Oral physiotherapy

Question 1

Describe the dental biofilm

Answer 1

Dental Biofilm is as an organised matrix derived from bacteria, salivary glycoproteins and extracellular microbial products that form on the hard non-sheading surfaces in the mouth

After 24 hours, the biofilm can be visually seen within:
○ interproximal areas of the teeth
○ facial surfaces of the molars and premolars
○ along the gingival margin
○ pits and fissures

Question 2

Discuss the dental biofilm aetiology in relation to Oral hygiene techniques

Answer 2

• The thickness of Dental Biofilm dictates its pathogenesis
• At approximately 48 hours the plaque is generally thick enough to produce bacterial toxins = inflammatory response i.e. Gingivitis
• The ongoing inflammatory response from gingivitis eventually progresses to periodontitis
• The main reason for he correct use of Oral Physiotherapeutic Aids is to inhibit the formation of Dental Biofilm

Question 3

Be able to recommended the best frequency for Dental Biofilm removal

Answer 3

• Twice daily cleaning but not with more frequent cleaning
• On average no more than 60% of Biofilm is removed at each episode of cleaning
• The overall benefit of twice daily cleaning is: the benefit of mechanical plaque removal combined with the chemical benefit of the toothpaste

Question 4

Describe the parts of and attributes of the most recommended kind of manual toothbrush

Answer 4

• The tooth brush also serves as the vehicle for delivering medicated products
• It comes with several filament designs from Hard, Medium to Soft
• Studies have shown that a toothbrush with a small head and soft bristles is preferable for effective biofilm removal and lower chances of damage to the dentition
• The toothbrush is made up of two main components; the handle and the head

Question 5

Recommended the ideal brushing time and pressure for a manual toothbrush

Answer 5

• For effective Biofilm removal correct brushing for 2 minutes is needed but brushing more than 2 minutes showed no additional benefits
• The amount of pressure used effects the amount of Biofilm removed but only ideally between 150-300g of pressure
• The tooth brush should be changed every 3 months or when then bristles become flared at the tips

Question 6

List the effects of incorrect brushing

Answer 6

• Gingival lacerations – brushing too hard and vigorously
• Gingival recession – brushing with to mush pressure over a long period of time
• Toothbrush abrasion is loss of tooth structure cause by repeated hard over brushing. Usually located along the cervical margin of canines and premolars

Question 7

Name the various manual tooth brushing techniques (6)

Answer 7

Other tooth brushing techniques are:
• Most recommended: Modified Bass Technique 
• Modified Stillmans 
• Modified Charters 
• Fones (Circular) 
• Leonards (Vertical) stroke 
• Horizontal stroke

Question 8

Describe the Modified Bass Technique tooth brushing technique

Answer 8

• The toothbrush head is placed at a 45 degree angle to the long axis of the tooth lightly inside the gingival sulcus
• Gently brush the the surface of 2-3 teeth using a vibrating back and forth motion
• The movement is then done for 10 vibrations/grouping of 2-3 teeth
• To finish complete several roll strokes sweeping up the buccal/facial surfaces towards the incisal/occlusal surface

Question 9

Describe the Modified Stillmans tooth brushing technique

Answer 9

• The brush is placed with the bristles angled towards the tip of the roots and in contact with the gum tissue
• It is then pressed until the gum blanches
• The brush is simultaneously vibrated back and forth and rolled away from the gingiva
• Repeated for each tooth

Question 10

Describe the Modified Charters tooth brushing technique

Answer 10

• The toothbrush is placed at a 90-degree angle to the long axis of the tooth
• The brush is moved in several small rotary motions so that the sides of the bristles are in contact with the gum margin
• After two or three such motions, the brush is removed and replaced in the adjacent area and the motions are repeated
• Finish with a roll towards the occlusal/incisal surfaces
Best used when Orthodontic wires, brackets in place and cleaning around fixed prosthetic appliances or post surgical procedures

Question 11

Describe the Fones (Circular) tooth brushing technique

Answer 11

• Used for the Buccal/Labial surfaces only
• The teeth are closed together and the brush is directed at 90 degree’s to the tooth surface
• Large circular movements are then employed to clean all teeth and gingival margins
• Always use a SOFT BRUSH

Question 12

Describe the Leonards (Vertical) tooth brushing technique

Answer 12

• Vertical stroke is used for Maxillary and Mandibular teeth, brushed separately
• Bristles are placed at 90 degrees to buccal/facial surfaces
• Brush vigorously without great pressure up and down
• This technique is no longer recommended as over time it caused gingival recession and toothbrush abrasion

Question 13

Describe the Horizontal Stroke tooth brushing technique

Answer 13

• Conducted by making short horizontal strokes along the tooth surface with the brush head at 90 degrees to the tooth
• This technique is no longer recommended except for the occlusal surfaces as over time it causes gingival recession and toothbrush abrasion to buccal/Labial surfaces

Question 14

Describe the 2 styles of electric toothbrushes and be able to recommend the best one and indicate why

Answer 14

Oscillating action: the design of a small rounded head with an oscillating action is the most effective for plaque removal and gingivitis prevention

Fish tail/ sonic electric action: Insufficient independent research data currently exists

Question 15

Describe the correct electric tooth brushing technique

Answer 15

• Optimal time of use is 2 minutes for most effective plaque removal with most brushes having an inbuilt timer
• Change the brush head every 3 to 4 months
• Angle the head of the brush at 90 degrees towards the tooth contacting the gum line
• Light pressure only, the brush will do the work for you
• Place the small amount of toothpaste on the brush and start the brush only when it is in contact with a tooth surface
• When cleaning interdental spaces angle the brush head into the space remaining in contact with the tooth surface

Question 16

Describe the ideal Interdental Cleaning methodology based on Evidence based research

Answer 16

• The most effective form of Interdental cleaning is professionally determined appropriately sized INTERDENTAL BRUSHES
• IDB’s are best for type 2 and 3 embrasures where the contact point is not present
• For type 1 embrasures where the contact is evident and where crowded or rotated teeth are present, Floss should be used

Question 17

Discuss the best interdental brushing technique

Answer 17

• The correct size should be selected which allows for the filaments to fill the interdental space contacting the interdental tooth surfaces
• The brush is moved in and out of the interdental space in a backwards and forwards motion a number of times
• For the posterior spaces never bend the brush from the base for access but from the middle of the brush
• Try to limit the amount of brush sizes you prescribe as simple is best for long term compliance

Question 18

List the factors you need to consider when personalising an individual regime for your patient

Answer 18

1. Patient factors 
	○ Motivation 
	○ Dexterity 
	○ Compliance 
	○ Periodontal disease status

2.  Local factors 
	○ Crowding, tooth inclination 
	○ Furcation involvement 
	○ Inflammation if present 
	○ Access (gag reflex, mouth size, tongue size) 

3. Type Embrasure/Interdental Space

Question 19

List the various types of Dental Floss

Answer 19

Waxed and Unwaxed Floss
• Dental Floss is rounded/circular or rope like in shape and when waxed it allows for an easier passage between the teeth into the interdental space

Dental Tape/Ribbon
• These are flatter, much like “sticky tape” in shape there by allowing for an increased surface area to clean the tooth surface

Superfloss/Ultrafloss
• There are designed for cleaning around bridges, crowns, implants and under orthodontic wires
• The are made up of up to 2-3 components of unwaxed floss, foamed floss and a “Threader” to allow for passage under a bridge margin or orthodontic wire

Question 20

Describe in detail the “C” flossing technique

Answer 20

• Up to 20 centimetres of Floss is dispensed
• Wrap it around the middle fingers a few times for anchorage
• The index (pointer finger) and thumb are used to control the floss
• Only a few centimetres between the thumb and finger is actually used
• For the upper posterior teeth floss is guided between the thumbs for best access
• For lower posterior teeth the index fingers are used
• For the front teeth a combination of both thumb and index finger can be used
• Place the floss in between the teeth, pass though the contact point wrapping the floss in a “C” like shape around the tooth surface, pass the floss up to 3 times under the gum line into the gingival sulcus on each tooth surface

• If the patient has trouble retaining the floss around the middle fingers, tie the floss off in the middle to form a circle and repeat the flossing technique

Question 21

Name other kinds of Floss Aids on the market

Answer 21

Floss Threaders
• Used to floss under bridges, orthodontic wires or access tight spaces
• The floss is passed through the loop and the threader passed though the area indicated bring the floss with it

Flossettes/Flosspics/Flossmates
• Used to floss when manual dexterity/access is an issue
• Flossettes/Flosspics are used for one full mouth flossing session only
• Flossmates usually have replaceable heads or fresh floss is passed though the end at each flossing session

Question 22

List other kinds of Oral Therapeutic Aids

Answer 22

• Single Tufted Molar Brushes
• Oral Irrigators
• Toothpicks
• Tongue cleaners

Question 23

Describe single tufted molar brushes

Answer 23

• Used for around single standing molars, wisdom teeth and large interdental spaces
• Small head = improved access
• The brush is angled at a 45 degree angle to the gingival margin and gentle, circular motions are used

Question 24

Describe oral irrigators

Answer 24

• Project water or Antiseptics at a controlled pressure into the gingival sulcus and in between the teeth
• Studies demonstrate limited benefit in plaque removal and gingivitis prevention
• Waterpic is best used on high pressure

They can be used:
• Post oral surgical procedures, on a low pressure
• Where the patients motivation level is low for IDB’s and floss
• Around crowns and implants

Question 25

Describe toothpicks

Answer 25

• Little benefit in interdental plaque removal and gingivitis reduction
• However Tea Tree oil coated toothpicks have been reported to help reduce gingivitis
• An alternative to recommend to those patients who refuse to use IDB’s, Floss or oral irrigators
• Best used for the removal of food from in between the teeth
• Rubber coated more favourable to use as less change of damage to the teeth/gingiva with incorrect or overuse

Question 26

Describe tongue cleaners

Answer 26

• Mainly considered beneficial in the removal of bacteria from the dorsum of the tongue
• Assists in the control of Halitosis or “Bad Breath” by removing dead epithelial cells and bacteria
• Should be used in conjunction with a personalised Brushing and Interdental cleaning regime