"Plaque Control - An Overview"
Plaque Control - An Overview
INTRODUCTION:
Plaque is a sticky film of bacteria that constantly forms on teeth. Bacteria in plaque produce acids after you eat or drink. These acids can destroy tooth enamel and cause cavities and gingivitis (gum disease). Plaque can also develop under the gums on tooth roots and break down the bones that support teeth. Untreated plaque can harden into tough-to-remove tartar. Proper oral hygiene, including daily brushing and flossing, gets rid of plaque.
Periodontal diseases are the most common chronic diseases of the oral cavity. Its prevalence is recorded along with the history of man, often his appearance on the earth. Experimental and epidemiological studies have demonstrated that these diseases are dependent on the microorganisms present in the plaque. Of all the local factors, bacterial plaque is the single most significant local factor in the initiation, development and progression of inflammatory periodontal diseases. Research evidence indicates that gingival inflammation can be reduced by consistently reducing and eliminating the accumulation of bacterial plaque. Therefore plaque control is the most effective method and the basis for the prevention of all inflammatory change sin periodontal tissues.
1)The primary role is the removal of soft deposits on the teeth and gingival tissues.
2)Gingival stimulation may play a role in increasing gingival tone, surface keratinization, and gingival vascularity.
CLASSIFICATION OF
PLAQUE CONTROL METHODS:
I. Mechanical plaque control
II. Chemical plaque control
I.
Mechanical
Plaque Control :
1. Tooth brush
2. Interdental aids
i. Dental floss
ii. Triangular tooth pick
Hand held triangular tooth pick
Proxapic
iii. Interdental brushes
Proxabrush system
Bottle brush
Single tufted brushes
iv. Yarn
v. Perioaid
3. Others
i. Gauze strips
ii. Rubber tip stimulator
iii. Water irrigation device
iv. Floss holders
II.
Chemical
plaque control
a. Antibiotics
b. Dentifrices
c. Mouthrinses
d. Disclosing solution
I. Mechanical Plaque
Control:
i. Tooth Brush : The tooth brush is the most effective and safest device used to remove dental plaque, it has no side effects, does not introduce distastefull flavour, it is easy to use and inexpensive used with tooth paste it removes stains, and is the vehicle for delivering breath freshening and therapeutic agents in tooth paste.
History: Chinese invented the modern tooth brush during Tang dynasty. They used hog bristles similar to those of more contemporary models.
ð
In 1780 William Addis of
ð In 1990's celluloid began to replace bone hands, in 1930's nylon bristles came into existence.
DIMENSIONS OF TOOTH
BRUSH,
1. Total brush length is about 15 cm.
2. Head should be only large enough to accommodate the tufts.
3. Length of brushing plane 25.4 mm to 31.8 mm, width 7.9 to 9.5 mm.
4. Bristle or filament height 11 mm.
5. 2-4 rows of bristles, 5-12 tufts in each row.
Technique: Place the head of the soft brush parallel to the occlusal plane, with the brush head covering 3 teeth, beginning at most distal tooth in the arch plane the bristle at the gingival margin, establishing one angle of 45o to the long axis of the teeth. Exert gentle vibratory pressure, using short back and forth motion without dislodging the tips of the bristles. The forces of bristles enters into gingival sulci as well as into interproximal embrasures and should produce perceptible blanching of gingiva. Complete 20 strokes in same position continue around arch, buccal, lingual brushing then move to mandibular arch. To reach occlusal surfaces, press bristles firmly and activate 20 back and forth strokes.
ð Short back and forth motion is easy to master.
ð It concentrates cleaning action on cervical and interproximal portions of teeth, where microbial plaque is detrimental to gingiva.
Recommended: For the routine patient with or without periodontal involvement.
THE ROLL OR ROLLING
STROKE METHOD:
Purpose and Indication:
ð Cleaning gingiva and removal of plaque, materia alba and food debris from the teeth without emphasis on gingival sulcus.
ð Used in children and adults with limited dexterity.
Technique: The roll technique is taught by explaining that teeth should be brushed the way they grow, down on the upper teeth and up on the lower teeth. This action is repeated five times in each location until all the teeth are brushed. The rolling strokes must be performed slowly so that the gingival one third of the teeth will be cleaned adequately.
ð Brushing too high during initial placement can lacerate the alveolar mucosal.
ð Tendency to use quick, sweeping strokes results in no brushing for cervical third of the teeth.
ð Replacing brush with filament tips directed into gingiva can produce punctuate lesions.
ð This method is originally described by Stillman.
ð The Modified Stillman incorporates a rolling stroke after the vibratory phase, and this minimises the possibility of gingival trauma and increases the plaque removal effects.
Technique: A soft or medium, multitufted brush can be used the brush should be placed with the bristle ends resting partly on the cervical portion of the teeth and partly on the adjacent gingiva, pointing in an apical direction at an oblique angle to the long axis of the teeth pressure is applied laterally against the gingival margin to produce a perceptible blanching. The brush is activated with 20 back and forth strokes and is simultaneously moved in a coronal direction along the attached gingiva, gingival margin and the tooth surface. This process is repeated on all tooth surfaces, proceeding systematically around the teeth.
This method was described by Charter.
Indications:
ð Massage and stimulation of gingiva.
ð Indicated to aid in plaque removal from proximal tooth surfaces when interproximal tissue is missing.
ð Indicated after periodontal surgery
Technique: A soft or medium multi tufted brush is placed on the tooth with the bristle pointed toward the crown at a 45o to the long axis of the teeth. The sides of the bristles are flexed against the gingiva and the back and forth vibratory motion is used to massage the gingiva. To clean the occlusal surfaces, the bristle tips are place in the pits and fissures and the brush is activated with short back and forth strokes.
Circular or the Fone Method:
This method was originally described by Fones.
Indication: May be recommended as an easy to learn first technique for young children.
Technique:
With the teeth closed, place the brush inside the cheek with the brush tip lightly contacting the gingiva over the last maxillary molar. Use a fast, wide circular motion that sweeps from maxillary gingiva to mandibular gingiva with very little pressure. Bring anterior teeth in end to end contact and hold lip out when necessary to make the continuous circular strokes. Lingual and palatal tooth surfaces require an in and out strokes.
The Smith's Method (Physiologic Method):
ð It was based on the principle that the tooth brush should follow the same physiologic pathway that food follows when it traverses the tissues of natural mastication.
ð A soft brush with small type of fine bristles in four parallel rows and trimmed to an even length was used in brushing stroke directed down over the lower teeth onto the gingiva and upward over the teeth for maxillary.
Scrub Method: Vigorously combined horizontal, vertical, and circular strokes with some vibratory motions for certain areas comprise a scrub technique. Soft brushes with rounded filaments were used. Technique is used with short strokes for plaque removal in the cervical area following perio surgery.
There are many types of power driven tooth brushes in the market today. These brushes employ several different types of stroke action. The heads of most powered or mechanical tooth brushes are smaller than manual tooth brushes and are usually removable to allow for replacements. The head follows three basic patterns when the motor is started (1) reciprocating a back and forth movement, (2) acute an up and down movement; and (3) elliptical a combination of the reciprocating and acute motions powered tooth brushes are consistingly superior to manual tooth brushes in plaque removal of gingivitis efficacy.
1) Powered tooth brushes can be particularly beneficial for parental brushing of children's teeth.
2) For patients who are physically handicapped mentally retraced age arthritic or otherwise with or dexterity is and far those patients who are poorly motivated.
3) These brushes are especially recommended for patients who require a large handle because powered models are easier to grasp.
The prime goal of dental profession since many years has been to develop system / device / technique that would make tooth brushing more enjoyable and also would automatically brush teeth on an optimum manner. Fredrich Tornberg a Swedish watch maker who in 1888 designed the first mechanical tooth brush to be followed by the introduction of the first electric tooth brush in 1959.
Patients with extensive prosthodontic on endosseous implants.
ð Orthodontic patients
ð Periodontal patients who are on periodontal maintenance / supportive periodontal therapy
ð Poor manual dexterity
ð Hospitalized or institutional patients who need a care taker or nurse to carry out oral hygiene
ð Cannot be use in patients with cardiac pacemaker.
ð Cannot be used in patients suffering from infectious diseases eg. AIDS, Hepatitis B etc.
The term ultrasonic is defined by Dorlands Medical Dictionary as pertaining to mechanical radiant energy having a frequency beyond the upper limit of perception to the human ear. That is, beyond 20,000 cycles / sec. The ultrasound brush is the tooth brush which sues ultrasound mechanism to destroy plaque and eliminate tooth decay.
Two types: One type, the head is powered by a battery and is like a simple electric motor, which produces oscillations.
Another method is by magnetostriction similar to ultrasonic scalars. Their frequency varies from 40 to 250 Hz.
Dental Floss: Historically dental floss was used for cleaning the interproximal surface in 1800th century.
ð Parmly in 1819 recommended waxed silken thread for flossing the teeth.
ð In 1948, Bass accomplished research and development of unwaxed floss in use today.
ð Floss is available as a multifilament nylon yarn that is either wisted or non-wisted bonded or non-bonded waxed or unwaxed.
A variety of individual factors, such as tightness of tooth contact, roughness of interproximal surfaces, and the patient’s manual dexterity determines the choice of the type of the dental floss.
Silk: Floss is made of silk fibres loosely twisted together to form a strand and waxed for interproximal cleaning.
Nylon: Nylon multifilaments, waxed or unwaxed, have been widely used in circular or flat form plaque removal.
Expanded PTFE: Plastic monofilament polytetrayfluoroethylene with wax is used for proximal tooth surface plaque removal.
Dental Flossing Methods:
ð Two frequently used flossing methods are ;
a) Spool Method
b) The circle or loop method
a) Spool Method: Suited for teenagers and adults who have acquired the level of neuromuscular co-ordination and mental maturity required to use floss.
ð A piece of floss approximately 18 inch long is taken and is wound lightly around the middle finger and the rest of the floss is similarly wound around the same finger of opposite side.
ð The last three fingers are clenched and the hands are moved apart, pulling the floss tact, thus leaving the thumb and index finger of each hand free.
ð To insert, the floss is gently eased between the teeth while sawing patient back and forth at the contact point.
ð Once part the constant point the floss is adapted to turn in each interproximal surface by creating a C-shape.
1) Pressure in col area: Can distract to the attachment.
2) Prevention of floss cuts and clefts.
Floss holder is a device that eliminates the need for placing fingers in the mouth. Recommended for individuals.
ð with physical disabilities
ð Lacking manual dexterity
ð Limited mouth opening
ð With a strong gag reflex
ð A floss holder usually consists of a yoke-like device with a three quarter to 1 inch space between the two prongs of the yoke.
ð The floss is secured tightly between the two prongs.
ð The patient grasps the handle of the device to guide it during use.
ð A floss threader is a plastic loop into which a length of floss is inserted.
ð It is used to carry floss through embrasure areas under defective contact points that are too tight for floss insertion.
ð Also used under pontics
ð Around orthodontic appliances
ð Under splinting
a) Wooden interdental picks / cleansers - made of wood or plastic and are triangular in cross section.
Indications: For cleaning proximal tooth surfaces where the tooth surfaces are exposed and interdental gingiva is missing.
Procedure: A rest is used by placing the hand on the cheek o chin, or by placing a finger on the gingiva convenient to the place where the tip will be applied.
ð Soften the wood by placing the pointed end in the mouth and moistening with saliva.
ð Hold the base of the triangular wedge toward the gingival border of the interdental area and insert with the tip pointed slightly toward the occlusal surfaces to follow the contour of the embrasure.
ð Clean the tooth surface by moving the wedge in and out while applying a burnishing stroke with moderate pressure.
ð Discard the cleaner as soon as the first signs of splaying are evident.
An interdental brush is a small, spiral, bristle brush used.
ð To clean spaces between teeth, around fractions, orthodontics bands and fixed prosthetic appliances.
ð Also in cases of periodontal therapy
ð To provide some stimulation to the gingival tissues.
ð To apply chemotherapeutic agents.
A) Small insert brushes with reusable handle.
B) Brush with wire handles
C) Single tuft brush (end tuft, unituft)
1) Soft nylon filaments are twisted into a fine stainless steel wire for insertion into a handle with an angulated shank.
2) The small tapered or cylindrical brush heads are of varying sizes approximately 12 to 15 mm in length with a diameter of 3 to 5 mm.
1) Soft nylon filaments are twisted into fine stainless steel wire the wire is continuous with the handle which is approximately 35-45 mm in length.
2) The diameter of the bristle should be slightly larger than the space to be cleaned the brush is moistened then inserted into the area at an angel approximating the normal gingival contour and an in and out motion is used to remove plaque and debris.
The single tuft or group of small tuft may be from 3 to 6 mm in diameter and may be flat or tapered and handle may be straight or contraangled.
Indications:
- For open interproximal areas
- For fixed dental prosthesis
ð Direct the end of the tuft into interproximal area and along the gingival margin.
ð Combine a rotating moting with intermittent pressure.
ð Knitting yarn Indicated on proximal surface of widely spared teeth
ð Gauze strip
ð For surfaces of teeth next to edentulous areas.
Indication:
ð For proximal surfaces when interdental gingiva is missing
ð For open furcation areas.
Irrigation is the targeted application of a pulsated or steady stream of water or other irrigant for cleaning for therapeutic purposes. Oral irrigation is an adjunctive method for the arrest and control of gingival infection.
ð Power driven device
ð Non power driven device
Procedure: Direct the jet tip toward the interdental area until almost touching the tooth surfaces and start on lowest pressure setting, increase slightly over time.
Advantages of Oral
Irrigation:
Reductions of Gingivitis:
Supragingival irrigation is effective for removing loosely attached bacterial plaque and reducing gingivitis.
ð Penetration into pocket: Subgingival access.
ð Reduction or alteration of microbial floraà Both supra and subgingival irrigation reduce microbial colonization.
ð Delivering antimicrobial agents.
Contraindications: The history of a patient who requires antibiotic premedication for dental treatment should be reviewed before introducing the use of an oral irrigation or other mechanical devices. The incidence of bacteremia from oral irrigation ranges from a low of 6% in patients with gingivitis to a high of 50% in patients with periodontitis.
Certain patients may not be willing or able to perform adequate mechanical plaque removal on regular basis. Patients who have poor plaque removal, habits due to physical impairment, mental impairment, poor motivation and intra oral conditions such as malposed teeth, bridge work or orthobands, these can be beneficial through chemical plaque control.
Antiplaque compounds have been categorized into first generation and second generation agents depending mainly on their antimicrobial efficiency and relative substantively.
First Generation Agents:
Antibiotics, phenols, quaternary ammonium compounds and sanguinarine. They reduce plaque by about 20-50% and their efficiency is limited by their poor retention in the mouth.
They reduce plaque by 70% to 90% more effectively retained by oral tissues and are released slowly. Ex. Chlorhexidine, triclosan etc.
Third Generation Agents:
Substantive with mild antibacterial effects but which interfere with bacterial effects but which interfere with bacterial adhesion referred to as third generation.
ð Prevent bacterial attachment (antiadhesive)
ð Inhibit bacterial division (antimicrobial agents)
ð Remove Plaque
ð Alter plaque etiology
Essential Oil
Oldest forms of mouth wash, most popular being Listerine which is compared of phenolic related essential oil. 0.06% thymol, 0.09% eucalytpic, mixed with 0.04% menthol.
Mechanism of Action: These agents interfere with enzymatic functioning of cell. At low concentration, adsorb to lip portion of cell and interfere with cell transport. These agents appear to reduce or extract cell was lipopolysaccharides and thus decrease the pathogenic potential.
Other essential oils used in oral products are cinnamon, clove, thymol etc.
Adverse Effects: Initial burning sensation.
Antibiotics: The bacterial nature of dental plaque and its primary role in the etiology of gingivitis has stimulated research into us of antibiotics in controlling these diseases.
Vancomylin:
It is a bactericidal antibiotic that is poorly absorbed after oral dosage. It was shown that daily application of ointment, containing the drug markedly reduced the plaque formation in mentally retarded institutionalized patients.
Erythromycin: Erythromylin suspension q.i.d. for seven days reduce the quantity of plaque by 35%.
Kanamylin: is an aminoglycoside antibiotic that has a broad spectrum of activity. 5% of kanamycin, topical paste when applied thrice daily for 3 weeks, inhibits plaque formation by 57%.
Phenol: Most phenols exert a non-specific antibacterial action which is dependent upon the ability of the drug to penetrate the lipid component of the cell walls of organisms the resulting structural damage will affect the permeability control of microorganisms in addition to several metabolic processes that are dependent upon enzymes contained in the cell membranes.
Triclosan: It is a bisphenol and a non-ionic germicide with low toxicity and broad spectrum of antibacterial activity. It is made in combination with zinc citrate to act as a potential antiplaque agent.
Quaternary Ammonium Compound: Are cationic, antiseptics and surface active agents. The cell was structure of the microorganisms is disrupted and permeability of the cell wall is increased. Quaternary amines tend to be more effective against gram positive than gram negative organisms.
Sanguinarine: It is an antiplaque and anticalculus agent. Sanguinarine is a alkaloid derived from the plant sanguinaria canadenris. It makes cells more vulnerable and less enzymatically active. But it has an adverse effect of burning sensation when used initially.
Mechanism of Action: It covalently binds to reactive sulphahydryl group by trapping thiol compounds and this renders cell more vulnerable and less enzymatically active.
CHLORHEXIDINE:
Chlorhexidine gluconate is a cationic bisbiguanide with pronounced antiseptic and antiplaque activities. The action of chlorhexidine as antiplaque agent was suggested by Schroeder in 1969. When used as a mouth rinse twice daily as a supplement to tooth brushing, showed reduction of plaque in the range of 50-55% and the reduction of gingivitis about 45%.
Mechanism Antiplaque Effect:
Chlorhexidines superior antiplaque activity is due to its property of sustained availability this involves a "reservoir" of chlorhexidine slowly desorbing from all oral surfaces resulting in a bacteriostatic milieu in the mouth.
ð An immediate bactericidal activity at the time of application.
ð Followed by a prolonged bacteriostatic action as a result of chlorhexidine adsorbing to the pellicle coated enamel surface.
DENTIFRICES:
These are defined as substances used with a tooth brush for the purpose of removing dental plaque, material alba debris and for applying specific agents to the tooth surfaces for preventive or therapeutic purposes.
· Detergents : 1- 2%
· Abrasive : 25-60%
· Binder (Thickeners) : 1-2%
· Humectant : 20-40%
· Flavourong agents : 1-1.5%
· Water : 15-50%
· Preservative, sweetener
· Coloring agents : 2-3%
· Lowers surface tension
· Penetrate and loosen surface deposits and stains
· Emulsify debris for easy removal by tooth brush and gives forms Eg. Sodium lauryl sulfate, Sodium N-lauryl sarcosinate.
1. Mild abrasive actin helps to eliminate plaque from teeth hence decrease plaque build up.
2. Abrasive agent removes stained pellicle from teeth, polishes the surfaces, restores natural lusture and enhances enamel whiteness, without an abrasive, teeth often become stained. Eg. Calcium carbonate, calcium pyrophosphate calcium, orthophosphate, silicate.
Abrasive to be chosen carefully so it polishes and cleans without scratching or damaging enamel or softer underlying tissues, dentine. So attention to be paid to size of particle and their shape and hardness.
Binders: Controls stability of consistency of tooth paste also affects ease of dispersion of paste in mouth, choice of correct binder and concentration is critical to ensure that the product can be readily squeezed from tube and yet have good appearance when on tooth brush.
1. Water soluble: Including originates alginates and Na carboxyl methyl cellulose.
2. H2O insoluble: Mg Al silicate, Na Mg silicate and colloidal silica.
1. Provides vehicle for abrasive, surfactant, drugs and other components of dentifrice.
2. Provide base on which to construct paste structure.
3. Retain moisture so as to prevent drying out of paste exposed to air during prolonged time period.
4. To prevent microbial growth
5. To add sweetness and other organoleptic benefits.
Eg. Glycerol, sorbitol, propylene xylol.
Sweetening agents: Until recently chloroform was added to augment sweet flavor + provide cool sensation, not practiced now as found to be carcinogenic. Artificial sweating agents eg. Sorbitol, glycerin, manitol are currently in use.
Therapeutic Agents: For delivering other oral health benefit they include anticaries agents, antiplaque, antitarter, antisensitivity and whitening agents.
Anticalculus dentifrice: Contains Zn compounds or soluble pyrophosphates or major calculus inhibitors.
Preservatives: Prevent bacterial growth. Eg. Alcohols, formaldehyde, benzoate, Dichlorinated phenol.
To make dentifrice desirable and mask the other lesser pleasant flavors e.g. essential oils like peppermint. Oil of wintegreen etc.
Attractiveness vegetables dyes are used.
Other Ingredients: Include titanium dioxide to whiten the appearance of product and preservative (benzoates) to ensure microorganism do not grow in paste.
CONCLUSION:
To achieve optimal oral health, tooth brushing must be supplemented with the use of specific interdental cleansing devices.
Emphasis must be placed on the efficiency of complete plaque removal at least once per day, rather than the frequency of brushing alone. To comparative merits of the various oral hygiene devices and the techniques, abilities and motivation of each patient should be carefully considered when recommending. Specific oral hygiene measures to meet the needs of each individual patient.
Dr. Mayank Chandrakar is a writer also. My first book "Ayurveda Self Healing: How to Achieve Health and Happiness" is available on Kobo and Instamojo. You can buy and read.
For Kobo-
https://www.kobo.com/search?query=Ayurveda+Self+Healing
The second Book "Think Positive Live Positive: How Optimism and Gratitude can change your life" is available on Kobo and Instamojo.
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