Prevention of Oral Disease – 2 Dr Omar Alkaradsheh

Reference Prevention of Oral Disease Murray, Nunn, Steele 4 th Edition 2003

Aims and Objectives of Course knowledge and confidence to incorporate the theories of prevention into patient care and treatment planning knowledge and confidence to incorporate the theories of prevention into patient care and treatment planning Use of evidence-based practices in prevention of oral diseases Use of evidence-based practices in prevention of oral diseases Identifying different risk groups to give patients the best care possible Identifying different risk groups to give patients the best care possible

Course Outline Prevention of Periodontal Disease Prevention of Periodontal Disease Prevention of Tooth Wear - Erosion Prevention of Tooth Wear - Erosion Prevention of Dental Trauma Prevention of Dental Trauma Prevention of Oral Mucosal Diseases Prevention of Oral Mucosal Diseases Prevention in the Ageing Dentition Prevention in the Ageing Dentition Preventing an Impairment Preventing an Impairment Preventing Non-Accidental Injury Preventing Non-Accidental Injury Introduction to Dental Public Health Introduction to Dental Public Health

Prevention of Periodontal Disease – 1 Mechanical Plaque Control Dr. Omar Alkaradsheh

Aims 1. Aetiology 2. Implications and importance of preventing periodontal disease 3. Preventive methods Mechanical plaque removal Mechanical plaque removal Chemical plaque removal Chemical plaque removal

Periodontal Disease Group of infections that affect the supporting structures of the teeth Group of infections that affect the supporting structures of the teeth Gingivitis – inflammation restricted to the gingival marginal Gingivitis – inflammation restricted to the gingival marginal Periodontitis – resorption of the supporting connective tissue attachment and apical migration of the junctional epithelia Periodontitis – resorption of the supporting connective tissue attachment and apical migration of the junctional epithelia

What causes Periodontal Disease? DENTAL PLAQUE Non mineralized, bacterial aggregation on the teeth and other solid structures in the mouth bacterial cells (70%) protein extracellular polysaccharides epithelial cells white blood cells

Dental Calculus? Result of mineralization within plaque Result of mineralization within plaque (70-90% inorganic content) Not in itself causative of periodontal disease Not in itself causative of periodontal disease provides a rough PLAQUE retaining surface provides a rough PLAQUE retaining surface distorts the gingival crevice and increases stagnation areas – allows greater bacterial proliferation within the crevice distorts the gingival crevice and increases stagnation areas – allows greater bacterial proliferation within the crevice

Factors affecting PD 1. Local factors 2. Host factors

Local factors that increase plaque accumulation Iatrogenic Rough surfaces Rough surfaces Overhanging restorations Overhanging restorations Removable partial dentures Removable partial dentures Fixed orthodontic appliances Fixed orthodontic appliances Space maintainers (band and loop, etc.) Space maintainers (band and loop, etc.)

Host Factors modifying the immune response 1. Smoking Periodontitis is 2 – 5 times more severe amongst smokers compared to non-smokers Nicotine Nicotine 2. Diabetes (type 1 and 2) fold increase risk of periodontitis related to degree of diabetic control, presence of complications and duration of the syndrome related to degree of diabetic control, presence of complications and duration of the syndrome

Aims Aetiology Aetiology Implications and importance of prevention Implications and importance of prevention Preventive methods Preventive methods Mechanical plaque removal Mechanical plaque removal Chemical plaque removal Chemical plaque removal

Implications for prevention Chronic gingivitis is reversible if effective plaque control is introduced Chronic gingivitis is reversible if effective plaque control is introduced GINGIVITIS and PERIODONTITIS can be prevented by adequate plaque control GINGIVITIS and PERIODONTITIS can be prevented by adequate plaque control Preventive strategy should be customized for each individual – variation in susceptibility Preventive strategy should be customized for each individual – variation in susceptibility

Why prevention is important? 1. Gingivitis is common in both children and adults Children - 26%- 63% (UK Children Dental Health Survey, 1993) Adults – almost 100% 1 mm attachment/bone loss Prevalence and severity of PD increases with age

Why prevention is important (cont) 2. Important cause of tooth loss Scotland - 55% caries 17% PD 3. Time-consuming and difficult to treat 4. Potential source of systemic bacteraemia Infective Endocarditis, coronary heart disease Infective Endocarditis, coronary heart disease Stroke Stroke Low-birth weight preterm infants Low-birth weight preterm infants Diabetes Diabetes

Aims Aetiology Aetiology Importance of preventing periodontal disease Importance of preventing periodontal disease Preventive methods Preventive methods Mechanical plaque removal Mechanical plaque removal Chemical plaque removal Chemical plaque removal

Mechanical Plaque Control

Self Care Self Care Toothbrushing Toothbrushing Interdental cleaning Interdental cleaning Professional Professional Scaling/Root planing Scaling/Root planing Polishing Polishing

Toothbrushes The first true bristled brush was invented in China in 1498 for the Emperor using animal hair (pigs) By the early 1800’s bristled brushes were in general use Nylon bristles were introduced around ’s – development of power toothbrushes (electric)

Requirements of a Satisfactory Toothbrush 1. Have good cleaning ability 2. Cause minimal damage to soft and hard dental tissues 3. Having a reasonable lifespan (good wear characteristics) 4. Non-toxic

Manual toothbrushes Handle size appropriate to the user’s age and dexterity Handle size appropriate to the user’s age and dexterity Head size appropriate for the user’s mouth Head size appropriate for the user’s mouth Adult – 2.5 cm Adult – 2.5 cm Child – 1.5 cm Child – 1.5 cm

Compact arrangement of soft, end rounded nylon filaments not larger than inches in diameter Compact arrangement of soft, end rounded nylon filaments not larger than inches in diameter Hard brushes should never be recommended Hard brushes should never be recommended lacerate the gingiva, gingival recession and tooth abrasion lacerate the gingiva, gingival recession and tooth abrasion Diameter is too large to enter the gingival crevice Diameter is too large to enter the gingival crevice

Bristle patterns that enhance plaque removal in approximal spaces and along gum margin Bristle patterns that enhance plaque removal in approximal spaces and along gum margin Filaments arranged at different heights and angles significantly more effective at reducing plaque and gingivitis than flat trim brushes (Balanyk et al., 1993)

Requirements of a Satisfactory Brushing Technique 1. Technique should clean all tooth surfaces, especially interdental and gingival crevice 2. Movement of the brush should not injure the soft or hard tissues 3. Simple and easy to learn 4. Well-organized so that each part of the dentition is brushed in turn and no area overlooked

Brushing Techniques 1. Vertical 2. Horizontal 3. Roll Technique 4. Vibrating (Bass, Stillman, Charter) 5. Circular 6. Scrub

Brushing Technique Bass technique most recommended by dentists

Brushing Technique 4. Bass technique aims to clean the gingival crevice aims to clean the gingival crevice brush held at 45° to the axis of the teeth so that the end pointing into the gingival crevice brush held at 45° to the axis of the teeth so that the end pointing into the gingival crevice

Brushing Techniques Research shows no particular method superior to any other Research shows no particular method superior to any other Modify the patients method Modify the patients method Emphasize need to repeat the procedure on all tooth surfaces Emphasize need to repeat the procedure on all tooth surfaces

Powered toothbrushes Oscillating, rotating or counter-rotational movements Oscillating, rotating or counter-rotational movements Oscillating/rotating (Braun Oral B) more effective in removing plaque and reducing gingivitis than a manual toothbrush (2003) Oscillating/rotating (Braun Oral B) more effective in removing plaque and reducing gingivitis than a manual toothbrush (2003)

Ultrasonic toothbrushes (Sonicare) high frequency vibration high frequency vibration (30,000 – 40,000 brush strokes/min) Two mechanisms of actions Two mechanisms of actions 1. Conventional - scrubbing effect 2. Vibratory motion – impact energy to oral fluid that surround the teeth – fluid pressure and shear forces

Which toothbrush????? Manual vs. Electric Which electric??? ??????

Manual vs. Electric Manual vs. Electric Electric toothbrushes remove more plaque than manual toothbrushes Electric toothbrushes remove more plaque than manual toothbrushes Electric toothbrush is recommended for individuals who are unable to maintain effective plaque control Electric toothbrush is recommended for individuals who are unable to maintain effective plaque control Physical or learning disability Physical or learning disability Fixed orthodontic appliances Fixed orthodontic appliances Institutionalized patients depend upon care providers Institutionalized patients depend upon care providers A manual toothbrush is appropriate for most people A manual toothbrush is appropriate for most people

Which electric toothbrush? Oscillating/rotating (Braun Oral B) performs better than Ultrasonic (Sonicare) (Strate et al., 2005)

Brushing in Children Start brushing as soon as the first tooth erupts Start brushing as soon as the first tooth erupts Preschool children need help with brushing Preschool children need help with brushing

Frequency and duration of brushing Effective plaque removal every second day has been shown to prevent gingivitis Effective plaque removal every second day has been shown to prevent gingivitis (Lang et al., 1973) Twice daily brushing is consistent with maintaining good gingival health Twice daily brushing is consistent with maintaining good gingival health minute duration is recommended minute duration is recommended

Replacing toothbrush Splaying of the toothbrush is the most obvious sign of toothbrush wear Splaying of the toothbrush is the most obvious sign of toothbrush wear Renewal is usually recommended after 3 months use Renewal is usually recommended after 3 months use

Interproximal Cleaning Periodontal conditions are worst in interdental areas

Plaque Removal

Interproximal cleaners 1. Dental floss 2. Interspace brush 3. Interdental brush 4. Wood points (toothpicks) 5. Irrigation devices

Dental Floss 1. Waxed/Unwaxed 2. Tape 3. Superfloss 4. Flosette

Dental Floss 1. Waxed/Unwaxed 2. Tape 3. Superfloss 4. Flosette

Flossing technique??

Dental Floss 1. Waxed/ Unwaxed 2. Tape 3. Superfloss 4. Flosette

Dental Floss 1. Waxed/Unwaxed 2. Tape 3. Superfloss 4. Flosette

Toothpicks Effective only when sufficient interdental space is available Effective only when sufficient interdental space is available Triangular toothpicks are superior to round or rectangular Triangular toothpicks are superior to round or rectangular Incorrect use may cause gingival lesions Incorrect use may cause gingival lesions

Interspace Brush Used for tipped, rotated or displaced teeth, teeth with gingival recession Used for tipped, rotated or displaced teeth, teeth with gingival recession Limited value except for surfaces adjacent to an extraction space Limited value except for surfaces adjacent to an extraction space

Interdental brush Superior to floss for cleaning open spaces Superior to floss for cleaning open spaces May be used for cleaning around fixed orthodontic appliances May be used for cleaning around fixed orthodontic appliances

Irrigation Devices A steady or pulsating stream of water through a nozzle under pressure A steady or pulsating stream of water through a nozzle under pressure Eliminate food residue accumulated interdentally Eliminate food residue accumulated interdentally

Irrigation Device (cont.) NOT A SUBSTITUTE FOR BRUSHING NOT A SUBSTITUTE FOR BRUSHING Time-consuming and messy Time-consuming and messy Used to deliver chemical agents to the oral cavity Used to deliver chemical agents to the oral cavity

Mechanical Plaque Control Self Care Self Care Toothbrushing Toothbrushing Interdental cleaning Interdental cleaning Professional Professional Scaling/Root planing Scaling/Root planing Polishing Polishing

Scaling and Root Planing Scaling sufficient to remove plaque and calculus from enamel leaving a smooth clean surface Scaling sufficient to remove plaque and calculus from enamel leaving a smooth clean surface Root surfaces - Root planing Root surfaces - Root planing calculus may be embedded in cemental irregularities calculus may be embedded in cemental irregularities Contamination of toxic substances in cementum – biologically unacceptable to gingival tissue Contamination of toxic substances in cementum – biologically unacceptable to gingival tissue

Recall intervals Aim 1. Prevent recurrence and progression of PD 2. Prevent tooth loss 3. Increase probability of diagnosing and treating in a timely manner other oral disease 1. Reinforcement of oral hygiene instruction 2. Supragingival scaling or root planing as necessary Frequency? 3 month recall is favoured by most clinical trials

Professional Cleaning - Polishing Polishing enamel – reorientation of surface crystals to create a smoother surface Polishing enamel – reorientation of surface crystals to create a smoother surface Experimental studies shown polishing inhibits formation of pellicle, plaque and calculus Experimental studies shown polishing inhibits formation of pellicle, plaque and calculus No evidence that periodontal health improves No evidence that periodontal health improves Removal of fluoride from superficial layers of enamel is a significant drawback Removal of fluoride from superficial layers of enamel is a significant drawback

Mechanical plaque control in special needs patients Mental disability Mental disability Physical disability Physical disability

Denture brush and regular toothbrush handles enlarged using soft rubber balls to give improved hand grip

Double-headed brush for improved plaque control in people who would otherwise require assistance with toothbrushing

Double-headed brush with modified handle (using silicone putty) for ease of grip

TePe interdental brush showing handle for easy holding

Boy with Asperger’s syndrome using a large- handled electric toothbrush

Toothpaste pump and dispenser

Carer cleaning the teeth of a person with a disability such that they can no longer perform this task

Aims 1. Aetiology 2. Implications and importance of preventing periodontal disease 3. Preventive methods Mechanical plaque removal Mechanical plaque removal Chemical plaque removal Chemical plaque removal

Conclusion Mechanical plaque removal is the backbone of periodontal disease prevention

Thank you