plaque control in children ppt .pptx

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Contents :
Classification
Mechanical Plaque Control
 Toothbrush
 Interdental Cleaning Aids
 Oral Irrigation
 Dentifrice
Plaque control in special child
Chemical Plaque Control
 Classification
 Various Chemical Agents Used
Conclusion
References

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INTRODUCTION
Removal of the plaque and the prevention of its accumulation on the teeth and
adjacent gingival surfaces.
OBJECTIVES
 Removal of soft deposits on the teeth and gingival tissues.
 Gingival stimulation
 Loe and his colleagues in n1965
 Sanders 1962
 Lang 1973

PLAQUE
CONTROL
Mechanical Chemical

Mechanical plaque control
 Tooth brush
 Interdental aids
 Dental floss
 Triangular tooth picks
 Interdental brushes
 Single tufted brushes
 Yarn
 Perioaid
Others
• Gauze strips
• Pipe cleaners
• Water irrigation device

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One of the earlier tooth brushes made in England was
produced by “William Addis” - 1780.

• Natural animal bristles were also replaced by synthetic
fibers, Nylon Bristles in 1938 by Du Pont

• The first electric tooth brush was invened in switzerland by
“Dr.Phillippe Guy Woog”
• The first american electrical tooth brush in US called
BROXODENT was released by Squibb in 1960

General Electric
introduced rechargable
cordless tooth
brush in 1961
Interplak was first
rotary action
electrical tooth
brush 1987

IDEAL REQUIREMENTS
 Use of soft filament configurations
 Filament patterns which enhance plaque removal in the
interproximal spaces and along the gum line.
 Inexpensive, durable, impervious to moisture, and easily cleaned.
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Tooth brush
ADA SPECIFICATION:
 Total brush length is about 15 cm.
 Head should be only large enough to accommodate the tufts.
 Length of brushing plane 25.4 mm to 31.8 mm,
 width 7.9 to 9.5 mm.
 Bristle or filament height 11 mm.
 2-4 rows of bristles, 5-12 tufts in each row.
15

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Different types of toothbrush bristle patterns

TEXTURE AND FILAMENT
 The texture of a toothbrush is determined by
 Diameter
 Length
 Size of the hole
 Number of tufts in a given area
 Number of filaments
 BRISTLES TEXTURE
 Made of highest quality nylon usually 0.007 or 0.008 inches
(0.1778 or 0.2032 mm) in diameter
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DIAMETER
 Softer bristles - more flexible, clean
 Hard-bristles - more gingival recession.
Soft brushes 0.007 inch (0.2 mm)
Medium brushes 0.012 inch (0.3 mm)
Hard brushes 0.014 inch (0.4 mm)
Extra soft 0.003 inch (0.075 mm)

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Bristle Textures Recommended
“Extra-soft" brush When the gingival tissue is particularly tender and prone
to bleeding when brushed.
“Soft" brush Normally for young children
Medium-grade brush most preferred –as they are sufficiently stiff to
effectively remove plaque on tooth surfaces and in the
gingival sulcus.
“Hard" brush When the brushing forces are heavy
Suitable for someone with heavily keratinized gingival
tissues that will withstand the stiffness.
“Extra-hard" bristles Only in extremely rare instances.
Disadv -- may cause gingival damage and cervical
abrasion, resulting in gingival recession.

Frandsen 1986 suggested that the outcome of tooth
brushing is dependent on:
(1) The design of the brush
(2) The skill of the individual using the brush
(3) The frequency
(4) Duration of brushing

Selection of Tooth brush
Toddler
head - compact &
fitted with soft end-
rounded nylon
Preschooler
small brush
head with small
or long handle
6 to 7 years
child
head should
be small

How to brush?
Brushing Techniques?

The Bass method / Sulcular
brushing
Dr. C.C. Bass in 1948.
 Rationale: To eliminate soft food debris and bacterial plaque
that has accumulated at the gingival margin as well as
beneath the marginal tissue within the sulcus.
I. Purposes and Indications
 For all patients for bacterial plaque removal adjacent to
and directly beneath the gingival margin.

• Cervical and interproximal area
of posterior teeth
• Easy to master.
• Provides good gingival
stimulation.
• Very-short strokes into a scrub-
brush technique may cause
injury to the gingival margin.
• Dexterity requirement may be
too high for certain patients.
• Time consuming.
ADVANTAGES LIMITATIONS

Modified Bass
 After the placement and slight vibratory – pressure motion, the
bristles are swept down over the crown toward the occlusal or
incisal surface.
 Indications:
1. As a routine oral hygiene measure.
2. For intrasulcular cleansing.

• Excellent sulcus cleansing.
• Good interproximal and
gingival cleaning.
• Good gingival stimulation.
• Time consuming
• Gingival margin injury
• Patients may tend to roll the
brush down over the crown
prematurely, thereby
accomplishing very little
sulcular brushing.
LIMITATIONS
ADVANTAGES

Roll/ rolling stroke/ sweep
method
Purposes and indication
 Cleaning gingiva and removal of plaque from the teeth
without emphasis on gingival sulcus.
 For children where a sulcular technique may seem
difficult for the patient to master.
 In conjunction with the use of a vibratory technique
 Preparatory instruction for Modified Stillman technique

Disadvantages
 Laceration of the alveolar mucosa.
 No brushing in the cervical third and interproximal areas.
 Replacing brush with filament tips directed into the gingiva can
produce punctate lesions.
 Requires some dexterity around the wrist.

Stillman method
Stillman 1932
 Massage and stimulation of the gingiva as well as for
cleaning the cervical areas of the teeth.

Modified Stillman Method
 Rolling stroke after the vibratory (rotary) phase.
 This modification minimizes the possibility of gingival trauma
and increase the biofilm removal effects.

Purpose and indications
 Plaque removal from cervical areas below the height of contour of the
crown and from exposed proximal surfaces.
 Cleaning tooth surfaces and massage of the gingiva.
 For cleaning in areas with progressive gingival recession and root
exposure to minimize abrasive tissue destruction.

Disadvantages
1. Tissue laceration can result when a hard brush is used
2. May be ineffective for plaque removal at the gingival margin.
3. Time consuming.
4. Improper brushing can damage epithelial attachment.

Charter’s method
Dr.W.J.Charters 1928,
 Stimulate the gingival margin “All around each tooth, especially
in the interdental spaces.”
Purpose and Indications
 Loosening of debris and bacterial plaque.
Massage and stimulation for marginal and interdental gingiva.
Recommended for cleaning in areas of healing wounds after
periodontal surgery.

Disadvantages
1. Brush ends do not engage the gingival sulcus to remove subgingival
bacterial accumulation.
2. In some areas, the correct brush placement is limited or impossible
3. Requirements in digital dexterity are high.

Fones method/ Circular scrub method
Alfred. C.Fones 1934
 Who founded the first course for dental hygienists.
 For young children and for patients with limited dexterity.
 A soft brush - 0.006 to 0.008 inch filament diameter is selected.

• It is easy to learn.
• Shorter time.
• Patients who lack dexterity,
physically or emotionally
handicapped individuals.
• Possible trauma to gingiva.
• Interdental areas not properly
reached.
• Detrimental to adults who use
the brush vigorously.
ADVANTAGES LIMITATIONS

Horizontal scrub method
 Used by individuals who never had instruction in oral hygiene
techniques.

Toothbrush Types
 Oscillating
a. counter
b. rotation
 Ultrasonic
 Sonic
 Circular
 Head Types
 Sub-Compact
 Standard
 Round
 Rectangular/Tapered
 Bristle Types
 Soft
 Extra Soft
 Sensitive
 Extra Sensitive.
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Indications :
 Patients with extensive prosthodontic
or endosseous implants.
 Orthodontic patients
 Patients who are on periodontal
maintenance / supportive periodontal therapy
 Poor manual dexterity
 Hospitalized or institutional patients
 Parental brushing of children's teeth
 Patients who are poorly motivated.
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Three basic types of tooth brushing actions:
1) Rotation in a arc of about 60o
2) Back and forth horizontal action
3) An elliptic movement
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Ultrasound toothbrush
 Mechanical radiant energy having a frequency beyond 20,000 cycles
/sec.
Mode of Action :
 One type, the head is powered by a battery and is like a simple electric
motor, which produces oscillations.
 Another method is by magnetostriction similar to ultrasonic scalars.
 Their frequency varies from 40 to 250 Hz.
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 3 minutes of normal brushing
2 times – removes 97% of
bacterial plaque
 Clinically proven safe, gentle
and incredibly effective
 Not used in patients with
cardiac pacemakers
 Not used by young children
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LIMITATIONS
ADVANTAGES

Sonic tooth brush
 Combination of direct plaque removal and penetrating fluid activity
beyond the bristle tip
 Operates at 520 brush strokes/sec (260 Hz)
 Head size comparable to manual toothbrush
 Bristles are scalloped
Eg: Sonicare Optiva Corp
Braun Oral –B Kids Power Tooth brush
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Electric vs Manual tooth brushing

Dental floss
 Dental Floss - interproximal surface in 1800th
century.
 Parmly in 1819 recommended waxed Silken thread for flossing
the teeth.
 In 1948, Bass accomplished research and development of
unwaxed floss in use today.
 Availability
a. Twisted or non-wisted
b. Bonded or non bonded
c. Waxed or unwaxed.
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Acc. To ADA specification
 Type I- Unbonded dental floss composed of yarn having no
additive
 Type II-Bonded dental floss composed of yarn having additives.
Other than binding agent or agent for cosmetic performance
 Type III-Bonded or unbonded having drug for therapeutic
usage.
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Techniques of dental flossing
Spool method

Introduction: The various methods for plaque control include mechanical plaque control
methods which comprises use of toothbrushes, flosses, interdental brushes, and chemical
plaque control which includes mouthwashes, dentrifices. The need for the study was to prove
the efficacy of flossing in children using gumchucks.
Materials and methods: A total sample size of 24 children age groups 6–12 years according to
chronological age were selected. In 12 patients, flossing using gumchucks was done and in 12
patients flossing using unwaxed floss without handle was done. Proximal plaque index was
taken at 0,2,4,6 weeks to assess the efficacy of both types of floss in removal of interproximal
plaque. At the end of 6 weeks, patient’s parents were asked to fill up the questionnaire.
Results: In the intragroup comparison for gumchucks, significant plaque reductions were
found at 4 and 6 weeks. In the intragroup comparison for unwaxed floss, significant reduction
for plaque marginal index were recorded from baseline to 2 and 4 weeks. In the intergroup
comparison, significant reduction in plaque index was recorded at 4 and 6 weeks.
Conclusion: Gumchucks have the high efficacy of plaque removal as well as easy in use for
children routinely. Also when surveyed majority of the patents preferred gumchucks if
available in the stores.
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Comparison of Plaque Removal Efficacy of A Novel Flossing Agent with
the Conventional Floss: A Clinical Study by 1 Shital DP Kiran, et al
( 2019) IJCPD

Dental floss threader
 A floss threader is a plastic loop into which a length of floss is
inserted.
Used for:
 Embrasure areas.
 Under pontics
 Around orthodontic appliances
 Under splinting
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Triangular tooth picks
 Wooden interdental picks / cleansers - made of wood or plastic and
are triangular in cross section.
Indications :
 For cleaning proximal tooth surfaces.
58

Technique
23-01-2012
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Disadvantage – Its hard to insert from lingual space.
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STIMUDENT
 A soft resilient type of wood toothpick shaped to fit the inter
dental space
 Used to dislodge food particle and effectively remove plaque
interdentally.
 Does not damage periodontal tissues and is pleasantly flavored to
leave a good taste after use.
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INTERDENTAL BRUSHES
 An interdental brush is a small, spiral, bristle brush.
Uses:
61

Interdental brushes
Types :
• Small insert brushes with reusable handle.
• Brush with wire handles
• Single tuft brush (end tuft, unituft)

Others
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Gauze strips
Pipe cleaners
Rubber tips
Knitting yarn

Procedure
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Follow a definite pattern across the mouth,
maxillary arch first then the mandibular arch
applying for 5-6 sec. at each Inter dental area.
Start on the low pressure and increase gradually
depending on the condition of the gingival
tissue comfort.
Direct the jet tip towards the Inter dental area
almost touching the tooth surface hold tip at
right angle to the long axis of the tooth

Advantages of Oral Irrigation :
 Reduction of Gingivitis
 Subgingival access.
 Reduction or alteration of microbial flora
 Delivering antimicrobial agents
 When used as adjunct to tooth brushing- retard formation of plaque
and calculus
Contraindications:
 Advanced periodontitis
 Medically compromised patients
66

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Dentifrices
Defined as substances used with a tooth brush for the purpose of
removing dental plaque, material alba debris and for applying
specific agents to the tooth surfaces for preventive or therapeutic
purposes.

Use of fluoridated toothpaste in children
Clinical effectiveness
 Reduction of dental caries
Potential harm
 Swallow considerable amount with risk of fluorosis (Mascaranhas
and Burt 1998)
 First 3yrs – most critical
 Parents advised – pea sized for young children
 Supervise brushing till 7yrs
Guidelines on the use of fluoride in children: an EAPD policy document
10(3):2009
69

70
Recommended use of fluoride tooth paste
Guidelines on the use of fluoride in children: an EAPD policy document
10(3):2009

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Oral hygiene in special child

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TOOTH BRUSH
Velco strapped brush Gripped toothbrush
Toothbrush grip modifications

73
SUPER BRUSH
 Manipulation: Those patients who can
position a toothbrush but cannot
manipulate it Kaschke et al.
 Three-headed brush performed best for
adults who otherwise required help
with their tooth brushing
 Use of powered toothbrush is also best
indicated in these individuals.
Text book of pediatric dentistry – Nikhil Marwah ( 3rd
edition )

74
GUIDELINES FOR HOME ORAL CARE OF
DISABLED CHILDREN
edition )

75
DISABLED CHILDREN
edition )

76
DISABLED CHILDREN
edition )

77
DISABLED CHILDREN
edition )

78
DISABLED CHILDREN
edition )

79
COLLIS CURVE
edition )

80
IMPROVE
edition )

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VAC-U-BRUSH
edition )

AQUAFRESH RADIUS
82
edition )

84
Chemical plaque control
Ideal properties
 Agent should affect only the target tissue.
 Active agents should remain at the site of the action for a time sufficient
 Agent should be safe to the oral tissues
 Agent should be safe to ingest at a level expected
 Agent should have desirable characteristics that enhance compliance with a
preventive regimen.
 Inexpensive.
 Agent should produce meaningful reduction in gingivitis or periodontitis, or both.
Mitchell, E.: Ideal properties. J. Am. Dent. Assoc., 112:24, 1986.

Jafer M, Patil S, Hosmani J, Bhandi SH, Chalisserry EP, Anil S. Chemical Plaque Control
Strategies in the Prevention of Biofilm-associated Oral Diseases. J Contemp Dent Pract
CLASSIFICATION OF CHEMICAL PLAQUE
CONTROLAGENTS
1. Effective in vitro
but lack
substantivity
2. Plaque reduction
by 20%-50%
3. Poor retention
within the mouth
E.g.: Antibiotics,
phenols, quaternary
ammonium
compounds
1. substantive and
effective - in vivo
2. Reduce 70%-90%
plaque
3. Exhibit better
retention
4. Slow release
E.g.: Bisbiguanides
1. Block binding
m/o to tooth or to
each other
2. Compared to
CHX , they do not
exhibit good
retentive
properties
E.g.: Delmopinol
I. Generations
FIRST GENERATION SECOND GENERATION THIRD GENERATION

ON THE BASIS OF CHEMICAL COMPOSITION
TYPE AGENTS
 Bis- biguanides CHX ; alexidine
 Antiseptics Cetylpyridinium chloride
Benzalconium chloride
(quaternary Ammonium compounds)
 Antibiotics Penicillin;metronidazole;tetracyclin
Vancomycin; kanamycin
 Enzymes Dextranase; glucose-
amylogluosidase
 Oxygenating agents Hydrogen peroxide sodium perborate
86

87
TYPE AGENTS
 Fluorides & SnF2; Chlorine dioxide; H2O2; NaCl;
Inorganic ions Domiphen bromide ; NaHCO3
 Natural products Sanguanarine, propolis
 Metal salts Tin, Zinc, Copper
 Phenols and essential oils Thymol, hexylresorcinol, triclosan
 Amino alcohols Octapinol, Delmopinol
 Surfactants and detergents Sodium lauryl sulfate

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Chlorhexidine
 CHX, an antimicrobial agent that can suppress the growth of mutans
streptococci, has been considered as having the potential to prevent
dental caries.
 Defined as the ability of an agent to bind to tissue surfaces and to be
released over time to deliver an adequate dose of active principle
ingredient against caries

89
 Adjunct to mechanical oral hygiene
 20
prevention
 Plaque control among physically and mentally handicapped
children
 Fixed orthodontic appliance wearers
 Medically compromised patients
 High caries risk patients
 In pts with IMF
Martin Addy & John M Moran (1997)

Antibacterial action of CHX
It shows two actions:
1. Bacteriostatic at low concentrations
Bacterial cell wall(-ve charge)
Reacts with +ve charged CHX molecule
Integrity of cell membrane altered
CHX binds to inner membrane phospholipids &
increase permeability
Vital elements leak out & this effect is reversible

91
2. Bacteriocidal action
Increased concentration of CHX
Progressive greater damage to membrane
Larger molecular weight compounds lost
Coagulation and precipitation of cytoplasm
Free CHX molecule enter the cell & coagulates proteins
Vital cell activity ceases
Cell death(irreversible)

92
Comparing the effect of 0.06% -, 0.12% and 0.2% Chlorhexidine
on plaque, bleeding and side effects in an experimental gingivitis
model: a parallel group, double masked randomized clinical trial
Maliha Haydari et al (2018) BMC
Abstract: Chlorhexidine is the gold standard of dental plaque prevention. The aim of the
present study was to compare the plaque and gingivitis inhibiting effect of commercial
products containing 0.2%, 0.12% and 0.06% chlorhexidine in a modified experimental
gingivitis model.
Methods: In three groups of healthy volunteers, experimental gingivitis was induced and
monitored over 21 days and simultaneously treated with the commercial solutions containing
0.2%, 0.12% and 0.06% chlorhexidine. The maxillary right quadrant of each individual
received mouthwash only, whereas the maxillary left quadrant was subject to both rinsing
and mechanical oral hygiene. Compliance and side effects were monitored at days 7, 14, and
21. Plaque and gingivitis scores were obtained at baseline and day 21.
Results: The commercial mouthwash containing 0.2% chlorhexidine resulted in statistically
significantly lower plaque scores than the 0.12 and 0.06% mouthwashes after 21 days use,
whereas no statistically significant difference was found between the effects of the two latter.
Conclusion: A commercially available mouthwash containing 0.2% chlorhexidine had
statistically significant better effect in preventing dental plaque than the 0.12% and 0.06%
solutions. Trial registration: ClinicalTrials.gov NCT02911766. Registration date: September
9th 2016.

94
Toxicology, safety and side
effects
 Less absorption through skin and mucosa
 No evidence of teratogenicity
 Hypersensitivity – few reports
 No bacterial resistance reported
 No super infection

95
Various forms
 Mouth rinses
 Gels – 0.12% or 0.2%
 Sprays – 0.1% or 0.12%
 Varnishes
 Chewing gums
 Chlorhexidine chips

Triclosan
 Phenol derivative
 Is synthetic and ionic
 Used as a topical antimicrobial agent
 Broad spectrum of action including both gram positive and gram negative
bacteria
 It also includes mycobacterium spores and Candida species
96

MECHANISM OF ACTION
triclosan
act on cytoplasmic membrane
induce leakage of cellular constituents
bacteriolysis

98
Essential Oil Mouth Wash
 Listerine - phenolic related essential oil.
0.06% thymol,
0.09% eucalytol,
0.04% menthol and
Methyl salicilate
 26.9% or 21.6% alcohol vehicle with a PH of 5.0 or 4.4 .
 They are effective to a lesser degree than Chlorhexidine in plaque
reduction
 Causes an initial burning sensation & bitter taste in mouth
MOA: Cell wall disruption & inhibition of bacterial enzymes

Quaternary Ammonium Compounds
• Cetylpyridinium chloride(CPC 0.05%), Benzathonium chloride
• More active against gm+ve micro organisms
• Moderate plaque inhibitory activity, low substantivity.
• Positively charged molecules react with the negatively charged
cell membrane phosphates- disrupts cell wall of micro
organisms

Povidine Iodine
• Reduces inflammation and progression of periodontal
diseases.
• Certain amount of iodine is absorbed through oral mucosa
making this compound unsatisfactory for prolonged use in the
oral cavity.
• No significant plaque inhibitory effect when used as 1%
mouth wash

Sanguinarine
• Alkaloid derived from rhizomes of Sanguinaria canadensis.
• Effective against gm –ve organisms.
• Good retentive properties
• Can be disclosed under long wave uv light because of its fluorescent
properties.

Delmopinol
• It is a morpholinoethanol derivative.
• It acts by interfering with plaque matrix formation and reduction of
bacterial adherence
• Can be used as pre brushing mouth rinse.
• Conc of 0.1-0.2%
• Adverse effects include
 transient numbness of the tongue
 tooth and tongue staining
 taste disturbance
 rarely mucosal soreness and erosion.

Enzymes
• Enzymes - active agents in anti plaque preparations.
• Group 1 - protease , lipase , nuclease , dextranase, mutanase
• Group 2 - glucose oxidase, amyloglucosidase
• Certain proteolytic enzymes are bactericidal
E.g.: mucinase , mutanase, dextranase, lactoperoxidase

REFERENCES
• Clinical Periodontology- Carranza F.A, Newman M.G.(10th
ed)
• Text book of pediatric dentistry – Nikhil Marwah ( 3rd
edition )
• Soben Peter – Textbook of community dentistry -3rd
edition.
• Michele Muller, Frederic Coursonb. Toothbrushing Methods to Use in
Children: A Systematic Review. Oral Health Prev Dent 2013;11(4):341-347
• Norman O.Harris. Primary preventive dentistry.
• Nicholas C. Claydon. Current concepts in tooth brushing and interdental
cleaning. Periodontology 2000, vol. 48, 2008, 10–22.
• Mandal A, Singh DK, Siddiqui H, New dimensions in mechanical plaque
control: An overview. Indian J Dent Sci 2017;9:133-9.
• George Philip, Dayakar M M, Vijayalakshmi Divater, Shivprasad :Emerging
concepts in oral chemical Plaque control – an overview
• Jafer M, Patil S, Hosmani J, Bhandi SH, Chalisserry EP, Anil S. Chemical
Plaque Control Strategies in the Prevention of Biofilm-associated Oral
Diseases. J Contemp Dent Pract 2016;17(4):337-343.

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