This document discusses levels of prevention of periodontal disease. It begins by introducing periodontal diseases like gingivitis and periodontitis. It then discusses factors that predispose to plaque accumulation and stages of periodontal disease. The main levels of prevention are primary, secondary, and tertiary prevention. Primary prevention focuses on health promotion through education and oral hygiene practices. Secondary prevention involves early diagnosis and treatment through screening and dental visits. Tertiary prevention aims to limit disability through treatment like surgery and rehabilitation. Methods of prevention include mechanical plaque removal using tools like toothbrushes and chemical approaches using mouthwashes.

2. LEVELsOF PREVENTIONOF
PERIODONTALDISEASE
PRESENTED BY-
IRA SOLANKI
(FINAL YEAR BDS-
GDC, JAIPUR)

3. CONTENTS
 INTRODUCTION
 STAGES OF PERIODONTAL DISEASES
 FACTORS PREDISPOSING TO PLAQUE
ACCUMULATION
 ORAL HYGIENE ASSESSMENT
 IMPLICATIONS FOR PREVENTION
 LEVELS OF PREVENTION OF PERIODONTAL
DISEASE
 METHODS OF PREVENTION OF PERIODONTAL
DISEASE
 Mechanical
 Chemical
 CONCLUSION

5. INTRODUCTION
 Periodontitis , one of the most common
disease of humans is an infectious condition
that can result in the inflammatory destruction
of periodontal ligament and alveolar bone.
 Gingivitis is an infectious inflammatory process
limited to gingiva.
 Periodontal disease is almost universal in its
occurrence affecting 95%of the population and
is intimately related to plaque and pocket
formation.
 Supragingival plaque formation and the onset
of early periodontal diseases can be
successfully controlled by mechanical oral
hygiene procedures and effective antiplaque

6. STAGES OF PERIODONTAL DISEASE
HEALTHY GUMS
GINGIVITIS
MILD PERIODONTITIS
MODERATE
PERIODONTITIS
ADVANCED
PERIODONTITIS

7. FACTORS PREDISPOSING TO PLAQUE
ACCUMULATION
FACTORS
PREDISPOSING
TO PLAQUE
ACCUMULATION
INADEQUATE
ORAL HYGIENE
TOOTH
MALALIGNMENT
RESTORATIONS
PROSTHESIS
CALCULUS
FACTORS
MODIFYING
INFLAMMATORY
RESPONSE

8. HOST
SMOKIN
G
BLOOD
DYSCRASIAS
ALTERATIONS IN
LEVEL OF
SEX HORMONES
VARIOUS HOST FACTORS MODIFYING INFLAMMATORY RESPONSE

9. ORAL HYGIENE ASSESSMENT
To modify the oral health behavior, it is
necessary to assess oral hygiene status
which involves determining the:
Amount of hard deposits
Awareness of his or her oral hygiene
status
Home care regimen being followed.

10. IMPLICATION FOR PREVENTION
 As gingivitis is caused by supragingival
plaque accumulation and gingivitis is
prerequisite for the development of
periodontitis, both diseases can be prevented
by an adequate standard plaque control.
 Regular frequent dental visits are indicated to
establish and maintain good oral hygiene and
to identify inflammatory changes at an early
and reversible stage.
 During the early regular dental visits, periodic
reinforcements can be induced through
effective oral hygiene education normally
given to the chairside.

11. Services offered by the
hospital
Oral hygiene education
(given by dentist or dental
hygienist at chair side)
Expected outcome is change in
Behavior and attitude of patient
Towards dental diseases

12. Levels of
prevention
PRIMARY
HEALTH PROMOTION SPECIFIC
PROTECTION
Services provided by
the individual
Periodic visits to dental
office
Demand for prevention
services
Oral hygiene practices
Services provided by
the community
Dental health education
programs
Promotion of research
Provision of oral
hygiene aids,
supervised school
brushing programs
Services provided by
the dental professional
Patient education
Recall reinforcement
Plaque control
program Correction of
malalinged teeth,
Prophylaxis

13. Levels of prevention SECONDAY
EARLY DIAGNOSIS AND PROMOT TREATMENT
Services provided by the
individual
Self examination and referral Utilization of dental
services
Services provided by the
community
Periodic screening and referral
Provision of dental services
Services provided by the
dental professional
Complete examination, Scaling and curettage,
Corrective restorative and occlusal services

14. Levels of prevention TERTIARY
DISABILITY
LIMITATION
REHABILITATION
Services provided by the
individual
Utilization of dental
services
Utilization of dental
services
Services provided by the
community
Provision of dental
services
Provision of dental
services
Services provided by the
dental professional
Deep curettage Root
planning and splinting
Periodontal surgery,
Selective extractions
Removable or fixed
partial dentures
Minor tooth movement

15. METHODS OF
PREVENTION OF
PERIODONTAL DISEASE
PREVENTION
OF BUILD UP OF
PLAQUE
REMOVAL OF
OTHER
ETIOLOGICAL
RISK FACTORS
METHODS OF PREVENTION OF PERIODONTAL DISEASE

16. ESSENTIAL
APPROACHES
TO PREVENT
THE BUILD UP
OF PLAQUE
MECHANICAL
PLAQUE
REMOVAL BY
INDIVIDUAL
MECHANICAL
PLAQUE
REMOVAL BY
DENTAL
PROFESSIONAL
CHEMO-
THERAPEUTIC
METHOD OF
PLAQUE
CONTROL
MECHANICAL
CHEMIC
AL

17. 1.TOOTHBRUSH
A.MANUAL TOOTHBRUSHES
B.ELECTRICAL TOOTHBRUSHES
C.IONIC TOOTHBRUSHES
D.SONIC AND ULTRASONIC TOOTHBRUSHES
2. INTERDENTAL ORAL HYGIENE AIDS
A.DENTAL FLOSS
B.DENTAL FLOSS HOLDER
C.TOOTHPICKS AND TOOTHPICK HOLDER
D.INTERPROXIMAL BRUSHES
E.SINGLE TUFT BRUSHES
3.ADJUNCTIVE AIDS
A.IRRIGATION DEVICES(WATER-PIK)
B.TONGUE CLEANER
C.DENTRIFICES
D.MOUTHRINSES (MOUTHWASHES)

18. TOOTHBRUSHES-
According to ADA’s council on Dental
Therapeutics “The tooth brush is
designed primarily to promote
cleanliness of teeth and oral cavity”.
Toothbrushes are the most widely
used oral hygiene aids.
It is the principal instrument in general
use for accomplishing the goals of
plaque control.

19. HISTORY OF TOOTH BRUSHES
 They very first introduced in China as early
as 1600 B.C. and was introduced into the
western world in 1640.
 By early 19th century craftsmen in various
European countries constructed handles of
gold, ivory or ebony in which replaceable
brushes heads could be fitted.
 Nylon came into use in toothbrushes
construction in 1938.
 Powered toothbrushes were actively
promoted after 1960.

20. OBJECTIVES OF TOOTH
BRUSHING
1. To clean teeth and interdental spaces of
food remnants, debris and stain.
2. To prevent plaque formation
3. To disturb and remove plaque
4. To stimulate and massage gingival tissue
5. To clean the tongue

21. MANUAL TOOTHBRUSHES
The ideal objectives of a toothbrush are-
o It should confirm to individual patient
requirement in size, shape and texture.
o It should be easily and effectively
manipulated.
o It should be durable and inexpensive.
Manual toothbrushes are designed to
reach and efficiently clean most areas of
the oral cavity

22. HANDLE The part grasped is the hand during
tooth brushing
HEAD The working end of a tooth brush that
holds the bristles or filaments
TUFTS Clusters of blisters or filaments secured
into the head
BRUSHING
PLANE
The surface formed by the bristles or
filaments
SHANK The section that connects head and
handle
Straight handle
Angulated handle
HARDNESS OF
BRISTLES
(DIAMETER OF
BRISTLE)
SOFT (0.007
INCH)
MEDIUM
(0.009 INCH)
HARD
(0.012INCH)
PARTS OF A
TOOTHBRUSH

23. ELECTRIC TOOTHBRUSH OR
POWERED TOOTHBRUSH
 HISTORY- In 1885, Fredrick Tornberg, a Swedish
watchmaker designed the first mechanical toothbrush
which was followed by the first powered toothbrush
in1939.
- The actual marketing of the brush was done in 1960’s.
 INDICATIONS- young children
- handicapped patients
-orthodontic patients
-patient with prosthodontic or
endosseous implants
The heads of these toothbrushes oscillate in a side-to-
side motion or in a rotatory motion. The frequency of
the oscillators is around 40Hz in an ordinary powered

24. SONIC AND ULTRASONIC
TOOTHBRUSHES
 These types of toothbrushes produce
high frequency vibrations (1.6MHz),
cavitation and accoustic micro
streaming.
 This phenomenon aids in stain
removal as well as disruption of the
bacterial cell wall (bactericidal).

25. IONIC TOOTHBRUSHES
 Ionic toothbrushes
change the surface
charge of a tooth by an
influx of positively
charged ions.
 The plaque with a similar
charge is thus repelled
from the tooth surface
and is attracted by the
negatively charged
bristles of the
toothbrush.
 However, further studies
are required to prove the
efficacy of these type of
toothbrushes

26. TOOTH BRUSHING
TECHNIQUES
THE BASS METHOD
MODIFIED BASS TECHNIQUE
MODIFIED STILLMAN’S TECHNIQUE
FONES METHOD OR CIRCULAR METHOD
CHARTER’S METHOD
THE ROLL TECHNIQUE

27. TECHNIQUES INDICATIONS ADVANTAGES DISADVATAGES
BASS
TECHNIQUE OR
SULCUS
CLEANING
METHOD
a. Adaptable for -
interproximal areas
b. -cervical areas
beneath the height
of contour of
enamel
c. -exposed root
surface
a. Effective method
for removing
plaque
b. Provide good
gingival
stimulation.
a. Cause injury to
the gingival
margin
b. Time
consuming.
MODIFIED BASS
TECHNIQUE
a. As a routine oral
hygiene measure
b. intrasulcular
cleansing
a. Excellent sulcus
cleaning.
b. Good
interproximal and
gingival
stimulation
a. Dexterity of
wrist is required.
MODIFIED
STILLMAN’S
TECHNIQUE
a. Dental plaque
removal
b. Cleaning tooth
surfaces and
gingival massage
a. Time consuming
b. Damage
epithelial
attachment

28. TECHNIQUES INDICATIONS ADVANTAGES DISADVANTAGES
FONES
METHOD OR
CIRCULAR /
SCRUB
METHOD
a. young children
b. physically &
emotionally
handicapped
individuals
a. It is easy to
learn
b. Shorter time is
required
a. Possible trauma to
gingiva
b. Interdental area
are not properly
cleaned
CHARTER’S
METHOD
Persons having-
a. Missing papilla and
exposed root
surfaces.
b. FPD or orthodontic
appliances
c. Periodontal surgery
d. Interproximal gingival
recession
Massage and
stimulation of
gingiva.
a. Poor removal of
subgingival
bacterial
accumulations
b. Limited brush
placement
THE ROLL
TECHNIQUE
a. Children
b. Adult patients with
limited dexterity
Provide gingival
massage and
stimulation.
a. Brushing too high
during initial
placement can
lacerate the
alveolar mucosa
b. May produce
lesions in gingiva

29. THE BASS METHOD OR SULCUS CLEANING
METHOD
 The bristles are placed at a 45 degree angle
to the gingiva and moved in small circular
motions.
 Strokes are repeated around 20 times, 3
teeth at a time.
 On the lingual aspect-brush is inserted
vertically and the heel of the brush is pressed
into the gingival sulci and proximal surfaces
at a 45 degree angle.
 The bristles then activated.
 Occlusal surfaces are cleansed by pressing
the bristles firmly against the pits and fissures
and then activating the bristles

30. MODIFIED BASS TECHNIQUE
 This technique combines the vibratory and
circular movements of the bass technique
with the sweeping motion of the roll
technique.
 The toothbrush is held in such a way that
the bristles are at 45 degree to the gingiva.
 Bristles are gently vibrated by moving the
brush handle in a back and forth motion.
 The bristles are then swept over the sides of
the teeth towards their occlusal surfaces in
a single motion.

31. MODIFIED STILLMAN’S THECHNIQUE
 The bristles are pointed apically with an
oblique angle to the long axis of the tooth.
 The bristles are positioned partly on the
cervical aspect of the teeth and partly on the
aadjacent gingiva.
 The bristles are activated by short back and
forth motions and simultaneously moved in
coronal direction.
 Following 20 strokes, the procedure is
repeated systematically on adjacent teeth.
 A soft toothbrush is indicated for this
technique.

32. FONES METHOD OR CIRCULAR/ SCRUB
METHOD
 The child is asked to stretch his/her arms
such that they are parallel to the floor.
 The child is then asked to make circles
using the whole arm to draw circles in the
air.
 The child is now ready to make circles on
the teeth with the toothbrush , making
sure that the teeth and gums are covered.

33. CHARTER’S METHOD-
 A soft/ medium multi-tuftedd toothbrush is
indicated for this technique.
 Bristles are placed at an angle of 45 degree
to the gingiva with the bristles directed
coronally.
 The bristles are activated by mild vibratory
strokes with the bristle ends lying
interproximally.

34. THE ROLL TECHNIQUE / THE ROLLING STROKE
METHOD / ADA METHOD / THE SWEEP METHOD
 In this technique, the bristles are placed at
a 45 degree angle and lightly rolled across
the tooth surface towards the occlusal
surfaces.
 This technique require some flexibility
around the wrist.

35. INTERDENTALORALHYGIENEAIDS
It is well-established fact that
periodontal conditions are worst in
interdental areas where standard
toothbrushes are ineffective at
removing proximal surface plaque
leading to further progress in disease
in those areas.

36. DENTAL FLOSS
 This type of interdental cleaning aids is indicated to remove
plaque from interproximal tooth surface.
 VARIOUS FORM- multifilament- twisted
/non twisted
- bonded / non bonded
- thick / thin
- waxed / non waxed
 FUNCTION-removal of adherent plaque and food debris from
the interproximal embrasure
-under the pontics of the FPD
-stimulating and massaging the interdental papillae.
 DISADVATAGES- it is time consuming
-requires skill
-carries the risk of tissue damage if not used
properly

37. TOOTHPICKS
 Also known as wood points.
 These are effective only where sufficient
interdental space is available to accommodate
it.
 These are inserted into the gingival embrasures
with the base of the triangle oriented towards
the gingiva.
 The wooden tip then may be repeatedly moved
in and out of the embrasure, thereby removing
soft deposits from the teeth and also
mechanically stimulating the gingiva.
 Triangular wood points are superior to round or
rectangular ones.

38. INTERPROXIMAL BRUSHES
 They are cone shaped or cylindrical
brushes made of bristles mounted on a
handle.
 They are particularly suitable for cleaning
large, irregular or concave tooth surfaces
adjacent to wide interdental spaces.
 They are inserted through interproximal
spaces and moved back and forth
between the teeth with short strokes.
 Interdental brush is superior to dental floss
in cleaning large interdental spaces
(maintain both supragingival and
subgingival sapces free of plaque).

39. ADJUNCTIVEAIDS
IRRIGATION DEVICES
 Irrigation devices have been proven to be a
valuable supplement for mechanical plaque
control measures.
 It is mainly beneficial in the removal of
unattached plaque and debris.
 It provide a pulsating stream of water
escaping through nozzle under pressure.
 Used in cases of- areas of dentition not
readily accessible to conventional
mechanical plaque removal.
-Delivery of chemical agents
(chlorhexidine) to the oral cavity.

40. TONGUE SCRAPERS
 Tongue scrapping is defined as “the process of
removing debris from the surface of the tongue
with some form of scraper designed for this
purpose.
 Most tongue scrapers are made of a soft flexible
plastic. Metal scrapers are also available.
 Tongue cleaning devices- The devices is placed
towards the back of the tongue on the dorsal
surface, then pulled forward with light pressure.
- they can be
recommended for patients who have elongated
papillae who have elongated papillae, deep
fissures or surface coating.

41. DENTRIFICES
According to the American Dental
Associations Council Dental therapeutics
“A dentifrice is a substance used with a
toothbrush for the purpose of cleaning the
accessible surfaces of the teeth.”
FUNCTIONS- minimizing plaque build up
- anticaries action
- removal of stains
-mouth freshner
They are available in the form of pastes,
tooth powders and gels.

42. CHEMICAL METHODS
 By far the most efficient plaque control
progammes are those combining
mechanical and chemical methods,
 For example the toothpaste used usually
contains not only an abrasive agent but
also antiplaque or antimicrobial agents
such as sodium lauryl sulphate, stannous
fluoride, triclosan plus zinc citrate, tri closan
plus copolymers etc.

43. GOALS OF CHEMICAL
PLAQUE CONTROL
1. To prevent plaque formation.
2. To control plaque formation.
3. To reduce, disrupt or remove existing
plaque.
4. To alter composition of plaque flora.
5. To exert bactericidal or bacteriostatic
effects on micro flora implicated in caries
and periodontal disease.
6. To alter surface energy of the tooth, in
turn, affecting the plaque adherence.

44. FACTORS INFLUENCING EFFECTS OF
CHEMICAL PLAQUE CONTROL
• Ability of an agent to bind tissue surfaces and be
released over time delivering an adequate dose of the
active principal ingredient in the agent
SUBSTANTIVITY
• Efficiency of an agent in penetrating deeply into the
formed plaque matrixPENETRABILITY
• Ability of the agent to affect specific bacteria in a mixed
populationSELECTIVITY
• Agent should not undergo chemical breakdown or
modification during storageSTABILITY
• Agent should reach the site of action and be
maintained at that site long enough to have sustained
effect
ACCESSIBILITY
• property of the active agent to be soluble in its delivery
vehicle to allow rapid release into oral environment.SOLUBILITY

45. ANTIPLAQUE EFFECTS
 Formation of the dental plaque can be prevented by
these chemical agents by one of the following
principles-
i. Inhibition of bacterial colonization,
ii. Inhibition of bacterial growth,
iii. Disruption of mature plaque,
iv. Modification of plaque biochemistry and ecology.
Most chemical plaque control agents used today
are broad-spectrum antimicrobials that exert
direct bactericidal or bacteriostatic effects.
Also they interfere with the adsorption of the
bacteria on the tooth surface by modifying
surface characteristics of the tooth surface, e.g.
surface energy, surface tension.

46. DELIVERY VEHICLE
 Various delivery
vehicles are used for
delivery of these
chemicals are-
i. Mouthrinses
ii. Gels
iii. Toothpastes
iv. Chewing gums and
lozenges
v. Irrigants
vi. Varnishes
 The delivery vehicle
should-
a) Be compatible with the
active agents
b) Provide optimal
bioactivity of the agent at
the site of the action.
c) Should be independent
of the patient
compliance, e.g.do not
require the modification
of the patient’s existing
habits

47. MOST COMMONLY USED
CHEMICAL PLAQUE CONTROL
AGENTS
CATIONIC
AGENTS
BISGUANIDE
DETERGENTS
CHLOEHEXI-
DINE
QUATERNARY
AMMONIUM
COMPOUND
BENZETHO-
NIUM
CHLORIDE
HEAVY METAL
SALTS
COPPER, TIN
PYRIMIDINES
HEXITIDINE
HERBAL
EXTRACTS
SANGUINAR-
INE
ANIONIC
AGENTS
SODIUM
LAURYL
SULPHATE
NON-ANIONIC
AGENTS
OTHER
AGENTS
COMBINATION
AGENTS
-PHENOL
-THYMOL
-TRICLOSAN
-2-PHENYLPHENOL
-HEXY RESORCINOL
-DELMOPINOL
-ENZYMES

48. CHLORHEXIDINE GLUCONATE (0.2%)
 Chlorhexidine gluconate is a cationic bisguanide
which is effective against an array of
microorganisms, including gram positive and
gram negative organisms, fungi, yeasts and
viruses.
 It exhibits both anti plaque and anti bacterial
properties.
 It inhibits plaque by-
i. Preventing pellicle formation by blocking acidic
groups on salivary glycoproteins
ii. Preventing adsorption of bacterial cell wall onto
the tooth surface by binding to the bacteria.
iii. Preventing binding of mature plaque by
precipitating agglutination factors in the saliva.

49.  Adverse effects of chlorhexidine-
a) Brownish staining of the teeth on
restorations. (staining however is
reversible).
b) Loss of taste sensation.
c) Rarely hypersensitivity to it has been
reported.
d) Stenosis of the parotid duct has also been
reported.
It is bacteriostatic at low concentrations and
bacteriocidal at high concentrations.
It should not be used before/immediately after
using a tooth paste as interaction with
anionic surfactants found within the
formulations, will reduce effective delivery of

50. METALLIC IONS-
 Some metal ions have a plaque inhibitory
capacity.
 Salts of zinc and copper are the ones most
commonly used.
 Metallic salts act by reducing the glycolytic
activity in microoraganisms and delay
bacterial growth.
Cu

51. DELMOPINOL-
 It has shown to inhibit plaque growth and reduce
gingivitis.
 It interferes with plaque matrix formation and also
reduces bacterial adherence.
 It causes weak binding of plaque to the tooth
surface, thus aiding in easy removal of plaque by
mechanical procedures.
 ADVERSE EFFECTS- transient numbness of
tongue.
- tooth and tongue staining.
- taste disturbance.
- sometimes mucosal soreness and erosion.

52. ENZYMES-
 Enzymes have been used as active
agents in antiplaque preparations, due to
the basic fact that-
They would be able to breakdown already
formed matrix of plaque and calculus.
Besides, certain proteolytic enzymes are
bactericidal to microorganisms and would
therefore be effective when applied
topically in the mouth.
e.g. – Mucinase

53. COMBINATON AGENTS-
 Plaque is a complex aggregation of
various bacterial species.
 Therefore, combining two or more
agents with complementary inhibiting
modes of action may enhance the
efficacy and reduce adverse effects of
chemical plaque control.

54. CONCLUSION-
 Periodontal disease is so prevalent that the
only possible solution to the problem is
“prevention”.
 Available data suggests that faithful
adherence to proper oral hygiene practices
should be at least as effective, in controlling
periodontal disease as fluoride has been in
controlling dental caries.
 To be effective, prevention requires
responsible action on the part of the
individuals themselves, government and