PLAQUE AND ORAL HEALTH

DR. SHUBHAM SRIVASTAV

PG PART - I
DEPARTMENT OF PEDIATRIC AND PREVENTIVE
DENTISTRY
CONTENTS
Introduction

Definition

Difference between tooth deposits

Classification of plaque

Composition of plaque

Plaque hypothesis

Plaque formation

Plaque control
 INTRODUCTION

Has been
estimated
that
As it passes Within hours
normal ,healt
through the Within 2 after birth-
After hy human
The human birth canal – week mature oral cavity
weaning- being
fetus inside acquires microbiota colonized
entire human comprises
the uterus is vaginal and establishes – mainly by
microbiota is 2KG of
sterile. fecal gut of facultative
formed. bacterial
microorganis newborn. and aerobic
population
ms. bacteria.
that of its
total body
weight.
The number of oral bacteria increases gradually – as a result of exposure to external environmental
microbial sources.

Streptococcus mitis and streptococcus salivarius – first and most dominant oral microbes- to
colonize the oral cavity of newborn infants.

S.oralis, Mutans streptococci,S. gordonii – present after first year of life.

Periodontal microbiota –complex

Affects the host, the oral environment and periodontal treatment.

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Microbiota establishes - harmony with the host.

Constant renewal - prevents the accumulation of microorganisms.

Teeth provide hard, non-shedding surfaces - accumulation & metabolism of bacteria on hard oral
surfaces is considered the primary cause of dental caries, gingivitis, periodontitis and peri- implant
infections.

In the oral cavity, the bacterial deposits have been termed dental plaque or bacterial plaque.
DEFINITION

Dental plaque is defined clinically as structured, resilient yellow grayish substance that adheres
tenaciously to the intraoral hard substances, including removable and fixed restorations.

WHO(1980) -Defined bacterial dental plaque as a specific but highly variable structural entity
resulting from colonization and growth of microorganisms consisting of various species and strains
embedded on an extracellular matrix.
Plaque is differentiated from other deposits - found on tooth surface such as Materia alba and
calculus.

Materia alba: refers to soft accumulation of bacteria, food matter, and tissue cells that lack the
organized structure of dental plaque are easily displaced with water spray.

Calculus: A hard deposit that forms by mineralization of dental plaque and is generally covered by
layer of unmineralized plaque.

Acquired pellicle: A non cellular thin film.

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 DIFFERENCE BETWEEN TOOTH DEPOSITS
Materia alba Dental plaque Calculus

White cheese like accumulation Resilient clear to yellow –grayish Hard deposits that forms by
substance mineralization of dental plaque

Composed of salivary proteins, Primarily composed of bacteria in Generally covered by layer of

some bacteria , many a matrix of salivary glycoproteins unmineralized dental plaque
desquamated epithelial cells , and and extracellular polysaccharides
occasionally disintegrated food
debris
Lacks an organized structure and Considered to be biofilm
is therefore not as complex as
dental plaque.

Easily displaced with water spray Impossible to remove by rinsing or

the use of sprays
Dental plaque is primarily composed of microorganisms .

One gram of plaque (wet weight) contains approximately 1011 bacteria.

Non bacterial microorganisms found in plaque- yeasts, protozoa , and viruses.

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CLASSIFICATION
Supragingival plaque: found at or above gingival margin.

Gram positive cocci and short rods –predominates at the tooth surface.

Gram negative cocci and filaments- predominates in the outer surface of mature plaque mass.

Prime importance in development of gingivitis.

It is associated with calculus formation and root carries.

• (i) Coronal Plaque - In contact with tooth surface.

• (ii) Marginal Plaque - Associated with the tooth surface at the gingival margin.
It can be detected clinically only after it has reached a certain thickness.

Small amounts of plaque can be visualized by using disclosing agents.

The color varies from gray to yellowish-grey to yellow

The rate of formation and location of plaque vary among indidivuals

Influenced by diet , age, salivary factors, oral hygiene, tooth alignment, systemic diseases and host
factors.
Subgingival plaque Found below the gingival margin, between the tooth and the gingival pocket
epithelium.

Usually thin

Within gingival sulci or periodontal pocket

Cannot detected by direct observation.

Host inflammatory cells and mediators –influences the establishment and growth of
bacteria – subgingival region.

Subgingival microbiota differs in composition from the supragingival plaque

Reason: local availability of blood products and a low reduction-oxidation

(redox )potential – characterizes the anerobic environment.
 Supragingival plaque Subgingival plaque

1.Matrix 50% matrix Little or no matrix

2.Flora Mostly gram positive Mostly gram negative

3.Motile bacteria Few Common

4.Aerobic/anerobic Aerobic unless thick Highly anerobic area present

5.Metabolism Predominantly carbohydrates Predominantly proteins

COMPOSITION OF PLAQUE

Bacteria + intercellular matrix= dental plaque

Bacteria makes 70 to 80 percent of total material.

Bacteria:
• Gram positive cocci
• Gram negative cocci
• filamentous bacteria
• flagellated bacteria

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Other than bacteria:
• Mycoplasma species
• protozoa
• yeasts
• viruses
Intercellular Also called inter-microbial matrix
matrix
Present between bacteria cells

Accounts for 20-30%

Consists of organic and inorganic materials derived from saliva and gingival
crevicular fluid.
Organic Polysaccharide - Dextran is predominant produced by bacteria.
Constituents Acts as organic skeleton of plaque, gives energy

Levans, glactose, rhamnose also present.

They play major role in maintaining the integrity of the biofilm.

Proteins

Glycoproteins – from saliva is an important constituents of pellicle

Lipid material- debris from membrane of disrupted bacterial and host cells
and food debris.
Albumin, originating from crevicular fluid.
II. Inorganic Calcium and phosphorus - predominantly.
Constituents
Traces amount - sodium ,potassium and fluoride.

Source is saliva in supragingival plaque and crevicular fluid in subgingival

plaque.

As the mineral content increases, the plaque mass becomes calcified to form
calculus.

Fluoride component of plaque is largely derived from external sources like

fluoridated toothpastes, rinses, fluoridated drinking water
PLAQUE HYPOTHESIS

Dental plaque hypothesis:

1. Nonspecific plaque
hypothesis

2. Specific plaque
hypothesis

3. Ecological plaque
hypothesis
NON SPECIFIC PLAQUE HYPOTHESIS

According to non specific plaque hypothesis periodontal disease results from “ elaboration of
noxious products by the entire plaque flora”

According to this hypothesis:

When small amount of plaque is present- noxious products neutralized by host

Large amount of plaque- produce large amount of noxious products-essentially overwhelm host’s
defenses.

Carranza's clinical periodontology 11th edition

Hypothesis was contradicted with fact that all plaque was pathogenic.

1. individuals with considerable amount of plaque and calculus, as well as gingivitis- never
developed destructive periodontitis.

2. individuals with periodontitis – demonstrated with site specificity in pattern of disease.

Depends on control of amount of plaque accumulation.

Current standard treatment of periodontitis by debridement ( non-surgical or surgical) and oral

hygiene measures still focuses on the removal of plaque & its products & it is founded in non-
specific plaque hypothesis.

Carranza's clinical periodontology 11th edition

SPECIFIC PLAQUE HYPOTHESIS

Hypothesis states that only certain plaque is pathogenic , and its pathogenicity depends on the
presence or increase in specific microorganisms.

Limited numbers of specific pathogen are present.

Acceptance of this hypothesis was because of recognition of Actinomycetemcomitans as pathogen

in localized aggressive periodontitis.

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 ECOLOGIC PLAQUE HYPOTHESIS

Given by marsh - 1990s

States that ,both the total amount of dental plaque and specific microbial composition of plaque contributes to
the transition from health to disease.

The health- associated dental microflora –stable over time and in state of dynamic equilibrium or “microbial
hemostasis”.

Changes in the host status, such as inflammation, tissue degradation, and or/high GCF flow-lead to shift in
microbial population in plaque – culmating periodontal disease.

Carranza's clinical periodontology 11th edition

According to ecological hypothesis- disease is caused by the overgrowth of specific elements of
dental plaque – when local environment changes.

Important consideration of hypothesis- therapeutic intervention can be useful on a number of

different levels.

Eliminating disease inducing stimulus whether host, or environmental- help to restore microbial
hemostasis.

Targeting specific microorganisms-less effective –conditions will remain same.

One pathogen will simply replaced by another.

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PROPERTIES OF BIOFILM

Cooperating community of various types of microorganisms: Microorganisms are arranged

in micro-colonies.

Microcolonies are surrounded by a protective matrix.

Within the microcolonies are differing environments.

Microorganisms have a primitive communication system.

Microorganisms in the biofilm are resistant to antibiotics, antimicrobials, and host

response.
BIOFILM STRUCTURE

The bacteria in a biofilm are not distributed evenly, they cluster

together to form sessile mushroom shaped micro colonies.

Each micro colony is an independent community with its own

customized living environment.

A protective extra cellular slime layer surrounds the microcolonies.

A series of fluid channels penetrate the slime layer & facilitate the
movement of nutrients & bacterial products throughout the biofilm

A primitive communication system of chemical signals allows

communication between the bacterial microcolonies.
Bacteria in the center of a micro colony may live in a strict anaerobic
environment, while other bacteria at the edges of the fluid channel
may live in an aerobic environment.

Fluid channels provide nutrients and oxygen for microcolonies,

waste products and enzymes within biofilm

The bacterial microcolonies use “chemical signals” to communicate

with each other.

Quorum sensing in bacteria “involves the regulation of expression

of specific genes through the accumulation of signaling compounds
that mediate intercellular communication” Prosser 1999
PLAQUE FORMATION

Process of plaque formation is divided into 3 phases:

• 1. the formation of pellicle on tooth surface.

• 2. initial adhesion/ attachment of bacteria.
• 3. colonization / plaque maturation.

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FORMATION OF PELLICLE
All surfaces in the oral cavity ,including soft and hard tissues ,are coated with a layer of organic
material – acquired pellicle.

Pellicle consists of more than 180 peptides, proteins, and glycoproteins.

Including keratins, mucins, proline-rich proteins – function as adhesion sites (receptors) for
bacteria.

After 2 hrs pellicle is in equilibrium between adsorption and detachment.

Bacteria that adhere to tooth surfaces – do not contact enamel directly –but interact with the
acquired enamel pellicle.

Pellicle is not merely a passive adhesion matrix.

Many proteins retain enzymatic activity –incorporated into pellicle such as alpha amylase ,
peroxidases and lysozyme – affect physiology and metabolism of adhering bacterial cells.
Forces responsible:

• Ionic
• Hydrophobic,
• Electrostatic
• van der Waals forces

between saliva and tooth surface.

32

Microbiology—Plaque Retention
Wolf u. a., Periodontology (ISBN 3131417617) © 2006 Georg Thieme Verlag
KG
INITIAL ADHESION/ ATTACHMENT OF
BACTERIA
Tooth brushing removes most but not all bacteria from exposed surfaces of teeth.

Recolonizations begins immediately

Bacteria can be detected in 3 minutes of introducing sterile enamel into mouth.

the initial step of transport and interactions with surface – non specific.

It is Specific interactions between microbial cell surface “adhesin” molecules and receptors in
salivary pellicle.
Various adhesions on bacteria:

• Fimbriae (Cisar et al. 1984, Sandberg et al. 1988)

• Cell-associated proteins (Socransky and Haffajee 1992)
• Lectins (Gibbons 1989)

Receptors on tissue surfaces:

• Galactosyl residues (Murray et al. 1986)

• Sialic acid residues (Murray et al. 1986)
• Proline-rich proteins or statherin (Socransky and Haffajee 1992)
• Type I and IV collagen (Socransky and Haffajee 1992)
It was established that colonization of an already established microbial niche by a new species is
difficult since it is hampered by a variety of microbial interactions.

Therefore intraoral translocation to and colonization of sterile surfaces might be different from
translocation and colonization of already colonized surfaces.

Only a relatively small proportion of oral bacteria possess adhesins that interact with receptors in host
pellicle.

Over the first 4 to 8 hours, 60 to 80 percent of bacteria present are members of genus streptococcus.

Other bacteria commonly present – obligate aerobes such as Neisseria spp, Hemophilus spp.

As well as facultative anaerobes actinomyces spp. And veillonella species.

These are primary colonizers

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Primary colonizers provide new binding sites for adhesion by other oral bacteria.

The metabolic activity of primary colonizers – modifies the local microenvironment- influence the
ability of other bacteria to survive in the dental plaque biofilm.

For example- by removing oxygen ,the primary colonizers provide conditions of low oxygen tension-
permits the survival and growth of obligate anaerobes.

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COLONIZATION AND PLAQUE MATURATION
The primary colonizing bacteria adhered to tooth surface provide new receptors for attachment by
other bacteria, in process known as co- adhesion.

Coadhesion leads to development of microcolonies and eventually mature biofilm.

As the biofilm matures, the most striking change is a shift from streptococcus-dominated
community to a plaque dominated by Actinomyces.

Such population shifts are known as microbial succession.

The principle of microbial succession, is that pioneer bacteria create an environment that is either
more attractive to secondary invaders or increasingly unfavourable to themselves.

The secondary colonizes attach to establish pioneer species via adhesin-receptor interactions (co –
adhesions)
Continuous adsorption of single microorganisms from saliva (co-adhesion) contributes to expansion of
biofilm.

In the surface layer ,some microorganisms co-aggregate with other species to form ‘bristle brushes’ or
‘corn cobs’ structures

As dental biofilms develop-some bacteria produce polysaccharide –contribute to biofilm matrix.

Biofilm matrix is biologically active ,retains nutrients, water (thereby preventing desiccation), and key
enzymes
As the biofilm become more diverse ,the bacteria can interact both in a conventional
biochemical manner and via specific signaling molecules.

As the biofilm becomes thicker, oxygen concentration decreases.

Thus ,in developing coronal plaque ,a progressive shift from aerobic and facultatively species to
facultative and obligately anerobic organisms predominate after 9 days.
COMPLEXES OF PERIODONTAL
MICROORGANISMS

Early colonizers:

• independent or defined complexes (Actinomyces naeslundii, A. viscosus)

• Yellow complex (streptococcus spp)
• Purple complex (A. odontolyticus)

Secondary colonizers:

• Green (E.corrodens, A.actinomycetemcomitans serotype a & capnocytophaga

species)
• Orange (fusobacterium, prevotella & campylobacter spp)
• Red complex (P. gingivalis, T. forsythia, & T. denticola)
Primary colonizers (both streptococci & actinomyces) are facultative anaerobes which
consequently prepare a favourable environment for secondary colonizers, which have more
growth requirements.

Secondary colonizers initially adhere to bacteria already in the plaque mass, but in latter stages,
coaggregation between different gram –ve species will predominate. E.g: F.nucleatum with P.
gingivalis or T. denticola
FACTORS AFFECTING SUPRAGINGIVAL PLAQUE FORMATION

Early undisturbed plaque formation on teeth follows an exponential growth curve.

During first 24 hours from a clean tooth surface- plaque growth is negligible.

Following 3 days –plaque coverage progresses on an average 30 % of the total coronal tooth area.

Microbial composition of the dental plaque changes with a shift toward a more anerobic and a more
a gram negative flora

Including an influx of fusobacteria, filaments, spiral forms, and spirochetes.

Carranza's clinical periodontology 11th edition

Bacterial growth in older plaque is much slower than in newly formed plaque.

Reason- nutrients become limiting for much of the plaque biomass.

TOPOGRAPHY OF SUPRAGINGIVAL PLAQUE

Early plaque formation on teeth – follows topographic pattern.

Initial growth is along gingival margin and from interdental space.

Later, extension in coronal direction is observed.

Pattern may fundamentally change –when the tooth surface contains irregularities- offers
favourable growth path.

Plaque formation can also starts from grooves, cracks ,perikymata or pits.
By multiplication, the bacteria spread out from starting up areas as a relatively even monolayer.

Surface irregularities are responsible for “ individualized” plaque growth pattern which is
reproduced in absence of optimal oral hygiene.

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SURFACE MICROROUGHNESS

Rough intraoral surfaces(eg., crown margins, implant abutments, and denture bases) accumulate
and retain more plaque and calculus in terms of thickness, area, and colony forming units.

Ample plaque reveals an increased maturity /pathogenicity of its bacterial components.

Characterized by an increased proportion of motile organisms and spirochetes .

Smoothing an intraoral surface decreases the rate of plaque formation.

Below a certain surface roughness(R<0.2µm)-further smoothing does not result in additional

reduction in plaque formation.

Seems to be threshold level for surface roughness (Ra around 0.2µm), above which bacterial
adhesion is facilitated .

Surface free energy and surface roughness are to factors that influences plaque growth .

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INDIVIDUAL VARIABLES INFLUENCING
PLAQUE FORMATION
The rate of plaque formation differs significantly between
subjects.

A multiple regression analysis showed

• the clinical wettability of the tooth surfaces

• the saliva induced aggregation of oral bacteria
• the relative salivary flow conditions around sampled teeth explained 90% of
variation.

Carranza's clinical periodontology 11th edition

VARIATION WITHIN THE DENTITION

Within a dental arch, large differences in plaque growth rate can be detected.

Early plaque formation occurs on lower jaw(compared to upper jaw)

More in molar areas , on the buccal tooth surfaces- compared to palatal sites (especially in the
upper jaw)

More in interdental regions- compared to buccal or lingual surfaces.

Carranza's clinical periodontology 11th edition

IMPACT OF GINGIVAL INFLAMMATION AND
SALIVA
Many studies indicated early in vivo plaque formation is more rapid on tooth surfaces facing
inflamed gingival margins than on adjacent healthy gingivae.

Studies suggest increase in crevicular fluid production enhances plaque formation.

Some substance from this excudate (eg., minerals, carbohydrates, or proteins) favor both initial
adhesion and /or growth of early colonizing bacteria.
During night , plaque growth rate is reduced by 50%

Seems to be surprising , since one would expect that reduced plaque removal and the decreased
salivary flow rate at night would enhance plaque growth.

The fact that supragingival plaque obtains its nutrients mainly from saliva appears to be of greater
significance than the antibacterial activity of saliva.

Carranza's clinical periodontology 11th edition

THE IMPACT OF PATIENT’S AGE

Study by fransson et al –no difference is detected in de novo plaque plaque formation between
a group of young (20 to 25 years of age)and older (65 to 80 years of age ) subjects who
abolished mechanical tooth cleaning for 21 days – neither in amount or in composition.

The developed plaque in the older patient group ,resulted, in more severe gingival inflammation
– seems to indicate an increased susceptibility to gingivitis with aging

Carranza's clinical periodontology 11th edition

 SPONTANEOUS TOOTH CLEANING

Many clinicians believe that plaque is removed spontaneously from the teeth such as during
eating.

Based on firm attachment between bacteria and surface, this seems unlikely.

Even in the occlusal surfaces of the molars, plaque remains, even after chewing fibrous foods
(carrot, apples or chips).

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DE NOVO SUBGINGIVAL PLAQUE FORMATION

One cannot sterilized periodontal pocket.

Early studies : after mechanical debridement there is partial reduction of 3 logs followed by fast
regrowth to almost pretreatement levels within 7 days.

Effectiveness of subgingival debridement – high proportion (5-80%) of tooth surfaces still harbor
plaque and calculus

Some pathogens penetrates soft tissues or dentinal tubules

CHARACTERISTIC OF BIOFILM BACTERIA
Metabolism of dental plaque bacteria

Majority of nutrients for dental plaque bacteria originates from saliva or GCF .

The transition from gram positive to gram negative microorganisms observed in structural
development of dental plaque.

The growth of P. gingivalis is enhanced by metabolic byproducts produced by other

microorganisms ,such as protoheme from campylobacter rectus.
Metabolic interactions occur also between the host and plaque microorganisms.

Increase in steroid hormones are associated with significant increases in the proportions of P.
intermedia found in subgingival plaque.

These nutritional interdependencies are probably critical to growth and survival of

microorganisms in dental plaque.

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COMMUNICATION BETWEEN BIOFILM BACTERIA

In a biofilm, bacteria have capacity to communicate with each other.

Example is quorum sensing –in bacteria secrete a signaling molecule that

accumulate in local environment and triggers a response such as a change in
specific gene expressions once they reach critical threshold concentration.

Two types of signaling molecules have been detected from dental plaque bacteria:

• 1. peptide signals are produced by gram-positive organisms during growth

• 2. universal signal molecule autoinducer 2(AI-2)
Responses are induced only when a threshold concentration of the peptide is
attained- thus peptides act as cell density, or quorum sensors.

Quorum sensing play a diverse roles .

For example: modulating the expression of genes for antibiotic resistance,

encouraging the growth of beneficial species to the biofilm, and discouraging
the growth of competitors.

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INTERACTIONS BETWEEN DENTAL PLAQUE
BACTERIA
Some studies stated that nonpathogenic organisms in subgingival dental plaque can modify the
behavior of periodontal pathogens.

In multispecies biofilms –interactions between genetically distinct microorganisms can be mutually

beneficial.

There are many examples of competitive interactions between different bacteria.

S. oligofermentans can convert lactic acid produced by S. mutans into hydrogenperioxide ,which
then kills cells of S. mutans.

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BIOFILMS AND ANTIMICROBIAL RESISTANCE
Bacteria growing in microbial communities adherent to a surface do not “behave” the same way as
bacteria growing suspended in liquid environment .

The resistance of bacteria to antibiotics is affected by their nutritional status , growth rate,
temperature, PH , and prior exposure to subeffective concentrations of antimicrobial agents.

Variations in any of these parameters will thus lead to a varied response to antibiotics within a
biofilm.

Extracellular enzymes such as beta lactamases ,formaldehyde and concentrated in the extracellular
matrix- thus inactivating some antibiotics.

Antibiotic resistance may be spread through a biofilm by intercellular exchange of DNA .

The high density of bacterial cells in a biofilm facilitates the exchange of genetic information among
cells of the same species and across species and even genera.
BACTERIAL TRANSMISSION AND
TRANSLOCATION
Transmission of the pathogens, from one locus to another –an important aspect of infectious
diseases.

Molecular fingerprinting techniques clearly illustrated –periodontal pathogens are transmissible

within members of a family.

Christersson and co-workers demonstrated a translocation of A. actinomycetemcomitans via

periodontal probes in localized juvenile periodontitis patients.

They were able to successfully colonize previously noninfected pockets with A.

actinomycetemcomitans by single course of probing with a probe previously inserted in an infected
pocket of the same patient.
THANK YOU!
PLAQUE CONTROL
PLAQUE CONTROL

Plaque control is removal of dental plaque on regular bases and prevention of its accumulation
on teeth and other gingival surfaces.

It also deals with prevention of calculus formation.

Essentials of public health dentistry- soben peter 5th edition

PLAQUE CONTROL
1. Mechanical
• Mechanical plaque control seems to be the most dependable form of plaque control
method .

2. Chemical
• Chemical plaque control has been used only as adjunct to mechanical means and not
as a substutite.

Essentials of public health dentistry- soben peter 5th edition

 Uses Of Disclosing Agents

In research studies
with regard to
Personalized patient To evaluate the
Self- evaluation by the effectiveness of
instruction and effectiveness of oral
patient. plaque control devices
motivation. hygiene maintenance.
like toothbrushes and
dentifrices etc.

Essentials of public health dentistry- soben peter 5th edition

 PLAQUE DISCLOSING AGENTS
It is a preparation in liquid, tablet ,or lozenge form which contains a dye or other coloring agent.

Used for identification of dental plaque.

Otherwise invisible to naked eye.

When applied to the teeth ,the agent imparts its color to soft deposits

Rinsed easily from clean tooth surfaces.

After staining, the deposits can distinctly seen providing a valuable visual aid in patient instructions.

Procedure can demonstrate dramatically to patients the presence of deposits and the areas that need
special attention during personal oral care

Essentials of public health dentistry- soben peter 5th edition

PROPERTIES OF AN ACCEPTABLE DISCLOSING AGENTS

A. Intensity Staining of deposits should be evident.

of color
The color should contrast with normal colors of oral cavity.

B. Duration The color should not rinse off with ordinary rinsing methods
of intensity
Or be removable by the saliva for period of time required to complete the
instruction or clinical service.
It is desirable for the color to be removed from gingival tissies and lips by
completion of appointment.
Essentials of public health dentistry- soben peter 5th edition
C. Taste The patient should not be made uncomfortable by an unpleasant or highly
flavoured substance.
Use of the agent should be pleasant and encourage cooperation.

D. Irritation The agent should not cause irritation to the oral mucosa.
to mucous
membrane

E. Solution should be thin enough so that it can be readily apply to exposed

surfaces of the teeth
Diffusibility
Thick enough to impart intenstive color to bacterial plaque.

Essentials of public health dentistry- soben peter 5th edition

F. Astringent It is recommended to apply an antiseptic prior to scaling and if antiseptic
disclosing agent is used- one solution serves a dual purpose.
and
antiseptic
properties:

Essentials of public health dentistry- soben peter 5th edition

AGENTS FOR DISCLOSING DISCLOSING PLAQUE

A) Iodine Skinner’s iodine solution

Preparations Diluted tincture of iodine
B) Mercurochrome Mercurochrome solution 5%
Preparations Flavored mercurochrome disclosing solution
C) Bismarck Brown

D) Merbromin

Essentials of public health dentistry- soben peter 5th edition

E) Erythrosine Fd and C (federal food drug and cosmetic act)Red No.3 /N0.28

F) Fast Green: FD and C green NO.3

G) Fluorescein FD and C yellow no. 8(used with special ultraviolet source to make agent
visible)

Essentials of public health dentistry- soben peter 5th edition

H) Two tone FD and C blue NO.1
solutions FD and C Red no.3
It mainly stains thicker (older)plaque blue
And thinner (newer)plaque red

F) basic
fuchsin

Essentials of public health dentistry- soben peter 5th edition

 APPLICATIONS OF DISCLOSING AGENTS

May be directly applied to the tooth surface using cotton pellets or it may be rinsed after proper
dilution.

The tablets and wafers may be chewed around the mouth for 30 to 60 seconds and rinsed.

Essentials of public health dentistry- soben peter 5th edition

 MECHANICAL PLAQUE CONTROL AIDS

1.Toothbrushes
• A. Manual tooth brush
• B. Electrical tooth brush
• C. Sonic & ultrasonic tooth brush
• D. Ionic tooth brush

2. Tongue scrapper

3. Oral irrigators

Essentials of public health dentistry- soben peter 5th edition

4. Interdental aids
A. Dental floss
B. Interdental brush
• Proxa brush system
• Single tufted brush
C. Wooden/plastic tips
• Hand-held triangular tooth pics
• Proxapic

Essentials of public health dentistry- soben peter 5th edition

 TOOTH BRUSHES

Mostly widely used oral hygiene aids.

Principal instrument in general use for accomplishing the goals of plaque control.

According to ADA’s council of dental therapeutics “the tooth brush is designed primarily to promote
the cleanliness of teeth and oral cavity”.

Essentials of public health dentistry- soben peter 5th edition

HISTORY First introduced in china as early as 1600 B.C

Introduced in western world in 1640.

Nylon came into use in toothbrush construction in 1938.

Powered toothbrush were actively promoted after 1960.

Essentials of public health dentistry- soben peter 5th edition

Objectives Of Tooth Brushing

• 1. to clean teeth and interdental spaces of food remnants , debris stain etc.
• 2. to prevent plaque formation.
• 3. to disturb and remove plaque.
• 4. to stimulate and massage gingival tissue.
• 5. to clean the tongue.

Toothbrushes vary in size and design as well in length,

hardness and arrangement of bristles.

Essentials of public health dentistry- soben peter 5th edition

 TYPES OF TOOTH BRUSHES

Manual toothbrushes

Powered toothbrushes

Sonic and ultrasonic toothbrushes

Ionic toothbrushes

There is no clear cut evidence that one particular type of toothbrush is superior to other.

Many authors recommend soft filament brushes than hard filaments in view of damage.

Essentials of public health dentistry- soben peter 5th edition

 MANUAL TOOTHBRUSH

Characteristics Should be designed for utility , efficiency and cleanliness.

Should be easily and effectively manipulated.

Should be durable and inexpensive.

Essentials of public health dentistry- soben peter 5th edition

 TOOTH BRUSH BRISTLES

Can be hard or soft

Natural or synthetic

Multi tufted or space tufted

Natural bristles are obtained from hair of hog or wild boar.

The bristles are tubular in form

More susceptible to fraying, breaking, contamination with microbial debris, softening and loss of
elasticity.

Essentials of public health dentistry- soben peter 5th edition

Synthetic bristles are made of nylon

Uniform in size and elasticity ,

Resistant to fracture

Do not get contaminant

Both of these remove plaque –nylon filaments are superior in terms of

homogenic.ity ,uniformity of bristles size

Essentials of public health dentistry- soben peter 5th edition

 ADA SPECIFICATIONS OF A TOOTHBRUSH

Brushing surface

1-1.25 inches in length

5/16 to3/18 inches in width

2 to 4 rows of bristles

5-12 tufts/row

Conventional toothbrushes may be modified in order to achieve plaque removal

Eg. Modifications of the handle grip, the head and the bristles.

Essentials of public health dentistry- soben peter 5th edition

 POWERED TOOTHBRUSH

In 1885 , Fredrick Tornberg designed first mechanical toothbrush which was first followed by
powered toothbrush in 1939.
Also known as automatic or electric or mechanical toothbrushes.

Mimic the action of manual toothbrushes and makes toothbrushing faster and efficient.

The heads of these toothbrushes oscillate side to side motion or in a rotatory motion.

Frequency of the oscillations is 40HZ in an ordinary powered toothbrush.

Essentials of public health dentistry- soben peter 5th edition

POWERED TOOTHBRUSH
Indications Of Powered Toothbrushes

• Young children
• Handicapped patients
• Individuals lacking manual dexterity
• Orthodontic patients
• Patients on supportive periodontal therapy
• Patients with prosthodontic or end osseous implants

Essentials of public health dentistry- soben peter 5th edition

ADVANTAGES

• Increases patient motivation resulting in better patient compliance.

• No specific brushing is required.
• Increase accessibility in interproximal and lingual tooth surfaces.
• Uses less brushing force than manual toothbrushes.
• Brushing timer is incorporated in some brushes to help the patient in brushing for
required duration.

Essentials of public health dentistry- soben peter 5th edition

 ADA SPECIFICATION 5 FOR TOOTHBRUSH

Length- 1 -1.25inches

Width- 5/16 -3/18inches

Surface area- 2.54-3.2cm

Number of rows- 2-4 rows of bristle

Number of tufts-5-12 tufts per row

Number of bristles- 80-85 bristles per tufts

Diameter of bristles
• Soft -0.007 inch ( 0.2mm)
• Medium-0.012 inch (0.3mm)
• Hard-0.014 inch (0.4mm)
Indian journal of comprehensive dental care
Toddler: Small size brush with a full size handle

Preschool upto 5 years: Small brush with small handle

Children 6 to 7 years of age: The brush head should be small

Children 8 to12 years of age: Medium sized head, bristles and handle

Mcdonald & avery’ Dentistry for Child and adolescent -south asia edition
 ADVANCES IN TOOTHBRUSH

Sonic And Ultrasonic

Toothbrush
• Produce high frequency vibrations (1.6Mhz)
• Lead to phenomenon of acoustic micro streaming
• Aids in stain removal as well as disruption of
bacterial cell wall.

Mandal et al new dimensions in mechanical plaque control: an overview Indian journal of dental sciences April-June 2017
 ULTRASONIC –STERILIZED TOOTHBRUSH
SYSTEM

Toothbrushes are rapidly contaminated with different microorganisms-possible cause of

infection or reinfection, especially in patients under periodontal therapy.

These microorganisms may not only originate from oral cavity but also from environment where
toothbrushes are stored.

Procedure for decontamination of toothbrushes would prevent the risk of reinfection or

infection by other organisms from the environment.

Mandal et al new dimensions in mechanical plaque control: an overview Indian journal of dental sciences April-June 2017
The ultraviolet (UV) ,sterilized toothbrush system concept , is helpful for those who have habit
of keeping everything clear and germ –free.

UV base helps to sterilize the toothbrush whenever it is placed and can hold upto a quartet of
UV pods to keep a small family's toothbrush safe and bacteria free whenever they are not in
use.
 IONIC TOOTH BRUSH

Change surface charge of a tooth by an influx of positively charged

ions .

Plaque with similar charge- repelled with from tooth surface-

attracted by negatively charged bristles of the toothbrush.

Mandal et al new dimensions in mechanical plaque control: an overview Indian journal of dental sciences April-June 2017
 LASER TOOTHBRUSH

Dentinal hypersensitivity is one of complications that affects both in day to day or after periodontal
therapy

Nd:YAG lasers can block depolarization of rapidly conducting A-β fibers , and such laser radiation can
block an action potential conduction in a simulated intradental nerve.

Low level laser therapy(LLLT) has gained attention as a new method of for pain control.

Laser toothbrush emits red (635nm) light in the visible spectrum produced by a diode laser inside
the toothbrush with an AA battery.

Mandal et al new dimensions in mechanical plaque control: an overview Indian journal of dental sciences April-June 2017
It reduces dentinal hypersensitivity

Another advantage of using laser in toothbrush is patient

can use it at home, cost effective, less time consuming and
easily used by patients.

Mandal et al new dimensions in mechanical plaque control: an overview Indian journal of dental sciences April-June 2017
 DISPOSABLE TOOTHBRUSH

Meant for one time use .

Important regimen for maintaining oral hygiene in travellers,

children, elderly patients, hospital patients and one who lack
manual dexterity.

Chewable toothbrush

Miniature plastic molded toothbrush that can be used when no

water is available

Mandal et al new dimensions in mechanical plaque control: an overview Indian journal of dental sciences April-June 2017
They are most commonly available from bathroom vending
machines and composed of xylitol, flavoring aqua, and
polydextrose.

Other types of disposable toothbrushes include those that are

a small breakable plastic ball of toothpaste on the bristles
which can be used without water and prove to be quite handy
to travelers

Mandal et al new dimensions in mechanical plaque control: an overview Indian journal of dental sciences April-June 2017
 103

3-PIECE TOOTH­BRUSH TRAINER SET

CONTAINS

• 2 brushes made with ultrasoft rubber and a very narrow and small brush with
soft bristles.

USE

• For infants during teething

• To introduce brushing to the infants.

Mandal et al new dimensions in mechanical plaque control: an overview Indian journal of dental sciences April-June 2017
 Soft Rounded Head to soothe baby's tender teeth

Detachable safety shield to allow care taker greater flexibility

Soft elastomer bristle ends for gentle cleaning

Thumb and finger rest – considering transition period

Mandal et al new dimensions in mechanical plaque control: an overview Indian journal of dental sciences April-June 2017
 TOOTH TOWELETTES

Method of plaque removal when tooth brushing is not possible.

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.

The plaque removal efficacy of such brushes, in particular proximal

plaque reduction is less than a regular manual toothbrush.

Mandal et al new dimensions in mechanical plaque control: an overview Indian journal of dental sciences April-June 2017
 FOAM BRUSHES

Foam brushes resemble a disposable soft sponge

soaked in chlorhexidine on a stick.

In medically compromised and immunocompromised

patients to reduce the risk of oral and systemic
infection.

Mandal et al new dimensions in mechanical plaque control: an overview Indian journal of dental sciences April-June 2017
 BRUSH REPLACEMENT

American dental association (ADA) recommends

To replace toothbrush approximately every three to four months or sooner as bristles are frayed.

Reason: if bristles are frayed and worn – they lose their effectiveness.

Children’s toothbrushes may need to replace more frequently than adult toothbrush.

Reason: children often brush more rigorously than adults.

Mandal et al new dimensions in mechanical plaque control: an overview Indian journal of dental sciences April-June 2017
 MAINTAINING TOOTHBRUSH

ADA recommendations

Rinse the toothbrush under tap water after you brush – to wash away lingering tooth paste and
saliva.
Store the toothbrush in vertical position ,with bristle positioned so they can air dry.

Storing a toothbrush in closed container can cause bacteria to build up.

Let bristles fully dry between each usage.

Mandal et al new dimensions in mechanical plaque control: an overview Indian journal of dental sciences April-June 2017
 TOOTH BRUSHING TECHNIQUES

Classified broadly according to Greene J.C (1966)

• The roll technique- modified stillman /rolling strokes

• The vibratory technique-stillman, charter’& bass methods
• The circular techniques- fones methods
• The vertical technique- Leonard’s technique
• The horizontal technique-scrub method
• The physiological technique – smiths method

Essentials of public health dentistry- soben peter 5 th edition

 THE BASS OR SULCUS CLEANING METHOD

Widely accepted

Most effective method – for removal of dental plaque adjacent to and directly underneath
gingival margin.
Indications

Adaptable for open proximal areas, cervical areas beneath the height of contour of enamel and
exposed root surfaces.
Routine patients with or without periodontal involvement.

Essentials of public health dentistry- soben peter 5 th edition

TECHNIQUE

The bristles are placed at 45° angle to gingiva and moved in small circular motions.

strokes are repeated – around 20 times – 3 teeth at a time.

On lingual aspect of anterior teeth- brush is placed vertically – the heel of brush is pressed into
gingival sulci and proximal surface at an angle of 45°angle.

Occlusal surfaces are cleaned – by pressing bristles firmly against pits and fissures –then
activating the bristles.

Essentials of public health dentistry- soben peter 5 th edition

Advantages

• Effective method for removing plaque

• Provides good gingival stimulation
• Easy to learn

Disadvantages

• Overzealous brushing –convert the “very short strokes” into a scrub brush
technique –cause injury to gingival margin.
• Time consuming
• Dexterity requirement is too high for certain patients.

Essentials of public health dentistry- soben peter 5 th edition

 MODIFIED BASS TECHNIQUE

Indications
• As a routine oral hygiene method.
• Intrasulcular cleansing.

Technique
• Combines the vibratory and circular movements of the bass technique with
sweeping motion of roll technique.
• Bristles are held at 45° angle to gingiva.
• Bristles are gently vibrated –by moving brush handle- in a back and froth motion.
• In a single motion- bristles are swept over the sides of the teeth towards their
occlusal surfaces.

Essentials of public health dentistry- soben peter 5 th edition

Advantages

• Excellent sulcus cleaning.

• Good interproximal and gingival cleaning
• Good gingival stimulation.

Disadvantages

• Dexterity wrist is required.

Essentials of public health dentistry- soben peter 5 th edition

 MODIFIED STILLMAN’S TECHNIQUE

Indications Dental plaque removal from cervical areas below the height of contour of
the enamel and from exposed proximal surfaces.

General application for cleaning tooth surfaces and for massage of gingiva.

Recommended for cleaning in areas with progressing gingival recession and

root exposure to prevent abrasive tissue destruction.

Essentials of public health dentistry- soben peter 5 th edition

TECHNIQUE
Bristles are pointed apically with an oblique angle to the long axis
of the tooth.

Bristles are partly positioned to cervical aspect of teeth and partly

on adjacent gingiva.

Bristles are activated by short back and forth motions and

simultaneously moved in coronal direction.

Following 20 strokes , the procedure is repeated systematically on

adjacent teeth.

A soft toothbrush is indicated.

Essentials of public health dentistry- soben peter 5 th edition

DISADVANTAGES

• Time consuming
• Improper brushing can damage epithelial attachment.

Essentials of public health dentistry- soben peter 5 th edition

 FONES/CIRCULAR OR/SCRUB METHOD

Indication Young children.

Physically or emotionally handicapped individuals

patients who lacks dexterity

Essentials of public health dentistry- soben peter 5 th edition

TECHNIQUE

Asked child to stretch his/her arms that they are parallel to the floor.

Child is asked to make big circles using the whole arm to draw circles in 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 toothbrush-making sure teeth and gums
are covered.

Essentials of public health dentistry- soben peter 5 th edition

ADVANTAGES Easy to learn

Less time is required

DISADVANTAGES Possible trauma to gingiva

Interdental areas are not properly cleaned.

Essentials of public health dentistry- soben peter 5 th edition

 VERTICAL METHOD –LEONARDS METHOD

Vertical strokes

Maxillary and mandibular are brushed separately.

Technique Bristles are placed 90° to facial surface of the teeth.

With teeth edge to edge , place the brush with filaments against the teeth
at right angles to the long axes of the teeth.

Stroke used is mostly up and down with slight rotation or circular

movement.

Essentials of public health dentistry- soben peter 5 th edition

Upper and lower teeth are brushed in same series of strokes.

Teeth are placed edge to edge to keep brush slipping over the occlusal or
incisal surface.

Essentials of public health dentistry- soben peter 5 th edition

ADVANTAGES More convenient and effective for small children with deciduous
teeth.

DISADVANTAGES Interdental spaces of permanent teeth of adults are not properly

cleaned.

Essentials of public health dentistry- soben peter 5 th edition

 CHARTER TECHNIQUE

Filaments positioned towards chewing surface of tooth

at 45 degrees to gingiva directed coronally

Direction opposite to Bass Technique.

Indication
• Open interdental spaces
• Fixed partial dentures
• Exposed root surfaces
• After periodontal surgeries
• Gingival recession

Mcdonald & avery’ - Dentistry for child and Adolescent - first south asia edition
 RECOMMENDED TECHNIQUE FOR CHILDREN

Mescher et al studied the tooth brushing effectiveness of 60 first, third & 6 th graders in an
elementary school.

A standardized hand function test was given each child and the children were then instructed on
how to perform sulcular tooth brushing with a child sized multi-tufted toothbrush.

The results showed that sulcular tooth brushing requires hand functions well beyond the ability
of most first graders and many third graders.

Only sixth graders were able to accomplish subgingival plaque removal with the sulcular
brushing technique.

So Children younger than 8 years of age should be taught less complex technique than sulcular
tooth brushing.

The scrub technique would be more appropriate.

Mcdonald & avery’ - Dentistry for child and Adolescent - first south asia edition
Scrub or circular scrub technique is probably best for young children with little manual dexterity.

Horizontal scrub is used most frequently by preschoolers and 6-8 years old children

Children betweenw 8- 12 yrs old should be taught the sulcular toothbrushing techniques.

When toothbrushing is not possible or is inconvenient, children should be taught to "swish and
swallow."

Mcdonald & avery’ - Dentistry for child and Adolescent - first south asia edition
 INTERDENTAL CLEANING AIDS

DENTAL FLOSS
• used to remove plaque from interproximal surface in which embrassure
are completely occupied by healthy interdental papilla (type-1)

Types of dental floss

• Twisted & non-twisted
• Banded & non-banded
• Thin & thick
• Microfilament & multifilament
• Waxed & non-waxed

Essentials of preventive and Community Dentistry-Soben Peter _ 5th edition

METHODS OF USING DENTAL FLOSS

Spool Flossing Method

• About 45 cm ( 18 inches ) long floss is

taken & about 10 cm ( 4 inches) from each
end is would around the middle finger of
each hands.
• In both the hands the last three fingers are
folded & closed & both the hands are
moved apart.
• In this way about 5 cm ( 2 inches) long floss
is held between the index fingers of both
the hands.

Essentials of preventive and Community Dentistry-Soben Peter _ 5th edition

2. Circle or loop flossing method
( for children & individual with limited manual
dexterity)

• Loop or circle made from about 18 inches long piece

& both ends are tied securely with the three knots.
• All the fingers except the thumb of the floss is held
by both the hands having about 2.5 cm floss
between fingers of both hands.

Essentials of preventive and Community Dentistry-Soben Peter _ 5th edition

 POWERED FLOSSING DEVICES

Consist of battery operated nylon tip that slip easily

between teeth and is very gentle to the gums.

They are very effective in patients wearing orthodontic

appliances.

Mandal, et al.: New dimensions in mechanical plaque control: An overviewIndian Journal of Dental Sciences ¦ Volume 9 ¦ Issue 2 ¦ April-June 2017
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

Mandal, et al.: New dimensions in mechanical plaque control: An overviewIndian Journal of Dental Sciences ¦ Volume 9 ¦ Issue 2 ¦ April-June 2017
 ORAL IRRIGATOR

Oral irrigation device include the use of water picks.

The high pressure, pulsating stream of water through a nozzle is

directed to the tooth surface and subgingivally, washing away
debris and plaque containing bacteria.

They are helpful surrounding orthodontic appliance, and when

used as an adjunctive treatment in shallow pocket depth.

Patients require antibiotic premedication should not use oral

irrigation.

Mandal, et al.: New dimensions in mechanical plaque control: An overviewIndian Journal of Dental Sciences ¦ Volume 9 ¦ Issue 2 ¦ April-June 2017
INDICATIONS:

• Conventional fixed prosthesis

• Supported implants

Periodontal diseases - water added with Clorhexidine & Sanguinarine

Irrigator that combines water with air, water comes out as microbubbles creating an effect of mini
turbine that spins at 8000 rpm

Has a microchip to regulate the water pressure

Mandal, et al.: New dimensions in mechanical plaque control: An overviewIndian Journal of Dental Sciences ¦ Volume 9 ¦ Issue 2 ¦ April-June 2017
 TONGUE SCRAPERS

Helps to clean the dorsal surface of tongue

Removes slime coating from the tongue

Removes food and bacterial deposits from the tongue

Stimulates the papilla

Removes bad odour due to accumulation of food or organisms

Can be
• Stainless steel tongue cleaner
• Copper made tongue cleaner
Mandal, et al.: New dimensions in mechanical plaque control: An overviewIndian Journal of Dental Sciences ¦ Volume 9 ¦ Issue 2 ¦ April-June 2017
GOOD MORNING!
CHOOSING THE RIGHT BRUSH AND
TOOTHPASTE FOR YOUR CHILD

Choose a toothbrush that is designed for children. It should

have a small head and soft bristles.
When choosing the right toothpaste, remember:
• for children 0–18 months of age – use only water, no
toothpaste
• from 18 months until the child turns six years old – use a
small pea-sized amount of low fluoride children’s toothpaste
(check on the pack)
• from six years of age – use a pea-sized amount of standard
fluoride toothpaste.

Toothbrushing – children 0-6 years [better health channel]

HOW TO BRUSH YOUR CHILD’S TEETH

Young children aren’t able to brush their own teeth well enough so they need an
adult to do it for them.
Start by finding a comfortable position. This could be with your child sitting on
your lap facing away from you with their head resting against your body while
you cup their chin with one hand.
•Brush the teeth and along the gum line to clean every tooth thoroughly (about
two minutes is a good guide).
•Brush gently in small circles. Brush along the inside surfaces and the outside
surfaces.
•Brush back and forth on the chewing surfaces of teeth.
•After brushing, ask your child to spit out toothpaste, and not to rinse with
water. The small amount of toothpaste remaining keeps protecting teeth.

Toothbrushing – children 0-6 years [better health channel]

TEACHING YOUR CHILD TO BRUSH
THEIR TEETH

Encourage children to take part in toothbrushing as they get

older. At around age two or three, help them develop the skill
by letting them have a go first before you follow up to make
sure all surfaces have been cleaned.
At around the age of eight years, children have developed the
fine motor skills needed for tooth brushing. However,
supervision is often needed past this age until you are sure
they can do it well by themselves.

Toothbrushing – children 0-6 years [better health channel]

CHEMICAL PLAQUE CONTROL
 CHEMICAL PLAQUE CONTROL

Classification (According to generations)

1. First generation antiplaque agents

• capable of reducing plaque scores by about 20-25%.

• Exhibits poor retention within the mouth.
• E.g., antibiotics, phenols, quaternary ammonium compounds, sanguanarine.

Essentials of preventive and Community Dentistry-Soben Peter -4th edition

2. Second generation anti-plaque agents

• Produce an overall plaque reduction of around 70-90%

• Better retained by the oral tissue
• Exhibit slow release properties. E.g., bisbigunides, chlorhexidine.

3. Third generation antiplaque agents:

• Block binding of microorganism to the tooth or to each other.

• As compared to chlorhexidine , they do not exhibit good retentive properties.e.g.,
Delmopinol.

Essentials of preventive and Community Dentistry-Soben Peter _ 4th edition

CHEMOTHERAPEUTIC PLAQUE CONTROL AGENTS

1. ANTISEPTIC AGENTS

Positively Charged Organic Molecules:

• Quaternary ammonium compounds—cetylpyridinium chloride
• Pyrimidines—hexedine
• Bis-biguanides—chlorhexidine, alexidine
Noncharged Phenolic Agents: Listerine (thymol, eucalyptol, menthol, and
methylsalicylate), triclosan, phenol, and thymol

Oxygenating Agents: Peroxides and perborate

Bis-Pyridines: Octenidine

Halogens: Iodine, iodophors, and fluorides

Heavy Metal Salts: Silver, mercury, zinc, copper and tin

Mcdonald & avery’ - Dentistry for child and Adolescent - first south asia edition
2. ANTIBIOTICS
• Niddamycin, kanamycin sulfate, tetracycline hydrochloride, and vancomycin
hydrochloride

3. ENZYMES
• Mucinases, pancreatin, fungal enzymes, and protease

4. PLAQUE-MODIFYING AGENTS
• Urea peroxide

5. SUGAR SUBSTITUTES
• Xylitol, mannitol

6. PLAQUE ATTACHMENT INTERFERENCE AGENTS

• Sodium polyvinylphosphonic acid, perfluoroalkyl

Mcdonald & avery’ - Dentistry for child and Adolescent - first south asia edition
IDEAL 1.Eliminate pathogenic bacteria only.
PROPERTIES 2. Prevents development of resistant bacteria

3. Exhibit substantivity

4. Safe to the oral tissues at the conc. and dosage recommended.

5. Inhibit plaque and gingivitis.

6. Inhibit calcification of plaque.

7.Do not stain teeth or alter taste.

8. No adverse effects.

9. Easy to use.

10. Inexpensive

Mitchell, E.: Ideal properties. J. Am. Dent. Assoc., 112:24, 1986.)

DELIVERY Tooth paste
SYSTEM
Mouth rinse

Gel

Sprays

Varnishes

Slow release vehicles

 GINGIVAL
EMBRASURES

Angularis nigra, Latin for 'black angle', also known

as open gingival embrasures, and colloquially
known as "black triangle", is the space or gap seen
at the cervical embrasure, below the contact point
of some teeth.
TYPES OF EMBRASURES CONDITIONS OF GINGIVA IN RECOMMENDED CLEANING AIDS
EMBRASURES

Type I Embrasures are completely Superfine and thin dental floss,

occupied by healthy interdental used only for cleaning sulcus
papilla

Type II About 75% of the embrasures is Medium or coarse and thick dental
occupied by the gingiva floss

Type III About 50% of the embrasures is Thin fine pointed small spiral
occupied by the gingiva interdental brushes

Type IV About 25% of the embrasures is Thick spiral interdental brushes and
occupied by the gingiva fine bristle ended unitufted brush

Type V Complete loss of interdental papilla Bristle ended unitufted brush and
thick spiral interdental brush
 OTHER INTERDENTAL
AIDS
MECHANICAL DEVICE INTERDENTAL AIDS
Interdental brushes Proximal tooth surfaces adjacent to open embrasures; orthodontic
appliances; fixed prosthesis; dental implants; periodontal splints; space
maintainers; concave proximal surfaces; exposed class IV furcations;
applications of fluorides for prevention of decay, particularly root surface
caries and any surfaces adjunct to any prosthesis; antibacterial agents for
control of plauqe and gingivitis; desensitizing agents
Interdental tips Plaque forming on tooth surface or just below gingival margin
Floss Proximal surface of each tooth and line angles
Tufted dental floss Wide embrasures; mesial and distal abutments of fixed partial dentures;
under pontics; orthodontic appliances
Gauze strips Proximal surfaces of widely spaced teeth; distal and mesial surfaces of
abutment teeth; distal portions of dentures supported by implants
Toothpicks in holders Plaque forming at or below gingival margin; interdental cleaning; concave
proximal teeth surfaces; exposed furcation areas; orthodontic appliances
Wooden dental cleaners Exposed proximal tooth surface
NON FLUORIDATED AND FLUORIDATED
TOOTH PASTE

THE SPECIFICATIONS AND INGREDIENTS FOUND IN COMMERCIALLY AVAILABLE TOOTHPASTES [ RAMCHANDRAN SS]
THE SPECIFICATIONS AND INGREDIENTS FOUND IN COMMERCIALLY AVAILABLE TOOTHPASTES [ RAMCHANDRAN SS]
 CLINPRO TOOTH
CREME
An anti-cavity toothpaste that aids in the prevention of dental cavities and
can be used in place of your usual toothpaste.
Helps to reverse white spots.

Perfect for patients at moderate or high risk of dental cavities.

Cleans and whitens teeth with low abrasion.

Contains 0.21% sodium fluoride (950 ppm fluoride ion) - components

found naturally in saliva.
Contains innovative functionalized tri-calcium phosphate ingredient (fTCP)
for optimal delivery.
Replaces conventional toothpaste regimen.
 HOW TO FLOSS YOUR POSTERIOR TEETH

The key to flossing your back teeth is using a longer piece of floss.

This provides the flexibility to reach the harder to reach spots.

If your back teeth are tight or crowded- use PTFE

(polytetrafluorethylene) floss- as it’s more durable and less likely to break when sliding between tight
teeth.
 CHLORHEXIDINE
GLUCONATE
Cationic bisbiguanide with broad antimicrobial activity –acts by rupturing cell membranes.

Commonly used as an antiseptic skin and wound cleanser for presurgical preparation of the patient.

As surgical scrub for health care personnel.

Also added as preservative to ophthalmic products.

Used internally in very dilute concentrations in the peritoneal cavity and urinary bladder.

Dentistry for child and adolescent –first south asia edition [Jeffrey A. Dean]
In dentistry, chlorhexidine is used
• for control of smooth surface caries
• for use as a denture disinfectants
• as plaque control agent

Numerous studies have been demonstrated that CH reduces plaque by 50-55% and gingivitis up to 45%.

Effective against
• gram positive and gram negative microorganisms
• yeasts, fungi and viruses

Exhibits both antiplaque and antibacterial properties.

Loe and Schioot reported highly significant inhibition of plaque formation and the prevention of gingivitis
with use of an aqueous 0.2% CH digulconate as mouthrinse twice daily with swishing 1 minute.

Dentistry for child and adolescent –first south asia edition [Jeffrey A. dean]
MECHANISM OF ACTION OF
CHLORHEXIDINE

1. ANTIPLAQUE ACTION

3 (Three) mechanisms of plaque inhibition

• Prevents pellicle formation by blocking acidic groups on salivary glycoproteins

thereby reducing glycoprotein absorption on to the tooth surface.
• Prevents absorption of bacterial cell wall onto the tooth surface by binding to the
bacteria.
• Prevents binding of mature plaque by precipitating agglutination factors in saliva
& displacing calcium from the plaque matrix.

Essentials of public health dentistry- soben peter 5th edition

2. ANTIBACTERIAL ACTION OF CHX

• Bacteriostatic at low concentration -> increased permeability -> increased

leakage, potassium.
• Bactericidal at high concentration -> precipitation of bacterial cytoplasm ->
death.
• These concentrations vary between bacterial species.
• After a single rinse with CHX saliva itself exhibits antibacterial activity for about
5 hours & suppresses salivary bacterial counts for over 12 hours.
• Following several rinses of chx number of aerobic & anerobic species in saliva
can be reduced by 80-90%.
THE ANTIBACTERIAL MODE OF ACTION OF CHLORHEXIDINE

The bacterial cell is characteristically Negatively Charged. The cationic chlorhexidine molecule is
rapidly attracted to the negatively charged bacterial cell surface, phosphate-containing
compounds.

This alters the integrity of the bacterial cell membrane and chlorhexidine is attracted towards the
inner cell membrane.

Chlorhexidine binds to phospholipids in the inner membrane, leading to increased permeability of

the inner membrane and leakage of low molecular weight components, such as potassium ions

Exhibits antimicrobial action

Chlorhexidine should not to be used before/ immediately after using a tooth paste- as
interactions with anionic surfantans –reduces effective delivery of chlorhexidine in an active
form.

Tooth paste should be used prior to chlorhexidine and excess toothpaste rinsed away with
water.

Essentials of public health dentistry- soben peter 5th edition

 AVAILABLE FORMS
Mouthrinses
• Aqueous alcohol solutions of 0.2% chlorhexidine
• 0.1% mouthrinse products
• 0.12% mouthrinse products
• 0.3 % mouthwash

2) Gel
• 1% CHX gel
• 0.2 & 0.12% CHX gel
3) Sprays
• 0.1 & 0.2%

4) Toothpastes
• 1% CHX toothpastes with or without fluoride
6
Chlorhexidine spray is effective with disabled and special child due to ease of administration.

Burtner and colleagues demonstrated 35% reduction in plaque levels in the study of severe
mental retardation.

Chitke and colleagues compared stannous fluoride spray and chlorhexidine spray among 52
individuals with mental disabilities.

It was found that plaque and gingival score was 48% and 52% in stannous fluoride group and
75% and 78% in chlorhexidine spray group

Chemical Plaque Control Strategies - Mohammed Jafar

Review Article
Journal Of Contemporary Dental Practice April 2016
Clinical uses As an adjunct to oral hygiene & professional prophylaxis
of CHX
For patients with jaw fixation

For gingival & oral hygiene benefits in mentally & physically handicapped

Medically compromised individuals predisposed to oral infections

High-risk caries patients

Recurrent ulcerations

Removable & fixed orthodontic appliance wearers

Subgingival irrigation

Carranza’s clinical periodontology-10th edition

Adverse effects Brownish staining of teeth on restorations. Staining is however reversible.
of
CHLORHEXIDINE
Loss of taste sensation.

Stenosis of the parotid duct has been reported.

Rarely hypersensitivity to chlorhexidine.

Essentials of public health dentistry- soben peter 5th edition

 OTHER PLAQUE CONTROL
AGENTS
TRICLOSAN

Phenol derivate which is recently included in mouth rinse and toothpastes.

Synthetic, non-ionic

Used as topical antimicrobial agent.

Broad spectrum activity against –

• gram positive
• gram negative organisms
• mycobacterium spores
• candida species
Essentials of public health dentistry- soben peter 5th edition
Triclosan acts on the microbial cytoplasmic membrane- inducing leakage of cellular constituents-
causing bacteriolysis.

Can delay plaque maturation

Inhibits formation prostaglandin’s and leukotrienes – key mediators of inflammation via inhibition
of both the cyclo-oxygenase and lipo- oxygenase pathways.

Essentials of public health dentistry- soben peter 5th edition

 DELMOPIN
OL
Morpholino ethanol derivative.

Inhibit plaque growth and reduce gingivitis.

Interferes with plaque matrix formation

Also reduces bacterial adherence.

Causes weak binding of plaque to tooth surface- aids in easy removal of plaque by mechanical
procedures. Therefore indicated as pre-brushing mouthrinse.

Essentials of public health dentistry- soben peter 5th edition

ADVERSE EFFECTS

• Transient numbness of tongue

• Tongue staining
• Taste alterations
• Mucosal soreness and erosion.

Essentials of public health dentistry- soben peter 5th edition

 METALLIC
IONS

Some of the metals have a plaque inhibitory capacity.

Example: salts of copper and zinc

Metallic ions acts by reducing glycolytic activity in microorganisms – delay the growth of
microorganisms.

Essentials of public health dentistry- soben peter 5th edition

 QUATERNARY AMMONIUM
COMPOUNDS
Cationic antiseptic and surface active agents

More active against gram positive than gram negative organisms

Therefore more effective against developing plaque ,which consists of predominantly consists of gram
positive organisms.

Mechanism of action:
• Positively charged molecule reacts with negatively charged cell membrane and phosphates
• Disrupts cell wall structure of microorganisms

Eg. Benzathonium chloride

Essentials of public health dentistry- soben peter 5th edition

 LISTER
INE

Essential Oil Mouth rinse

Combination of Thymol and eucalyptus mixed with menthol and methyl salicylate

Twice daily – recommended

Inferior in action to CHX

Chemical Plaque Control Strategies - Mohammed Jafar

Review Article
Journal Of Contemporary Dental Practice April 2016
 SANGUINARI
NE

Benzophenanthridine alkaloid

Derived from plant sanguinaria canadensis

Effective against gram negative organisms

Exhibits good retentive properties with dental plaque when used as mouth rinse.

Essentials of public health dentistry- soben peter 5th edition

 ENZYMES

1st group – not truly antimicrobial agents, more plaque removal agents

Dextranase, Mutanase, Protease

• Potential to disrupt early plaque matrix, dislodging bacteria from the tooth surface.
• Poor Substantivity
• Mucosal Erosions

2nd group – enhance host defense mechanisms.

• Glucose oxidase, amyloglucosidase
 ANTIBIOTICS

Antibiotics such as vancomycin, erythromycin, niddamycin, and kanamycin- used as plaque

control agents

Use of antibiotics have reduced- due to bacterial resistance and hypersensitivity reactions.

Essentials of public health dentistry- soben peter 5th edition

 ALOE VERA EXTRACT

Contains 98-99% water and 2 % active compounds

Main agents are Aloin, Aloemodin, Aloeride, Flavanoids, Methylchromones, sterols, amino acids
and vitamins.

Inhibits the growth of S Mutans, Streptococcus Sanguis, A Viscosus, and Candida Albicans

Chemical Plaque Control Strategies - Mohammed Jafar

Review Article
Journal Of Contemporary Dental Practice April 2016
AGE SPECIFIC HOME ORAL HYGIENE INSTRUCTIONS

Prenatal counselling

Infants(0-1 year)

Toddlers(1-3 years)

Preschoolers(3-6 years)

School aged children(6-12 years)

Adolescents(12-19 years)

Mcdonald & avery’ - Dentistry for child and Adolescent - first south asia edition
 PRENATAL
COUNSELLING
Best time to begin counseling parents and establishing a child's dental preventive program.

Preventive health recommendations.

Counseling them on their own hygiene habits and the effect they can have on their children as
role models.

Discussing about pregnancy gingivitis with the mother-to-be.

Mcdonald & avery’ - Dentistry for child and Adolescent - first south asia edition
 INFANTS (0-1
YEAR)
Moistened washcloth or Wet gauze to be used

Once daily

Infant brushes

No dentifrices

1st dental visit

Mcdonald & avery’ - Dentistry for child and Adolescent - first south asia edition
TODDLERS (1-3 YEARS)

Parents should be totally responsible.

Tooth brush introduced

Smear layer sized toothpaste (Rice grain)

Lap to lap position

Other plaque control aids not required

Flossing – if tight contacts present

Mcdonald & avery’ - Dentistry for child and Adolescent - first south asia edition
 PRESCHOOLERS(3-6 YEARS)

Fluoride dentifrice can be introduced at 3 years of age.

Pea sized toothpaste

Learn to expectorate

Flossing

Parent standing behind the child

Parents have passive role

Fluoride gel and rinses- home use-small quantity

Chemotherapeutic plaque control agents-not recommended.

Mcdonald & Avery - Dentistry for child and Adolescent - first south asia edition
SCHOOL AGED CHILDREN (6-12 YEARS)

Parental involvement still needed for supervision.

Disclosing agent

Use of mouthwash- introduced

Proper health care needed- early treatment of malocclusion, dental caries,

periodontal disease.

Fluoridated gels or rinses- strongly encouraged

Mcdonald & avery’ - Dentistry for child and Adolescent - first south asia edition
ADOLESCENTS(12-19 YEARS)

Developed skills

Compliance is the major problem

Poor dietary habits

Hormonal changes

Parents should adapt to their child’s changing personality and continue to reinforce the need for
oral health care and hygiene.

Mcdonald & avery’ - Dentistry for child and Adolescent - first south asia edition
IN-OFFICE ORAL HYGIENE
PROGRAMS
Oral prophylaxis

Reinstruction and remotivation in the plaque controlling program

Recare intervals should be personalised to individual patient’s need.

Education about dental treatments should be given for the awareness of the patient.

Mcdonald & avery’ - Dentistry for child and Adolescent - first south asia edition
THANK YOU!
INTERDENTAL ANATOMY
The interdental space is the physical space present between two adjacent teeth, and its shape and volume
are determined by the morphology of the teeth. The interdental papilla represents the gingival tissue that
fills this space and is formed by dense connective tissue covered by oral epithelium and may be influenced
by the height of the alveolar bone, distance between the teeth and interdental contact point.

Three types of gingival embrasure are seen:

a) Type I: Embrasures are completely occupied by healthy interdental papilla.
b) Type II: About 75% of embrasure is occupied by the gingiva.
c) Type III: About 50% of the embrasure is occupied by gingiva.

Interdental Aids-A Literature Review

Types of Condition of the Cleaning aids
embrasures gingiva in embrasures recommended for
embrasure cleaning
Type I Embrasure Embrasures are Dental floss is used.
occupied
by healthy interdental
papilla.
Type II Embrasure Slight to moderate Interdental brush and
degrees of recession. wooden toothpicks are
effective.
Type III Embrasure Extensive recession or Bristle ended unitufted
complete loss of brushes and thick spiral
interdental papilla. interdental brushes.

International Journal of Current Advanced Research Vol 8, Issue 01(C), pp 16866-16869, January 2019
 WOOD STICKS
Wood sticks are one of the earliest and most persistent “tools” used to “pick
teeth.” It dates back to the days of the cave people, who probably used sticks to
pick food from between their teeth.

Originally, dental wood sticks were advocated by dental professionals as ‘gum

massagers’ used to massage inflamed gingival tissue in the interdental areas to
reduce inflammation and encourage keratinization of the gingival tissue. They are
fabricated from soft wood to improve adaptation into the interdental space and to
prevent injury to the gingiva.

A triangular wood stick seems to have the correct shape to fit the interdental
space. 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 sides
against the adjacent tooth surfaces. The tapered form makes it possible for the
patient to angle the wood stick interdentally and even clean the lingually
localized interdental surfaces
Interdental Aids-A Literature Review
DENTAL FLOSS
• Used to remove plaque from interproximal surface in which embrassure are completely occupied by
healthy interdental papilla (type-1)

Method to use Dental floss

1. Spool method
2. Circular or Loop method

Interdental Aids-A Literature Review

Spool Flossing Method

• About 45 cm ( 18 inches ) long floss is

taken & about 10 cm ( 4 inches) from each
end is would around the middle finger of
each hands.
• In both the hands the last three fingers are
folded & closed & both the hands are
moved apart.
• In this way about 5 cm ( 2 inches) long
floss is held between the index fingers of
both the hands.
2. Circle or loop flossing method
( for children & individual with limited manual
dexterity)

• Loop or circle made from about 18 inches long piece

& both ends are tied securely with the three knots.
• All the fingers except the thumb of the floss is held
by both the hands having about 2.5 cm floss between
fingers of both hands.
Types of Dental Floss
 Waxed dental tape – Embrasures II,III large surface area, can be use with dentifrice.

 Waxed dental floss- Embrasure I, around rough tooth surface and restorations.

 Unwaxed round floss- Embrasure I, tight contacts.

 Tufted super floss (stiff end)- Embrasure II,III bridge(stiff end), exposed furcation, orthodontic
appliances, implant prosthesis.

 Colored floss – visualization of plaque and debris, by beginner, used by those with weak eyesight.

 Flavored floss – more appealing, lack of motivation.

 Impregnated floss tape containing fluoride, herbal extracts, abrasives, antibiotics-

therapeutic effect on gingiva

Interdental Aids-A Literature Review

Floss threaders it has a eye loop at one end, into
which the dental floss is passed. It is used to clean
Fixed partial dentures.The floss is passed through
the eye end.

Interdental Aids-A Literature Review

Tufted dental floss (Floss/yarn combination-
Regular dental floss is alternated with a thickened
tufted portion) eg- Super floss- 2 foot length
composed of 5 inch tufted portion adjacent to 3
inch stiffened end. Used in Fixed appliance or
orthodontic attachment.

NUFloss- roll like regular floss and has a cutting

device to
allow selection of preferred length. Tufted portion
(1 inch long) alternate with plain floss (1 ½ inch
long).

Interdental Aids-A Literature Review

METHOD OF TOOTH
BRUSHING IN CHILDREN
Horizontal scrub and Fones technique were two methods recommended for children commonly.

In horizontal scrub technique, the head of brush is placed perpendicular to the tooth surfaces and plaque
removal is done with back and force movement. Some authors suggested horizontal scrub for children and
claim that this technique had better plaque removal than Fones method.

In Fones technique, the child occluded their teeth, the toothbrush bristles place perpendicular to the tooth.
The plaque remove with fast, wide, circular motion extended from marginal gingiva of the maxilla to the
marginal gingiva of the mandible using light pressure. This technique recommended for young children
because it is easy to learn.

Mascher et al. suggested to educate sulcular technique (Bass method) to children aged 8 and above as they
obtained required motor skills and hand abilities.

Atarbashi-Moghadam F, Atarbashi-Moghadam S. Tooth Brushing in Children. J Dent Mater Tech 2018; 7(4): 181-4.
 HOW TO BRUSH YOUR CHILD’S TEETH
Young children aren’t able to brush their own teeth well enough so they need an
adult to do it for them.

Start by finding a comfortable position. This could be with your child sitting on
your lap facing away from you with their head resting against your body while you
cup their chin with one hand.

•Brush the teeth and along the gum line to clean every tooth thoroughly (about two
minutes is a good guide).
•Brush gently in small circles. Brush along the inside surfaces and the outside
surfaces.
•Brush back and forth on the chewing surfaces of teeth.
•After brushing, ask your child to spit out toothpaste, and not to rinse with water.
The small amount of toothpaste remaining keeps protecting teeth.

Atarbashi-Moghadam F, Atarbashi-Moghadam S. Tooth Brushing in Children. J Dent Mater Tech 2018; 7(4): 181-4.
TEACHING YOUR CHILD TO BRUSH
THEIR TEETH

Encourage children to take part in toothbrushing as they get older. At

around age two or three, help them develop the skill by letting them have
a go first before you follow up to make sure all surfaces have been
cleaned.

At around the age of eight years, children have developed the fine motor
skills needed for tooth brushing. However, supervision is often needed
past this age until you are sure they can do it well by themselves.

Atarbashi-Moghadam F, Atarbashi-Moghadam S. Tooth Brushing in Children. J Dent Mater Tech 2018; 7(4): 181-4.
CHOOSING THE RIGHT BRUSH AND
TOOTHPASTE FOR YOUR CHILD

Choose a toothbrush that is designed for children. It should have a small

head and soft bristles.

When choosing the right toothpaste, remember:

• for children 0–18 months of age – use only water, no toothpaste
• from 18 months until the child turns six years old – use a small pea-
sized amount of low fluoride children’s toothpaste (check on the pack)
• from six years of age – use a pea-sized amount of standard fluoride
toothpaste.

Atarbashi-Moghadam F, Atarbashi-Moghadam S. Tooth Brushing in Children. J Dent Mater Tech 2018; 7(4): 181-4.
CHILDREN WITH SPECIAL NEEDS

Powered toothbrush had superiority in plaque removal and decrease gingivitis in patients with
neuromuscular disability, visual impairments, and cerebral palsy.

Besides the ease of use and better motivation and compliance with powered toothbrushes for
physically and mentally disabled patients, better plaque removal from interproximal areas can help in
reducing gingivitis.

Goyal et al. concluded that verbal oral hygiene instruction in mentally handicapped patients was less
comprehensible. They suggested that visual demonstration of tooth brushing technique had a superior
effect in this group of patients even with manual toothbrushes.

Instead, in visually impaired children tell and touch method on a model seems to be an effective
method of oral hygiene instruction.

Atarbashi-Moghadam F, Atarbashi-Moghadam S. Tooth Brushing in Children. J Dent Mater Tech 2018; 7(4): 181-4.
CHILDREN WITH ORTHODONTIC APPLIANCES
Orthodontic appliances are plaque retentive devices which make plaque control more difficult and
finally predisposed the patients to dental caries and periodontal diseases. Powered toothbrushes
with soft filaments are very effective in plaque removal and around orthodontic appliances. Also,
specific orthodontic head for powered toothbrushes exist.

Shukla et al. found increase colonization of Streptococcus mutans and Candida albicans in oral
cavity of patients with fixed orthodontic appliances during treatment period. They claimed that
tooth brushing especially with powered toothbrush can control this condition, especially, if started
within the first month of orthodontic therapy.

Special orthodontic toothbrushes (bilevel) with short middle row was also designed which can use
directly over the appliances with short horizontal stokes. Sulcular technique (Bass or Modified
Bass method) is the method of choice for plaque removal at marginal gingiva, if the patients were
not predisposed to gingival recession. If regular toothbrush was used, the patient instructed to use
charter's method for cleaning the gingival side of brackets. Super floss or interproximal brush
were used for interproximal cleaning. Mouthwashes are recommended as an adjunctive for plaque
removal.
Atarbashi-Moghadam F, Atarbashi-Moghadam S. Tooth Brushing in Children. J Dent Mater Tech 2018; 7(4): 181-4.
Individuals with physical dysfunction like arthritis or stroke face a greater challenge in maintaining oral
care than people who do not have disabilities. It is essential to maintain good oral hygiene as neglecting it
causes dental diseases such as dental caries, gingivitis, and periodontitis. Brushing requires manual
dexterity, which is mostly diminished in patients with arthritis or stroke. The limited movement of hand
and finger makes holding the toothbrush a cumbersome task. So, it is essential to have a handle that fits
correctly in one’s hand to carry out brushing correctly.

Method of making 3D-printed customized handles that are individually adapted for use by an elderly
patient with limited manual dexterity. The customized handle allows better grip on the toothbrush, thus
making it easier for them to brush their teeth or denture. The technique is simple, cheap, and requires less
time than other techniques. The same handle can be used for toothbrushes and an interproximal
toothbrush.

Individually Modeled 3D Printed Toothbrush and Interproximal Brush Handle With Name for Patients With Limited Manual Dexterity. Cureus 14(7): e27097.
Molded handle around toothbrush and interproximal brush.

Individually Modeled 3D Printed Toothbrush and Interproximal Brush Handle With Name for Patients With Limited Manual Dexterity. Cureus 14(7): e27097.
Correct fit of interproximal handle into toothbrush handle.
Individually Modeled 3D Printed Toothbrush and Interproximal Brush Handle With Name for Patients With Limited Manual Dexterity. Cureus 14(7): e27097.
3D printed image.
Individually Modeled 3D Printed Toothbrush and Interproximal Brush Handle With Name for Patients With Limited Manual Dexterity. Cureus 14(7): e27097.
3D printed handle.

Individually Modeled 3D Printed Toothbrush and Interproximal Brush Handle With Name for Patients With Limited Manual Dexterity. Cureus 14(7): e27097.
3D printed handle with toothbrush. 3D printed handle with interproximal brush.

Individually Modeled 3D Printed Toothbrush and Interproximal Brush Handle With Name for Patients With Limited Manual Dexterity. Cureus 14(7): e27097.
ADA SPECIFICATIONS FOR ACCEPTABLE TOOTHBRUSH

1) Brushing surface- Length : 1-1.25 inches and 5/16- 3/8 inches wide

2) Surface area : 2.54-3.2cm

3) Number of rows : 2-4 rows of bristles

4) Number of tufts : 5-12 tufts per row

5) Number of bristles : 80-85 bristles per tuft

Toothbrush, its Design and Modifications : An Overview [Silky Mehta; C.V.Sruthi Vyaasini, Lucky Jindal, Vishnu Sharma, & Talika Jasuja
BASED ON THE SIZE OF ORAL CAVITY, DIFFERENT SIZES OF HEADS ARE AVAILABLE ACCORDING
TO THE AGE.

0-2 years : Brush head size should be approximately the diameter of a Hong Kong 10- cent coin
(~15mm)

2-6 years Brush head size should be approximately the diameter of a Hong Kong 20 – cent coin
(~19mm)

6-12 years Brush head size should be approximately the diameter of a Hong Kong 50 – cent coin
(~22mm)

12 years and above Brush head size should be approximately the diameter of a Hong Kong one
dollar coin (~25mm)

Toothbrush, its Design and Modifications : An Overview [Silky Mehta; C.V.Sruthi Vyaasini, Lucky Jindal, Vishnu Sharma, & Talika Jasuja
ADA Specification for bristle

2 - 4 rows of bristles

5 -12 tufts per row

80-86 bristles per tuft

Diameter of commonly used bristles are :

Soft = 0.007 inch (0.2mm)

Medium = 0.012 inch (0.3mm)

Hard = 0.014 inch (0.4mm)

Toothbrush, its Design and Modifications : An Overview [Silky Mehta; C.V.Sruthi Vyaasini, Lucky Jindal, Vishnu Sharma, & Talika Jasuja
PATTERN : The different bristle designs include flat trim, multilevel, wavy design,
zigzag design etc. The firmness of a bristle depends on three factors i.e.
Materials, diameter and length.

BRISTLE SHAPE : Toothbrush bristles with sharp edges (also known as burrs) are more
destructive to oral tissues than endrounded bristles. The soft-bristled
brushes that are ADA approved are end-rounded.

BRISTLE (Multitufted brushes) usually offer assorted bristle sizes and shapes and
ARRANGEMENT: are engineered for better cleaning.

Toothbrush, its Design and Modifications : An Overview [Silky Mehta; C.V.Sruthi Vyaasini, Lucky Jindal, Vishnu Sharma, & Talika Jasuja
HANDLE DESIGN
Assists with ease of brushing and helps patient compliance when brushing. A handle with an
offset or an angled offset design provides contact in line with the longitudinal axis of the handle
during tooth brushing
Patient state Characteristic Recommended Site Device Tooth- Effect
method brush

General No specific Rolling Buccal/Lingual Medium hardness Plaque Removal

problems Horizontal scrub Occlusal Gingival Massage
over age 7 Sweep in to out Inn Front Teeth prevention of
calculus deposit

Preschool Under age 6 Fones’ (circular) Lab/Buccal Small size Easy habit for child
Horizontal scrub Occ/Lingual
Perio. Problem Local Gingivitis Modified Bass Gingival sulcus 2-lane brush Sulcus cleaning
Perio pocket Gingival Massage
Gingivitis Wide gingivitis Modified Gingival Soft brush Gingival Massage
Stillmans
Hypersesitivity Premolar, Canine Rolling Cervical abrasion Soft brush, desensitization
desensitization effect
dentifrice

Bridge wearer Interdental M. Charters Brush tip -45 Zig-zag B. Proximal Cleaning
Pontic bottom degree Super fl. Pontic cleaning
Buccal to
Lingual
Hye-Jeong Bok and Cheon Hee Lee ： Proper Tooth-Brushing Technique According to Patient’s Age and Oral Status
Patient state Characteristic Recommended Site Device Tooth- Effect
method brush
Fixed Orthodo. Bracket site Horiz. ＋ Labial/Buccal Proxa B. Bracket cleaning
appliance Gingival site Charters Labial/Buccal Wat. Pik Ging.ma.
Proximal Bass Interdental area Proximal
Lingual Interd. Brush Lingual Cleaning
Rolling Concave head

Implant. Interdental Watanabe, T.Pik Proximal 2lane Br Periimplantitis

Denture wearer Partial denture Modifed Rolling Partial denture Partial Brush Denture
Full denture Full denture Full Brush Cleaner

Hye-Jeong Bok and Cheon Hee Lee ： Proper Tooth-Brushing Technique According to Patient’s Age and Oral Status
 TOOTH-BRUSHING METHOD

Horizontal scrub method

It has been the most popular motion for tooth-brushing

technique by uneducated people. It is a motion for scrub
tooth-surface with horizontal movement as back and forth
ward. It can be occurred the accumulation of micro-debris at
the inter-dental area and happen the cervical abrasion or
hypersensitive dentin through the using this motion for a long
time as 20 or 30 years.

Hye-Jeong Bok and Cheon Hee Lee ： Proper Tooth-Brushing Technique According to Patient’s Age and Oral Status
Rolling method

Rolling method of tooth-brushing is world-wide spread method

recommending for general peoples who have not specific oral
problems.
It has been suggested the movement of rolling through wrist the
hand which had hold a tooth-brush.
Sweep the tooth surface from up to down movement with
rolling the hand-wrist in upper teeth, and from down to up in
lower teeth.
Insert the tooth-brush straight with obliquely at inner side of
frontal teeth, both in upper and lower teeth, and sweep the
brush from inside to outside and horizontal movement as back
and forth for occlusal surface of posterior teeth, both upper and
lower.
Rolling technique is known as comparatively easy for learning
and effective for removal of plaque even at proximal area
Hye-Jeong Bok and Cheon Hee Lee ： Proper Tooth-Brushing Technique According to Patient’s Age and Oral Status
Bass technique

Bass technique of tooth-brushing has been recommended

for periodontal problem dental patient, even though it had
been some difficult to perform.
It needed for soft and 1 or 2 lane tooth-brush to vibrate
shortly and lightly with holding tooth-brush handle with
lightly. Short and light vibration would be needed inserting
one lane of tooth-brush into the gingival sulcus or
periodontal pocket which had been some inflammatory
tissues.
Vibratory action could induce the plaque removal and
gingival massage effect at the gingival sulcus, inorder to
subsid the gingivitis. Recent years, the modification of
Bass method as adding the rolling motion together to Bass
method has been recommended for subsiding gingivitis as
well as plaque removal effectively.

Hye-Jeong Bok and Cheon Hee Lee ： Proper Tooth-Brushing Technique According to Patient’s Age and Oral Status
Stillman method

Stillman method would be applied for gingival

inflammation area with relatively wide spread.
Short zig-zag movement with soft bristled and 3 or 4 lane
tooth-brush holding with lightly, from up to down ward
sweep with short vibration on the gingiva at the upper
jaw and from down to up at the lower jaw.
Gingival massage effect would be great to increase the
blood circulation on the inflammatory gingival area.
Also modification would be performed by adding the
rolling motion after zig-zag vibration at gingiva

Hye-Jeong Bok and Cheon Hee Lee ： Proper Tooth-Brushing Technique According to Patient’s Age and Oral Status
Fones’ method

Dr. Fones was a pediatric dentist and try to supply the

proper and easy method for tooth-brushing for preschool
child as sweeping with small sized kids tooth-brush with
motion as drawing continues circle on the teeth with
closing the mouth slightly. It could be easier to change
the rolling method after school aging than in horizontal
scrub method. Horizontal scrub action would be
accomplished on brushing on occlusal site and lingual
site

Hye-Jeong Bok and Cheon Hee Lee ： Proper Tooth-Brushing Technique According to Patient’s Age and Oral Status
Charters method

This method of tooth-brushing is emphasize to clean the

interdental area especially.
Insert tooth-brush tip with perpendicular direction to
longitudinal tooth axis at the proximal area or revers 45
degrees from the gingiva to tooth direction. And then,
short vibration would be needed focusing on the proximal
area.
But, this method is a little bit hard to perform at lingual
side of the tooth surface. This method is effective for
bridge wearer and well done at the bottom of the artificial
tooth on bridge area. Of course, it could be applied as
modified method by adding the rolling motion

Hye-Jeong Bok and Cheon Hee Lee ： Proper Tooth-Brushing Technique According to Patient’s Age and Oral Status
Watanabe’s, tooth-pick method

Dr. Watanabe has suggested that plaque removal and gingival

massage would be very important for periodontal problem
patient or dental implant patient, and they should eliminate the
plaque through the tooth-brushing movement of pushing
action from buccal side to lingual side with short vibration, so
we call as tooth-pick method.
It might be some hard for patient to perform by oneself at the
first without professional person aid., and it needed some
trainings from the dental professions.

Hye-Jeong Bok and Cheon Hee Lee ： Proper Tooth-Brushing Technique According to Patient’s Age and Oral Status