history, aids, brushing technique, floss, flossing techniqes

1. MECHANICAL
PLAQUE
CONTROL
DEPARTMENT OF PERIODONTICS
AND IMPLANTOLOGY
Seminar by :
Dr. Sangeeta Roy
1st year PG

2. INTRODUCTION
 DENTAL PLAQUE IS CAUSE OF
1. Dental caries
2. Periodontal diseases
 Experimental and epidemiologic studies have
demonstrated that these diseases are dependent on
the microorganisms present in plaque.

3. Plaque
 Dental plaque is defined as a structured, resilient
yellow-grayish substance that adheres tenaciously to
the intraoral hard surfaces , including removable and
fixed restorations. - Carranza

4.  Mechanical or chemical elimination of dental plaque
either by preventing its formation or by its eradication
shortly after it forms will markedly reduce the
potential for development of caries. (Nikifork-
1985)
 Healthy gingiva developed clinical gingivitis within a
period of 2-3 weeks , if dental plaque was allowed to
accumulate. –Loe et al.(1965)

5. METHODS OF PLAQUE
CONTROL
 Mechanical
 Chemical

6. OBJECTIVE
 physical clearing away of microorganisms and their
pathogenic products.
 prevent dental and periodontal infections.
MECHANICAL PLAQUE CONTROL

7. MECHANICAL PLAQUE
CONTROL AIDS
 various aids used for mechanical plaque control
1. TOOTHBRUSHES
a) Manual tooth brush
b) Electrical tooth brush
c)Sonic & ultrasonic brushes
d)Ionic brushes
2. INTERDENTAL AIDS
a) Dental Floss
b) Triangular Tooth Picks
- Hand held triangular toothpicks
- Proxapic
c) Interdental Brushes
- Proxabrush system
- Bottle-brushes
- Single-tufted brushes (flat or tapered)

8. d) Yarn
e) Superfloss
f) Perio-Aid
3. AIDS FOR GINGIVAL STIMULATION
a) Rubber Tip Stimulator
b) Balsa Wood Edge
4. OTHERS
a) Gauze Strips
b) Pipe Cleansers
c) Water Irrigation Device
5. AIDS FOR EDENTULOUS OR PARTIALLY EDENTULOUS PATIENTS
a) Denture & Partial Clasp Brushes
b) Cleansing Solutions

9. INDIGENOUS ORAL
HYGIENE METHODS IN
INDIA
 Indians knew about a natural toothbrush called 'Datun’
 These are fresh piece of twig (Neem,Babool,Guava), 8
to 10 inches long , one end is chewed and crushed to
make into fine bristles to clean the teeth and oral
cavity.
 The juice extracted from the fresh twig have
antiseptic and astringent properties.

10. Cleaning Efficiency
with Datun and Finger
 Datun and finger do not clean interdental surfaces of
the teeth, interproximal spaces, deep pits and fissures,
and second and third molars properly as they couldn,t
reach there.
 Gupta and Indurkar (1996) also confirmed that bristles
of the toothbrush can clean all the surfaces of the teeth
better than finger

11. Historical Background
 Initially crudely contrived toothpicks
(metal or wood) and wooden chewsticks.
Davis GN (1963), Kimmery
Stallard.R.E(1968)
 Gold toothpicks were used by Sumerians
around 3000 BC.
 Religious training & rituals-“miswak” or
“siwak” was said to be given by
Mohammed and is still used by muslims
even today.
 First bristle brush- by hog bristles early
Chinese literature 15th century.
TOOTHBRUSHES

12.  Earliest toothbrushes~England~William Addis in 1780.
 The first patent for a bristle toothbrush in United
Nations was issued to H.N. Wardsworth in 1857.
 Nylon bristles came into use in 1938.
 Powered toothbrushes were developed earlier but not
until 1960 were they actively promoted.

13. Types of toothbrushes
 Manual toothbrushes
 Powered toothbrushes
 Sonic & ultrasonic toothbrush
 Ionic toothbrushes

14. MANUAL TOOTHBRUSHES
Ideal characteristics for a Toothbrush -
 It should confirm to individual patient requirement in
size, shape and texture.
 Be easily and effectively manipulated.
 Be readily cleaned and aerated impervious to moisture.
 Be durable and inexpensive.
 Be designed for utility efficiency and cleanliness

15. Parts of a toothbrush
 Handle:
 :Head
 Tufts:
 Brushing plane:
 Shank:

16. Toothbrush Bristles:
Natural bristles (Hogs)
Artificial filament( Nylon)
 Hard & Soft
 Natural & Synthetic
 Multitufted & Space tufted

18. The stiffness of bristles
vary based on the
following factors:
 Diameter of bristles:
 Length of bristles:
 Number of filaments in a Tuft:
 Curvature of filaments:
Bristle hardness is proportional to the square of the
diameter and inversely proportional to the square of
bristle length.

19.  Diameters of commonly used bristles range from –
0.1mm ultra soft brushes
0.2 mm(0.007inch) soft brushes
0.3 mm(0.012inch) medium brushes
0.4 mm(0.014inch) hard brushes.

20. ADA SPECIFICATION OF A TOOTHBRUSH
 1-1.25 inches in length
 5/16 to 3/8 inches in width
 2 to 4 rows of bristles
 5-12 tufts/ row
Bass recommended
 straight handle
 Nylon bristles
 0.2mm in diameter
 rounded ends
 arranged in 3 rows of tufts
 Six evenly spaced tufts per row
 80-86 bristles /tufts.

21. RECENT MODIFICATIONS
BI-LEVEL/
ORHODONTIC
TOOTHBRUSHES
 Two rows of longer
bristles on each side
of a middle row of
shorter and stiffer
bristles to clean
teeth and gingival
tissue as well as
orthodontic
brackets.
(Dr.Butler lactona, Oral
B)

22. Brushes with flexible joint
 Toothbrush
with flexible
joint in the
middle of the
head and
reducing the
risk of
damage to
the gums

23. FOLDING HANDLE
TOOTHBRUSH
 compact and
convenient for
travellers.

24. Double headed brush
 The double-headed
"front to front"
toothbrush cleans
both the front and
the back of a tooth
simultaneously.
 Bastian (1984) and
Gibson et al. (1988)
reported that lingually-
double-headed brush
was superior to the
single headed brush.

25. Light energy conversion
tooth brush
 incorporation of a semiconductor (TiO2)
 photo-electro-chemical effect on dental plaque.
Hoover et al. (1992)

26. Electric/Powered
toothbrushes
There are 3 basic patterns the head follows when the
motor is started:
 Reciprocating- A back and forth movement
 Arcuate- Up and down movement.
 Elliptical- A combination of reciprocating and arcuate
movements.

28. Indications
 physically handicapped
patients
Smith(1964),Nowak(1976)]
 Mentally retarded
patients
 Patients undergoing
special dental
treatment, such as in-
Patients wearing
orthodontic appliance,
complex restorative
and prosthodontic
treatment, dental
implants in their oral
cavity.

29. Advantages of Powered
Toothbrushes
 Increases patient motivation resulting in
better patient compliance.
 Increased accessibility in interproximal
and lingual tooth surfaces.
 No specific brushing technique required.
 less brushing force than manual
toothbrushes.
 Brushing timer is incorporated in some
brushes to help the patient in brushing
for the required duration.

30. SONIC AND ULTRASONIC
TOOTHBRUSHES
 These types of toothbrushes produce high frequency
vibrations (1.6 MHz), which lead to the phenomenon of
cavitation and acoustic micro streaming.
 This phenomenon aids in stain removal as well as
disruption of the bacterial cell wall (bactericidal).
 Sonic toothbrushes with silicone rubber bristles
induced gingival fibroblast proliferation to a greater
degree than a manual toothbrush. (Takaaki et al
2004)

31. Ionic toothbrush
 It has a 3 volt lithium battery located under the metal
band on the handle.
 bristles are negatively charged through the metal rod
with the brush head. When holding the metal band on
the toothbrush handle with moistened fingers, the
positively charged ions are transferred to the teeth.

32. Mechanism of action

33. Musical toothbrushes
 The toothbrushes contain a micro chip will transmit
music from the jaw bones to the inner ears, someone
standing nearby will only hear a humming sound.
Hasbro (2005)

34. TOOTHBRUSHING
 most important preventive and therapeutic procedure
administered by the patient.
 no single method completely cleans all the surfaces of
the teeth and massages the gums. Therefore. the
combinations of the various methods are recommended
for proper cleaning of all the surfaces of the teeth as
well as massaging the gums.

35. OBJECTIVES OF
TOOTHBRUSHING
 to clean teeth and interdental spaces of food remnants,
debris and stain, etc.
 prevent plaque formation.
 disturb and remove plaque.
 stimulate and massage gingival tissue.
 clean the tongue.

36. BASIC MOTIONS IN
TOOTHBRUSHING
 Scrub or Horizontal reciprocating back and forth
 Vertical sweeping.
 Vibratory
 Rotary (clockwise and anticlockwise).

37. TOOTHBRUSHING
TECHNIQUES
 These methods are classified broadly
according to Greene J.C (1966) as –
 The Roll technique:
Modified Stillman / Rolling Stroke
 The Vibratory technique:
Stillman, Charters & Bass method
& Modified bass
 The Circular technique:
Fones method

38.  The Vertical technique:
Leonard’s method
 The Horizontal technique:
"Scrub- Brush" method
 The Physiological technique:
Smiths method

39. Bass Method
 Bristle Placement –bristles are positioned in the
gingival sulcus at 45 degrees angle to the long axis of
the tooth, The bristles are gently pressed to enter the
sulcus.
 Motion – A vibratory action, very short back and forth
horizontal jiggle, bristle end remain in sulcus causing a
pulsing of the bristle to clean the sulci. Ten such
strokes are advocated for such area. Interdental areas
are also included.
 The Bass technique is efficient
and can be recommended for
any patient with or without
periodontal involvement.

40. Advantages
 Effective method for removing plaque adjacent to and
directily beneath the gingival margin, cervical areas
and sulcus.
 Provide good gingival stimulation.
 Easy to learn.
Disadvantage
a. Small area are covered at one time hence more time
consuming.
b. Special qualities of toothbrush are desired which are
the following –
c. Individualized toothbrush size
d. Easily and effectively manipulatable
e. Readily cleanable
f. Durable and cheap .
g. Improper brushing can damage the epithelial
attachment.

41. Modified Bass Method –
 Motion – Sweeping towards occlusal along with the
above. Sulcular brushing is also done either before or
after the sweeping rolling method.
Advantages –
almost all the surfaces are cleaned along with
gingival stimulation.
Disadvantage –
much attention is required.

42. Charter’s Method
 Bristle Placement – bristles are pointed toward the
crown with the sides of the bristles half on the teeth
and half on the gingiva at 45 degrees to the tooth
surface.
 Motion – Vibratory technique with slight pressure to
clean the interdental areas. The toothbrush bristles are
gently manipulated in to the interdental spaces. Small
clockwise circulatory motions with bristles end
remaining stationary. After few seconds bristles are
withdrawn.
This technique can be recommended for cleaning in
areas of healing wounds after periodontal surgery.

43. Advantages
 Interdental areas are cleaned.
 Provide very good gingival stimulation.
 useful in when fixed partial dentures and orthodontic appliances are present.
Disadvantage
 Difficult to learn.
 Difficult to place brush in some areas of mouth.
 Gingival sulcus is not cleaned properly.

44. Modified Charter’s Method
Motion – In addition to above, sweeping occasionally on all surfaces is done.
Advantages –
supragingival cleaning is also obtained.
Disadvantage –
learning is little difficult.

45. Stillman’s Method
Bristle Placement –
 On buccal and lingual surfaces -bristles at 45 degree
angle to the long axis of the tooth. End rest of gingiva
and cervical portion of tooth.
 On occlusal surfaces - bristles perpendicular to the
occlusal surface.
Motion –
 On buccal and lingual surfaces- vibratory pulsating,
slight rotatory motion with bristle end stationary with
slight pressure to stimulate the gingiva.
 On occlusal surfaces - horizontal movements

46. Advantages
 Provide good gingival stimulation.
 Interdental areas are cleaned along with brushing of
occlusal surfaces.
 For gingival recession
Disadvantage
 Gingival sulcus is not properly cleaned as bristles do not
enter sulcus.
 Moderate dexterity of the wrist joint is required.

47. Modified Stillman’s
Method
 Motion –The bristles are slowly pressed and rolled
to sweep occlusally along with vibratory motions.
Sweeping toward occlusal along with above.

48. Advantages
 supragingival cleaning of the entire facial and lingual surfaces of teeth
also take place.
 Recommended time for ideal toothbrushing was 8 minutes with 96 strokes
for each jaw.
Disadvantage – Dexterity of joint is required.

49. Fones Method
Bristle Placement –
 The toothbrush are
positioned perpendicular
to the tooth crown.
Motion –
 On buccal surface wide
circular strokes to include
gingiva and tooth surface.
 On lingual surface
horizontal back and forth
motion.

50. Advantages
 Easy to learn especially by children.
 Gingiva is provided with good stimulation.
Disadvantage
 Possible trauma to gingiva .
 Interdental area are not properly cleaned.

51. Leonard’s Method
Bristle Placement –The bristle are placed at 90 degree
angle on the facial surfaces of the teeth while upper
teeth are touching the lower teeth.
Motion – Vertical up and down brushing movements on
the facial surfaces of the cleanched anterior and
posterior teeth.
Advantages –
It provided both tooth cleaning and supragingival cleaning and
stimulation.
Disadvantage –
Interdental areas are not properly cleaned.

52. Horizontal Reciprocating
or Scrub Method
Bristle Placement –
 bristles are placed perpendicular to the crown of the tooth.
Motion –
 The brush is moved back and forth in the horizontal movements on
all the surfaces of the teeth.
Advantages
This is the most convenient and effective for small children with deciduous
teeth.
Disadvantage
Interdental spaces of the permanent teeth of the adults are not properly
cleaned .
Cervical abrasion on buccal and lingual surfaces takes place in aged
patients

53. Physiologic Method of
Smithbell
Bristle Placement – Bristles are pointed
incisally or occlusally and then along and
over the tooth surfaces and gingiva.
Motion – Gentle sweeping from incisal or
occlusal surfaces over to facial surfaces
and progressing towards and over the
gingiva .
 It is almost an attempt to duplicate
nature’s self cleansing and gingival
stimulation mechanism, during
mastication of food.

54. Advantages –
 It has all the advantages of the nature’s self cleansing
and stimulation mechanism.
 Supragingival cleaning is good.
Disadvantage –
 Interdental spaces and sulcus areas of the teeth are not
properly cleaned.

55. INTERDENTAL
CLEANING AIDS:
Factors in selection of an interdental cleaning aid:
 type of gingival embrasures
 Alignment of teeth.
 Fixed prosthesis / orthodontic appliances
 Open furcation areas
 Contact areas

56. DENTAL FLOSS
 Levi Spear Parmly (1859) was the inventor of dental
floss
 Floss is available as monofilament or multifilament,
waxed or unwaxed, bonded or non-bonded.

57. WAXED UNWAXED
Smooth surface that is provided
by the wax covering of nylon thread
helps to prevent trauma to soft tissue.
Thin floss may be helpful when contacts
are tight but forcing the floss may break it
Slides through contact area with ease,
wax lubricating effect.
Pressure against teeth spreads the nylon
fibers and gives wider surface for plaque
removal.
Resist breakage when passed over
irregular tooth surface, restoration or
calculus deposit.
Squeaking sound effect when floss
moves on a clean tooth surface may
provide motivation for patient
thoroughness.
Wax gives strength and durability during
application.
Unwaxed floss because can break more
easily, may cause patient to be
discouraged, thereby causing less of
motivation to flossing
Floss if wound tightly around finger tend
to cut, hurt and cause discomfort as is
not with waxed floss.

58. Functions
 Removal of the adherent plaque and food
debris from the interproximal embrasures
and under the pontics of the fixed
partial dentures.
 Polishing of the tooth surfaces during
removal of the plaque and debris.
 Stimulating and massaging the interdental
papillae
 Helping in locating the following:
a. Subgingival calculus deposits.
b. Overhanging margins of the
restorations.
c. Proximal carious lesions.

59.  Improving oral hygiene.
 Reducing gingival bleeding.
 Vehicle for the application of polishing or therapeutic
agents to interproximal and subgingival areas. For this
purpose tapes are better than floss.

60. DENTAL TAPE It is a thin nylon 2 to 5 mm wide ribbon, used like the floss for the same
purpose. It is wider and little bulkier than floss.
 Generally floss is preferred over the tape because of convenience in use.

61. Types of floss:
 Tufted dental floss:
Super floss
NU floss
 Fluoride-impregnated dental floss:
Combination of a mechanical agent and a
chemical agent-increase of F in the enamel
after flossing-proximal surfaces are high
caries risk areas where a toothbrush and
dentifrice with fluoride cannot always reach
Manji and Fejerskov-
(1990)

62.  SUPER FLOSS:
Is available in a 2-foot
length composed of a
5-inch tufted portion
adjacent to a 3 inch
stiffened end for
inserting under a
fixed appliance or
orthodontic
attachment.

63.  NU- FLOSS
The tufted portions (about
1 inch long) alternate
with the plain floss
(about 1 ½ inches long

64. Method of flossing
 The spool method
 The circle or loop method
 Flossing is recommended after every
meal especially before going to bed in
the night.

65. Floss holders
Useful for the following type of patients:
 Physically handicapped patients.
 Patients below 12 years and
above 60 years of age.
 Patients with restricted mouth
opening.
 Effective cleaning of interdental
spaces and interproximal
surfaces.

66. Electromechanical
Flossing
 These devices have a single bristle that moves in a
circular motion easier to use.
 The tip is inserted into interproximal space and a bristle
comes out of the tip and moves in a circular motion
when the device is turned on.

67. Interdental tip stimulator
 Wooden or rubber tips are used with or without a
handle.
 Are placed in the interdental space in such a way
that the base of the triangle rests on the gingival
and the sides are in contact with the proximal
tooth surfaces. The tip is then moved repeatedly
in and out of the embrasure, removing soft
deposits from the teeth.
 Uses
 remove debris and redundant tissue.
 clean the interdental space and interproximal
surfaces of the teeth.
 increase the interdental epithelial keratinization.
 massage the interdental tissue.
 reshape and recontour the gingiva.

68. Toothpicks
 They are used for
interproximal cleaning.
 They have the advantage of
being a common device and
readily available at most
home.
 Fluoridated toothpicks
produced similar or
somewhat higher fluoride
concentrations in the
proximal area.
Perio-Aid (Toothpick on a handle)

69. Interdental Brushes
 They are cone shaped or cylindrical brushes
made of bristles mounted on a handle.
 Single tufted brushes or multi-tufted brushes
are available.
 Ripple design toothbrush -The design had longer
rippled outer bristles which provided
significantly superior interdental penetration
than other brush designs.

70. Interdental marginal
brushes

71. TONGUE CLEANERS
 25 cms (10 inches) long and 0.6 cm (0.25 inch) wide thin strips made up of
stainless steel or flexible plastic.
 used to scrap the dorsum of the tongue to remove the soft coating due to
smoking. etc.
 The routine daily vigorous use of metallic tongue cleaners is not advisable.
 soft plastic tongue cleaners may be used daily but gently and carefully.
 Metallic tongue cleaners with sharp edges should never be used.
 To be on the safer side it is better to clean the dorsum of the tongue with
soft bristles of a toothbrush.

72. Effect of Tongue
Cleaning
 Reduction of oral debris.
 Retardation of bacterial plaque formation and total
plaque accumulation.
 Reduction of number of microorganisms. When brushing
of the organisms increases.
 Contribution to overall cleanliness.
Tongue scraper

73. PIPE CLEANER
 It is used for proximal surfaces when interdental gingiva is missing and
for furcation areas.
 Types of Embrasures and Selection of
Interdental Cleaning Aids
 Depending on the conditions of the interdental papilla and gingiva in
the embrasures.
 they can be divided into five types.

75. GINGIVAL MASSAGE
 Massaging the gingiva with a toothbrush or an interdental cleaning devices
produces epithelial thickening, increased keratinization and increased
mitotic activity in the epithelium and connective tissue.
 ORAL IRRIGATION DEVICES
 To clean all the surfaces of the teeth mechanical and electrical devices are
used which give forceful steady or pulsating streams of water through a small
and thin nozzle over the tooth surfaces.
 The water pressure and force is generated by a built in pump or by
attaching a device to a nozzle of the main water supply line.
 It increases circulation and causes stimulation of the soft tissues.
 It causes least injury to the soft tissues and never induces bacteremia.

76. THANK YOU