9.plaque control

Introduction
 PLAQUER---------- TO PLATE
 Dental plaque is an adherent intercellular matrix consisting
primarily of proliferating microorganisms, along with a
scattering of epithelial cells, leucocytes & macrophages.

DENTAL PLAQUE:
 Dental plaque can be defined as the soft deposits that form
the biofilm adhering to the tooth surface or other hard
surfaces in the oral cavity, Including removable & fixed
restoration. (Newmann, carranza.)

 Dental plaque is a specific but highly variable structural entity resulting
colonization of microorganisms on tooth surfaces, restorations and other parts
of oral cavity and consists of salivary components like mucin, desquamated
epithelial cells, debris and microorganisms all embedded in a gelatinous
extracellular matrix
WHO

Dental plaque is broadly classified as:
 1) supragingival plaque.
 2) subgingival plaque.

Mechanical or chemical elimination

Disclosing agents
 liquid, capsule, tablet or lozenges
 contain a dye or other coloring agent

Indication
 Patient education.
 Instruction to pt about plaque control
 Self assessment by the pt
 Evaluation of effectiveness of plaque control measures.
 Assessment of the clinician.

Various agents used in disclosing solution
 Basic fuchsin
 Fast green
 Erythrosine
 Vegetable and food coloring dyes
 Iodine
 Gentian violet
 Two tone die

Various formulations of disclosing agents:
1) Skinner solution
2) Iodine preparations
3) Mercurochrome preparation
4) Bismark brown
 preparation:
 tincture of iodine-21ml, water-
15ml.
 Zinc iodide-1g, water-30ml,
glycerine-16ml, I crystals.
 Mercurochrome-1.5g, water,
oil of peppermint, non-
cariogenic sweetener.
 Bismark brown, ethyl alcohol,
glycerin.

 5) Erythrosine
 6) Two –tone solution.
 7) plaque light system.
 A)Topical application:
 Erythrosine, water, alcohol, oil of
peppermint
 B) Tablet :
 FD & C Red No.3, sodium
chloride, sodium sucaryl, calcium
stearate, white oil.
 FD & C Green No.3, FD & C Red
No.3
 Sodium fluorescein, glycerine-
75% FD & C Yellow No.8

 Dis-plaque dye
stains older plaque blue tones &
recent thin deposits in red tones.

Plaque control
It is of two types:
A) mechanical method.
B) chemical method.

 Mechanical methods of plaque control are the most widely accepted
techniques .
 Tooth brush MANUAL
POWERED
Brushing technique
Dentrifices.
Flossing
Interdental brushes.
Oral irrigators
Toothette.
Tongue scrapers.
Gauze piece for use in infants

Tooth brush-Historical background
 3000 BC Egyptians use small branches to clean teeth
 1223 Chinese invent bristle toothbrush
 1690 First reference to word toothbrush in Europe
 1780 William Addis invents toothbrush
 1857 First patent for a toothbrush by HN Wadsworth

1938 First nylon bristles introduced by DuPont
1954 Electric toothbrush Broxodent invented by Philippe
Guy Woog, Switzerland.
1960 electric toothbrush introduced in US
1980 First modified angulation of toothbrush-Reach
1987 1st rotary action electric toothbrush for home use
2000 Low-price power toothbrushes become popular

Manual tooth brush
 Most common method
 Variables -design and
fabrication of
toothbrushes.

ADA specifications of a tooth brush: The head of the brush should
be :
1) 1 inch to 1 ¼ inches long.
a) 1 inch or less in children.
2) Width—5/16 to 3/8 inches
3) Surface area—2.54 to 3.2 cm
4) 2-4 rows of bristles.
5) 5-12 tufts per row.
6)80-86 bristles per tuft.

Design of the tooth brush
:
toe
heel

Bristles :
 Two types : a) nylon (synthetic) b) natural (hog).
 Nylon bristles are preferred.
Hardness :
Depends on material, diameter & length.
Nylon bristles more flexible.
Soft: nylon filament 0.007 inches to 0.009 inches in
with 24 to 33 tufts-indicated for children.

 Medium : 0.010 inches to 0.012 inches (No.10, 11,12).
 Hard : 0.013 inches to 0.014 inches (No. 13, 14).
 Extra hard: 0.015 inches (No.15).
 length - 0.406 inch adult
- 0.344 inch kids

 Seven basic designs predominate in the arrangement of the tufts:
A) oval or convex.
B) curved tuft-ended.
C) straight tuft-ended.
D) short oval.
E) straight serrated trim.
F) straight multi tuft with the center 2 or 3 rows depressed
longitudinally.
G) straight non serrated multituft.

Size of Toothbrush According to Age

• No ideal toothbrush in terms of shape, size, or handle
• Manual toothbrush with short head, straight cut (same
length), round ended soft to medium artificial bristles
(nylon) and 3-4 rows of tufts is recommended and is
more effective
Ideal Toothbrush

It was suggested (Frandsen 1986) that the outcome of
tooth brushing is dependent on:
(1) the design of the brush
(2) the skill of the individual using the brush
(3) the frequency and
(4) duration of brushing
2
9

Brushing techniques
The more predominant brushing techniques advocated for
children :
A) Roll method
B) Fone’s technique
C)charters method
D) circular scrubbing method.
E) horizontal scrubbing method.
F) Bass method.
G)Modified stillman method.

Roll method
 The bristles - 45degree angle on the attached gingiva,
 Brush head -rolled in a coronal direction using an accurate
motion.
 The occlusal surfaces -anteroposterior scrubbing motion.

Advantage
Easy to learn
Good gingival stimulation
Disadvantage
Does not clean sulcus area.

Fones techniques
Recommended for children
 Bristle placement: perpendicular to the
tooth
 Motion: with teeth in occlusion move
brush in rotary motion over both arches
and gingival margin

Advantage
Easy to learn
Young chidren-minimal
manual dexterity.
Disadvantage
Interproximal areas not
cleaned
May cause trauma

Charter’s method
-45 degree
-firmly pushed into the interproximal spaces with a slight
rotary & vibratory action.
-Occlusal surfaces-bristles in a slight rotary movement
into pits & fissures.
 Advantage
 Cleans interproximal areas
 Gingival stimulation.
 Disadvantage
 Hard to learn and position brush

Circular scrub method
 The tooth brush head -
90°
 Entire brush head is
moved in a circular
scrubbing motion using
light pressure.
 Disadvantage : no
intrasulcular cleansing.

Horizontal scrubbing method
Brush is placed horizontally on B/L surfaces
Moved back & forth with a scrubbing motion.
 Disadvantage
 Interdental areas not cleaned
 Causes cervical abrasion--
& gingival recession

Advantages:
 Good gingival stimulation
 Remove plaque from cervical area,
interproximal & sulcular area.
Disadvantage:
 Errors in placement of bristles-
traumatize the attached gingiva.
Bass technique:

Modified stillmans technique
Advantages
 Good gingival stimulation
 Cleaning of interproximal
areas

Recommended Techniques in Pediatric Patients
Scrub or circular scrub technique -
 Probably best for young children with little manual
dexterity
Horizontal scrub -
 Used most frequently by preschoolers and 6-8 year old
children.

Powered tooth brush
Introduced in 1954.
Three basic types of electric tooth brushing
actions:
1) Rotation in an arc of about 60 degree.
2) Back & forth horizontal actions.
3) Elliptical movement (combines oscillating
with back-and-forth.)

 Recommended for:
individual lacking motor skill
physically handicapped or mentally retarded
patients.
preschool children
patient who have orthodontic appliance.
Removed significantly more plaque than manual
toothbrush in preschool children.

Orthodontic brushes
 2 rows of longer bristles on each side of a middle row of
shorter & stiffer bristles in order to clean the teeth, gingival
tissues, orthodontic brackets, wires & attachments

Dentifrice:
It is a substance used with a toothbrush for
the purpose of cleaning the accessible
surfaces of the teeth
(American Dental Association)
TOOTHPASTE:
Toothpaste is a colloidal suspension of a
mixture of ingredients that must be
carefully balanced in order to provide an
efficacious, safe, and consumer friendly
product

COMPOSITION
1. Detergent – 1.2%Sodium lauryl sulphate
• Use – To lower surface tension -Penetrate and loosen
surface deposits and strains
• Emulsify debris for easy removal by toothbrush Contribute
to the foaming action
2. Cleaning and polishing agents - 20-40% Calcium
carbonate, calcium pyrophosphate bicalcium phosphate
• Uses– Act as abrasive agents for cleaning and polishing
objectives.
10
9

• 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
11
0

4. Humectants : 20-40%Glycerin : Sorbitol
• Use – Added to retain moisture
• Prevent hardening on exposure to air.
• To stabilize preparation
5. Preservatives - Alcohol, formaldehyde ; dichlorinated phenols
Use – To prevent bacterial growth and to prolong shelf life
11
1

6. Sweetener : 2-3%Sorbitol ,sodium saccharin, sorbitol,xylitol
Use – To import a pleasant flavor for patient acceptance
7. Flavoring agent : 1-15%Peppermint : cinnamon, menthol
Use – To make the dentifrices desirable

11
2
8. Therapeutic agent 1-2 %Fluoride
• Use – For medical value
9. Coloring agent
10. Water 20-40%Main transport medium

Prophylactic or theraputic dentrifices:
 Tooth sensitivity reduction
 Bacterial plaque formation reduction
 Gingivitis reduction
 Calculus promotion reduction by adding pyrophosphate
system or zinc system

Fluoride dentrifices:
 Play a significant role in prevention of caries.
 Dental caries prevention by stannous fluoride, sodium
fluoride, sodium monofluorophosphate is well known.

Physicomechanical:
Reduce the cariogenicity of the plaque by rinsing or flushing action.
Removes fermantable food debris.
Chemical function
 fluoride deposited into the enamel and forms fluorapatite crystals.
 increase the acid resistance of the enamel.

Recommendation for use of fluoridated
dentrifices in children
CHILD AGE RECOMMENDATION FOR USE OF
FLUORIDE TOOTH PASTE
Below 4 year Fluoride tooth paste is not
recommended
4 to 6 years Brush once daily with fluoridated tooth
paste
6 to 12 years Brushing twice daily using fluoridated
tooth paste
Above 12 years Brushing three times with fluoride tooth
paste

 Dentifrice for babies aged 4 months to 3 years:
1)Baby orajel tooth & Gum cleanser
It is non-foaming without fluoride & it contains a mild
surfactant & simethicone , sugar free-in vanilla &
fruit flavours.

Dental floss:
 First paper & inventor - Parmly in 1819
 1882, Codman and Shurtuff (first commercial, made of silk)

 Jhonson & Jhonson company(New Brunswick) manufactured silk dental
flosses of both waxed & unwaxed type--1898.
 Dr Charles C Bass who in 1948-nylon is superior to silk
 Almost all dental flosses are made of nylon filaments.

 multiple nylon filaments of 2 to 3 denier thick.
 Each dental floss-made with 4 to 18 ends of filaments twisted in a
predetermined number of twists per inch.
 Unwaxed floss is most recommended by the dentist.

Types of dental floss
1. Flavored and unflavored.
2. Waxed and unwaxed.
3. Thin and thick.
4. Nylon and Teflon.
5. Twisted and non twisted.
6. Banded and non banded.
7. Micro filament and multi filament.

According to ADA specification:
Type I: Unbonded dental floss composed of yarn having no
additives.
Type II: Bonded dental floss composed of yarn having no
additives other than binding agent or agent for cosmetic
performance.
 Type III: Bonded or unbonded having drug for therapeutic
usage.

In school children dental flossing by trained
personnel over a 20 month period show a 50%
reduction of interproximal dental caries.
Flossing should be done at least once a day –
convenient time.

For orthodontic patients the use of superfloss or a
floss threader helps in negotiating the floss under
the archwires to allow for interproximal cleaning.

 Dental floss holder: is a supplimentary tool for flossing
 Types of holders
knife shape
y shape
holder with short handle are more difficult to use ,so always
try to select one with longer handle for children

Interdental cleaning Aids
 Interdental brushes.
 These are cone shaped brushes made of bristles mounted
on handle ,single tufted brushes or small cylindrical brushes.
 For best results diameter is
larger than the gingival
embrassure.

These brushes are classified as:
 Tapered ( Christmas tree appearance)
 Nontapered (Bottle neck appearance)
According to ISO standard 16409:2006
Passage Hole Diameter in mm.

Indications :
 Cleaning large irregular or concave tooth surfaces adjacent to
wide interdental spaces.
 Single tufted-furcations areas, deep recession, effective on
lingual surface of mandibular molar & premolar.

End-tufted Brush
 Cleaning along the gumline adjacent to the teeth.
 The bristles shaped in a pointed arrow pattern-closer
adaptation to the gums .

Uses
 ideal for cleaning specific difficult to-reach areas,
between crowns,
bridgework,
crowded teeth and
fixed orthodontic appliances

Wooden tooth picks or tips
 Used with or without handle
 Remove the soft deposit in the interdental area
 Handles- improve access to all areas
 Wooden tooth tips is useful-anterior areas –buccal
surfaces.

Rubber tips
 Conical & mounted on handles or the ends of tooth brushes
they can be easily adapted to all proximal surfaces in the
mouth.
 It is reusable.

Other adjuncts for oral hygiene

Tongue scrapers
 They may be flexible ,plastic or
metal stick which helps in
cleaning the rough dorsal surface
of the tongue

Benefits of Tongue Scraping
 Halitosis-reduced
 Enhancing immunity- removes bacteria & toxins
 Improving the sense of taste
 Digestive system, respiratory system etc improves with a
regular tongue scraping

Disadvantages of Tongue Scraping
 Gag reflex - vommiting.
 Damage to the taste buds
 Too much pressure -tongue bleeding
 Tongue Scraping With Your Tooth Brush
 Tongue Scraping With Tongue Brush
 Tongue Cleaning with a Tongue Scrapper
Tongue Scraping Options and Tools

Toothette
 It is a swab of sponge
attached to a stick
 Used in hospitals and in pts
extremely fragile tender
gingiva or mucosal lesions
 Used to deliver moisture to
dried oral mucosa as well as
clean oral cavity –topical
anesthetics.

Gauze piece for use in infants
 A moist gauze piece wrapped
around the finger can be ideal for
cleaning gum pads in infants.

CHEMOTHERAPEUTIC PLAQUE
CONTROL AGENTS

 Many patients are unable, unwilling or untrained to
practice - mechanotherapy.
 Certain pts with dental diseases :
(e. g.periodontitis, immunocompromised conditions -
additional assistance beyond mechanotherapy.

classification
Antiseptic agents
 Positively Charged Organic Molecules:
Quaternary ammonium compounds: cetylpyridinium
chloride
Pyrimidines—hexedine
Bis-biguanides—chlorhexidine, alexidine
 Noncharged Phenolic Agents: Listerine ,triclosan, phenol,
and thymol
 Oxygenating Agents: Peroxides and perborate
1. AADDY M (1986

 Bis-Pyridines: Octenidine
 Halogens: Iodine, iodophors, and fluorides
 Heavy Metal Salts: Silver, mercury, zinc, copper, and tin

ANTIBIOTICS
Niddamycin, kanamycin sulfate, tetracycline hydrochloride,
and vancomycin hydrochloride
ENZYMES
Mucinases, pancreatin, fungal enzymes, and protease
PLAQUE-MODIFYING AGENTS
Urea peroxide
SUGAR SUBSTITUTES
Xylitol, mannitol
PLAQUE ATTACHMENT INTERFERENCE AGENTS
Sodium polyvinylphosphonic acid, perfluoroalkyl

FIRST-GENERATION
COMPOUNDS
SECOND-GENERATION
COMPOUNDS
 Antibiotics,
Phenols
 Quartenary
Ammonium
Compounds
 Sanguinarine
 Capable of
reducing plaque
scores by about
20-50%.
 Efficacy limited –
Due to poor
retention with in
the mouth.
 Bis-Biguanides
 Triclosan with
other copolymers
or zinc citrate
 Reduce plaque
scores by about
70-90%.
 More effectively
retained by
tissues due to
slow-release
properties.
According to generation
10
THIRD GENERATION
Delmapinol
Octapinol
Blocks by binding
of micro-organisms
to each other or to
the tooth.

Action of chemicals can be fit into four categories:-
1. Antiadhesive
2. Antimicrobial
3. Plaque removal
4. Antipathogenic
12

Antiseptic agents
positively charged organic molecules:
 Bis –biguanides: chlorhexidine
 Quarternary ammonium compounds :
cetylpyridinum chloride.

Chlorhexidine:( developed in late 1940’s)
 Primary agent-chemical plaque control
 It is a cationic bisbiguanide - broad spectrum anti bacterial activity.
 0.2%conc-in oral cavity.
 2%-irrigating root canal.
 At low con – bacteriostatic
At high con- bactericidal

Mechanism of action
antibacerial activity

Anti-plaque mode of action
 Blocking the acidic groups on the salivary glycoprotein -reducing the
protein adsorption to the tooth surface
 Binding to the bacterial surface in sublethal amounts
 Substantivity
 Precipitating the agglutination factors in saliva and displacing calcium
from the plaque matrix

Indication of chlorhexidine:
 Adjunct to mechanical oral hygiene
 Prevention following oral surgical procedures
 For plaque control in physically and mentally handicapped
pts
 In high caries risk pts
 In pts having fixed orthodontic appliance
 Immunocompromised pts

Disadvantage:
 discolouration of mouth,
 increase of Tartar formation on the teeth,
 taste problems such as decreased taste or change in taste,
 tooth discoloration
serious side effects
 mouth ulcer,
 white patches or sores inside the mouth or on the lips,
 swelling of salivary glands,
 signs of an allergic reaction- difficulty in breathing or swelling of
face,lips,tongue and throat

Chlorhexidine products
Mouthrinse
 0.2% chlorhexidine were first made available in Europe for daily use in
1970
 0.1% also became available, however the activity is less
 In U.S, a 0.12% mouthrinse was manufactured but to maintain the almost
optimum 20mg doses derived from 10ml of 0.2% rinses, the product was
recommended as a 15ml rinse (18mg dose)
 The studies revealed equal efficacy of 0.2% & 0.12% rinses when used at
appropriate similar doses (Segreto et al 1986)
41

Gels
1% chlorhexidine gel
Delivered on a toothbrush or in trays
The distribution appears to be poor & preparations must be
delivered to all tooth surfaces to be effective
In trays it was found to be particularly effective against
plaque & gingivitis in handicapped patients.
Available as 0.2% & 0.12% gels.
42

Toothpaste
Difficult to formulate into toothpaste.
0.1% chlorhexidine toothpaste with or without fluoride
was found to be superior to the control product for the
prevention of plaque & gingivitis in a 6 month home use
study (Yates et al;1993)
43

Varnishes
Has been used mainly for prophylaxis against root
caries than as antiplaque agent in the mouth
 CHX-containing varnishes were developed
increase the substantivity,
length of the time of suppression
44
H.J. SANDHAM et al Clinical trial in adults of an antimicrobial
varnish for reducing mutans streptococci.Journal of Dental
Research,1991

 Varnish has been shown to reduce the numbers of S mutans in several studies.
 Suppression of S mutans for periods of up to five months has been achieved by
the application of a varnish containing a high concentration of chlorhexidine
(40%).
1991. Clinical trial in adults of an antimicrobial varnish for reducing mutans
streptococci. Journal of Dental Research

 Twetman stated in his review that clinical data on caries in prevention
effects remain sparse and that the recent literature was inconclusive for
use of chlorhexidine varnishes for caries prevention in risk groups.

SPRAYS
 0.1% & 0.25% chlorhexidine in sprays
 Studies with 0.2% spray have revealed that small doses of
approximately 1 – 2 mg delivered to all tooth surfaces
produces similar plaque inhibition to a rinse with 0.2%
mouthrinses (Kalaga et al 1989)
 They appear particularly useful in physically & mentally
handicapped groups.

Chlorhexidine is considered gold standard because:-
Superior antiplaque effect
Irreversible adsorption
Dual antibacterial effect
Dicationic nature
45

Quaternary ammonium compounds
 Most commonly used con - 0.025% to 0.05 %
(antiplaque properties).
 Cationic and bind to the oral tissues
 Used orally - bind strongly to plaque and tooth
surfaces.
 Cetylpyridinium chloride as main ingredient.

Mechanism of action
Rupture the cell wall and alter the cytoplasmic contents.
Adverse effects
Yellowish brown discoloration
Burning sensation
Occasional desquamation also seen

Listerine
 Most widely --listerine
 1ST over the counter mouth rinse to be accepted by the
council of dental therapeutics.
 effectiveness in plaque reduction- 20 to 34 %
 Gingivitis reduction -28 to 34%.

 Mechanism of action
cell wall disruption and inhibition of bacterial enzyme
 Adverse effects
An initial burning sensation and bitter taste in the mouth

Sanguinarine
 Used in mouth rinse & toothpaste.
 It is an alkaloid extract-blood root plant-sanguinalia
canadenses.
 It contains the extract at 0.03% & 0.2% zinc chloride.
 Plaque reduction-17-42%, gingivitis reduction-18-57%.
 Adverse effect:
 Burning sensation-initially.

Triclosan
It is a broad spectrum effective
against gram +ve and -ve bacteria
Acts on microbial cytoplasmic
membrane
leakage of the cell contents /
bacteriolysis
Reduces plaque formation and
gingival bleeding.

Stannous fluoride
 Reduces dental plaque formation
 Anti-plaque property at conc of 0.1 to 8%.
 Stannous fluoride above 125 ppm – bactericidal against S.
mutans
 Low con 10ppm –alteration in DNA and glucan production
by s.mutans

 Stannous fluoride used as a adjunctive therapy in periodontal
treatment
 It reduces plaque formation , gingivitis, and bleeding on
probing.
 Stannous fluoride chlorhexidine dentrifice reduce and control
supra and sub gingival plaque bacteria.

Antibiotics
 Kanamycin ,
non absorbable aminoglycan with a broad spectrum activity
reduce plaque and gingivitis when used topically.
 Antibiotics - penicillin, tetracyclines , metronidazole and
clindamycin used- conjunction with scaling and root planing.

 Treatment of juvenile periodontitis
–local application of tetracycline by hollow cellulose
acetate fibers
–delivers an effective conc of drug in the gingival fluid.
 Long term use of antibiotic for plaque control is
inappropriate
-high risk & low benefit

Enzymes :
A dentifrice (zendium, oral-B)-its enzyme system is able to inhibit plaque
bacteria.
enzymes - amyloglucosidase, glucosidase and lactoperoxidase
It enhances the lactoperoxidase system already present in human saliva.
Thyocyanate oxidizes(H2o2) hypothycyanate.

Hypothiocyanate + sulfhydril groups of oral micro-organisms
resulting in their inhibition.
Clinical trials has shown that some reduction in plaque &
gingivitis

Antitartar agents:
 Dentrifice containing 3.3 % pyrophosphatase shows 26 %
reduction calculus formation
 It prevent calcification by interfering with the conversion of
amorphous calcium phosphate to hydroxy apatite.
 2% zinc chloride is an effective ingredient in anti calculus
dentrifice

plaque-modifying agents, and plaque
attachment interferance agents :
 Urea peroxidase as a plaque modifying agent
- increased stability and
- protein denatauration effect of urea
 Delmopinol affects by binding to salivary proteins & altering the
cohesiveness of the plaque film

9.plaque control

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