recession and tooth abrasion. The technique should be simple to use and simple to learn. The method most be well organized so that, each part of the dentition is brushed in turn and no area over looked. D Caroline Mohamed34

Charters method Bass method 35D Caroline Mohamed

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 Dentist should be noted that a plaque control devices should be tailored to the individual, similarly to his or her plaque control program.  Controlled studied evaluating the most common brushing technique have shown that no one method is superior. D Caroline Mohamed46

D Caroline Mohamed47  Toothbrush adaptations  The most common tool for effective mechanical control of dental plaque is a toothbrush. The presence of physical and/or cognitive disabilities can create difficulties both in holding and manipulating a toothbrush.

 Grasp, manipulation and control  Grasp – for people who cannot grasp and hold, the objective is to fasten the brush handle to the hand. velcro strap with a pocket on the palm side into which the toothbrush can be inserted.  Fixed fingers – for a patient with fingers permanently flexed or fixed in a fist. The handle of some brushes can be modified by immersion in hot water. no spill beaker' D Caroline Mohamed48

 Limited hand closure or reduced manual dexterity – here, the objective is to enlarge the diameter of the brush handle to fit the hand. Plastazote tubing and silicone putty the use of sponges plastazote tubing bicycle handlebar grips wrapping the handle of the brush in tape or pushing it into a soft rubber D Caroline Mohamed49

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 Any tooth brush, regardless of the brushing method, does not completely remove interdental plaque. Even for patients with wide-open dental embrasures. ( Gjermo, 1970, Schmid 1976).  The majority of dental and periodontal disease's originate in interproximal area, interdental plaque removal is necessary. 51D Caroline Mohamed

 Tissue destruction associated with periodontal disease often leave large, open spaces, between teeth and exposed roots with anatomic concavities and furcations which are difficult to clean and access with the toothbrush.  The purpose of Interdental cleaning aids is to remove plaque, not to dislodge food wedged between teeth. D Caroline Mohamed52

 Remove plaque and debris that adhere to the teeth; restorations, orthodontic appliances, fixed prostheses and pontics, gingiva in the interproximal embrasures; and around implants.  Polish the surfaces as it removes the debris.  Massage the interdental papillae  Aids in identifying the presence of subgingival calculus deposits, over –hanging restorations, or interproximal carious lesions.  Reduces gingival bleeding and control of halitoses.  May be used as a vehicle for the application of polishing or chemotherapeutic agents to interproximal and subgingival areas. D Caroline Mohamed53

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 Types: unwaxed, waxed, tape floss, EPTFE floss, and Superfloss. ◦ Waxed floss contained wax to facilitate passing the floss through the contact and alleviate fraying. ◦ Tape floss contain criss-cross fiber and eliminate fraying. ◦ PTFE floss (Glide floss) is the teflon floss which allow passing through very tight contact easily without fraying. ◦ Superfloss is the web-like material which improved proximal cleaning efficiency. 55D Caroline Mohamed

 Best done before brushing.  There are no significant difference between various types of floss to remove dental plaque, they all work equally well. ( Grossman 1979, Keller 1969).  Super floss X Waxed dental floss  Superfloss superior (50%) 56D Caroline Mohamed

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 Indicated for patients with physical disabilities.  Patients lacking manual dexterity.  Individuals with large hands.  Individuals with strong gag reflex.  Caregivers.  Type I embrasures.. 58D Caroline Mohamed

 More time consuming.  Unable to mantain the tension of the floss.  Must be rethreaded when the floss becomes soiled or frayed.  Need to set fulcrum to avoid floss cuts.  Incorrect use may cause: wearing down of papillae, cuts, abrasion,  can force bacteria or debris into gingival attachment,  Opening of embrasure. D Caroline Mohamed59

 Interdental brush are conical shape brushes made of bristles mounted on a handle, single tufted brushes, or small conical brushes.  They are suitable for cleaning large, irregular, or concave tooth surfaces adjacent to wide interdental spaces. 60D Caroline Mohamed

- Type II and Type III embrasures, -Diastemas, -Exposed root furcations, -Orthodontic and fixed appliances, -Application of fluoride, antimicrobial or desensitizing agents. D Caroline Mohamed61

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 Studies have been conducted to compare the efficacy of tooth pick, dental floss, and multi- tufted brush.  Dental floss removed more plaque at lingual interproximal surface than toothpicks.  Tooth picks may erode teeth. 63D Caroline Mohamed

 Oral irrigation device include the use of water picks.  The high pressure, pulsating stream of water through a nozzle is directed to the tooth surface and subgingivally, washing away debris and plaque containing bacteria.  They are helpful surrounding orthodontic appliance, and when used as an adjunctive treatment in shallow pocket depth.  Contra indicated:  Patients require antibiotic premedication. (patients that had bone marrow transplants, history of endocardites, rheumatic fever, and congenital heart disease, cardiac pacemakers, cardiovascular prosthesis… 64D Caroline Mohamed

 Adjuncts to toothbrushing  Do not use in full strength!  ( Robinson and Hoover, 1971) 65D Caroline Mohamed

 Miswak (chewing stick) in the Islamic countries.  Miswak use is as effective, tooth brushing for reducing plaque and gingivitis.  Antimicrobial effect.  Association with Islam, maximum benefits may be achieved by encouraging optimum use of the miswak.  Oral hygiene may be improved by complementing traditional miswak use with modern technological developments such as tooth brushing. Al-Otaibi D Caroline Mohamed

 Danielsons, et al-showed that there was a reduction of plaque on the front teeth more than the posterior teeth and recommended Miswak as a tool for oral hygiene. ( Danielsons B, et al 1989)  Cross-sectional studies show conflicting results. A cross- sectional study in Ghana among adults revealed higher plaque and gingival bleeding in chewing stick users as compared with toothbrush users. (Norman S, 1989)  Another retrospective study showed that Miswak users had deeper pockets and more prevalence of periodontal diseases (Gazi M,1990) 67D Caroline Mohamed

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 Dental Health Education Objectives:  Change in behavior  Prevente the initiation and progression of dental caries and periodontal disease and make the patient as much as possible, independent of professional support.

 Chair side  Self educational program Self exam Instruction manual Motivated by the health profissional

 Dental Hygiene and oral habits  Self exam  Diet influencing the plaque formation, e.g. dietary sugars, natural cleansers such as fruits and vegetables, etc.  Smoking cessation.

 To provide information about the dental health  To provide information and guidence about methods and techniques of plaque control  Motivate the patient to bring about a change in his behaviour; which promotes dental helth.  Age, culture, mental and physical capacity

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 Removal of infected deposits- plaques & calculus, and stains from surfaces of teeth.  Simple procedure by a dentist to keep your gums healthy and firm.

 Removal of extrinsic tooth stains for cosmetic reasons and psychological effect of having clean teeth maybe are the principal effects of polishing.  Maybe indicated in when plaque removal is inhibited by surface roughness. D Caroline Mohamed78

 Step 1. Supragingival cleaning  Step 2. Subgingival cleaning  Step 3. Polishing D Caroline Mohamed79

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 1. Loe, H. Theilade, E., Jensen, SB. Experimental Gingivitis in Man. Journal of Periodontology, 36: 177,  2. Sanders, WE. Robinson, HBG. The effect of toothbrushing on deposition of calculus. Journal of Periodontology 33: 386,  3. O’Leary, Shafer W., Swenson H, Nesler D. Possible penetration of crevicular tissue from oral hygiene procedure. Use of the toothbrush. J. Periodontology, 41:163, 1970 A.  4. Caranza, Newman. Textbook of clincal periodontology. Eighth edition. WB Saunders,  5. Grant, Stern, Listgarten. Textbook of Periodontics. Sixth Edition. The C.V. Mosby Company,  6. Genco, R., Goldman, H., Cohen, W. Contemporary Periodontics. The C.V. Mosby Company,  7. Killoy, W. Love J., Fedi, P. Tira, D. The effectiveness of a counterrotary action powered toothbrush and conventional toothbrush on plaque removal and gingival bleeding. Journal of Periodontology, 60: 473,  8. Lamberts, D. Wunderlich, R. Caffesse, R. The effect of waxed and unwaxed dental floss on gingival health. Part 1. Plaque removal and gingival response. Journal of Periodontology, 53: 393,  9. Graves, R. Disney J. Stamm J. Comparative effectiveness of flossing and brushing in reducing interproximal bleeding. Journal of periodontology, 60: 243,  10. Ciancio, Mahter, Zambon, Reynolds, H. Effect of chemotherapeutic agent delivered by an oral irrigation device on plaque, gingivitis, and subgingival microflora. Journal of Periodontology, 60: 310,  11. Eakle, W. Ford, C., Boyd, R. Depth of penetration in periodontal pockets with oral irrigation. Journal of clinical Periodontology, 13: 39,  12. Danielsons B, Baelum V, Manji F and Fejerskov O. Chewing stick, toothpaste and plaque removal. Acta Odontol Scand 1989; 47:  13. Norman S and Mosha HJ. Relationship between habits and dental health among rural Tanzanian children. Comm Dent Oral Epidemiol 1989; 17:  14.. Gazi M, Saini T, Ashri N and Lambourne A. Meswak chewing stick versus conventional tooth- brush as an oral hygiene aid. Clin Preventive Dent 1990; 12:  Griffiths J, Boyle S. Holistic oral care – a guide for health professionals. Sections 2–3. London: Stephen Hancocks Ltd,  Guljot Singh, D. S. Mehta, 1 Shruti Chopra, and Manish Khatri.Comparison of sonic and ionic toothbrush in reduction in plaque and gingivitisJ Indian Soc Periodontol Jul-Sep; 15(3): 210–214. Guljot SinghD. S. MehtaShruti ChopraManish Khatri 81D Caroline Mohamed

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Please, Buy and use 3 different type of tooth brushes and a power brush. Next class bring a report comparing the advantages and disadvantages of the different characteristics of each tooth brush in relation to design (handle and head shape), bristle type (soft, medium), cleaning ability, prices and general satisfaction with it. D Caroline Mohamed83