1. Plaque Control and Oral Hygiene 2023.pdf

Etiology Hypothesis of Periodontal Diseasae Bacteria in the mouth are responsible for breakdown of periodontal structures. Why should plaque be removed? Plaque Control Reduces or eliminates the risk for: • Plaque control is the removal of microbial plaque and the prevention of its accumulation...

Etiology Hypothesis of Periodontal Diseasae Bacteria in the mouth are responsible for breakdown of periodontal structures. Why should plaque be removed? Plaque Control Reduces or eliminates the risk for: • Plaque control is the removal of microbial plaque and the prevention of its accumulation on the teeth and adjacent gingival surfaces. - Glickman, 1984 • • • • • • • • • Dental caries Calculus Gingivitis Periodontitis Examples of plaque control neglect ß Calculus “bridge” Dental caries Calculus Gingivitis Periodontitis Halitosis Without plaque removal, oral health can neither be attained nor preserved. Plaque Biofilm Disclosing Products Disclosing Chewable à Tablets. Disclosing solution à 1 wk. no oral hygiene (upper L quad only) Health (disclosed) Surgical site Oral hygiene helps prevent “There is little value in providing professional mechanical plaque removal without oral hygiene instruction. Repeated oral hygiene instructions for personally applied plaque control appear as influential as professional cleanings on periodontal health.” Needleman I, et al.: A systematic review of professional mechanical plaque removal for prevention of periodontal diseases. Journal of Clinical Periodontology. 32 (Suppl. 6): 229-282, 2005. Periodontitis http://www.ada.org/sealprogramproducts.aspx Toothbrushing ____________________________________ Toothbrush • Myriad of toothbrush head design • Multi-level or angled bristles perform better than conventional flattrimmed bristles Toothbrush - The most widely used device/method for removing plaque from the teeth. Toothbrush • Myriad of toothbrush head design • Multi-level or angled bristles perform better than conventional flattrimmed bristles Classification of Toothbrushes by Bristle Diameter • SOFT • MEDIUM • HARD Natural Bristles Toothbrush = .16 to .22mm (.006 to .008 inches) = .23 to .29mm (.009 to .011 inches) = .30mm or greater (0.12 inches or greater) ßbamboo Nylon Bristles Toothbrushes are Superior to Natural • • • • • • Homogeneity of material Uniformity of size Elasticity Resists fracture Lacks sharp bristle tips Repels water and food debris Toothbrushing Techniques/Methods Categorized according to the pattern of bristle placement and motion: • Vibratory: Bass’, Stillman’s and Charter’s Technique • Roll: Roll-Stroke or Modified Stillman’s Technique • Circular: Fones’ Technique • Vertical: Leonard’s Technique • Horizontal: Scrub Technique Patients with periodontal disease are most frequently taught a sulcular brushing technique with vibratory motion. Effective Toothbrushing • • • • Guided, professional instruction Continual supervision Development of manual dexterity Knowledgeable dental staff https://www.youtube.com/watch?v=xm9c5HAUBpY&t=50s Bass’ Toothbrushing Method It is the most accepted and effective method for the removal of dental plaque present adjacent to and underneath the gingival margin. INDICATIONS: • It is most adaptable for: • Open interproximal areas • Cervical areas beneath the height of contour of enamel • Exposed root surfaces • It is recommended for patients with or without periodontal involvement. Charles C. Bass, M.D. 1875-1975 Bass’ Toothbrushing Technique Bass’ Toothbrushing Technique Proper positioning of the brush in the mouth aims the bristle tips toward the gingival margin Place the head of a soft brush parallel to the occlusal plane, with the brush head covering three to four teeth. This hygiene procedure begins at the most distal tooth in the arch and systematically proceeds mesially. Place the bristles at the gingival margin, pointing at a 45-degree angle to the long axis of the teeth Place the bristles at the gingival margin, pointing at a 45-degree angle to the long axis of the teeth Bass’ Toothbrushing Technique ADVANTAGES: • Effective method for removing plaque. • Provides good gingival stimulation. • Easy to learn. DISADVANTAGES: • Overzealous brushing may convert very short strokes into scrub technique of brushing and cause injury to the gingival margin. • Time consuming. • In certain patients dexterity requirement is too high. Charter’s Technique TECHNIQUE: Bristles are placed at an angle of 45° to the gingiva with the bristles directed coronally. The bristles are activated by mild vibratory strokes with the bristle ends lying interproximally. Exert gentle vibratory pressure using short, back-and-forth motions without dislodging the tips of the bristles. This motion forces the bristle ends into the gingival sulcus area as well as partly into the interproximal embrasures. The pressure should be firm enough to blanch the gingiva. Charter’s Technique INDICATIONS: • Individuals having open interproximal spaces with missing papilla and exposed root surfaces • Those wearing fixed partial dentures or orthodontic appliances • Patients who have had periodontal surgery • Patients with moderate interproximal recession Stillman’s Technique • Like the other vibratory techniques, the filaments are placed at a 45° angle to the tooth. • Unlike the Bass Method, the bristles are placed half in the sulcus and half on the gingiva. • The same stroke is used as Bass (small circular motions). Which method is best? Sequence of Toothbrushing • Each patient has different needs • Not one method is perfect for all patients. Some patients may use more than one method. • The important thing is to brush thoroughly for at least two minutes each time and two times a day… Sequence of Toothbrushing Facial #17 to #32 Sequence of Toothbrushing Lingual #17 to #32 Facial #1 to #16 Maxillary – Lingual (Stillman Method) Sequence of Toothbrushing Lingual #1 to #16 Sequence of Toothbrushing Maxillary and Mandibular occlusal surfaces Dorsum of the tongue • Force applied to tissues. • Rigidity of the bristles (hard vs. soft toothbrush. • Morphology of the bristle tips. • Method of brushing (requires more evidence). Hard bristled brushes caused 3.6 times more abrasion than soft brushes using the same dentifrice. Manly, RS and Brudevold F: JADA 55: 779-780, 1957 Gingival Abrasion ------------------------ Factors Associated with Toothbrushing Gingival Trauma and Abrasian Rolled gingival margins Hard tissue damage caused by oral hygiene procedures is thought to be mainly due to abrasion agents in dentifrices, whereas lesions in the gingiva may be produced by toothbrushing alone. Sangnes, G. J. Clin. Periodont. 3:94-103, 1976 Soft toothbrush only! All have polished, end-rounded bristles. Splaying of the bristles indicates that the patient is brushing with too much force. When ready to replace in 2 to 4 months, there should be no splaying! CDM Periodontics Toothbrushing Instruction Tips 1. 2. 3. 4. 5. Patient must understand why plaque needs to be removed. Demonstrate technique in the patient’s mouth while patient looking in a hand mirror! Light force - hold manual toothbrush with 3 fingers. • If toothbrush bristles are splaying, patient is brushing too hard. Reinforce sequence of tooth brushing. Replace toothbrush every 2 - 4 months. Toothbrush Summary • 100% plaque removal is impossible to achieve. • No difference in effectiveness between brushes. • 40-50% plaque removal. • Duration 2 minutes: manual and powered. • Frequency? Once every 24-48 hours (Kelner et al. and Lang et al. J Perio 1973 and 1974) Mechanical Toothbrush Toothbrush Summary • No technique significantly better • Subgingival range of brush = approx. 1mm • Supragingival plaque control has no effect on the subgingival plaque in deep pockets. Powered Toothbrush Summary 1) 2) 3) 4) 0 - 30% additional plaque removal compared to manual toothbrush. Subgingival penetration ≈ 1-2 mm. No one electric toothbrush has been shown to be superior to another. Indicated for patients who do not achieve adequate plaque control with manual toothbrush. Powered Toothbrush Summary Dentifrices “A substance used with a toothbrush for the purpose of cleaning the accessible surfaces of teeth.” Cosmetic: cleans and polishes Therapeutic: must reduce disease (including sensitivity) Most have 5 key ingredients: fluoride, abrasives, flavors, humectants and detergents. Dentifrices Dentifrices FLUORIDE • Nature’s cavity fighter • Mineral that helps strengthen enamel, making it less susceptible to cavities and less likely to wear down from acidic foods and drinks • To earn the ADA Seal of Acceptance, a dentifrice MUST contain fluoride Dentifrices FLAVORS • Sweeting agents, such as saccharin or sorbitol. HUMECTANTS • Keep toothpaste from drying out and becoming crumbly, by trapping water in the toothpaste. • Sorbitol, glycol and glycerol. DETERGENTS • Foamy effect ensures that other active ingredients coat the teeth; • Sodium lauryl sulfate, most common detergent in toothpastes. ABRASIVES • Considered an inactive ingredient, but important because they help remove food debris and surface staining from teeth; • Ancient Egyptians and Romans used crushed eggshells or crushed oyster shells in their toothpaste; • Calcium Carbonate, Dehydrated silica gels, and hydrated aluminum oxides; • Scrub and polish the teeth surface without damaging the enamel; • Keep abrasives in mind, and ensure you are not pressing your toothbrush too hard against the teeth. Dentifrices Do NOT enhance plaque removal!!! Historically, NaF has been the primary added fluoride ingredient Stannous fluoride (SnF) – antimicrobial properties, but due to staining hexametaphosphate has to be added Dentifrices • Baking soda may help to reduce bleeding • Perio Patients may benefit from dentifrices with arginine, Calcium sodium phophosilicate, NaF, SnF and strontium, which have been shown to be clinically effective in treating dentinal hypersensitivity Many other toothpastes available! Prescription toothpaste with 5000 ppm fluoride By prescription only! Subgingival One Flossing Technique Wrapping floss around middle fingers ≈ 18 inches “C” • Interproximal disease • Cleanse 40-50% of surfaces Frees up the index fingers and thumbs One use for the index fingers and thumbs • Waxed versus unwaxed? no difference! ≈ 1 inch Dental Floss Summary ___________ Thread the stiffened end under interdental contacts and appliances . Spongy part of the floss ß • No significant differences between waxed and unwaxed floss; • 30 to 50% plaque removal; • Subgingival penetration = 2 to 3mm • Supragingival plaque control has no effect on the composition of subgingival plaque in deep periodontal pockets. August 2016 2011 Cochrane Systematic Review U.S. Department of Health and Human Services removed flossing as a recommended practice. • Including floss, sticks, interdental brushes, and oral irrigators. • Evidence on the topic is of very low quality due to small numbers of studies, sample sizes, and interpretation of results. Rationale is that the overall evidence is “weak, very unreliable” and carries a “moderate to large potential for bias”. • Conclusions from short-term studies (up to 6 month follow-up) “The majority of available studies fail to demonstrate that flossing is generally effective” • Flossing in addition to brushing leads to a statistically significant (although small) reduction in gingivitis. What about caries? • Meta analysis: JDR Hojoel et al. Dental flossing and interproximal caries: a systematic review. • Regular (5 days per week) professional flossing results in a significant reduction in interproximal caries. This result is not seen with intermittent (every 3 months) professional flossing nor self-flossing. What do we tell patients? • How do we give guidance when there isn’t strong evidence? • Keep in mind that patients look to us for advice. • The average benefit may be small, and the “quality” of the evidence is low (true benefit may be higher or lower) HOWEVER nearly half of all Americans have periodontal disease so even a small benefit could be significant. • Chance for benefit, low cost, low risk- why not? Other Oral Mechanical Devices Floss Holder Floss Threader 1614 Interproximal Brushes 1612 New! When you see open interproximal spaces, think interdental brush! Go-Betweens (smallest) For on the go Interproximal Spaces à Under pontics Proxabrush inserted from the lingual aspect. à Through and through furcations à Buccal furcation access Subgingival Penetration Toothbrush 1 mm Floss 2 – 3 mm Interdental Brush 2 – 3 mm Supragingival plaque control has no effect on the composition of subgingival plaque in deep periodontal pockets. Note bleeding Greenstein, G. J. Periodontol. 63: 118, 1992 à Perio-Aid The Natural Dentist® Tighten the collar à Round tapered ends Marquis Dental Break off the long end à Held in your fingers y ximall terpro Use in Waterpik (“Water Flosser”) American Dental Association Supports Water Flossing ADA has updated its website to reflect Water Flossing as an option in place of string floss. 9/15/2015 Rubber Tip Sunstar GUM® Stimulator Supposedly a gingival “massager.” Ø There is no benefit known to "stimulating/massaging" gum tissue. Ø Indicated in wide interproximal areas or under pontics. Ø Not efficient at plaque removal.