Plaque Control for the Periodontal Patient

The reference for this lecture is chapter 44 in the 11th edition of the book (Carranza's clinical periodontology), or chapter 50 in the 10th edition. The doctor was merely reading the slides aloud; so they might be enough by themselves. Patient motivation and oral hygiene instructions are basic in the periodontal clinic. Without these, the treatment cannot succeed. Plaque control is the regular removal of dental plaque and the prevention of its accumulation on the teeth and adjacent gingival surfaces. Rationale: In the absence of bacteria in gnotobiotes (germ-free animals) gingivitis and periodontitis do not develop. Accumulation of plaque on teeth induces an inflammatory response in adjacent gingival tissues while plaque removal results in resolution of gingival inflammation. Optimal oral hygiene, preventing re-growth of bacterial deposits, is critical in the long-term success of periodontal therapy. Le et al (1965) andTheilade et al (1966), conducted studies on dental students, whom they asked to stop brushing their teeth. (This is considered unethical nowadays!) It was found that: All of the subjects rapidly formed supragingival plaque. Gingivitis developed within 7-21 days. When oral hygiene was resumed, the condition was reversed and health was reestablished (within one week). This is a classic study that provides evidence for the importance of oral hygiene. In a three-year study by Axelsson&Lindhe(1978), regular OHI and prophylaxis were given to stimulate adults to adopt proper oral hygiene habits: Persons who utilized proper oral hygiene techniques had: Negligible signs of gingivitis. No loss of periodontal tissue attachment. No new carious lesions.

Control patients who merely received traditional dental care (symptomatic treatment) suffered from: Gingivitis. Lost periodontal tissue support. New and recurrent carious lesions. The results of this study indicate the importance of oral hygiene at home. Dental treatment alone is highly ineffective in curing caries and periodontal diseases. The initiating factor of periodontal disease is mainly plaque. And so the goal of oral hygiene is the physical and chemical disruption of the biofilm on a frequent basis. Microbial plaque growth occurs within hours, and it must be completely removed at least once every 48 hours to prevent inflammation. The ADA recommends that individuals brush their teethtwice& use floss or other interdental cleaners onceper day. So if the inflammation only occurs after 48 hours, why brush twice and floss once a day? Because you can't remove all the plaque at once; brushing your teeth a second time improves the results. There are two approaches to plaque control: mechanical and chemical. Both can be performed either by the individual himself/herself, or by the dental professional.

The following diagram summarizes the techniques in which home care can be performed.

Tooth brushing: Carries dentifrice to tooth surface. Removes dental plaque, and disrupts its reformation. Cleans teeth of food debris and stains. Massages the gingival tissue. Ideal toothbrush: Handle size is appropriate to age and dexterity. Head size is appropriate to the size of the individual patients requirements. Use of end-rounded nylon or polyester filaments (not larger than 0.23 mm in diameter). Has soft filament configurations as defined by the acceptable international industry standards (ISO). Has filament patterns which enhance plaque removal in the proximal spaces and along the gum line. Inexpensive, durable. Impervious to moisture, easily cleaned. The ADA's specifications for the heads of toothbrushes: 1 inch to 1 inches long. 2-4 rows of bristles. 5/16 inch to 3/8 inches wide. 5-12 tufts per row.

 80-86 bristles per tuft. Toothbrush bristles are either natural or synthetic. Synthetic bristles Natural bristles Source Hair of hog or wild bear No uniformity in texture Synthetic bristles Mainly NYLON but also of synthetic plastic material Uniformity controlled of size & elasticity

Uniformity

are superior.

Diameter

Varies depending on portion of bristle taken, age & life of animal Deficient, irregular, frequently openended 1) Cannot be standardized 2) Wear rapidly & irregularly 3) Hollow ends allow microorganisms & debris to collect inside.

Range from soft at 0.2mm to medium at 0.3 mm & hard at 0.4mm End rounded to ensure fewer trauma

End shape

4) Rinse, clean, dries rapidly. 5) Durable & maintain longer. 6) End rounded & Advantage, closed, repel Disadvantage debris & water. 7) More resistant to accumulate micro-organisms Claydon N andAddy Mcompared four commercially available toothbrushes for total plaque removal at a single brushing. All toothbrushes removed plaque equally. Plaque removal depends on the brushing technique rather than the design. Toothbrush care: Keep on a clean surface. Clean after use. Store in open air in no contact with other brushes. Replace when worn. Disinfect or replace after illness. Replace every 3 to 4 months. The usual recommendation to brush twice daily is reasonable, not only to remove plaque but also to apply fluoride through the use of dentifrice in order to prevent caries. It is likely that the thoroughness and duration of the oral hygiene session, rather than the frequency, are the critical factors.The optimum tooth-brushing duration is 2 minutes. Brushing techniques:

Horizontal

Vertical

Circular

Vibratory

Roll

Scrub techni que

Leonar d techni que (1939)

Fones techni que (1934)

Stillma n, Bass, and Charte rs techni ques

Roll method or modified Stillman technique

Circular brushing technique It can be learned and mastered by small children.

The Bass brushing technique The bristles are angled into the sulcus at a 45-degree angle.

And then they are moved in a short vibratory stroke that has a circular pattern.

The modified Bass technique (picture above) is the most often recommended, because it emphasizes sulcular placement of bristles to reach supragingival plaque and access subgingival plaque as much as possible. The Charters brushing technique The bristles are held perpendicular to the long axis of the teeth and are forced into the interproximal spaces. Then bristles of the brush deflect toward the occlusal surface. This technique is recommended when the patient has firm gingival biotype with recession or a high risk of recession; because here the bristles are not held towards the gingiva, but towards the occlusal surface.

The Modified Stillman or Roll" Technique The bristles are angled into the sulcus at a 45-degree angle and overlap onto the facial gingiva. The head of the brush is then "rolled" so that the bristles move occlusally.

Summary of brushing techniques: Charters bristles on cervical crown obliquely pointing coronally, horizontal motion with rotations bristles in sulcus 45 pointing apically, horizontal back & forward motion bristles in sulcus 45 pointing apically, horizontal motion with rotations to occlusal bristles 90 to tooth surface, up & down motions bristles in gingival margin obliquely towards the apex. Vibratory movements without moving the brush bristles in gingival margin obliquely towards the apex. Vibratory movements with rotations towards occlusal

Bass

Modified Bass Leonard Stillman

Modified Stillman

Electrical brushes They are indicated for children and adolescents, patients with physical or mental disabilities, hospitalized patients including older adults who need to have their teeth cleaned by care givers, and patients with fixed orthodontic appliances. They are easy to use. Their main disadvantage is that they are a bit expensive. Different designs for electrical brushes:

The brush should reach the gingival margin, as shown below.

The result of a study by Heanue et al. (2003) that compared electrical toothbrushes to manual ones is that "powered toothbrushing is at least as effective as manual brushing and there is no evidence that it will cause any more injuries to the gums than manual brushing." So if your patient can afford an electrical toothbrush, advise them to one.

Dentifrices Dentifrices can be in the form of powder, gel, or paste (which is the commonest). It has the following ingredients:

Calculus control toothpastes Also called tartar control toothpastes, they contain pyrophosphatesnthat interfere with crystal formation in calculus. They reduce the formation of new supragingival calculus by 30% or more. They do not affect subgingival calculus formation or gingival inflammation. They reduce the deposition of new supragingival calculus but do not affect existing calculus deposits. Interdental cleaning aids A toothbrush, regardless of the method in which it's used, does not remove interdental plaque. That's why these aids (floss, interdental brushes, unitufted brushes, and toothpicks) are used. Most dental and periodontal diseases originate in the proximal area, and so it's very important to clean them well. The choice of which aid to use depends on: The size and shape of the interdental embrasure and the degree to which soft tissue fills the space. Presence of furcations, tooth alignment.

 Presence of Orthodontic appliances or fixed prostheses. Ease of use and patient cooperation.

Interdental space (soft tissue) classification and choice of interdental cleaning aid:

Dental floss Can be twisted or non-twisted, bonded or non-bonded, waxed or unwaxed, thick or thin. Instructions: 12 to 18 inches should be taken Floss is slipped between contact area and wrapped around tooth surface- up and down strokes

Superfloss It has the following parts:

It has a stiff end for ease of insertion under the bridge. The stiff end is inserted first, and then the tufted floss is used for cleaning. Floss holders They are used to assist patients who have difficulty flossing.

Interdental brushes They are used in open embrasures with low papillary height where the brush can fit easily in the available space without causing trauma to the papilla.

The ones shown below are called proxy brushes.

The interdental brush is inserted into the interdental area and used to remove the plaque. The aim of interdental aids is not to remove food debris, but to remove plaque.

In open contact areas, or furcation areas, the interdental brush is used (and not the floss), because it can reach all surfaces (picture below).

Single-tufted brush The tuft can be 3-6 mm in diameter, and it can be tapered or flat.

It's used to: Improve access to distal surfaces of posterior molars, tipped, rotated or displaced teeth. To clean around and under fixed partial dentures, orthodontic appliances, or precision attachment. To clean teeth affected by gingival recession and irregular gingival margin or furcation involvement.

Tongue cleaner It has a raised edge for cleaning the middle and it's smooth on the sides.

Tongue cleaning is an important part of oral hygiene instructions, because the tongue is considered a reservoir for microorganisms. Chemical plaque control It will be covered in more detail in a forthcoming lecture. Remember: mechanical plaque removal remains the primary preventive method to control dental diseases. However, chemical plaque control could be an adjunct to mechanical plaque control.

The ADA has accepted just two types (agents) of chemical plaque control: 1. Prescription solutions of Chlorhexidinedigluconate oral rinse (2 daily rinses with 10 ml of a 0.2%). (Plaque reductions of 45% to 61% and more importantly, gingivitis reductions of 27% to 67 %.) The patient is advised to use the Chlorhexidine mouth rinse 30 minutes after brushing and not immediately afterwards, because the toothpaste contains sodium laurate, which might intereact with Chlorhexidine. The patient is also advised not to eat or drink for 30 minutes after rinsing.

2. Nonprescription essential oil mouthrinse. (Plaque reductions of 20% to 35% and gingivitis reductions of 25% to 35 %.) Mechanism of action of Chlorhexidine: One charged end of Chlorhexidine (dicationic) molecule binds to the tooth surface whereas the other remains available to initiate the interaction with the bacterial membrane as the microorganism approaches the tooth surface, and thus it destroys bacteria.

Side effects of Chlorhexidine: Primarily brown staining of the teeth, tongue, and silicate and resin restorations. Transient impairment of taste perception. Oral mucosal erosion. Unilateral, bilateral parotid swelling rare, unexplainable. The following pictures illustrate these effects.

Oral hygiene instruction Oral hygiene instruction can be achieved either by personal (one-toone) instruction, or through other self-instructional approaches (e.g. videos, booklets). Both approaches are equally effective. A formal plaque-reduction protocol should be part of all dental practices, regardless of the method used. Compliance is the degree to which a patient follows a regimen prescribed by a healthcare practitioner.

Disclosing agents Erythrosine dye is applied to teeth and it discolors plaque (pink areas in picture below). This helps show the patient where plaque is, and how to remove it.

Cases in which the patient fails to perform dental home care (and ways to improve their performance) are illustrated in the picture below.

The patient knows what to do, but is unable to perform

(lacks dexterity)
The patient does not know what to do

best to find an alternative method (e.g., an EMB) that will enhance her efforts. It may also be necessary to see her more frequently for maintenance.

(lacks knowledge)
The patient knows what to do, is able to do it, but simply doesn't comply with the regimen

Reinstruction is indicated. If continued efforts at instruction and feedback are ineffective, an alternative might be considered, such as another brushing technique or an EMB.

(lacks motivation)

motivation is missing The key is to focus on the problem: the presence of unacceptable amounts of plaque and the associated biologic response to the plaque, such as bleeding on probing.

The following two pictures show the adverse effects of incorrectly used (interdental) plaque-control techniques. Incorrect use of floss can cause a cleft in the gingiva. Forceful tooth-brushing can cause abrasion and sensitivity.

Reinforcement of daily plaque control practices and routine visits to the dental office for maintenance care are essential to successful microbial plaque control and long-term success of therapy

Please excuse the higgledy-piggledy manner in which this script is written; circumstances hadarisen that made it very difficult to do it properly.