Periodontology

 The toothbrush is the principal instrument in
general use for removal of dental biofilm and is
a necessary part of oral disease control.

 3500-3000 B.C when the Babylonians and the
Egyptians made a brush by fraying the end of a
twig. Tombs of the ancient Egyptians have been
found containing tooth sticks alongside their
owners.
 3000 B.C – Sumerians Excavations at Ur in
Mesopotamia uncovered gold toothpicks.
 Around 1600 B.C, the Chinese developed
"chewing sticks" which were made from
aromatic tree twigs to freshen breath.

 Earliest record about care of mouth was
associated with a religious ritual and training –
Buddhist used ‘tooth stick’ & Muslims used
‘Miswak’ - crushing the end & spreading the
fibers in a brush-like manner
 The first toothbrush of a more modern design
was made by William Addis in England around
1780 – the handle was carved from cattle bone
and the brush portion was still made from swine
bristles. In 1844, the first 3-row bristle brush
was designed.

 1857 – H. N. Wadsworth was the first person to
patent the toothbrush - design had a bone
handle with holes –
 Natural bristles were the only source of bristles
until Du Pont invented nylon. The invention of
nylon started the development of the truly
modern toothbrush in 1938.
 The first electric toothbrush was made in 1939
and the first electric toothbrush in the US was
the Broxodent in 1960.

 To clean teeth and interdental spaces of food
remnants, debris & stains.
 To prevent plaque formation.
 To disturb and remove plaque.
 To stimulate and massage gingival tissues.
 To clean the tongue.
 Halitosis control
 Sanitation of oral cavity

 Conforms to individual patient requirements in
size, shape & texture.
 Easily & efficiently manipulated.
 Impervious to moisture ; readily cleaned &
aerated.
 Durable & Inexpensive.
 Has prime functional properties of flexibility,
softness, & of strength, rigidity & lightness of
the handle.

Toothbrushes consist of a head of tightly
clustered bristles mounted on a handle, which
facilitates the cleansing of hard-to-reach areas
of the mouth.

A. Manual toothbrush :
1. According to head shape 
 Conventional : all
conventional toothbrush head
designs are effective in
cleaning every tooth surface.
 Diamond shape : the tips of
these toothbrush heads are
narrower than those of the
conventional ones, these tips
are designed for easy access
to posterior teeth.

2. According to head size 
 0-2 years : brush head size
should be approximately 15
mm of diameter.
should be approximately 19
mm.
should be 22 mm.
 12 years and above : brush
head size should be
approximately 25 mm.

3. According to bristle
pattern 
 Block pattern : the bristles
are of the same length and
are arranged neatly like a
block.
 Wavy or V-shape pattern :
the bristles form a V-shape
or wavy pattern, this is
intended to give the
bristles a better contact
with the areas around the
adjacent tooth surfaces.

 Multilevel trim pattern: the
manufacturer claimed
that it enables brush to
reach difficult to clean
areas.
 Criss - cross pattern :
according to the
manufacturer, this design
can lift up plaque
effectively.
 Polishing-cup bristles : it
is claimed that the
bristles can clean surface
stains effectively.

4. According to handle
design :
 Straight handle : all
conventional toothbrushes
have straight handles that
are easier to control.
 Contra-angle handle : this
handle design is similar to
a dental instrument,
intending to access to the
difficult-to-clean areas.

 Flexible handle : this kind
of handle intends to reduce
gum injury caused by
excessive brushing force.
 Slip prevention grip handle
: this handle intends to
prevent the toothbrush
from slipping away during
tooth brushing.

 performs oscillations or rotations of its bristles,
driven by a motor.
 most studies report a medical performance
equal to that of a manual brush, the electric
version can be more comfortable, and an
additional timer and pressure sensors can
encourage a correct cleaning process.
 can be classified according to the speed of their
movements as standard power toothbrushes,
sonic toothbrushes or ultrasonic toothbrushes.
 uses less brushing force than manual
toothbrushes.
 mostly indicated for handicapped and elderly
patients.

Mostly accepted and effective method for the
removal of dental plaque present adjacent to
and underneath the gingival margin.
Indications :
 interproximal areas.
 cervical areas beneath the height of contour of
enamel .
 exposed root surfaces.
Advantages 
effective method for removing plaque.
provides good gingival stimulation.
Disadvantages 
cause injury to the gingival margin.
time consuming.

Procedure :
 The bristles are placed at a 45 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 of the anterior teeth, the
brush is pressed into the gingival sulci and
proximal surfaces at a 45 angle. The bristles are
then activated.
 Occlusal surfaces are cleaned by pressing the
bristles firmly and then activating the bristles.

2 . Modified Bass Method :
Differs from bass technique in that it has
sweeping motion from cervical to incisal or
occlusal surface.
Indication :
As a routine oral hygiene measure intrasulcular
cleansing.
Advantage 
 excellent sulcus cleaning.
 good inter proximal and gingival cleaning.
 good gingival stimulation.

3. Stillman's Method :
 Like the Bass Method the filaments are placed
at a 45° angle to the tooth.
 Unlike the Bass Method the filaments are placed
half in the sulcus and half on the gingiva.
 The same stroke is used as the Bass.

Indication :
 dental plaque removal
 cleaning tooth surfaces and gingival
massage .
Disadvantages 
 time consuming.
 damage epithelial attachment.

Indications :
 missing papilla and exposed root surfaces.
 FPD and orthodontic appliances.
 periodontal surgery.
 interproximal gingival recession.
Disadvantages 
 Poor removal of subgingival bacterial
accumulations.
 Limited brush placement.
 Requirements in digital dexterity are high.
Advantage 
Massage and stimulation of gingiva.

Procedure :
 Position the filaments toward the
chewing surface of the tooth
 Place the sides of the filaments against
the enamel and angle them at a 45° to
the tooth.
 Vibrate the filaments gently but firmly,
keeping the filaments against the tooth.
 Reposition on the next set of teeth.

 Direct the filaments toward the root of the
tooth.
 Place side of the brush on the gingiva and
have the plastic part of the brush even with
the tooth.
 When the plastic portion is even with the
tooth press the filaments against the
gingiva and roll the brush over the teeth.
 The wrist is turned slightly and the
filaments follow the contours of the teeth.

6. Scrub Brush Method :
Requires vigorous horizontal , vertical & circular
motion
Disadvantage 
 Not very effective at plaque control.
 Tooth abrasion and gingival recession.

 Vertical stroke is used
 Maxillary and mandibular teeth are brushed
separately.
 Bristles of brush are placed at 90° to the facial
surface of teeth.
 Brush vigorously without great pressure
mostly up and down strokes.
Advantage 
most convenient and effective for small
children with deciduous teeth.
Disadvantage 
interdental space of permanent teeth of adult
are not properly cleaned.

8. Physiologic Method :
 Based on the principle that toothbrush
should follow the physiologic pathway that
is followed by the food when it traverses
over the tissue during mastication.
 Bristles are pointed incisally or occlusally
and then moved along and over the tooth
surface and gingiva.
Advantages 
 natural self cleansing mechanism.
 supragingival cleaning is good.
Disadvantages 
interdental spaces and sulcular areas of
teeth are not properly cleaned.

9. Circular Method :
Indication :
 Young children.
 Physically or emotionally handicapped
individuals.
 Patients who lack dexterity.
Advantage 
 easy to learn.
 shorter time required.
Disadvantage 
 possible trauma to gingiva.
 interdental areas not properly cleaned.

Method :
 Place the toothbrush on a set of teeth, then
activate the bristle by slightly pressing
them over the teeth.
 Give circular motion 4 -5 times on each set
of the teeth.
 Move on to the next set of teeth.

* There are several different acceptable
tooth brushing methods because each
patient has different needs.
* Not one method is perfect for all
patients. Some patients may use more
than one method.
* The important thing is to brush
thoroughly for at least two minutes each
time and two times a day….

 Don’t share toothbrushes :
using someone else’s toothbrush exposes you
to another person’s body fluids and potential
germs, which could make you sick. People with
compromised immune systems or who are sick
with something they could pass on to another
person should take special care to use only
their own toothbrush.
 Rinse your toothbrush after brushing :
give it a thorough washing to remove any
leftover toothpaste or debris.

 Store your toothbrush in an upright position :
When you’re done brushing, try to store it
standing straight up and allow it to air-dry until
your next brushing. If there’s more than one
brush in the same holder, try to keep them as
separate as possible to prevent cross-
contamination.
 Keep your toothbrush out in the open :
do not routinely cover toothbrushes or store
them in closed containers. A moist environment,
such as a closed container, is more conducive to
the growth of microorganisms than the open air.

 Replace your toothbrush every 3-4 months :
bristles that become frayed and worn with use
and will be less effective at cleaning teeth.

Interdental gingiva that fills the
interproximal area is called
interdental papilla.

Types of gingival embrasures :

Posterior teeth 
two papilla(one facial and
one palatal) connected by
col
• epithelium of col is thin
and nonkeratinized
Anterior teeth 
single pyramidal papilla

Planning of Interdental Care :
 History of personal oral care
 Dental and gingival anatomy
assessment-teeth position,
embrassure, probing depth
 Extent and location of dental biofilm
 Personal factors- handicap or
disability, knowledge of interdental
oral care

Interdental aids include :
 Dental floss and tape
 Knitting Yarn
 Gauze strip
 Interdental tips
 Toothpick in holder
 Wooden interdental
cleaner

 Dental floss is a bundle of thin filaments
which may be made of either nylon or silk, it
is placed between the teeth and pulled to
clean the gaps between the teeth, as it is
pulled, it removes food particles and other
debris which may have got stuck between
teeth.
 Some of them coated with fluoride, it can be
flavored or unflavored..Some of them may
be waxed or unwaxed.

Features of waxed :
 Smooth floss surface
which prevents trauma
to soft tissue
 Slides through contact
area easily
 Monofilament resist
breakage or shedding
 Wax gives strength and
durability

Features of unwaxed floss :
 Thinner floss-used in tight
contacts
 Pressure against tooth
surface spreads nylon on
wider surface for biofilm
removal
 Sharper edges require
special attention

Types of flosses :
1. Regular floss 
 It is commonly supplied in plastic dispensers
which contain 10 to 100 meters of floss.
 Available in different thickness.

2. Specialized plastic wands

 Aka as floss picks
 Advantages 
 they do not pinch fingers
like regular floss does.
 enhanced reach of wand
can make flossing the
back teeth easier.
 Disadvantage 
it makes it difficult to floss
at all angles which are
possible with regular floss

3. Ergonomic Flosses 
 Have improved handle for
better grip.
 Its floss head have a
unique feature that it can
rotate in any direction
making it accessible to
any pair of teeth in the
mouth.

4. Automatic flosses 
suit those who find it
difficult to perfect their
flossing techniques.

Technique of flossing :
1. Measure around 18 inches of floss and wind
each end around the middle finger of both of
your hands. Grab around 2 inches of floss with
your thumb and index finger.
2. Move floss smoothly between your teeth in a
sawing motion and take extra care not to break
the floss while doing this or it will hurt your
gums.
3. When the floss is between your teeth curve it
(making a C shape) and slide it up and down.
When done, curve the floss in the opposite
direction and do the same.
4. In the end, brush your teeth and rinse with
mouthwash or water.

Benefits of flossing :
 Improves oral hygiene.
 Also Clean those area where toothbrush
cannot reach.
 Removes plaque and food particles from
interdental spaces.
 Cleans tooth surface beneath gum line.
 Prevents halitosis.
 Polishes tooth surface.

Indications 
 Proximal surface of widely spaced teeth.
 Surfaces of teeth next to edentulous area.
 Distal & mesial surface of abutment teeth.
 Under posterior cantilever section of fixed
appliance.

Types :
A. Small Insert brushes with reusable handle
B. Brushes with wire handles
Indications 
 Proximal tooth surfaces adjacent to open
embrasures , orthodontic appliances , fixed
prosthesis, periodontal splints.
 Concave proximal surfaces.
 Exposed class IV furcation.
 For application of chemotherapeutic agents –
fluoride dentifrices, antibacterial agents,
desensitizing agents.

It is a toothbrush with a very small head
supplied by single tuft or group of small tufts ,
3 mm in diameter, flat or tapered with straight
or contra-angled handle.
Can be used to clean wisdom teeth and
crooked teeth effectively.
There are various shapes of brush head. The
effectiveness of cleaning by different shapes
of the brush head is similar.

Indications 
 For open interproximal areas.
 For dental prosthesis.
 Difficult to reach area – lingual surface of
mandibular molars, abutment teeth , distal
surface of posterior most teeth.
Procedure :
 Direct the end of tuft into the interproximal
area along the gingival margin.
 Combine a rotating motion with intermittent
pressure.

Conical or pyramidal flexible rubber tip
attached to handle.
Indications 
 For cleaning debries from interdental areas
 Biofilm removal at and just below gingival
margin.
Procedure :
 Trace along the gingival margin with the tip
position just beneath the margin (1-2 mm )
 Rub the tip against the teeth as it is moved in
& out of an embrasure and under a contact
area. Position with gingival form.

2 inch long device made of Bass wood or
Birch wood used for wider gingival
embrasures.
Procedure :
 First teach the patient to use a rest by
placing the hand on cheek/chin/ or by
placing a finger on the gingiva , convenient
to the place where tip will be applied.
 Soften the pointed end of wood in mouth &
moistening with saliva.

 Hold the base of the triangle towards the
gingival border of interdental area & insert
horizontally.
 Clean the tooth surface by moving the
wedge in & out while applying the
burnishing stroke with moderate pressure
, 1st on one side of the embrassure & then
on other. Four strokes each

 Irrigation helps to reduce the levels of
biofilm and debris from around crowns,
bridges, orthodontic appliances and
implants, and in interdental areas.
 There are a variety of devices on the market.
Usually power driven and handheld, these
deliver a pulsating jet of water (or
prescribed solution) from a reservoir to the
required area .
 The pressure at which the solution is
delivered can be altered by the patient.
 A selection of tips are often available,
depending on manufacturer, for targeted
delivery of the solution.

Method of use :
 The manufacturer’s instructions should be
followed, the tip should be directed towards
the interdental area and held at 90° to the
long axis of the tooth.
 Patients should start with a low pressure
setting until they are used to the device.
 The temperature of the liquid should be
comfortable to them
 A sink or basin should be nearby, so water
or solution can be drained away
 Tissues/towels should be nearby.

 After you have given your teeth a good
brushing, focus on your tongue.
 The tongue harbors bacteria and food particles
trapped under a thin layer of mucus.

It is simple enough to use the bristles of your
toothbrush. You can also try a specialized
brush with a built-in tongue cleaner on the
back of the head.
Use a small dab of toothpaste and carefully
brushing the top of the tongue. Start by
reaching to the back of the tongue, and then
work forward toward the opening of the
mouth. Brush the entire top surface of the
tongue using gentle pressure, and finish by
rinsing with water.

For a more thorough cleaning, use a tongue
scraper. This tool is usually made of soft,
flexible plastic and gently peels the thin mucus-
based layer of debris from the tongue. Rinse the
scraper under warm water after each swipe of
the tongue.
If your tongue feels sore or begins to bleed, you
are using the tongue scraper with too much
force. Work slowly and with light pressure.
Concentrate on the center of the tongue where
the bulk of odor-causing bacteria lies.

How Often to Clean Your Tongue ?
Each time you brush and floss your teeth,
finish your dental care routine with a tongue
cleaning. At a minimum, clean your tongue
once in the morning and once in the evening
before bedtime. If you have dry mouth or
notice a foul taste in your mouth midday, try
cleaning your tongue to remedy the
situation.
.. A mouthwash rinse used after cleaning your
tongue moisturizes the mouth and kills
additional bacteria ..

 The miswak is a teeth cleaning twig made
from a twig of the Salvadora persica tree,
also known as the arak tree or the peelu
tree.
 The miswak is predominant
in Muslim areas but its use predates the
inception of Islam. Its use has spread from
the Middle East to South and Southeast
Asia, where it is known as Kayu
Sugi (Malay for 'chewing stick'). It is often
mentioned that the Islamic
prophet Muhammad recommended its use.

 Miswak is a pencil sized stick 15-20 cm long
and with diameter 1-1.5 cm that is prepared
from the root, stem, twigs or bark. The stick
is chewed or tapered at one end until it
becomes frayed into a brush.
 Miswak is generally used for a longer period
of time than is a modern toothbrush and the
cleaning is usually implemented for 5 to 10
min each time. The plant fibers remove
plaque and simultaneously massage the
gum.
 Miswak extracts have been shown to inhibit
the growth of different microorganisms.

Benefits of miswak :
 Natural way of brushing teeth.
 Keep you safe against all teeth
diseases.
 Kills bad odor.
 Requires no toothpaste.
 Easy to carry around.
 It has no harmful side-effects.
 Miswak clears the voice.

Periodontology

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