Plaque control

PLAQUE CONTROL
GUIDED BY
DR K REKHA RANI
PROFESSOR & HOD.
PRESENTED BY
R ANIL KUMAR
IInd year POST GRADUATE.

• Introduction
• Definition
• Methods to control plaque
• History
• Mechanical plaque control
• Chemical plaque control
• Biological method of plaque control
• Conclusion
• References
CONTENTS

 Plaque control is the regular removal of microbial plaque and the prevention of its
accumulation on the teeth and adjacent gingival surfaces.
 Microbial plaque is the major etiology of periodontal diseases
 Patient cooperation in daily plaque removal is critical to long-term success of all
periodontal treatment.
 In 1965, Löe et al conducted the classic study relationship between plaque
accumulation and the development of experimental gingivitis in humans.
 Stopped brushing and other plaque control procedures, resulting in the development
of gingivitis in every person within 7 to 21 days.
INTRODUCTION

 The composition of the plaque bacteria also shifted so that gram negative organisms
predominated, and these changes were shown.
 Plaque formation begins on the interproximal surfaces where the toothbrush does
not reach.
 Masses of plaque first develop in the molar and premolar areas, followed by the
proximal surfaces of the anterior teeth and the facial surfaces of the molars and
premolars.
 Patients consistently leave more plaque on the posterior teeth than the anterior
teeth, with interproximal surfaces retaining the highest amounts of plaque.

DEFINITIONS
PLAQUE
 Defined clinically as a structured, resilient, yellow-grayish substance that adheres
tenaciously to the intraoral hard surfaces, including removable and fixed
restorations. - carranza 12th edition.
PLAQUE CONTROL
 It is the removal of microbial plaque and the prevention
of its accumulation on the teeth and adjacent gingival
tissues. It also deals with the prevention of calculus
formation.

METHODS TO CONTROL PLAQUE
PLAQUE CONTROL
MECHANICAL
Most dependable way
to achieve oral health
TOOTH BRUSHES INTERDENTAL AIDS
CHEMICAL
Adjunctive to mechanical
Method
MOUTH WASHES
ANTIBIOTICS
ENZYMES

 1600 - Bristle toothbrush appear in China
 1728 - Pierre Fauchard in his book ‘The Surgeon Dentist’ advocated wet sponges
and specially prepared herb roots
 1780 - William Addis of England made the first toothbrush
 1840 - England, France and Germany started producing bristle toothbrush.
 1857 - H.N. Wadsworth patented the first American toothbrush
 1900 - Celluloid handles were used
 1919 - AAP defined specifications
 1938 - Nylon was first applied to toothbrush construction(doctors west’s miracle
tuft tooth brush)
 1939 - Synthetic were substituted for natural materials.
Historical perspective of toothbrush

CLASSIFICATION OF MECHANICAL PLAQUE CONTROLAIDS
i. Chewing sticks
• Neem stick
• Mango leaves
• Miswak stick.
ii. Toothbrush
Depending on type of bristle used
• Natural
• Synthetic.
Depending on the function
• Manual toothbrush
• Powered toothbrush.
• Single headed
• Double headed
• Triple headed.
Depending on diameter of bristles
• Soft
• Medium
• Hard
Depending on number of tufts present
• Space tufted
• Multitufted.

iii. Interdental aids
a. Dental floss/tape
• Twisted; Nontwisted
• Bonded; Nonbonded
• Waxed; Unwaxed
• Thick; Thin
• Floss/Knitting yarn combinations
• Monofilament floss
• Manual floss
• Powered floss.
b. Interdental brushes
• Cone shaped
• Cylindrical shapes
• Small insert with reversible handle
• Brushes with wire handle
• Single-tufted marginal
• Multitufted interdental.
c. Toothpicks
d. Wooden tips
e. Yarn
f. Perio-Aid
g. For gingival stimulation
• rubber stip stimulator.
• Basla wood wedge.
h. Tounge cleaner
Others :
• gauze strips
• Oral irrigation devices.

TOOTHBRUSHES
Objectives of tooth brushing
• To clean the teeth and interdental spaces of food remnants, debris and stains.
• To prevent plaque formation.
• To disturb and remove plaque.
• To stimulate and massage the gingival tissue.
• To clean the tongue.
Types of tooth brushes
1. Manual
2. Powered
3. Sonic and ultrasonic
4. Ionic tooth brush.

 Toothbrushes vary in size and design as well as in length, hardness and
arrangement of bristles.
According to ADA’s council on dental therapeutics.
• “the tooth brush is designed primarily to promote cleanliness of teeth and oral cavity”.
IDEAL CHARACTERISTICS
• It should confirm to individual patient requirement in size, shape and texture.
• It should be easily and effectively manipulated.
• Readily cleaned and impervious to moisture
• Durable and inexpensive.
Parts of a tooth brush
• Head, handle, tufts, brushing plane, shank, toe .
DESIGN OF TOOTH BRUSH

HEAD:
The working end of a tooth brush that holds the bristles or filaments.
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.

 Scopp et al (1976) studied a toothbrush with a concave surface and reported that
plaque levels were lower compared to conventional brush.
 Wasserman (1985) observed statistically significant reduction in plaque
accumulation after use of a deep grooved design toothbrush.
Handle:
The part grasped in the hand during tooth brushing.
 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.
 Davies et al (1988) found that under conditions of supervised brushing, tooth
brushes with long and contoured handles performed significantly better than other
designs (Short handle, not contoured).
 Kanchanakamol and Srisilapanan (1992) evaluated a newly designs “Concept 45”
tooth brush.
 Kieser & Groeneveld (1997) novel toothbrush design (Snake brush)

TOOTHBRUSH PROFILES
 When viewed from the side, toothbrushes have four basic lateral profiles: concave,
convex, flat, and multileveled rippled or scalloped.
TOOTH BRUSH
PROFILE
The concave shape with shorter
bristles in the middle of the head
could be most useful for
increased cleaning of facial tooth
surfaces.
Convex shapes with longer
bristles in the middle of the head
appear more useful for improved
cleaning of lingual surfaces.
In laboratory and clinical studies,
toothbrushes with multilevel
profiles were consistently more
effective, especially when
interproximal efficacy was
evaluated.

 Shank: It is the part that connects the head and the handle.
 Tuft: Bristles when bunched together are known as tufts.
 Bristles: Two kinds of bristle materials are used in tooth brushes:
Natural bristles from hair of hog or wild boar.
Artificial filaments made predominantly from Nylon (0.006 to 0.4 mm). In case of
interdental brush 0.075 mm.
 Bristle hardness is proportional to square of diameter and inversely proportional to
square of bristle length
 Diameter of bristle
 Ultra soft = 0.075 mm
 Soft brush = 0.2 mm
 Medium brush = 0.3 mm
 Hard brush = 0.4 mm

 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. According to the manufacturer, this is
intended to give the bristles a better contact with the areas around the adjacent
tooth surfaces.
 Criss-cross pattern
According to the manufacturer, this design can lift up plaque effectively.

 Bergenhottz et al (1969) compared the plaque removing ability of four standardized
tooth brushes that differed with respect to the stiffness and density of, their bristles
(hard and soft, multi tufted and space tufted) in a single used study in dental
students and found no significant difference.
 The logic that smooth ﬁlament tips would cause less trauma than ﬁlament tips with
sharp edges or jagged projections has been validated with both animal and clinical
studies (Breitenmoser et al. 1979).
 Beatty et al (1990) done a comparative analysis of the plaque removal ability of
0.007 inch and 0.008 inch tooth brush bristles and demonstrated favorable results
for the thinner bristles in school children.

 According to ADA the method and toothbrush choice depends on patient oral health
manual dexterity, personal preferences. ADA specification for toothbrush is as
follows,
• Length of brushing surface = 1 to 1.25 inches long(25.4-31.8mm)
• Width of brushing surface = 5/16 to 3/8 inches wide(7.9-9.5 mm)
• Rows of bristles=2-4
• Tufts per row= 5-12.
• Bristles per tuft=80-86.
Toothbrush specification

Frequency and duration of tooth brushing
 There is no consensus as to the optimum frequency of tooth brushing
 How often and how much plaque has to be removed in order to prevent dental
disease from developing is not known.
 The best estimate of actual manual brushing time seems to range between 30 and
60 seconds.
 2 min an optimum in plaque removing efficacy was reached with both manual &
electric tooth brush (Vander Weij den et al 1993)
Toothbrush wear and replacement
 It is generally recommended that toothbrushes be replaced before the first signs of
the filaments becoming worn
 The useful life of an average toothbrush has been estimated to be 2–3 months

 Not all patients take this advice, and evidence indicates that the average age at
which a toothbrush is replaced ranges from 2.5–6 months (Bergstrom 1973).
 Kreifeldt and co-workers (1980) showed that new brushes were more efﬁcient in
removing dental plaque than old brushes. They examined worn toothbrushes and
observed that, as a result of wear, the ﬁlaments showed a taper, proceeding from the
insertion to the free end
 They concluded that among other wear factors, tapering contributed the
most to loss of effectiveness.

Brushing force
 Studies have shown brushing force with powered toothbrushes to be lower than that
of a manual toothbrush(Van der Weijden et al. 1996).
 Mierau and Spindler (1984) observed that in a group of subjects without recession
the mean brushing force with a manual tooth brush was 2.12 N. Where as a group
with multiple recession had a mean force of 3.75 N.
 There is an approximately 1.0 N difference between manual and powered
toothbrushes

MANUAL TOOTHBRUSHING METHODS.
 The brushing techniques are broadly classified according to the motion of the brush
during brushing.
Horizontal:
• Scrub technique.
Vibratory:,
• Bass(sulcular) technique.
• Stillman brushing technique.
• Charters brushing technique
Vertical:
• modified bass brushing technique
• modified still man brushing technique
• Leonard brushing technique
• smith bell(physiological) brushing technique
Circular: Fones technique.

Horizontal tooth brushing
 Horizontal brushing is probably the most commonly used tooth brushing method
 It is most frequently used by individuals who never had instruction in oral hygiene
techniques
 The head of the brush is positioned perpendicular to the tooth surface and then
a horizontal back and forth movement is applied.
 This technique is known to cause excessive toothbrush abrasion

Vertical brushing (Leonard (1939) technique)
 Leonard advocated a vertical stroke in which maxillary and mandibular teeth are
brushed separately.
 Technique The bristles of the toothbrush are placed at 90° angle to the facial surface of the
teeth. With the teeth edge to edge, place the brush with the filaments against the teeth at right
angles to the long axes of the teeth.
 Advantage: Most convenient and effective for small children with deciduous teeth
 Disadvantage: Interdental spaces of the permanent teeth of adults are not properly
cleaned.

Circular brushing (Fones (1934) method)
Indication
 Young children
 Physically or emotionally handicapped individuals
 Patients who lack dexterity.
Technique
The child is asked to stretch His/her arms such that they are parallel to the floor. The child is then
asked to make big circles using the whole arm to draw circles in the air. The circles are reduced in
diameter until very small circles are made in front of the mouth. The child is now ready to make
circles on the teeth with the toothbrush, making sure that the teeth and gums are covered.
Advantages
• It is easy to learn
• Shorter time is required
Disadvantages
• Possible trauma to gingiva , Interdental areas are not properly cleaned.

Bass brushing (sulcular (1948) technique):
 It is the most widely accepted and most effective method for the removal of dental
plaque present adjacent to and directly underneath the gingival margin.
Indications:
 Particularly adaptable for open interproximal areas, cervical areas beneath the
height of contour of the enamel and exposed root surfaces.
Technique:
 The bristles are placed at a 45° angle to long axis of teeth, and bristles are gently forced into
gingival sulcus and interterproximal areas and moved in short back and forth Strokes with
vibratory action for repeated around 20 times, 3 teeth at a time.
 On the lingual aspect of the anterior teeth, the brush is inserted vertically and the heel of the
brush is pressed into the gingival sulci.

 The bristles are then activated. Occlusal surfaces are cleansed by pressing the bristles firmly
against the pits & fissures and then activating the bristle
 Studies showed that with the use of this brushing method the plaque removal could
reach a depth of approx 1 mm subgingivally (Waerhaug 1981).
Advantages
• Easy to learn .
• Provides good gingival stimulation & cleans gingival sulcus.
• Removes plaque from interdental and cervical areas.
Disadvantages
• Overzealous brushing may convert the "very short strokes" into a scrub brush technique and
cause injury to the gingival margin
• Time consuming

Vibratory technique (Stillman (1932) method):
 This technique is similar to the bass technique except that the bristles are placed
partly over the cervical portion of the teeth and partly on the adjacent gingiva.
 The brush is placed in the same manner as described for bass technique at 45angle
apically to the long axis of the teeth. The brush is activated with 20 short back-forth
strokes and is simultaneously moved in a coronal direction along the attached
gingiva, marginal gingiva and tooth surface

INDICATIONS.
 For spongy gingival tissue where massaging is valuable.
 For cleansing areas with the progressive gingival recession and root exposure to
minimize abrasive tissue destruction.
ADVANTAGES
 These technique is that it provides stimulation along with plaque and debris removal
from cervical margins of the teeth and wide embrasures.
DISADVANTAGES
 Similar to bass technique ,this technique requires patience for placing the
toothbrush in many different positions throughout the dentition.

Indications
 Individuals having open inter dental spaces with missing papilla and exposed root
surfaces.
 Those wearing fixed partial dentures or orthodontic appliances.
 For patients who had periodontal surgery.
 Patients with moderate interproximal gingival recession.
Technique
 The brush is placed at marginal gingiva and directed 45° to long axis of tooth.
 Bristles are forced into interproximal area with slight rotatory and vibratory
movement.
Vibratory technique (Charters (1948) method)

 The bristles should contact gum margins producing massaging action.
 Small circular motions with apical movement towards gingival margin.
 Occlusal surface is slightly rotatory in movements.
ADVANTAGES
 Plaque removed gently without much pressure.
 It massages gingiva & encourages healing, hence advised during post surgical
period.
DISADVANTAGES
 Poor plaque removal when indicated in routine patients.
 Brush ends don’t engage the gingival sulcus to remove subgingival bacterial
accumulation.

 This method of brushing is also known as the Rolling Stroke method or ADA method
or the Sweep method.
 It works fairly well for patients with anatomically normal gingival tissues.
INDICATIONS
 Children
 Adult patients with limited dexterity
Technique
 In this method, the bristles are placed at a 45° apically on attached gingiva and
lightly rolled against gingiva in coronal direction to blanch tissue momentarily . This
technique requires some flexibility around the wrist.
THE ROLL TECHNIQUE

Advantage
 Provides gingival stimulation.
 It is more appropriate when the patient is in normal health.
Disadvantages
 Poor plaque removal from the gingival 3rd of posterior teeth because of the counter of
the teeth.
 Poor plaque removal from the sulcus area.
 Brushing too high during initial placement can lacerate the alveolar mucosa.

Modified Bass/Stillman technique
 The Bass and Stillman methods were designed to concentrate on the cervical
portion of the teeth and adjacent gingival tissues
 Each of these methods can be modified to add a roll stroke
 The brush is positioned similarly to the Bass/Stillman technique
 After activation of the brush head in a back and forth direction
 the head of the brush is rolled over the gingiva and tooth in occlusal direction
making it possible for some of the filaments to reach interdentally

PHYSIOLOGIC METHOD-SMITH METHOD
 The physiologic method was described by Smith and advocated later by Bell. It was
based on the principle that the toothbrush should follow the physiologic pathway
that is followed by food when it travels over the tissues during mastication.
Technique
 Bristles are pointed incisally or occlusally and then moved along and over the tooth
surfaces and gingiva
 The motion is 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.

Advantages
• Natural self cleansing mechanism.
• Supragingival cleaning is good
Disadvantages
• Interdental spaces and sulcular areas of teeth are not properly cleaned.

S.No Brushing techniques comment
1. Fones technique Most recommended brushing technique in children
2. Charters technique Most recommended brushing technique after periodontal surgeries.
3. Modified Charters
technique
Most recommended brushing technique for cleaning fixed orthodontic appliances.
4. Modified Stillman
technique
Most recommended brushing technique in case of gingival recession.
5. Sulcular technique Most recommended brushing technique for patients with periodontal diseases.
6. Bass technique Most recommended brushing technique for any individual with or without
periodontal diseases
7. Bass or sulcular
technique
Most commonly recommended brushing technique
8. Modified Bass
technique
Most recommended brushing technique for sulcus cleaning.
9. Scrub technique Brushing technique which cause tooth abrasion
Striking features about tooth brushing technique

SUPER BRUSH
 Designed by Dr.Barman
 It is a triple headed manual tooth brush in which three brush heads are combined
together.
 It is designed such that when placed on the chewing surface, all the three surfaces
of tooth are cleaned simultaneously.
 Dogan M chem, et al. concluded in his study that triple headed super brush could
be an effective and cheaper alternative for use in children including disabled
individuals.
 It shortens the brushing time.

Powered toothbrush
 1886-Powered toothbrushes were first advertised in Harper's Weekly.
 Electrically powered toothbrushes designed to mimic back- and- forth brushing
technique were invented in 1939.
 1939-The prototype of the first electric toothbrush was developed in Switzerland
by Dr. Phillippe- Guy Woogin
 Rely primarily on mechanical contact between the bristles and the tooth to remove
plaque.
 1960- Squibb marketed the first Americanmade electric toothbrush called the
Broxodent.
 1961-General Electric introduced a rechargeable cordless toothbrush

 These newer designed toothbrushes remove plaque in a shorter time than a
standard manual brush (Van der Weijden et al. 1993).
 The new generation of electric brushes have better plaque removal efﬁcacy and
gingival inﬂammation control in the approximal tooth surfaces (Egelberg & Claffey
1998)
 Studies have shown the three-dimensional movements carried out by the brush are
safe to use and more efficient regarding plaque removal (Danser et al. 1998)
 Toothbrushes with this mode of action reduced plaque by 7% and gingival bleeding
by 17% when compared with manual brushes (Robinson et al. 2005)

Design and Mode of Action
 Generally, the brush heads of powered toothbrushes tend to be more compact than
those of conventional, manual brushes.
 The bundles of bristles are arranged in either in rows or in a circular pattern
mounted in a round head.
 Bristles are also arranged as more compact single tufts which facilitate interproximal
cleaning and brushing in less accessible area of the mouth.
 The traditional designs of head, operate with a conventional side-to-side, arcuate
or back and forth motions where as circular brush heads have oscillating, rotational
or counter-rotational movements.

 Reciprocating – more back and forth in a line.
 Arcuate – filament ends follow an arc as they move up and down.
 Orbital - circular
 Vibratory
 Elliptical – oval
 Dual motion – more than one of the previous motions mentioned
Speed
 Speed varies from low to high among the different models.
 The number of strokes/min varies from 1000 cycles/min for a replaceable battery
type to about 3600 oscillations/min for an arcuate model.
 The rechargeable battery types operate at approximately 2000 complete cycles/min.
Types of motion

Ideal characteristics for powered toothbrush: (Heasman 1998)
 An active brush tip to facilitate plaque control around posterior teeth and at inter
dental sites.
 An orthodontic head for brushing around and beneath the components of fixed
orthodontic appliances.
 Rotating / spiraling filaments for inter proximal cleaning.
INDICATIONS
1. Children
2. Handicapped patients
3. Hospitalized patients
4. Patients with orthodontic appliances
5. Preference of patient
6. Patients lacking fine motor skills.

Sonic Powered toothbrush
 These types of toothbrushes produce high frequency vibrations (1.6MHz)which
leads to the phenomenon of cavitation and acoustic microstreaming
 This phenomenon aids in stain removal as well as disruption of the bacterial cell
wall (bactericidal).

Electrically active (ionic) toothbrush
 Ionic toothbrush works on the principle of polarity that every element in nature has a
positive or a negative charge.
 It works on the principle of changing surface charge of tooth to repel plaque even
from inaccessible areas of teeth.

 The bonding between the pellicles and bacteria is mediated by Ca2+ bridge
formation.
 The anions supplied by the lithium battery inhibits the bonding between the bacteria
and Ca2+ and prevents the bacteria from adsorbing to the pellicles.
 Hence, the plaque accumulation is reduced because the anions continuously
supplied from the tips of the bristles of the ionic toothbrushes prevent the mild
electrostatic bonding between the bacteria itself.
 Deshmukh et al. in 2006 conducted a clinical study to evaluate the effectiveness of
an ionic toothbrush on oral hygiene status. There was a significant reduction in
plaque index and gingival index scores as well as there was no soft-tissue trauma
following the use of ionic toothbrushes.

NOVEL TOOTHBRUSHES
Ultrasonic toothbrushes
• The ultrasonic toothbrush is a manual toothbrush, in which a Piezoelectric
ultrasonic emitter is embedded in the brush head.
• The ultrasonic emitter is driven by a power supply located in the handle that
operates at 1.6 MHz.
• The plaque destroying power of ultrasound and the deep, gentle cleansing wave
action of sonic vibration penetrate the gumline to a depth of 5 mm.
• This results in the destruction of the periodontal pathogen.
• Emmi-dent is the first ultrasonic toothbrush that was provided with its nonabrasive
nano-bubble toothpaste. It worked motionlessly

Ultraviolet-sterilized toothbrush system
 The ultraviolet (UV), sterilized toothbrush system concept, is helpful for those who
have habit of keeping everything clear and germ-free. On an average, 10,000,000
bacteria live on a toothbrush.
 In the UV-sterilized toothbrush system, UV base help to sterilize the toothbrush
whenever it is placed and can hold up to a quartet of UV pods to keep a small
family`s toothbrushes safe and bacteria free whenever they are not in use.
Toothbrushes have color-coding.
 the use of UV light can be considered as the most effective household method to
sanitize the toothbrushes after contamination.

Laser toothbrushses
 Dentinal hypersensitivity is one of the most common complications that affect
patients both in day-to-day life as well as after periodontal therapy.
 Laser toothbrushes are an improved version of the modern toothbrush that emits red
(635 nm) light in the visible spectrum produced by a diode laser inside the
toothbrush powered with an AA battery

 The LLLT with the help of such toothbrushes help to reduce dentinal
hypersensitivity.
 Another advantage of using laser in toothbrush is that the patient can use it at
home, which is cost-effective, less time-consuming and easily used by patients.
 Ko et al. in 2014 and Yaghini et al. in 2015 tested the efficacy and the safety of a
low-level laser-emitting toothbrush on the management of dentinal hypersensitivity
and concluded that the use of the low-level laser-emitting toothbrush is a safe and
effective treatment option for the management of dentinal hypersensitivity.

Chewable toothbrush
 It is a miniature plastic molded toothbrush that can be used when no water is
available.
 should not be swallowed and should be disposed of after use composed of xylitol,
flavoring aqua, and polydextrose.. These brushes should be used between the teeth,
to swivel from left to right and then, the tongue need to be used to move the brush
around the mouth similar to the way one would use chewing gum.
 Myoken et al. in 2005 investigated the effectiveness of the chewable toothbrush in
a care-dependent elderly population and concluded that chewing the brush results
in the removal of a significant amount of plaque.

Tooth towelettes
 Tooth towelettes are being marketed as a method of plaque removal
when tooth brushing is not possible.
 Their use is not meant to replace a daily tooth brushing regimen.
 Finger brushes are mounted on the index finger of the brushing
hand, and the agility and sensitivity of the finger are used to clean
the teeth.
 Consequently, the pressure with which they are applied can be well
controlled because the finger can actually feel the tooth and gingival
surfaces and helps in positioning the brush for more effective
scrubbing.
 However, the plaque removal efficacy of such brushes, in particular
proximal plaque reduction is less than a regular manual toothbrush.

 Foam brushes resemble a disposable soft sponge soaked in chlorhexidine on a stick.
 They have been dispensed to hospital patients for intraoral cleansing and refreshing
since the 1970s.
 They are used in particular for oral care in medically compromised and
immunocompromised patients to reduce the risk of oral and systemic infection.
Foam brushes

 The beam brush is first application connected toothbrush with a sensor embedded to
record & map brushing behavior as a saved data which can be used in a personnel
management, clinical & gamification environment.
 It was launched in 2010 & its advanced version came in 2012 from beam
technologies.
 Beam brush can collect up to 3 weeks brushing data & upload it wirelessly on
android mobile that can be sent or shared with the dentist or can be recorded for
subjects own regular check purpose.
 Along with tracking record for oral health it use all active two-minute brushing with
quadrant indicator which is helpful in oral health information
Beam Toothbrush

 Toothbrush for Earlier Dental Caries Detection C-SMART, an improved version of the
modern toothbrush that will be able to tell the users whether they have caries
developing on their teeth.
 To detect the caries, C-SMART uses laser technology that collects reflected light from
the caries that is sent to a microcomputer chip in the toothbrush handle.
 This toothbrush is under experimentation & still has to be launched by C SMART
company.
Caries Detection toothbrush : C-SMART:

INTERDENTAL CLEANING AIDS
(INTERPROXIMAL CLEANING AIDS/INTER DENTAL
PHYSIOTHERAPY AIDS)
 The toothbrush does not reach the approximal surfaces of teeth as efficiently as it
does for the facial, lingual, and ooclusal aspects nor does it reach into the
interproximal area between adjacent teeth
 Among the numerous aids available, dental floss and interdental cleansers such as
wooden or plastic tips and interdental brushes are most commonly recommended.

 The use of dental floss, interproximal brushes, and woodsticks may also induce soft
tissue damage
 In most cases, however, this damage is limited to acute lesions, such as lacerations
and gingival erosions (Gillette & Van House 1980)
 Gingival bleeding during interdental cleaning can be a result of trauma or an
indication of inflammation.
INDICATION
 Type of gingival embrasure
 Alignment of teeth
 Fixed prosthesis / orthodontic appliances
 Open furcation areas
 Contact areas.
 After periodontal therapy

Factors determining the selection of interdental aids are the type of embrasures
• Type 1: The interdental papilla fills up the embrasure. Dental floss is advised
• Type 2: Moderate papillary recession is seen in such situations, miniature interdental brushes
and wood tips are recommended.
• Type 3: Where there is complete loss of papilla and interdental gingiva is tightly bound to
underlying bone (seen in diastema). Unitufted brushes are recommended.

Dental floss and tape
• Of all the methods used for removing interproximal plaque, dental flossing is the
most frequently recommended technique
• Levi Spear Parmly, a dentist based in New Orleans, is credited as being the inventor
of modern dental floss.
• Nylon based dental floss was developed by Dr. Charles c bass in 1940.
• In 1950 dental tape was developed.
• Various type of dental floss available currently which include,
a) Waxed and unwaxed
b) Teflon floss
c) Thread floss
d) Flavoured floss and unflavoured floss.
e) Tape floss.

 clinical research has demonstrated no significant differences in the ability of the
various types of floss to remove dental plaque ; they all work equally well (Hill
HC et al. 1973 )
 Recently, powered flossing devices have been introduced.
 They consist of battery operated nylon tip that slip easily between teeth and is
very gentle to the gums.

 They are very effective in cases of patients wearing orthodontic appliances.
 Shibly et al. in 2001 conducted a study comparing powered flossing device
(Waterpik power floss®) with that of manual dental floss. From the study, they
concluded that in case of oral hygiene maintenance powered floss are equally
effective as manual floss.

 To facilitate flossing a special floss holder may be used
 The holder may be re-used and is normally made of plastic material, durable,
lightweight, and easily cleaned
 Research reveals that reductions in bacterial plaque biofilm and gingivitis are
equivalent with either the use of a hand flossing or flossholder.

Technique of using dental floss
The two methods for holding the floss are,
1. The spool method
 It is recommended for teenagers and adults who have
acquired the required the level of neuromuscular coordination
and mental maturity to use floss correctly
 Break off about 18 inches of floss and wind most of it around
your middle finger. Wind the rest of the floss similarly around
the middle finger of your other hand.
 Move the floss between your teeth with your index fingers and thumbs.
 Maneuver the floss up and down several times forming a “C” shape around the tooth.
 While doing this, make sure you go below the gum line, where bacteria are known to
collect heavily.

2. The circle or loop method
 The loop method is often effective for children or
adults with dexterity problems like arthritis.
 Break off about 18 inches of floss and form it into a
circle.
 Tie it securely with two or three knots.
 Place all of your fingers, except the thumb, within
the loop.
 Use your index fingers to guide the floss through
your lower teeth, and use your thumbs to guide the
floss through the upper teeth, going below the gum
line and forming a “C” on the side of the tooth.

 Picking teeth may be one of humanity’s oldest habits and the toothpick one of
the earliest tools.
 In 1872, Silas Noble and J.P. Cooley patented the first toothpick-manufacturing
machine.
 The key difference between a toothpick and a wood stick (wooden
stimulator/cleaner) relates to the triangular (wedge-like) design
Woodsticks

 Wood sticks are inserted interdentally with the base of the triangle resting on the
gingival side
 The tip should point occlusally or incisally and the triangles against the adjacent
tooth surfaces
 Triangular wedge-like wood sticks have been found to be superior in plaque
removal when compared with round or rectangluar wood sticks since they fit the
interdental area more snugly (Bergenholtz et al. 1980; Mandel 1990).
 Unlike floss they can be used on the concave surfaces of the tooth root.

 Interdental brushes were introduced in the 1960s as an alternative to woodsticks
 They are effective in the removal of plaque from the proximal tooth surfaces
(Bergenholtz & Olsson 1984)
 The interdental brush consists of soft nylon filaments twisted into a fine stainless
steel wire
 This ‘metal’ wire can prove uncomfortable for patients with sensitive root surfaces.
 Interdental brushes represent the ideal interdental cleaning tool, especially for
periodontitis patients.
 Waerhaug (1976) showed that individuals who habitually used an interdental
brush were able to maintain supragingival proximal surfaces free of plaque and to
remove some subgingival plaque below the gingival margin.
Interdental brushes

 These are designed with smaller brush heads that have a small
group of tufts or a single tuft.
 The tuft may be 3–6 mm in diameter and can be flat or tapered
 The handle can be straight or contra-angled
 Angulated handles permit easier access to lingual and palatal
aspects
 The filaments are directed into the area to be cleaned and activated
with a rotating motion.
 These are designed to improve access to distal surfaces of posterior
molars, tipped, rotated or displaced teeth, to clean around and
under fixed partial dentures ,pontic, orthodontic appliances, or
precision attachment, and to clean teeth affected by gingival
recession and irregular gingival margin or furcation involvement.
Single-tufted/end-tufted brush

Technique
 Always use the interdental brush without toothpaste.
 Hold the interdental brush just behind the bristles between
the thumb and forefinger. Support can be achieved when
necessary by placing your other fingers on your chin.
 From the outer side of the space, push the interdental brush
carefully between the teeth, taking care that the brush
remains at a right angle to the teeth.
 You may bend the interdental brush slightly to improve
accessibility to the posterior interdental spaces.
 Slide the brush in and out of the space using the full length of
the bristle part of the brush. This action will remove the
dental plaque.

Adjunctive aids
Dental water jet
 A dental water jet or water flosser or oral irrigator (OI) is an
electric device that delivers a pulsating stream of fluid
through controlled pressure which is aimed at the removal of
interdental and subgingival plaque biofilm on tooth surfaces
to reduce inflammation as an adjunct to tooth brushing.
 The devices may be power or nonpower driven and depending
on the type of application; they are designed for both
professional as well as patient applied home irrigation.

 The two main physical features of water bossing action include pulsation and
pressure.
 A combination of these two actions causes disruption of bacterial activity, expulsion
of subgingival bacteria, and the removal of loosely lodged debris and food particles.
 Waterpik® oral irrigation device is one of such devices consisting of a reservoir and
a handle with replaceable tips.
 The tip design varies according to the purpose for which they are being used.

Tongue cleaners
 The dorsum of the tongue, with its papillary structure and
furrows, harbors a great number of microorganism
 It forms a unique ecologic oral site with a large
surface area (Danser et al. 2003).
 The tongue bacteria may serve as a sourceof
bacterial dissemination to other parts of the oral
cavity,e.g. thetooth surfaces and may contribute to
dental plaque formation.
 Therefore, tongue brushing has been advocated as part of daily
home oral hygiene together with the tooth brushing and flossing
(Christen & Swanson 1978).

 Extend the tongue as far as possible out of mouth.
 Breath calmly through nose.
 Place the cleaner as far as possible on the back of the tongue
and press lightly with it so that the tongue becomes flattened.
 Ensure full contact of the tongue with tongue cleaner.
 Pull the tongue cleaner slowly forward
 Clean the middle part of the tongue first using the raised edge on
one side of the instrument
 Use the smooth surface of the tongue cleaner on the sides of
tongue
 Repeat these scraping movements a number of time
 Rinse the mouth several times

It is an effective aid for cleaning the proximal surfaces of teeth specially adjacent to
edentulous areas.
Technique
It is used by positioning the gauze edge length wise with the folds towards the gingiva.
Any loose ends are folded inwards to avoid gingival irritation. Gauze is adapted by
wrapping it around the exposed proximal surface to the facial and lingual line angles of
the tooth. A facial-lingual ‘shoeshine’ stroke is used to loosen plaque and debris.
Indications
1. Type III embrasures.
2. Diastemas.
3. Teeth adjacent to edentulous areas.
4. Implant abutments.
Disadvantage
The patient may damage an appliance while removing stuck
gauze.
GAUZE STRIP

 It consists of a conical, flexible, rubber or plastic tip attached to a handle or to the
end of a toothbrush.
 Rubber or plastic tips are recommended for gingival stimulation and for plaque
removal in open embrasures.
 When using these devices for plaque removal, the tip is placed at a 90° angle in the
interdental area next to the gingival margin.
 The tip is then moved with a sweeping motion from the gingival margin toward the
incisal edges or moved from buccal to lingual using short back and forth strokes.
 Patients should be careful not to traumatize the tissue with the tip.
Rubber Tip Stimulator

Indications
1. Type II and Type III embrasures.
2. Reshape or recontour the gingiva following periodontal surgery
3. Exposed furcations.
4. To increase epithelial keratinization of the interdental tissue.
Contraindications
1. Type I embrasures.
2. Healthy gingiva.
Disadvantage
1. It can cause tissue trauma specially when used with excessive
pressure

Disclosing agents are materials used to make the presence of plaque biofilm visible.
 Since dental plaque is white, it cannot easily be identified particularly if it is not
thick enough.
 They are available in liquid or tablet form.
 Pellicle, plaque, debris and calculus absorb the disclosing agent.
DISCLOSING AGENTS
Ideal requirement of a disclosing agent:
1. It should distinctly stain only the plaque.
2. It should have a pleasant taste.
3. It should be biocompatible.
4. Preferably it should stain new and old plaque in different colors for identification.
5. The color should remain in the plaque for about 15-30 minutes (instruction period)
and should not be removed by saliva.
6. It should have antiseptic and astringent properties

A. Iodine solutions
B. Erythrosine
C. Basic fuchsin
D. Fast green — FD&C Green No-2.5 percent or 3.5 percent
E. Bismark Brown
F. Mercurchrome preparations
1. Mercurochrome solution (5%)
2. Flavored mercurochrome disclosing solution
G. Merbromin
H. Fluorescein FD&C Yellow No 8.
I. 1-3 Tetrazolium compound with methylene blue.
J. 2-Tone----FD&C Green No 3 & FD&C Red No 3 FD&C — Food Drug and Cosmetic
Chemicals Used as Disclosing Agents

Interpretation
• Clean tooth surfaces do not absorb any colouring agent.
• When pellicle and dental biofilm are present they absorb the disclosing agent and
become stained.
• Pellicle stains as a thin relatively clear layer and dental biofilm appears darker,
thicker and more opaque.
2-Tone disclosing solution stains:
• Red—newly formed biofilm usually supragingival and is thin.
• Blue—older biofilm which is thicker and more tenacious usually seen at and just
below the gingival margin, specially on proximal surfaces. It may be associated with
calculus deposit.

Uses
1. Patient instruction and motivation.
2. Self evaluation.
3. To carry out plaque index.
4. To evaluate the effectiveness of oral hygiene maintenance.
5. In research, to evaluate the effectiveness of plaque control devices like dentifrices,
toothbrushes, etc.
Contraindications
1. Should not be used on teeth with glass ionomer and resin filling to prevent the
staining of these filling.
2. Should not be used in patients with known allergy to any type of disclosing agent.

 Chemical plaque control agents have proven to be an ideal adjunct to mechanical
plaque control procedures.
 Approaches to chemical supragingival plaque control
 Anti-adhesive.
 Antimicrobial.
 Plaque removal.
 Antipathogenic
Addy and moran 1997
CHEMICAL PLAQUE CONTROL

Anti-adhesive.
 Act at the pellicle surface to prevent the initial attachment of primary plaque forming
bacteria.
 Unfortunately the chemicals in such application are either too toxic for oral use or
ineffective against dental bacteria.
 Amine alcohol and delmopinol fits somewhere between the concepts of
antiadhesion and plaque control. (Collaert et al 1992; Claydon et al 1996)
 inhibition of bacterial attachment and bacterial proliferation/division.
 Destroys all of the microorganisms either attaching or already attached to the tooth
surface
Antimicrobial.

 Agents expected to remove plaque deposits.
 Likely to be toxic
 Nearest success is the enzyme proteases directed at pellicle and dextranase and
mutanase at bacterial matrices (kornman 1986)
Plaque removal Agents.
 agent could have an effect on plaque microorganisms, which might inhibit the
expression of their pathogencity without necessarily destroying the microorganisms
(Cummins 1992)
 I.e. alter the pathogeniticity of plaque.
Anti pathogenic agents

Should decrease plaque & gingivitis
Prevent pathogenic growth
Should prevent development of resistant bacteria
Should be biocompatible
Should not stain teeth or alter taste
Should have good retentive properties
Should be economic and easy to use , Inhibit calcification of plaque to calculus.
Ideal requisites
 The features of the ideal chemical agent for plaque control have been proposed by
different authors (Loesche 1976; van der Ouderaa 1991; Baker 1993; Fischman
1994):

CLASSIFICATION OF CHEMICAL PLAQUE CONTROL AGENTS:
Chemical agents are classified according to their substantivity.
{Kormann (1986)}
• capable of reducing plaque scores by about 20-50%.
• Exhibits poor retention within mouth.
• Ex: antibiotics ; phenols ; quaternary ammonium compounds and sanguanarine.
First Generation
• Produce an overall plaque reduction of around 70-90%
• Are better retained by the oral tissues
• Exhibit slow release properties.
• Ex: bisbiguanides [Chlorhexidine(CHX)]
Second Generation
• They block binding of m/o to tooth or to eachother.
• Compared to CHX , they do not exhibit good retentive properties.
• Ex: delmopinol .
Third Generation

ON THE BASIS OF CHEMICAL COMPOSITION
Essentials of preventive and community dentistry -soben peter IV edition

Classification by (Mandel)
A. Antiplaque enzymes Amyloglucosidase, glucose oxidase, dextranase, fungal
enzymes, mucinase, mutanase, pancreatin, proteinase-amylase, zendium
B. Plaque – modifying agents Ascoxal (astra zeneca), urea peroxide
Based on chemical composition
a Cationic
b Anionic
c Nonionic
d Other combinations

Phenols & essential oils.
 It is a combination of phenol related essential oils,
thymol ,eucalyptol, menthol and methylsalicylate in
hydro alcoholic base.
 Listerine is an essential oil/phenolic mouthwash which
has been shown to have moderate plaque inhibitory
effects and some anti-gingivitis effects.
 It has poor oral retention.
 MOA: cell wall disruption & inhibition of bacterial
enzymes.
 Anti inflammatory property
FIRST GENERATION CHEMICAL PLAQUE CONTROLAGENTS.

 Side effects include burning sensation, bitter taste and staining.
 Lamster et al (1983) reported that twice daily supervised rinsing with listerine
resulted in22.2% in plaque and 28.2% reduction in gingivitis when compared with
placebo.
 Fine et al (1985) demonstrated a 50% to 60% plaque reduction with essential oils in
combination with regular oral hygiene as compared to placebo rinses.
 However , when compared with CHX, essential oils are less efficacious in plaque
reduction.

METAL SALTS
 A number of metal ions have been studied for their effects on plaque.
 zinc, copper and tin, have been shown to possess plaque inhibitory activity.
 Both copper and tin suffer from the local side effect of staining.
 Some fluoride compounds such as stannous fluoride and amine fluorides also have
plaque inhibitory activity.
 zinc when combined with hexetidine, triclosan, and sanguinarine show additive or
synergistic effect.

 zinc may assist the inhibition of glycolysis by sanguinarine which could in turn
limit plaque formation.
 Gilbert and ingramm (1988) in one study showed that after brushing with 1gm
toothpaste containing zinc, 38% of zinc was retained in the oral tissues. Also
increased levels of zinc were observed in bacterial plaque and saliva.

NATURAL PRODUCTS
 These include Sanguinaria extract, propolis, chamomile, sage, myrrh, echinacea,
rhatany and peppermint oil.
Sanguinarine:
 It is a benzophenanthridine alkaloid, which is derived from the plant Sanguinaria
Canadensis.
 It exhibits good retentive properties when used as a mouth rinse.

 It contains the chemically reactive iminium ion which is probably responsible for its
activity.
 The activity of sanguinarine is attributed to its ability to interfere with bacterial
glycolysis and bind to plaque to prevent adherence of microorganisms.
 It has been demonstrated that its concentration of 16 μg/ml completely inhibited
98% of microbial isolates from human dental plaque.
 It is retained in plaque several hours after its application in oral cavity which
accounts for its substantivity.
 when compared to CHX, it has been found less efficient in plaque and gingivitis
reduction.

Propolis
 Propolis is a naturally occurring bee product used by bees to seal
openings in their hives.
 It mainly consists of wax and plant extracts and contains flavones,
flavanones and flavanols.
 The most effective flavonoid agents against bacteria are galangin,
pinocembrin, and pinostrobin. Other chemicals in propolis which
contribute to its antibacterial action are ferulic acid and caffeic
acid.
 It has been used in homoeopathic remedies as an antiseptic, anti-
inflammatory, antimycotic and bacteriostatic agent, and because of
these properties it has been suggested as a constituent of a plaque
inhibitory mouthwash.

 Fluorides primarily have anticaries action.
 MOA: it interference with bacterial biochemical synthesis,
metabolism and aggregation.
 0.04 percent concentration is the most effective.
 However, snf2 and amine fluoride demonstrate plaque
inhibitory activity, particularly when they are combined
together.
 Short term studies have shown a significant reduction in
plaque and gingival inflammation with the use of SNF2 mouth
rinse.
 When compared with CHX they show less inhibitory effects
against plaque and gingivitis.
FLUORIDES

ANTIBIOTICS AND ANTIMICROBIALS
 The primary etiology of periodontal diseases is microbial.
 For this reason, the systemic and local use of antibiotics and antimicrobial agents
has been used.
 They are not indicated for plaque and gingivitis, but they may be used as adjuncts in
the treatment of other periodontal diseses.
 Antibiotics such as Vancomycin, Erythromycin, Niddamycin and Kanamycin
have been used as agents for plaque control.
 However, the side effects of these antibiotics and antimicrobials are of great concern
when they are used for long term. Even when they are used locally, few side effects
can be seen. Most important side effect is the development of ANTIBIOTIC-
RESISITANT BACTERIA such as methicillin-resistant staphylococcus aureus
may cause serious life threatening infections.

QUATERNARY AMMONIUM COMPOUNDS
 Quaternary ammonium compounds such as cetyl pyridinium
chloride (CPC) have moderate plaque inhibitory activity.
 Although they have greater initial oral retention and equivalent
antibacterial activity to chlorhexidine, they are less effective in
inhibiting plaque and preventing gingivitis.
 It has also been found that the antibacterial properties of these
compounds are considerably reduced once adsorbed onto a surface
and this may be related to the monocationic nature of these
compounds.
 A CPC pre-brushing mouthrinse used as an adjunct to mechanical
oral hygiene has not been found to have an additional beneficial
effect on plaque accumulation.

 A slow release system containing CPC has been tried to increase the retention time
for CPC in the mouth. The plaque inhibitory effect over 18 days of this device was
compared with that of a CPC mouthrinse, CPC lozenges (Cepacol) and a
chlorhexidine mouthrinse (Peridex). As expected, the chlorhexidine mouthrinse
(Peridex) had the most profound effects and these were not approached by the other
formulations. However, there were no differences between any of the CPC
formulations which showed that the slow release system had no effect on the efficacy
of CPC.
 The side effects of Quaternary ammonium compounds as mouth rinse include tooth
staining, mucosal ulceration and discomfort.

 Oxygenating agents such as H2O2 , buffered sodium peroxyborate and
peroxycarbonate in mouthrinses have a beneficial effect on acute ulcerative
gingivitis, probably by inhibiting anaerobic bacteria.
 As obligate anaerobes are important in the development of gingivitis and
periodontitis, these effects could be useful.
 H2O2 has been used for long time for cleaning the oral tissues, but its use an
antiplaque or anti gingivitis agent is limited. Problem with H2O2 is that it is unstable
and difficult to formulate and store in concentration acceptable foe human use(<3%).
 H2O2 in a concentration of 3% tends to increase the tissue injury in existing wounds
and delays wound healing , which raises its safety concern.
 The concentration of less than 3% of H2O2 efficacy in plaque and gingival
inflammation reduction is less as compared to CHX.
Oxygenating agents

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.
Enzymes used for antiplaque activity can be divided into
two categories.
 Enzymes that disrupt the early plaque matrix.
 Enzymes that enhances the host defence mechanisam.
ENZYMES

 First group contain:- dextranase, mutanase and other proteases which disrupt the
plaque matrix.
 In late 1960 and early1970 the enzymes were analyzed for their anti-plaque action.
However their poor substantivity and local side effects such as mucosal erosion,
limited their usage.
 Second group of enzymes include glucose oxidase and amylglucosidase that act to
enhance the host defense system by catalyzing the synthesis of hypothiocyanite from
thiocyanate through the salivary lactoperoxidase system.
 The hypothiocyanite has an inhibitory effect on bacterial metabolism, thus exerting
its antibacterial action.

 Sodium lauryl sulfate (SLS) is most common component of
tooth paste and mouth rinse products.
 Because of its detergent action ,SLS exerts antimicrobial
action by acting on the bacterial cell membrane.
 SLS has moderate substantivity between 5 to 7 hours in
oral cavity almost similar to triclosan.
SURFACTANTS/DETERGENTS

SECOND GENERATION CHEMICAL PLAQUE CONTROL AGENTS
Bisbiguanide
 Bisbiguanide are a class od chemically related organic compounds which are known
for their bactericidal properties.
 These group contain agents like chlorhexidine, alexidine and octenidine.
 CHX is presently the most widely used antiplaque and antigingivitis agent.
CHLORHEXIDINE
 The digluconate of chlorhexidine (1:6-Di 4'-chlorophenyl-diguanidohexane) is a
synthetic antimicrobial drug which has been widely used as a broad spectrum
antiseptic.
 As an antimicrobrial agent, chlorhexidine is effective in vitro against both Gram-
positive and Gram-negative bacteria including aerobes and anaerobes and yeasts
and fungi.
 Although it is not considered as virucidal, such as HIV, herpes 1 and 2, influenza A .

 Chlorhexidine was developed in the 1940’s by Imperial Chemical Industries in
England.
 In the year 1954, it was marketed as an antiseptic for skin wounds
 In dentistry, it was initially used for presurgical disinfection of the mouth and in
endodontics.
 Schroeder in 1969, investigated plaque inhibition property of chlorhexidine for the
first time.
 A definitive study of chlorhexidine on development of dental plaque was first
performed by Loe and Schiott in 1970’s.
 First study , which evaluated the application CHX mouthrinse with toothbrushing
was carried out by FLOTRA et al in 1972 , on group of soldiers for a period of 4
months and they reported 66% reduction in plaque and 24% reduction in gingivitis.
History

 Chlorhexidine is available in three forms like digluconate,
acetate, and hydrochloride.
 It is a bisbiguanide antiseptic consisting of 4 chlorophenyl
rings and 2 biguanide groups connected by a central
hexamethylene bridge.
 The compound is a strong base and its pH is 3.5.
 Being a dicationic in nature with two positive charges on
either side of hexamethylene bridge, it is extremely
interactive with anions.
Structure of Chlorhexidine

MECHANISM OF ACTION
 Chlorhexidine is a potent antibacterial agent.
 At low concentration, it acts as a bacteriostatic, by altering the osmotic balance of
the bacterial cell which leads to increased permeability with leakage of intracellular
component like potassium.
 It also acts as a bactericidal when used at high concentration, causing precipitation
of cytoplasm and cell death.

A Textbook of Public Health Dentistry by CM Marya

Antiplaque Action Of Chlorhexidine:-
Rolla and Melsen (1997) postulated that Chlorhexidine inhibited
plaque formation in the following ways:
1. It influences the adsorption of plaque onto the tooth surface by
binding to the bacteria in sub-lethal amounts.
2. It influences pellicle formation by blocking the acidic groups on the
salivary glycoprotein, thus reducing the protein adsorption on the
tooth surface.
3. It also influences the formation of plaque by precipitating the
agglutination factors in saliva and displacing calcium from the plaque
matrix.

Mouthrinses:
 It is now available in 0.2% and 0.12% concentrations.
 Approximately 30% of the drug is retained back in the oral
cavity after rinsing with 10 ml of 0.2% aqueous solution of
chlorhexidine for 1 min.
 Saliva itself exhibits antibacterial activity upto 5 hrs after
single rinse with chlorhexidine. whereas persistence at the oral
mucosal surfaces has been shown to suppress salivary
bacterial counts for over 12 hours.
 The ideal regimen is twice daily (morning and night) which will
have a substantivity for 12 hours.
 The studies revealed equal efficacy for 0.2% and 0.12% rinses
when used at appropriate similar doses (Segreto et al. 1986).
Different Forms of Chlorhexidine

Gel:
 1%, 0.2%, 0.12% chlorhexidine gels are available.
 It can be delivered onto the tooth brush or in a tray.
 In trays the chlorhexidine gel was found to be particularly
effective against plaque and gingivitis in handicapped
individuals (Francis et al. 1987).
 Chlorhexidine gel has therapeutic effects, like reducing oral
malodour and also reduces chlorhexidine staining.
Sprays:
 0.1% and 0.2% chlorhexidine sprays are commercially available.
 0.2% of chlorhexidine spray delivered 1-2 mg of chlorhexidine to
all tooth surfaces have similar plaque inhibition properties as
that of 0.2% mouthwash. (Kalaga et al. 1989).
 It has been demonstrated to be well received by physically and
mentally handicapped patients. (Francis et al. 1987,Kalaga et
al. 1989).

Toothpastes:
 It is difficult to formulate chlorhexidine into a tooth paste
form because of its bicationic nature which reacts with
anionic substances in the tooth paste like sodium lauryl
sulphate and compete for retention on the tooth surface.
 1% chlorhexidine tooth paste with or without fluoride was
found to be superior to control paste for prevention of
plaque and gingivitis as compared to other products in a
6 months home based study. (Yates et al. 1993).
Varnishes:
 Chlorhexidine varnishes are used for prophylaxis against
root caries but could potentially be used as an anti
plaque agent too.

Periochip:
 It is a 5×4×0.3 mm film that contains 2.5mg of chlorhexidine gluconate which is
incorporated in a biodegradable matrix of hydrolyzed gelatine cross linked with
glutaraldehyde.
 It is a controlled subgingival delivery device.
 Tooth with probing pocket depth of > 5mm are selected for the placement of chip.
The area is dried and chip is inserted into periodontal pocket with tweezers, after
thorough scaling and root planing.
 The area is protected with periodontal pack. After seven days, patients are recalled
for pack removal

 It is as an adjunct to oral hygiene and professional prophylaxis.
 Post oral surgery and periodontal surgery/ root planing.
 In physically and mentally handicapped patients, chlorhexidine sprays can be used.
 Medically compromised patients who are predisposed to oral infections
 Management of denture stomatitis,
 Recurrent oral ulceration
 Patients with high risk caries
 Subgingival irrigation
 Patients undergoing orthodontic treatment.[Shaw et al 1984]
 Oral malodour
 For surgical skin preparation
Clinical uses of chlorhexidine

1. Brown discoloration of the teeth and some restorative materials and the dorsum of
the tongue.
2. Taste perturbation where the salt taste appears to be preferentially affected (Lang et
al. 1988) to leave food and drinks with a rather bland taste.
3. Oral mucosal erosion.
4. Stenosis of the parotid duct
5. Rarely hypersensitivity
• This appears to be an idiosyncratic reaction and concentration proteins on
to the tooth surface, thereby increasing pellicle thickness and/or precipitation of
inorganic salts on to or into the pellicle layer.
• Chlorhexidine also has a bitter taste, which is difficult to mask completely
side effects of CHX

Chlorhexidine staining
• The mechanisms proposed for chlorhexidine staining can be debated (Eriksen et al.
1985; for reviews see Addy & Moran 1995; Watts & Addy 2001) but have been
proposed as:
Degradation of the chlorhexidine molecule to release parachloraniline.
 Catalysis of Maillard reactions
 Protein denaturation with metal sulfide formation
 Precipitation of anionic dietary chromogens.

Anti-discoloration system (ADS) was launched=Europe
The possibility of reducing and / eliminating pigmentation associated with the use of
chx based products by adding antioxidants such as essential oils , peroxyborate ,
polyvinypyrolidine , sodium metabisulphite or ascorbic acid by interrupting the
maillard reaction and interfering with the pigmentation reaction comes from the
reduction of Fe III to Fe II thereby avoiding the reaction between Fe III and SH groups.
 A clinical study supporting to show reduced staining had significant drawbacks in
design and presentation (Bernadi et al. 2004).
 A laboratory study found no difference in staining potential (Addy et al. 2005)
 plaque regrowth study showed significantly reduced plaque inhibition for the ADS
rinse (Arweiler et al. 2006).

 After the use of chlorhexidine mouthwash the intake of tea, coffee and red wine must
be avoided.
 The usage is restricted in cases of anterior composite restorations and glass ionomer
restorations.
 There should be a 30 minute lapse between the usage of a dentifrice and
chlorhexidine mouth wash.
 It is so advised because the toothpastes contain detergents which are predominantly
anionic agents.
 Chlorhexidine molecule being dicationic tends to bind with the anionic agents
leading to a reduction in the substantivity of chlorhexidine mouthrinse.
DEACTIVATION

Russel AD 1986 [23] Shown lower risk of developing gingivitis
Geossman et al 1986, Gunsolley JC
2006
Improved plaque index
Loe and schiott 1970 Complete plaque elimination
Vandana K L 2010 compared the ozonated water and 0.2%
chlorhexidine in
treatment of periodontitis and concluded that
ozone is an
alternative management strategy due to its
powerful
ability to inactivate microorganisms.
Cristina Trigo Cabral etal 2007 On osteoblasts,CHX has a higher cytotoxicity
delay in wound healing
Flemingson etal 2008 On gingival fibroblasts, Chx higher cytotoxicity
delay in wound healing
Studies on mouthrinses
Nazam Lakhani. Chlorhexidine – An Insight. International Journal of Advanced Research (2016), 4, 7, 1321-1328.

THIRD GENERATION CHEMICAL PLAQUE AGENTS.
 It is amino-alcohol with documented antibacterial action.
 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. It is therefore indicated as a prebrushing
mouthrinse.
 However, transient numbness of tongue, tooth and tongue staining, taste
disturbance and sometimes mucosal soreness and erosion are the adverse effect.
Delmopinol

Salifluor
 It is a salicylanide which has both antibacterial and anti-inflammatory properties.
 To improve oral retention and to maximize adsorption, Gantrez (PVM/MA) has been
incorporated in saliflour tooth paste and mouth rinse formulations.
 Studied for its effects of plaque inhibition and retardation of onset of gingivitis
(Furuichi et al. 1996).
 Perhaps, 0.12% of saliflour has shown equal effectiveness with 0.12% chlorhexidine
in retarding 4 day plaque growth. (Furuichi et al. 1996).
 Despite this – long term studies yet to be carried out.
OTHER AGENTS.

 Povidone iodine has an affinity for the cell membrane, thereby delivering free iodine
directly to the bacterial cell surface.
 It has a broad spectrum of activity against bacteria, fungi, protozoa, and viruses.
 The mouthwash has been shown to be effective in reducing plaque and gingivitis and
may be a useful adjunct to routine oral hygiene.
 Absorption of significant levels of iodine through the oral mucosa may make this
compound unsatisfactory for prolonged use in the oral cavity.
Povidone Iodine

Proposed in 1965 as antonym to antibiotic
 Most of the lactobacillus strains isolated from periodontally healthy and diseased
individuals have reported to exert antimicrobial activity against periodontopathic
bacteria such as aggregatibacter actinomycetemcomitans, porphyromonas gingivalis,
prevotella intermedia.
 Among the Lactobacillus species, L. salivarius TI2711(LS1), isolated from saliva of a
healthy human volunteer, was highly susceptible to both acidity and lactic acid.
 The acid-susceptibility of LS1 also suggested that this strain could be used as a non-
cariogenic probiotic for maintaining a healthy ecosystem for the oral microflora.
Probiotics
Biological method of plaque control

 Immunization against periodontal disease has been a central research topic in recent
decades.
 The aim is to inhibit adhesion or to reduce the virulence of putative microbial
etiologic agents
These vaccines can be of three types which include:
 1) Vaccines prepared from pure cultures of streptococci, and other oral
microorganisms.
 2) Autogenous vaccines
 3) Stock vaccines
Immunization
There are many limitations in periodontal vaccination, which may include:
 Contamination with unwanted proteins, toxins or live viruses in hypersensitive
individuals.
 If killed vaccines are not completely killed they may cause serious problems in
immunecompromised patients

DENTIFRICE
• A dentifrices is a substance used with a toothbrush for the purpose of cleaning the
accessible surface of teeth. (ADA)
OR
• Dentifrice is a paste, gel or powder used with a toothbrush as an accessory to clean
and to maintain the aesthetics and health of teeth.
 Dentifrice is the French word for toothpaste.
 Dentifrice is used to promote oral hygiene and most of the cleaning is done by the
mechanical use of the toothbrush, not by the toothpaste.

HISTORY
Dr. Lahari Buggapati. Dentifrices: An overview from past to present. International Journal of Applied Dental Sciences 2017; 3(4): 352-
355

AVAILABLE AS (FORMS)
Paste Gel
Powder

Composition of tooth paste

COMPOSITION OF DENTIFRICE
(Therapeutic agents)

FACTORS AFFECTING DENTIFRICE ABRASIVENESS
EXTRA ORAL FACTORS
 Amount of dentifrice used.
 Toothbrush type.
 Tooth brushing method and force applied during brushing.
 Tooth brushing frequency and duration.
 Patient’s coordination and mental status
INTRA ORAL FACTORS
 Saliva consistency and quality
 Xerostomia induced by drugs, salivary gland pathology, and radiation therapy
 Exposure of dental root surfaces
 Presence of restorative materials, dental prostheses, and orthodontic appliances

1. Anticavity dentifrice:
 It contains fluoride to stop enamel decalcification, promote remineralization and
thus protects teeth from decay and cavities.
Fluorides
 Commercially available dentifrices contain sodium fluoride [NaF] 0.22%, stannous
fluoride [SnF2] 0.4% or sodium monofluorophosphate [MFP] 0.76%.
Calcium/Phosphate
 Calcium and phosphate supplementation in a dentifrice will increase the
concentration of these ions in the oral cavity.
Sodium Bicarbonate
 It increases the pH in saliva, and in this way creates an unsuitable environment for
the growth of aciduric bacteria.
 It also prevent caries by reducing enamel solubility and increase remineralization.
TYPES OF DENTIFRICES

2. ANTICALCULUS/TARTAR CONTROL TOOTH PASTE
Tartar, sometimes called calculus, is plaque that has hardened on teeth by the deposition of mineral salts (such as calcium
carbonate).
Proper brushing with tartar control dentifrice can prevent its formation.
Main constituents of tartar control tooth paste are pyrophosphate (tetrasodium pyrophosphate), zinc citrate and zinc chloride.
Pyrophosphate is added as tetrasodium pyrophosphate, tetrapotassium pyrophosphate or disodium pyrophosphate.
It has been shown that pyrophosphate has high affinity to hydroxyapatite (HA) surfaces, probably by an interaction with Ca2+ in the
hydration layer.
By interacting with HA and the enamel surface, pyrophosphate reduces their protein-binding capacity.
It also has the ability to inhibit calcium phosphate formation.
It is therefore conceivable that pyrophosphate introduced in the oral cavity through dentifrices may affect pellicle formation.

3. DESENSITIZING TOOTH PASTE
 Dentine hypersensitivity results from open dentinal tubules at the surface.
 Sensitivity occurs when fluid flows in open dentinal tubules towards the surface of
the tooth as a result of hydrodynamic forces (Brännström’s theory), in response to
stimuli. This fluid flow is believed to result in the pain associated with
hypersensitivity.

 There are two mechanisms by which desensitizing dentifrices can work.
1. By preventing the transmission of neural signals, thereby preventing pain
2. By blocking the dentinal tubules

 Antiplaque agents reduce plaque growth. This can have a positive effect in reducing
plaque growth on teeth, reducing gingivitis, and potentially reducing caries.
 Some antiplaque agents include triclosan, papain and sanguinaria extract
Triclosan
 Triclosan is a synthetic nonionic chlorinated phenolic agent with antiseptic qualities.
 Triclosan has a broad-spectrum efficacy on gram-positive and most gram-negative
bacteria.
 The mechanism of its antiseptic action is by acting on the microbial cytoplasmic
membrane, inducing leakage of cellular constituents and thereby causing lysis of the
4.Anti-plaque/anti-gingivitis dentifrice

 They contain special ingredient such as hydrogen peroxide for teeth bleaching and
whitening.
 The peroxides deliver oxygen radicals to enamel.
 According to (ADA), because it acts as a bleaching agent, hydrogen peroxide actually
changes the color of the enamel on the surfaces of the teeth by cleaning the extrinsic
stains that discolor the outside of the tooth.
 Tooth whitening dentifrices have higher abrasive value than normal tooth paste to
remove food, smoking and other stains
5.Whitening tooth paste

6. Fresh breath dentifrice:
 They contain enhanced flavoring agent along with antibacterial agents that help to
fight against halitosis.
 They may also contain aloe vera leaf juice and essential oil of peppermint.

 These kind of modern tooth pastes are specially created for children.
 They have pleasant flavors and come in attractive colors.
 These tooth pastes contain no sugars and have low concentration of fluoride (500-
1000ppm) to prevent cases of fluorosis.
7. Tooth paste for children:

8. Natural dentifrice/herbal dentifrice:
 Herbal dentifrices are made from natural ingredients and some are certified as
organic. These days many consumers have started to switch to natural dentifrices in
order to avoid synthetic and artificial flavors commonly found in regular dentifrice.
 They don’t contain dyes, artificial flavors or chemicals.
 It is good choice for people who are allergic to mint or to sodium lauryl sulfate, a
foaming agent that is included in most commercial tooth paste brands

 In 2006, it appeared in Europe as the first dentifrice containing biometric synthetic
hydroxyl apatite as an effective alternative to fluoride for the remineralization and
repair of tooth enamel.
 Function of the biometric hydroxyl apatite is to protect the teeth by creating a new
layer of synthetic enamel around the tooth instead of hardening the existing layer
with fluoride that chemically changes into fluoroapatite.
9. Dentifrice containing biometric synthetichydroxyl apatite:

 Striped tooth paste was invented by Leonard Lawrence in 1955 at New York.
 The red area represents the material used for the strips and rest is the main paste
material.
 Two materials are not in the separate compartments.
 They are sufficiently viscous, that they do not mix.
 Applying pressure to the tube causes the main material to squeeze down the thin
pipe to the nozzle.
 Simultaneously, some of the pressure is forwarded to the strip material which is
then pressed on the main material through the holes in the pipe.
10. Striped tooth paste:

Recent Advancements in Dentifrice
 It is formulated with stabilized stannous fluoride and optimized with the
remineralizing potential of amorphous calcium phosphate (ACP) technology.
 It provides fluoride as well as calcium and phosphate to teeth which help to
strengthen the enamel.
 The remineralization process is enhanced by converting soluble calcium and
phosphate to naturally hydroxyapatite.
 The amount of fluoride used in the product is substantially less than that found in
the usual 5000 fluoride dentifrices currently available.
 Enamelon contains just 970 ppm fluoride and yet, according to the studies on the
product, provides more than twice the fluoride uptake into enamel lesions.
1.Enamelon

 It not only reduces the solubility of enamel, thereby preventing caries but also
interfere with the harmful effects of plaque associated with gingivitis.
 The ACP technology helps periodontal patients with exposed root surfaces by
relieving sensitivity through tubular occlusion.
 It also contains Ultramulsion, a patented saliva-soluble coating that moisturizes and
soothes oral soft tissues.
 Ultramulsion may provide improved therapeutic performance by enhancing
substantivity.
 It has a great tasting mint flavor. It does not contain sodium lauryl sulfate (SLS),
abrasives, gluten and dyes.

 Bioactive glass called NovaMin is the most recent technology in this category.
 It was introduced into the dental market as a desensitizer in December 2004.
 The active ingredient in NovaMin is calcium sodium phosphosilicate.
 Saliva in the mouth reacts with calcium sodium phosphosilicate present in Novamin
to form a protective layer of hydroxyapatite on teeth. This layer creates a barrier that
prevents tooth sensitivity. NovaMin containing dentifrice proved more effective than
other desensitizing dentifrices containing potassium nitrate and fluoride.
 According to a study conducted by Burwell A. et al, NovaMin adheres to exposed
dentin surface and reacts with it to form a mineralized layer, occluding dentin
tubules and hence decrease hypersensitivity.
2.Desensitizing dentifrice:

 It is not a dentifrice but a topical tooth créme that helps to strengthen teeth by
binding calcium and phosphate to the tooth surfaces, plaque and surrounding soft
tissue.
 It contains RECALDENT (CPP-ACP Casein Phosphopeptide - Amorphous Calcium
Phosphate), a special milk-derived protein which maintains saturation of levels of
minerals, especially calcium and phosphate, at the tooth surface thereby decreasing
demineralization and enhancing remineralization of teeth.
 It is applied topically to teeth and gums to provide extra protection for teeth and to
neutralize acid challenges from bacteria in plaque.
 Tooth Mousse with RECALDENT (CPP-ACP) has a proven clinical success record for
patients with high caries risk and white spot lesions
3. Calcium phosphate dentifrice:
i. Tooth Mousse:

 It delivers a unique combination of fluoride, calcium and phosphate, which are
components found naturally in saliva.
 During the manufacturing process, a protective barrier is created around the
calcium allowing it to coexist with the fluoride ions.
 As the dentifrice comes in contact with saliva during brushing, the barrier breaks
down and makes the calcium, phosphate and fluoride readily available to the tooth.
 The tooth naturally absorbs these components, helping to prevent the initiation and
further progression of demineralization and allowing remineralization to occur.
ii. Clinpro Tooth Crème:

 It is low-cost, compact liquid dentifrice that uses essential oils and functions as a
dentifrice, mouthwash and breath freshener all at once.
 OraMD is made solely from 100% natural almond, spearmint and peppermint oils.
 It has no sweeteners, no coarse minerals to erode tooth enamel, no fluoride, no
artificial sweeteners, etc.
 It is not artificial or toxic, unlike other harmful chemicals found in conventional
dentifrice products available in market.
 Even better, these botanical oils of peppermint, spearmint and almond are natural
bacteria fighters, meaning they help in maintaining good oral hygiene.
4. OraMD:

1. Nanotechnology dentifrice:
 Nanodentistry is defined as the science and technology of diagnosing, treating and
preventing oral and dental diseases, relieving pain, and improving dental health,
applying materials structured on the nanometer scale.
 The durability of the tooth would be improved by replacing enamel layers with
sapphires or diamonds since diamonds are 100 times harder than regular tooth
enamel.
 With the use of this technology, it can lead to a whole new future of Nanodentistry.
There will be the use of nanorobots that will interact with the human body to clean
the teeth.
 These devices would also identify food particles, plaque, or tartar, and lift them from
teeth to be rinsed away
THE FUTURE OF DENTIFRICES

2. Weather dentifrice: The dentifrice is called "Tastes Like Rain".
 A little computer is dispensed which checks the internet for the day's weather, and
mixes together several different flavors of dentifrice accordingly.
 If it's going to be warmer than yesterday, one will get a higher proportion of
cinnamon dentifrice, and if it's going to be cooler, one will get more mint.
 A blue stripe means it's going to rain.
3. Dentifrice in tablet form:
There is a new innovation in the world of dental disposables that will help to prevent
the spread of germs.
A concern for many households is that bacteria can be transferred from the brush to
the tube, so various cold and flu are more likely to spread, when the dentifrice is
shared between members of the family.
This also helps to prevent wastage, as one cannot accidentally squeeze out more than

CONCLUSION
 Chemical is an adjunct to mechanical plaque control.
 Brushing method should emphasize access to the gingival margins of all accessible
tooth surface and extension as far onto the proximal surfaces as possible.
 Reinforcement of daily plaque control practices and routine visits to the dental
office for maintenance care are essential to successful plaque control and long
term success of therapy.

REFERENCES
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 Carranza, Clinical Periodontology 9th edition
 Shantipriya reddy
 Essentials of preventive and community dentistry -soben peter
 A Textbook of Public Health Dentistry by CM Marya
 Primary Preventive Dentistry_ Pearson New International
 Textbook of Public Health Dentistry - S. S. Hiremath - 3rd Edition
 Clinical periodontology sahithya reddy.
 Textbook Of Periodontology And Oral Implantology- Dilip nayak.
 Textbook of Pediatric Dentistry by Nikhil Marwah

 Joanna Asadoorian, Position Paper on Tooth Brushing.Canadian Journal Of Dental
Hygiene. 2006; 40(5): 232-248.
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2000 vol 8
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children? A pilot study. J Pediatr Dent 2015;3:41 5.

 B.M.ELEY ,Antibacterial agents in the control of supragingival plaque — a review,
british dental journal,1999;186:286-296.
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 Parappa Sajjan, Nagesh Laxminarayan. Chlorhexidine as an Antimicrobial Agent in
Dentistry – A Review. OHDM- Vol. 15- No.2 - April, 2016.
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