Dr.

Wesam Azar BDS, Msc of Periodontics, Jordanian Board JUST

In the absence of bacteria in gnotobiotes (germ-free animals) gingivitis and periodontitis do not develop

Accumulation of plaque on teeth induces an inflammatory response in adjacent gingival tissues while plaque removal results in resolution of gingival inflammation

Optimal oral hygiene, preventing re-growth of bacterial deposits, is critical in the long-term success of periodontal therapy

(Le et al 1965, Theilade et al 1966)

In a series of classic experiments conducted in the 1960s, oral hygiene was suspended in a group of dental students.
All of the subjects rapidly formed supragingival plaque Gingivitis developed within 7-21 days When oral hygiene was resumed, the condition was reversed and health was reestablished

Axelsson & Lindhe 1978 3-year period:

By regularly repeated OHI & prophylaxis, stimulate adults to adopt proper oral hygiene habits
Persons who utilized proper oral hygiene techniques had
Negligible signs of gingivitis No loss of periodontal tissue attachment

No new carious lesions

Control patients, who received merely traditional dental care (symptomatic treatment) suffered from

Gingivitis

Lost periodontal tissue support

New as well as recurrent carious lesions

Results indicate that dental treatment (ALONE) is a highly ineffective means of curing caries and periodontal disease

Microbial plaque growth occurs within hours, and it must be completely removed at least once every 48 hours to prevent inflammation

ADA: Individuals brush twice & use floss or other interdental cleaners once per day

1. Mechanical:
Individual Professionalfor subgingival plaque control, e.g. scaling and root planing.

2. Chemical:
Individual Professional.

Tooth brushing

Interdental cleaning devices

Tongue cleaning

Manual brushes (MTB)

Dental floss

Electric (powered) brushes (PTB)

Interdental brushes (IDB)

Wood sticks Dentifrices (toothpastes)

Initially aromatic plants and Miswak from arrack trees

were used In 1600 Chinese invented the modern toothbrush In 1,780, William Addis designed a toothbrush with bone handle and hog bristles

In 1,900 celluloid (plastic) brushes with bone handle

were introduced World War IINylon bristles were introduced

Carry Dentifrice to tooth surface Remove the dental plaque,Disturb reformation Clean teeth of Food Debris and stain Massage the gingival tissue

Handle size appropriate to user age and dexterity

Head size appropriate to the size of the individual patients requirements

Use of endrounded nylon or polyester filaments

(not larger than 0.23 mm in diameter)

soft filament configurations as defined by the acceptable international industry standards (ISO)

Filament patterns which enhance plaque removal in the proximal spaces and along the gum line

The head of thebrush should be:

1 inch to 1 inches long. 2-4 rows of bristles. 5/16 inch to 3/8 inches wide. 5-12 tufts per row. 80-86 bristles per tuft.

Natural bristles
Source
Hair of hog or wild bear

Synthetic bristles
Mainly NYLON but also of synthetic plastic material Uniformity controlled of size & elasticity Range from soft at 0.2mm to medium at 0.3 mm & hard at 0.4mm End rounded to ensure fewer trauma 1) 2) 3) 4) Rinse, clean, dries rapidly. Durable & maintain longer. End rounded & closed, repel debris & water. More resistant to accumulate micro-organisms

Uniformity

No uniformity in texture Varies depending on portion of bristle taken, age & life of animal Deficient, irregular, frequently open-ended 1) 2) 3) Cannot be standardized Wear rapidly & irregularly Hollow ends allow microorganisms & debris to collect inside.

Diameter

End shape

Advantage, Disadvantage

Compared four commercially available toothbrushes for total plaque removal at a single brushing

All four toothbrushes removed plaque equally

No one design was superior to others

ADA recommends that toothbrushes be replaced every 3 to 4 months

The usual recommendation to brush twice daily is reasonable, not only to remove plaque but also to apply fluoride through the use of dentifrice in order to prevent caries It is likely that the thoroughness and duration of the oral hygiene session, rather than the frequency, are the critical factors

2 minutes an optimum in plaque-removing efficacy was reached with both a manual and electric toothbrushes (Van der Weijden et al. 1993)

Horizontal

Vertical

Circular

Vibratory

Roll

Scrub technique

Leonard technique (1939)

Fones technique (1934)

Stillman, Bass, and Charters techniques

Roll method or modified Stillman technique

To learn and can be mastered by small children

The bristles are angled into the sulcus at a 45degree angle

The bristles are moved in a short vibratory stroke that has a circular pattern

Modified Bass method

most often recommended

because it emphasizes sulcular placement of bristles, to reach supragingival plaque and accessing subgingival plaque to the extent possible.

The bristles are held perpendicular to the long axis of the teeth and are forced into the interproximal spaces. Then bristles of the brush deflect toward the occlusal surface

The bristles are angled into the sulcus at a 45degree angle and overlap onto the facial gingiva. The head of the brush is then "rolled" so that the bristles move occlusally

Charters
Bass Modified Bass Leonard Stillman Modified Stillman

bristles on cervical crown obliquely pointing coronally, horizontal motion with rotations
bristles in sulcus 45 pointing apically, horizontal back & forward motion bristles in sulcus 45 pointing apically, horizontal motion with rotations to occlusal bristles 90 to tooth surface, up & down motions bristles in gingival margin obliquely towards the apex. Vibratory movements without moving the brush bristles in gingival margin obliquely towards the apex. Vibratory movements with rotations towards occlusal

Indicated for:
Children and adolescents

Patients with physical or mental disabilities

Hospitalized patients including older adults who need to have their teeth cleaned by care givers

Patients with fixed orthodontic appliances

reach the gingival margin

"powered toothbrushing is at least as effective as manual brushing and there is no evidence that it will cause any more injuries to the gums than manual brushing"
Heanue et al 2003

Tartar control toothpastes

Contain pyrophosphatesn that Interfere with crystal formation in calculus Reduce the formation of new supragingival calculus by 30% or more Do not affect subgingival calculus formation or gingival inflammation Reduce the deposition of new supragingival calculus but do not affect existing calculus deposits

Toothbrush, regardless of the brushing method used, does not completely remove interdental plaque
Most dental and periodontal diseases originate in interproximal areas

The choice of aids depends largely on

The size and shape of the interdental embrasure and the degree to which soft tissue fills the space Presence of Orthodontic appliances or fixed prostheses

Presence of furcations, tooth alignment

Ease of use and patient cooperation

Twisted or non twisted Bonded or non bonded Waxed or unwaxed Thick or thin

12 to 18 inches should be taken Floss is slipped between contact area and wrapped around tooth surface- up and down strokes

To assist patients who have difficulty flossing

In open embrasures with low papillary height where the brush can fit easily in the available space without causing trauma to the papilla

The tuft may be 36 mm in diameter and can be flat or tapered 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 precission attachment To clean teeth affected by gingival recession and irregular gingival margin or furcation involvement

It has raised edge for cleaning the middle and on other side smooth to clean the sides

REMEMBER Mechanical plaque removal remains to be a primary preventive method to control dental diseases and it should not be replaced by chemical plaque control

chemical plaque control can be used as an adjunct to effectively control gingival inflammation

Eliminate pathogenic gingivitis microorganisms only Inhibit calcification of Prevent development of plaque to calculus. resistant bacteria Not alter taste Exhibit substantivity Not have adverse Be safe to oral tissues at effects on teeth or recommended dental materials. concentration Be easy to use Significantly reduce Be inexpensive plaque formation and

ADA has accepted two agents for treatment of gingivitis:

prescription solutions of chlorhexidine digluconate oral rinse (2 daily rinses with 10 ml of a 0.2% )
(plaque reductions of 45% to 61% and more importantly, gingivitis reductions of 27% to 67%)

1.

2.

nonprescription essential oil mouthrinse

(plaque reductions of 20% to 35% and gingivitis reductions of 25% to 35%)

One charged end of chlorhexidine (dicationic) molecule binds to the tooth surface where as the other remains available to initiate the interaction with the bacterial membrane as the microorganism approaches the tooth surface

Side Effects (reversible):

Primarily brown staining of the teeth, tongue, and

silicate and resin restorations Transient impairment of taste perception Oral mucosal erosion Unilateral, bilateral parotid swelling rare, unexplainable

Personal one-on-one Instruction Other self-instructional approaches

booklets Video

Similarly effective

Proper clinical setting. (Face to face) Talk at the patients level. Gradually build a relationship and an understanding with your patient Explain to your patient his/her condition. Show your patient their periodontal condition clinically and radiographically. Explain treatment plan. Explain to the patient their role in treatment Help the patient to recognise the benefits of prevention (prevention of tooth loss, financial benefit, aesthetics, others) Better when explained in patients mouth.

Check patients technique & modified according to patient needs and abilities. Gradual tapering towards Ideal. Avoid overwhelming patient with information at a single visit Continuous assessment of patients plaque control. Continuous reinforcement throughout visits. Provide positive reinforcement (praise progress; start with "small wins and try for incremental improvement) Show patient residual plaque. Keep records of compliance (chart plaque and bleeding and give patient a written copy of the current score, the target score, and the score at last visit) Identify potential non-compliers and modify treatment as needed (avoiding surgery in patients with poor plaque control)

Erythrosine dye

The patient knows what to do, but is unable to perform

(lacks dexterity)
The patient does not know what to do

best to find an alternative method (e.g., an EMB) that will enhance her efforts. It may also be necessary to see her more frequently for maintenance.

(lacks knowledge)
The patient knows what to do, is able to do it, but simply doesn't comply with the regimen

Reinstruction is indicated. If continued efforts at instruction and feedback are ineffective, an alternative might be considered, such as another brushing technique or an EMB.

(lacks motivation)

motivation is missing The key is to focus on the problem: the presence of unacceptable amounts of plaque and the associated biologic response to the plaque, such as bleeding on probing.

Reinforcement of daily plaque control practices and routine visits to the dental office for maintenance care are essential to successful microbial plaque control and long-term success of therapy