oral hygiene

1. Plaque control
Dr Neeraj Bali

2. Index
 Introduction
 Plaque
 Plaque control
 Mechanical plaque control
 Disclosing solutions
 Toothbrush
 Dentifrices
 Dental floss
 Interdental cleaning aids

3.  Chemical plaque control
 Principles of chemical plaque control
 Classification of antiplaque agents
 Antibiotics
 Phenols
 Sanguinarine
 Metallic ions
 Quaternary ammonium compounds
 Bisbiguanides
 Enzymes
 Povidone iodine
 Delmopinol
 References

4. Introduction
 Dental caries and
periodontal diseases
 Dependant on the
microorganisms present in
the plaque.

5. PLAQUE
 Is a highly specific variable structural
entity formed by the sequential
colonization of the microorganisms on the
tooth surface, epithelium and restorations.
 The natural physiologic forces that
clear the oral cavity are inefficient in
removing dental plaque.

6. PLAQUE CONTROL
 It refers to the procedures for the removal
of the plaque and the prevention of it
accumulation.
 Plaque control is critical component of
dental practice, permitting long term
success of periodontal and dental care
 1965, Loe et al..

7.  Treating and preventing gingivitis.
 The treatment and prevention of
periodontal diseases.
Mechanical
Chemical

8. MECHANICAL PLAQUE
CONTROL
 The most dependable way of achieving
oral health benefits

9. MECHANICAL PLAQUE
CONTROL
 Disclosing solutions.
 Toothbrushes
 Manual
 Electrical / Powered
 Dentifrices

10.  Interdental Cleaning Aids
 Dental Floss {also Knitting Yarn}
 Wooden tips {Stim – u- dent}
 Perioaid
 Interdental brushes, bridge cleaners, pipe
cleaners. Gauze strips.
 Oral irrigation devices.

11. DISCLOSING SOLUTIONS
 A disclosing agent is a preparation in
liquid, tablet or lozenge form, which
contains a dye or other coloring agent.
 In dentistry, a disclosing agent is used
for the identification of soft deposits for
the instruction, evaluation and research.

12. Properties
 Intensity of color
 Duration of intensity
 Taste
 Irritation to mucous membrane
 Diffusibility
 Astringent and Antiseptic property

13. Solutions Available
 Iodine preparations
 Mercurochrome preparations
 Bismark brown {Easlick’s Disclosing
solution}
 Merbromin
 Erythrosine {F.D.C. Red No. 3}

14.  Fast green {F.D.C. Green No. 3}
 Fluorescein {F.D.C Yellow No. 8 – used
with U.V Light}
 Basic fuschin, Malachite Green
 Two- tone {F.D.C Red No. 3, F.D.C Green
No. 3}

15. Uses of disclosing solutions
 Personalized patient
instructions.
 Self- evaluation by
the patient.
 Continuing
evaluation of the
effectiveness of the
instructions given to
the patient.

16.  Preparation of plaque
indices.
 Research studies e.g.
effectiveness of
specific plaque control
devices, antiplaque
agents.

17. Toothbrush

18. TOOTHBRUSHES
 The toothbrush is the principal instrument
for accomplishing plaque removal as a
part of disease control.
 1600 B.C its primitive form as a “ chew
stick” by the Chinese.
 Mohammedans used the “miswak” or
“siwak” as a primitive brush

19.  The bristled brush appeared about the
year 1600 in China.
 by William Adis in 1780
 First patented in the U. S. in 1857.

20. Desirable Characteristics of a
Toothbrush
 Conform to the individual patient
requirements in size, shape and texture.
 Be easily and efficiently manipulated.
 Be readily cleaned and aerated;
impervious to moisture.
 Be durable and inexpensive.

21.  Have prime functional properties of
flexibility, softness of bristles and strength,
rigidity and lightness in the handle.
 Be designed for utility, efficiency and
cleanliness.

23. Parts of a toothbrush
 HEAD – The working end that holds the
bristles.
 HANDLE – the part grasped in the
hand.
 SHANK – Section that connects the
head and the handle.

24. A.D.A - the range of dimensions
 Length of Head ---- 1 – 1.25
inches
 Width of Head ---- 5/16 – 3/8
inches
 No. of rows of tufts ---- 2-4
 No. of tufts per row ---- 5-12
 No. of bristles per tuft ---- 80-85

25. Types of bristles used in
toothbrushes
 Natural – from hog or wild boar
 Artificial – nylon

26. Depending on the diameter
 Soft {0.2 mm}
 Medium {0.3 mm}
 Hard {0.4 mm}

27. POWERED TOOTHBRUSH
 Invented in 1939
 Patient acceptance is good
 Types of movements achieved by these
brushes are reciprocal {back and forth},
circular and elliptical.
 Commercially available powered brushes
are Interplak, Rotadent, Sonicare and
Braun Oral – B Plak Control.

28.  Hamerlynck JV, Middeldorp S, Scholten RJ.
2005, When compared to the use of
manual toothbrushes, the use of powered
toothbrushes with a rotating oscillation
action reduced gingivitis and plaque.

29. Indications:
 Individuals lacking fine motor skills
 Small children or handicapped or
hospitalized patients
 Patients with orthodontic appliances
 Patients who prefer to use them.

30. Ionic Toothbrushes
 Change the surface charge of tooth.
 Plaque with similar charge repelled from
tooth.
 Attracted by negatively charged bristles.

31. Duration of Tooth brushing
 Recommended is approximately 2 minutes
 Any one method of brushing is followed
judiciously then it would take 3- 5 minutes
to effectively brush the entire dentition.
 Frequency of Brushing

32. Attin T, Hornecker E . Tooth brushing
once per day is sufficient to maintain oral
health and to prevent caries and
periodontal diseases.
Maintenance of toothbrushes.

33. Tooth brushing Methods:
 Roll : Roll method or Modified Stillman
Technique or Modified Bass Technique
 Vibratory : Stillman, Charter’s or Bass
Technique
 Circular : Fone’s Technique
 Vertical : Leonard Technique
 Horizontal : Scrub Technique
 Physiological : Smith’s Technique
Open inter dental spaces,
exposed roots
FPD, ortho appliances
Perio surgeries, Gingival
recession
Massage and stimulation of
gingiva.
Children, adults- limited
dexterity
Gingival massage, stimulation.
No emphasis on gingival
sulcus.
Prepratory instructions for
other techniques.

34. Effects Of Improper Tooth
brushing
 Trauma to the gingiva
 Acute Alterations {e.g. Lacerations}
 Chronic Alterations {e.g. Recession,
Change in gingival contour}
 Abrasion of the teeth
 Bacteremia
ACUTE ALTERATIONS
Scuffled epithelial surface with
denuded connective tissue.
Punctate lesions, diffuse redness,
denuded attached gingiva.
CHRONIC ALTERATIONS
Recession.
Changes in gingival contour.
Abrasion of teeth.

35. DENTIFRICES
 A dentifrice is a substance used with a
toothbrush for the purposes of removing
dental plaque, materia alba and debris,
and for applying specific agents to the
tooth surfaces for preventive or
therapeutic purposes.
pastes toothpowders gels

36. The main function of toothpaste
 Minimizing build up of plaque
 Strengthening teeth against caries
 Cleaning the teeth by removing stains
 Removing food debris
 Freshening the mouth

37. main components / ingredients
 Abrasives {20 – 40 %}
 E.g. Calcium Carbonate, Dicalcium
phosphate, alumina and porous silica {for
gels}
 Eliminates plaque, reduces plaque build up
 Removes stained pellicle, polishes the tooth
surface.

38.  Humectant {20 – 40 %}
 E. g Glycerin, sorbitol, polyethylene glycol
 Helps to reduce the loss of moisture from
the paste
 Minimizes the plug formation inside the tube
 Improves texture and feel of the product
 Also acts as sweetening agent.

39.  Binder / Thickner {1- 2%}
 E.g. Sodium alginate, carboxy
methylcellulose, colloidal silica.
 Controls the stability and consistency of the
dentifrice.

40.  Surfactant {1-2%}
 E.g. Sodium lauryl sulfate
 Lowers the surface tension
 To penetrate and loosen surface deposits
and stains
 To emulsify debris for easy removal
 Foaming action to aid in dispersion of the
product in the mouth.

41.  Preservatives
 E.g. alcohols, benzoates, formaldehyde
 Prevent bacterial growth in the product.

42.  Flavoring agents
 E.g. peppermint oil, spearmint oil,
methylsalicylate {wintergreen}
 Makes dentifrice desirable
 Mask the taste of other less pleasant in
flavor ingredients.

43.  Therapeutic agents
 E.g. antiplaque agents, antitartar agents,
desensitizing agents, whitening agents
 Coloring agents and Sweeteners
 E.g. vegetable dyes
 To improve the attractiveness of the product
 E.g. saccharin.

44.  Antibacterial agents
 Anticaries agents
 Active agents
 Anticalculus agents
 Desensitizing agents
Triclosan, Delmopinol, Metallic
ions, Zinc citrate trihydrate.
Sodium monoflurophosphate,
sodium fluoride, stannous fluoride.
Fluoride
Pyrophosphates, Zinc citrate, Zinc
chloride, Gautrez acid( copolymer of
methyl vinyl ether, malic anhydrite)
Sodium fluoride, Potassium
nitrate, Strontium chloride.

45. RECENT DEVELOPMENTS
 Toothpaste for children.
 Natural toothpaste
 Whitening toothpaste.
 Sodium bicarbonate toothpaste.
 Breath freshening toothpaste
 Seductive toothpaste

46. DENTAL FLOSS
 Dental floss is the most widely
recommended tool for removing plaque
from the proximal tooth surfaces
 Levi Spear Parmly from New Orleans
invented dental floss

47. Types of Dental Floss
 Monofilament or Multifilament {Teflon
type}
 Bonded or Nonbonded
 Waxed or Unwaxed
 Thick or Thin

49. INTERDENTAL CLEANING
AIDS
 WOODEN TIPS
 It is a hard balsa wood wedge, 2 inch long
wooden toothpick, commercially known as
“Stim – u – dent”
 Is triangular in cross section

50.  Can be used either with or without handle
 Used for cleaning interdental areas where
there are exposed tooth surfaces and
missing interdental gingiva.

51. PERIO – AID {Toothpick
Holder}
 To remove plaque from the concave
proximal tooth surfaces and exposed
furcations areas.
 Useful orthodontic treatment.

52. INTERDENTAL BRUSHES
 Are cone- shaped or cylindric brushes.
 Can be single tufted or small cylindrical
brushes.
 They can be -small insert brushes or can be
brushes with wire handles.

53.  To clean open interproximal areas,
exposed bifurcations or trifurcations or to
supplement tooth brushing
 Depending on the amount of papilla loss.
 E.g. interproximal brush, unitufted brush
etc.

54. ORAL IRRIGATION DEVICES
 Oral irrigators for daily home – use
work by directing a high – pressure,
steady or pulsating stream of water
through a nozzle to the tooth surfaces.
 Particularly helpful in removing debris
from inaccessible areas, around
orthodontic appliances and fixed
prosthesis

55. Contraindications
 Patients requiring antibiotic premedication
– Bacteremia
 Deep periodontal pockets – risk of abscess
formation
 Patients with acute conditions – e.g.
ANUG, periodontal abscess
 Clinically healthy gingiva – constant
pressure of water stream may reduce the
height of the papilla

56. CHEMICAL PLAQUE CONTROL
 The first reference is credited to Chinese
medicine who recommended mouth
rinsing with child’ urine for treatment of
gum diseases
 also prevalent among Romans
 Europeans believed in “therapeutic
rinsing” until the early 18th century.

57. PRINCIPLES OF CHEMICAL
PLAQUE CONTROL
 Inhibit microbial colonization
 Prevent subsequent development of
plaque
 Plaque already present should be
eliminated by dissolution or altered into
less or non-pathogenic deposits.
 Inhibit calcification of plaque into calculus.

58. CLASSIFICATION OF
ANTIPLAQUE AGENTS
 First Generation {20 – 50 %
reduction}
 Antibiotics
 Phenols
 Quaternary ammonium compounds
 Sanguinarine
 Second Generation {70 – 90 %}
 Bis biguanides {chlorhexidine}
 Third generation- E.g: Delmopinol.

59. Ideal properties of antiplaque
agents
{By Bral and Brownstein, 1988}
 Eliminate pathogenic bacteria only.
 Prevent development of resistant bacteria
 Exhibit substantivity
 Safe to the oral tissues at the
concentrational and dosages
recommended

60.  Significantly reduce plaque and gingivitis
 Inhibit the calcification of plaque and
calculus
 Do not stain teeth or alter taste
 No adverse effects on teeth or dental
materials
 Easy to use
 Inexpensive

61. ANTIBIOTICS
 Vancomycin,
Kanamycin,
Erythromycin
 Problems of bacterial
resistance and
hypersensitivity
reactions

62. PHENOLS
 E.g. Listerine, Triclosan
 Phenols act by acting on the lipid
component of the cell wall of Gram – ve
organisms and thereby changing the
permeability of the cell.
 Listerine, a blend of thymol, menthol,
eucalyptol, methyl salicylate, benzoic
acid and boric acid

63.  Triclosan formulations with Zinc citrate are
helpful at inhibiting plaque and reducing
gingival inflammation.
 The phenolic compound have anti-
inflammatory effects.

64.  The application of a 0.45% SnF2 gel
significantly inhibited the onset of
gingivitis compared to Triclosan/sodium
fluoride/copolymer

65. SANGUINARINE
 An alkaloid derived from the plant
Sanguinaria Canadensis.
 It has a prolonged retentivity in the
mouth.
 It has fluorescent properties enabling it to
be disclosed under long wavelength U.V
light.

66. Metallic ions
 Salts of zinc and copper.
 Reduce the glycolytic activity and delay
bacterial growth.

67. Quaternary Ammonium Compounds
 Cationic antiseptics and surface active
agents.
 +ve > -ve
 Positively charged molecule react with the
negatively charged cell membrane
phosphates and disrupts cell wall.
 Benzathonium chloride, Benzalleonium
chloride, cetlypyredinium chloride.

68.  Cetylpyridinium chloride (CPC)
mouthrinses containing 0.075% and
0.10% CPC

69. BISBIGUANIDES
 E.g. Chlorhexidine, Alexidine
 The most effective antiplaque agents
currently in use.
 They have very broad antibacterial
properties and exhibit considerable
substantivity.

70. CHLORHEXIDINE
 The drug was first synthesized and
reported by ICI in 1954.
 It is not neutralized by soaps, body fluids
or other organic compounds.
 Application as antiplaque and calculus
agent was suggested by Schroeder in
1969.
 Its mode of action is purely topical and it
does not penetrate oral epithelium.

71. Mechanism of inhibition of
plaque
 Blocking of acidic proteins reduces
their adsorption to hydroxyapatite and
thereby the formation of acquired pellicle.
 Adsorption of chlorhexidine to the
polysaccharides in bacterial capsules
reduces their binding to tooth surfaces.
 Chlorhexidine may compete with calcium
ions for acidic agglutination factors in
plaque.

72. Factors that affect retention
 Concentration and Volume of rinse:
 pH of the mouth : decrease in pH reduces
retention
 Free Calcium Ions : they reduce the oral
binding of chlorhexidine.
 Detergents :
 Acid Etching : acid etched and primed
teeth show prolonged antibacterial action of
chlorhexidine.

73. Mode of Action
 The antibacterial effect is concentration
dependant.
 The bacteriostatic effect is due to the change in
membrane permeability of the cell.
 The bactericidal effect is due to intracellular
coagulation.

74. Adverse Effects
 Discoloration of teeth
 Painful desquamative lesions of the oral
mucosa
 Transient impairment of taste
 Parotid swelling is rare and subsides
spontaneously.

75. Indications
 As an adjunct to mechanical plaque
control
 Secondary prevention after periodontal
surgery and after extraction {reduces the
incidence of dry socket}
 In patients with intermaxillary fixation
 As plaque control method in physically
and mentally challenged individuals

76.  In medically compromised patients with
predisposition to oral candidiasis
 In high-risk caries patients, it has
synergistic effect with fluoride.
 In patients suffering with minor recurrent
apthous ulcers. But, it is of little value in
established major apthous ulcers.

77.  Patients wearing removable and fixed
orthodontic appliances.
 Helpful for patients undergoing dental
implant treatments.
 To limit bacteremia while instrumentation
and also to reduce the bacterial content of
aerosol spray during ultrasonic scaling.

78. Enzymes
 Active agents in anti plaque preparations
 Breakdown already formed matrix of
plaque and calculus.
 Effective topically.
 E.g: Mucinase, Dehydrated pancreas,
Mutanase, Dextranase, Lactoperoxidase,
Thyocyanate systase.

79. Povidone Iodine
 Reduce inflammation and progression of
periodontal disease.
 No significant plaque inhibitory activity at
1%.
 Unsatisfactory for prolong use.

80. Delmopinol
 Morpholinoethanol derivative.
 Inhibit plaque growth, reduces gingivitis.
 Limited substantivity.
 Causes week binding of plaque to tooth
surface- easy removal.
 So, Pre-brushing mouth rinse.

81. Adverse effect
 Transient number of tongue tooth staining
and taste disturbance. Sometimes
soreness and erosion.

82. REFERENCES
 Clinical periodontology 9th edition by
Carranza.
 Newbrun. Cariology 3rd ed. Quintessence
publishing Co, Inc 1989. Checago.
 Harris NO, Christen AG. Primary
preventive dentistry 4th ed. Appleton and
Lange, Stamford, Connecticut.
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