CONTENTS1. Definition – Plaque, Calculus, material alba.2. Plaque formation3. Identification of plaque (Disclosing agent)4. Plaque control (a) Mechanical (b) Chemical5. Mechanical plaque control (a) Toothbrush (b) Dentifrice (c) Interdental cleaning aids (i) Dental floss (ii) Interdental cleaning devices - Interdental brushes - Balsa wood wedge tooth pick - Tooth pick in special holder - Gauze stripe, pipe cleaner & yarns (d) Oral irrigation
MECHANICAL PLAQUE CONTROLPlaque :Its defined as a highly specific variable structural entityformed by sequential colonization of micro-organisms on the toothsurface, epithelium & restorations. ORIts also defined as the soft disposition that forms the biofilm adhering totooth surface or other hard surface in the oral cavity including removal andfixed restoration.Plaque is differentiated from other deposits such as calculus and materialalba. on the tooth surface.
Calculus ` Its hard deposit that forms by mineralization of dentalplaque and is generally covered by a layer of unmineralizedplaque.
Material alba It refers to soft accumulation of bacteria andtissues cell that lacks the organized structure of dentalplaque and easily removed with water spray
CompositionPlaque begins to form within a minute on a cleaned toothsurface. It begins as a film formed from saliva products whichstick firmly to the tooth enamel. This film then becomescolonised by bacteria within the saliva. There areapproximately 100 million bacteria per ml of saliva and 500different species presentPlaque changes over a time period of 1-12 days as differentbacteria colonise it. It eventually becomes a tightly packedmass of moving bacteria called a "biofilm". The longer plaque ispresent, the more harmful the biofilm becomes.
Figure 1. Electron microscopy of the formation of plaque.
Plaque FormationPlaque formation is divided into 3 phases :2. Formation of dental pellicle3. Initial colonization on the tooth surface.4. Secondary colonization and plaque maturation.
Dental plaque divided intoA. Supragingival plaque B. Sub gingival plaque • Found at or above the • below the gingival gingival margin margin between the • Also called as marginal tooth & the gingival plaque sulcular tissue.
Identification of plaque deposits Main objective is to identify the plaque and distinguish from calculus and other deposits present on teeth. Name PreparationIodine preparation Skinner solution Diluted tincture of Iodine crystal – 3.3g , Potassium Iodine-1.0g iodine , zinc Iodide – 1.0g Tincture of iodine – Water distilled – 16.0 ml 21.ml Glycerin – 16.0ml Water – 15.0 mlMercurochrome • Mercurochrome -1.5gpreparations • Water – 30 ml • Oil of peppermint – 3 drops • Artificial non-calorigenic sweetenerBismark brown • Bismark brown – 3.0 g[Easlicks disclosing • Ethyl alcohol 10 mlagent] • Glycerin – 120 ml • Flavoring agent – 1 dropErythrosine For direct topical application Erythrosine – 0.8g, water – 100 ml, Alcohol (95%) – 10.0 ml, Oil of peppermint - 2 dropPlak light system Sodium fluorescein, glycerin – 0.75% ,f.d. & yellow no. 8
Supragingival plaque Disclose with dyeSupragingival plaqueDisclose with dye
Plaque control Its defined as the removal of microbial plaque & prevention of its accumulation on the teeth & adjacent gingival tissue. It also deals with prevention of calculus formation. Objectives of plaque control –2. Primary role in removal of soft deposits on teeth and gingival tissue.3. Gingival stimulation (gingival massage)3. Regular effective plaque control has to walled effect on the tissue.4. Helps in increasing gingival tone, surface keratinization, gingival vascularity and gingival circulation.
Plaque control can be done by two methodMechanical plaque control Chemical plaque control In this type In this type mechanical methods specialized chemical are used in are used in plaque control Controlling plaque Eg, toothbrushes Eg, chlorhexidine Dental floss etc. Alhexidine
Tooth Brushes- 1728 toothbrushes made from Horses Hair- 1857 manual brushes panted in America- Generally toothbrushes very in size, design as well as inlength and arrangements of bristles hardness to overcomethis variation ADA given specification of toothbrushes.Length - 1 to 1.25 inchesWidth - 5/16 to 3/8 inchesSurface area - 2.54 to 3.2 cmNo. of rows - 2 to 4 rows of brushesNo. of tufts - 5 to 12 per rowNo. of bristles - 80 to 85 per tuft
Ideal properties of toothbrushes or tooth brush selection1. Tooth brush should be able to reach and efficiently clean most area to teeth.2. No Single tooth brush is adequate for all patient.3. Proper brush should provide easy accessibility to all area the mouth.4. Small handed brushes are often helpful5. Easy for patient to manipulate6. Brushes should be compatible with recommended brushing technique.7. Both natural and nylon bristles are satisfactory.
Two types of material used in tooth brush2. Natural bristles from Hog.3. Artificial filament made predominantly of Nylon. Nylon filament is superior due to its homogeneity of material, unfortunate of brittle size resistance to fracture and repulsion of water and debris Rounded bristles make fewer scratches on the gingiva than flat cut bristle with sharp end Soft bristle are more flexible, clean beneath the gingival margin and each bristle reach further into proximal surface. Hard bristles results in gingival recession. Overzealous brushing also result in gingival recession. Most tooth brushes wear out in 3 months. Brushes with wear reminder are current available, the blue dye on bristle type with use and can be helpful in reminding patient to replace their tooth brush. Handle should fit palm of hand it may be straight or angled.Conclusion For most patient short headed brushes with straight cut rounded ended soft to medium nylon bristle arranged in 3-4 row of tuffs are recommended.
Powered tooth brush• In 1939 powered tooth brush invented to make plaque control easier.• Its mainly recommended for(d) Individual lacking motor skills(e) Handicapped patient(f) Patient with orthodontic applied(g) Whosoever wants to use There are many powered tooth brushes some with reciprocal of back and back motions and some with combination of both some are circular and elliptical motion. Powered tooth cleaner resembles a dental prophylaxis and hand piece with rotary rubber cap. Patient should be lustrated for proper use.In children – Braun – oral B kinds toothbrush D10 is most effective. It hasoscillatory round brush head so causes no soft tissue damage. It also plays music at 1min. interval for monitoring brushing time.
Tooth brushing method. Many method of tooth brushing have been describedbut no one method of tooth brushing it adequate to meet theneed of all patients.Selection of method depends on the individual Certain criteria should be assessed when selecting atoothbrush and toothbrush technique for the individualpatient.
1. Patient clinical situation :(b)State of gingival and periodontal l tissue in regard to health is. Tissue stage (contour, tone, texture, size) Papillary contour (open & filed embrasure space) Pocket or sulcus depth.(g) Anatomical limitations Size and contour of the dental arch. Position inclination and contour of the individual teeth. Presence of edentulous areas.2. Patient personal situation Patient level of manual dexterity. Motivational level, ability and willingness of patient to act onrecommended procedure.
Brushing sequence and timing Regardless of the tooth brushing method selected a sequence of brushing should be given to the patient. 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. Same procedure is the followed for other arch. Last surface to be brush are occlusal. Patient instructed to stroke each area ten time of spend 10 seconds per area then move on to next area.
Method Bristle placement Motion Advantage/ disadvantageScrub Horizontal on gingival margin Scrub in anterior position direction Easy to learn & best suited keeping brush horizontal fro childrenBASS Apical towards gingival into sulcus at Short back and forth vibratory Cervical plaque removal 450 to tooth surface motion while bristles remain in Easily learned sulcus. Good gingival stimulationCharters 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 margin brush Clears inter proximal Gingival stimulationFones 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 traumaRoll Apically, parallel to tooth and then On buccal and lingual inward Doesnt clean sulcus area over tooth surface pressure, then rolling of head to Easy to learn sweep bristle over gingiva & tooth good gingival stimulationStillmans 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 areaModified Pointing apically at and angle of 45o Apply pressure as in stillmanss Easy to masterstillmans to tooth surface method but vibrate brush and also Gingival stimulation move occlusally
DENTIFRICESDefinitions Its substance used with tooth brush to remove bacterial plaque, material alba and debris from the gingiva and teeth. Its used from back 1500 Bc by Egyptian &Y Hippocrates was Ist to recommended the use of dentifrices.
COMPOSITION1. Detergent – 1.2%Sodium lauryl sulphateUse – To lower surface tension Penetrate and loosen surface deposits and strains Emulsify debris for easy removal by toothbrush Contribute to the foaming action2. Cleaning and polishing agents - 20-40% Calcium carbonate, calcium pyrophosphate bicalcium phosphateUses– Act as abrasive agents for cleaning and polishing objectives. Polishing agent is used to produce a smooth shining tooth surface that resists discoloration, bacterial accumulation and retention.3. Binders – 1.2%Organic hydrophilic colloids, alginates, magnesium aluminium silicate, colloidal silica.Use – To prevent separation of the solid & liquid ingredients during storage.
4. Humectants : 20-40%Glycerin : SorbitolUse – Added to retain moisture Prevent hardening on exposure to air. To stabilize preparation5. PreservativesAlcohol, formaldehyde ; dichlorinated phenolsUse – To prevent bacterial growth and to prolong shelf life.6. Sweetner : 2-3%Sorbitol and glycerinUse – To import a pleasant flavor for pt. acceptance7. Flavoring agent : 1-15%Peppermint : cinnamon, mentholUse – To make the dentifrices desirable. To make other ingredients that may have less pleasant flavor.8. Therapeutic agent 1-2 %FluorideUse – For medical value9. Coloring agent 2-3% -Added for all activeness10. Water 20-40%Main transport medium
III. Interdental cleaning aids It has been noticed that regardless of brushing, there incomplete removal of plaque from interproximal areas of tooth in individual with healthy periodontal condition or in periodically involved patient with open embrasure. Because of majority of dental and periodontal diseases originate in interproximal area, interdental plaque removal is necessary.It includes4. Dental floss5. Interdental cleaning devices (a) Interdental brushes (b) Balsa wood wedge tooth pick (c) Tooth pick in special holder (d) Gauze stripe ; pipe cleanness and yarns
Dental floss In 1882 codman and shurtuff made silk dental floss In 1948 bass nylon dental floss Its recommended method of removing plaque from proximal surface Size of floss – 300-1500 denier (D) Floss is constructed with the help of individual filaments 2 to 3D thick.
Types of floss2. Twisted and non-twisted3. Banded and non-banded4. Thin & thick5. Microfilament and multifilament6. Acc. To ADA specificationType I- Unbonded dental floss composed of yarn having no additiveType II-Bonded dental floss composed of yarn having no additives. Other than binding agent or agent for cosmetic performanceType III-Bonded or unbounded having drug for therapeutic usage.
Technique 1. String – floss method Use 18 inches floss. Wrap 2-3 inches of floss around middle finger or left hand and similarly to right hand. 2. Circle – floss method Take floss tie a double learnt to secure it. The size of circle is like an orange. Position the knot to the left side of working area and place middle, little rings finger of both hand on the inside of circle to keep it taut. Rotate counter clock wise for fresh segments.
APPLICATION Hold floss firmly in a diagonal/oblique positionGuide the floss past contact area with a gentle motion Control floss to prevent snappingthrough the contact area onto the gingival tissues Pass the floss between gingival margin, curve to adapt the flossaround the tooth, press, and side up and down over the tooth surface.
Flossing can be made easier by using a floss holder –Floss holder should have – 1. One or two fork that enough to keep the floss tent even when its moved pass tight contact area 2. An effective and simple mounting mechanisms
Interdental cleaning devices For cleaning in narrow gingival embrasures that areoccupied by intact papilla and bordered by tight contact zone. Dental floss in probably the most effective dental hygiene aids. But concave root surface and fraction cannot be reached with dental floss.Therefore special cleaning aid are available cleaning for these surface. These are : Inter dental brushes Balsa – wood wedge tooth pick Toothpick in special holder Gauze strips, pipe cleaners and yarns.
Inter dental brushes These are cone shaped brushes made of bristle mounted on handle. Single tufted brushes or small conical brushes. Interdental brushes area particularly suitable for cleaning large, irregular or concave tooth surface adjacent to wide interdentally space. For best cleaning efficiency the diameter of brush should slightly larger than gingival embrasure so that bristle can exert pressure on the tooth surface. Single tufted brushes are highly effective on lingual surface of mandible molar and premolar. Where tooth brush is often impeded by the tongue and for isolated area of deep recession.
Balsa wood wedge tooth pick Wedge tooth pick is made of soft wood and is triangular in shape contour to interdental spaces. Its effective in removing plaque and debris, stimulating the gingival recourting the interental papilla. Contraindicated areas when interdental papilla is present in interdental gingival embrasure space. It may cause tissue injury. Plastic tip area also available.
Technique Tooth pick is firstly moistened in mouth to soften it. Its thanplaced interproximally with the base of the triangle towards the gingival & at slight angle towards the crown. Then tooth pick pressed firmly against the proximal surface of the adjacent tooth.Toothpick is than moved in and out or up and down depending on the size of the interdental space.Disadvantage – Its hard to insert from lingual space.
3. Tooth pick in special holder Small rounded polished tooth picks can be placed inspecial plastic handle. This handle allow more flexibility in placing thetoothpick from the lingual aspect and in other area withlimited access.4. Gauze strips and pipe cleaners and yarns This are effective cleaning aid in special situations. Pipe cleaners are effective for cleaning open furcation area. Gauze strips and four play cotton yarn are effectiveaids for cleaning the proximal surface of teeth adjacentto edentulous area and open embrasure space.
Oral irrigationIts targeted application of a pulsated or steady stream ofwater for removing debris. It can be done by patient or the clinician. Oral irrigation cleans adherent bacteria and debris from the oral cavity more effectively than do toothbrush and mouth rinse.
Its delivered by Power driven device Non-power driven deviceGenerats an intermittent or Its attached to a householdpulsating jet of fluid. water supply and deliveredAn adjustable dial for regulation through a hand heldof pressure is provided along with interchangeable tip that can bea hand held interchangeable tip used for application at the gingivalthat rotates 360o for application margin.at the gingival margin. Disadvantage – Uncontrolled water pressureDelivery method Target of the oral irrigation in the loosely attached sub gingival bacterial plaque. When pulsated irrigant is directed perpendicular to the long axis of the tooth, Hydrokinetic activity is started.
Procedure Direct the jet tip towards the interdental area almost touching the tooth surface;hold tip at right angle to the long axis of the tooth Start on the low pressure and increase gradually depending on the condition of the gingival tissue comfort. Follow a definite pattern across the mouth, maxillary arch first than the mandibular arch applying for 5-6 sec. at each interdental area.* Contraindication Advance periodontitis Medically compressed patient like Leukemia, AIDS, diabetes, Bleeding, disorder
Advantage –* Help in removing debris from orthodontic appliances and fixed prosthesis.* When used with tooth brushing, these devices can have a beneficial effect on periodontal health by retarding the accumulation of plaque and calculus and by reducing gingival inflammation.
CONCLUSION• All patients required regular use of tooth brush , either manual or electric , at least once per day.• Dental floss should be use in all interdental spaces that are filled with gingiva.• Interdenatl aids such as interproximal brushes , wooden tips, rubber tips or tooth picks should be use in all area where the tooth brush and floss technique can not adequately remove the plaque.• Sub gingival irrigation may be good choice for reduction of inflammation and deep pockets.• Reinforcement of daily plaque control practices and routine visit to the dental office for maintenance care are essential to successful plaque control and long term success of therapy
REFERENCESCLINICAL PERIODONTOLOGY – NEWMAN -TAKEI -CARRANZACOMPREHENSIVE PEDIATRIC DENTISTRY – NIKHIL MARWAHTEXTBOOK OF PEDODONTICS – SHOBHA TENDONIMAGES FROM NET - GOOGLE