Plaque Control and Oral Hygiene Techniques

Posted on Aug 24, 2024 in Biology

Plaque

Entity formed by the colonization and growth of microorganisms of varying strains and species that accumulates on the surface of teeth, gingiva, and other restorations.

Plaque Control

Plaque control is the removal of microbial plaque and the prevention of its accumulation on the teeth and adjacent gingival surfaces.

Disclosing Agents

  1. Plak-lite mirror fluorescing solution

Methods of Plaque Control

Mechanical Plaque Control

  • Tooth brushing
  • Interdental aids
  • Oral physiotherapy
  • Oral irrigation

Chemical Plaque Control

  • Adjuncts to mechanical plaque control

Toothbrushes

1 – 1.25 inches (25.4 to 31.8mm) long

5/16 to 3/8 inches (7.9 to 9.5mm) wide

2 to 4 rows of bristles

5 to 12 tufts per row

80-85 bristles per tuft

Objectives of Mechanical Plaque Control

  1. Remove and/or disturb plaque.
  2. Remove food debris and stain.
  3. Stimulate gingival tissue.
  4. Apply therapeutic agents.

Toothbrush Bristle Types

  • Super soft – 0.1mm
  • Soft – 0.2mm
  • Medium – 0.3mm
  • Hard – 0.4mm

Note: Soft bristles are recommended for patients with dentinal hypersensitivity. Hard bristles are associated with more gingival recession.

Toothbrushing Methods

Horizontal Brushing (Scrub)

Most commonly used technique due to its simplicity. The occlusal, lingual, and palatal surfaces of the teeth are brushed with the mouth open, and the vestibular surfaces are cleaned with the mouth closed.

Vibratory Technique (Stillman Technique)

Partly on the gingival margin and partly on the tooth surface.

Roll Technique (Modified Stillman Technique)

Head of the brush rotates progressively in an occlusal direction. Recommended for cleaning areas with progressing gingival recession and root exposure to prevent abrasive tissue destruction.

Bass Technique

Useful in removing plaque not only at the gingival margin, but also subgingivally. Recommended for routine patients with or without periodontal involvement.

Charters Technique

Directed towards the occlusal surface. For cleaning in areas of healing wounds after periodontal surgery.

Frandsen (1986)

“Improvement in oral hygiene is not dependent upon the development of better brushing methods but upon improved performance by the persons using any one of the accepted methods.”

Wolf and Rateitschak

  1. Oral surfaces
  2. Facial surfaces
  3. Occlusal surfaces
  4. Interdental areas with special oral hygiene aids

Toothbrushing Trauma

  • Painful ulceration of the gingiva
  • Bacteremia
  • Wedge-shaped defects in the cervical area of root surfaces
  • Gingival recession

Electric Toothbrushes

Recommended for:

  • Young children and adolescents
  • Handicapped patients who lack the dexterity for manual brushing
  • Fixed orthodontic appliance users
  • Hospitalized patients

The brush is moved systematically around the mouth, providing better plaque removal in approximal areas.

Ionic Toothbrush

Has a 3-V lithium battery in the handle that supplies a positive electrical charge to the metal handle and a negative charge to the bristles.

Van Swol et al (1996) – using a manual ionic toothbrush – significant improvement in the plaque and gingival indices as compared with controls.

Special Toothbrushes

  • Denture brush
  • Orthodontic brush – 2 types:
    • Single-row brushes – allow cleaning the area above and below the band.
    • 3-row brush – has a shorter center row of bristles.

Dentifrices

A substance used with a toothbrush or other applicator to remove bacterial plaque, materia alba, and debris from gingiva and teeth, for cosmetic and sanitary purposes and for applying specific agents to the tooth surfaces for preventive and therapeutic purposes.

Abrasive/Polishing Agent

20-40%: calcium carbonate, calcium phosphate, or sodium phosphate. Modern abrasives such as silica, alumina, and aluminum hydroxide are very hard substances. Abrasiveness depends on particle size and homogeneity.

Requirements for Dentifrices

  • Sufficiently abrasive
  • Should have a margin of safety
  • Enhances action by 40 times
  • Abrasion more prevalent on maxilla than mandible and more on left than right
  • Beneficial against supragingival deposits, not for subgingival calculus

Uses of Dentifrices

  • Cosmetic
  • Cosmetic-therapeutic
  • Therapeutic
  • Desensitizing toothpastes – Potassium nitrate, Strontium chloride, Formalin, Sodium fluoride

Single-Tufted Brush

A single-tufted brush is recommended for cleaning furcation areas, distal surfaces of the most posterior molars, and oral or lingual tooth surfaces with an irregular gingival margin. Also useful for lingual surfaces of mandibular molars and palatal and distal surfaces of maxillary molars.

Rubber Tip

Recommended for cleaning, stimulating, and massaging the gums. The dual-angled head helps reach every corner of your mouth.

Modifications of Floss

  • Teflon (polytetrafluoroethylene (PTFE) floss)
  • Fiberless floss – prevents fraying, suitable for fixed orthodontic cases

Mouthrinses

ADA recognizes that only mouthrinses containing CHX & Listerine formula are effective in controlling plaque & gingivitis.

Chemicals Influence Plaque Quantitatively & Qualitatively

  1. Prevent bacterial adhesion
  2. Stop or slow bacteria proliferation, using antimicrobials
  3. Remove established plaque, sometimes termed “chemical toothbrush” (e.g., hypochlorites)
  4. Alters the pathogenicity of plaque (not attempted due to an incomplete understanding of microbial etiology of gingivitis & periodontitis)

Principles of Chemical Plaque Control

  • Inhibition of plaque development
  • Elimination & dissolution of already existing plaque
  • Inhibition of calcification of plaque
  • Inhibition of microbial colonization of tooth surface
  • Alteration of pathogenic plaque into a lesser or non-pathogenic one

Rationale of Chemical Plaque Control

  • Mechanical therapy alone may not control infection
  • Poor plaque control increases the rate of re-infection
  • Root surfaces, tongue, tonsils & other niches harbor pathogenic bacteria

Indications for Chemical Plaque Control

  • Poor mechanical plaque control
  • Extensive splinting
  • Extensive fixed bridgework
  • Intraoral fixation
  • Orthodontic patients
  • Overdentures, abutments & implants
  • Post-surgically

Modes of Delivery of Chemical Agents

  • Routine oral hygiene aids
  • Mouthrinses
  • Dentifrice
  • Gels
  • Chewing gum
  • Lozenges & Chewable tablets
  • Varnish
  • Irrigators / Sprays
  • Periodontal Dressings

Mouthrinses (According to Kornman)

1st Generation Mouthrinses

Reduced plaque by 20-50% when used 4 times daily, have antibacterial activity, and have no substantivity. Examples: Cetylperidinium chloride, benzalkonium chloride, phenolic compounds.

2nd Generation Mouthrinses

Reduced plaque by 70-90% when used 1-2 times/day and have antibacterial activity as well as effective substantivity lasting 12-18 hours or longer. Examples: Chlorhexidine, triclosan with copolymer or zinc citrate.

3rd Generation Mouthrinses

They have a selective effect on specific bacteria that are essential to disease development.

Ideal Properties of Mouthrinses

  • Antimicrobial spectrum appropriate for the site of application
  • Exhibit selective activity for some essential microbial biochemical reactions that are not reactions of the host
  • Rapidly effective
  • Bactericidal instead of bacteriostatic
  • Be stable & not inactivated by body fluids or infectious exudates
  • Good therapeutic index
  • Have low surface tension to facilitate penetration

Varnish

Polymer-based matrix that slowly releases the agent onto the surface to which it is applied and also to saliva. The main purpose is to prevent root caries.

Types:

  • Chlorzoin
  • EC40
  • Cervitic

Types of Irrigant

Cavimed – designed to concurrently irrigate & scale by delivering an antimicrobial agent.

Pitchel (1980) – Direct irrigation at the gingival margin was superior to mouth rinsing in gaining access interdentally.

Criteria for Usage (Kornman)

  • Substantivity – prolonged contact time between substance & substrate
  • Safety/selectivity – tested in animal studies
  • Stability – stable at room temperature
  • Efficacy – Bactericidal therapeutic guidelines as determined by MIC of the agent for a fixed number of bacteria which have been associated with dental disease
  • Favorable cost: benefit
  • Vehicle should be designed to avoid accidental overdosage

Mode of Action of Phenols & Essential Oils

  • Cell wall disruption (high concentration)
  • Inhibition of bacterial enzymes (low concentration)
  • Anti-inflammatory property
  • According to Goodson, it has prostaglandin synthetase inhibitory activity

Disadvantages of Phenols & Essential Oils

  • Initial burning sensation
  • Bitter taste
  • Occurrence of minimal tooth sensitivity

Quaternary Ammonium Compounds

Disadvantages of Quaternary Ammonium Compounds

  • Tooth staining
  • Burning sensation of soft tissues
  • Increased calculus formation
  • Desquamative lesions (high concentration)

Oxygenating Agents

Disadvantages of Oxygenating Agents

  • Pathologic changes in pre-neoplastic lesions
  • Inhibits collagen synthesis
  • Inhibits glucose metabolism in bone

Chlorhexidine (CHX)

Properties of CHX

  • Strong base & dicationic at pH>3.5 (Albert & Sargeant 1962)
  • Broad antibacterial activity (gram-positive, gram-negative bacteria, yeast, dermatophytes & lipophilic viruses)
  • Low toxicity
  • Strong affinity for binding to skin & mucous membrane
  • Different effects at different concentrations

Side Effects of CHX

  • Dulling of taste sensation
  • Bitter taste
  • Burning sensation of mucosa
  • Dryness & soreness of mucosa (precipitation of mucin layer, reduced immune defense)
  • Epithelial desquamation

Adverse Reactions of CHX

  • Bronchospasm
  • Skin irritation
  • Parotitis
  • Pruritis
  • Dental pain
  • Dyspnea
  • Urticaria
  • Vesicular rash
  • Wheezing

Indications for CHX

Adjunct to oral hygiene and professional prophylaxis:

  1. Post oral surgery, including periodontal surgery & root planing
  2. In patients with jaw fixation
  3. For oral hygiene & gingival health benefits in mentally & physically handicapped individuals
  4. Medically compromised individuals predisposed to oral infection
  5. High caries risk patients

Contraindications for CHX

  • Anterior tooth restorations

Anti-Calculus Agents

  1. Pyrophosphate
  2. Zinc salts
  3. Diphosphonates
  4. Calcium lactate