PAP4 -Self performed plaque control Flashcards
what is essential for periodontal disease to be controlled?
plaque levels must be below the individual’s disease threshold
who needs better plaque control?
The higher the patient’s susceptibility, the better their plaque control needs to be (if stability is to be achieved and maintained)
what were the findings of adult dental health survey?
• 75% of dentate adults claimed to clean their teeth x2 daily
• 66% had visible plaque on >1 tooth
• Mean proportion of teeth affected increased from 30% in 25-34 year olds to 44% in those aged 65+
• Dentate adults who reported attending a dentist regularly were less likely to have visible plaque (61% versus 76% in patients who only attend with problems)
• Most people find it difficult to clean their teeth effectively.
• 78% of adults claimed to have received a demonstration of toothbrushing from the dental team
• Only 21% reported to use dental floss
• Patients must receive tailored OH instruction if
periodontal treatment is to be effective
what is the outcome of any periodontal treatment reliant on?
the patients level of home care
what are the 3 current recommendations in DDH periodontal clinic?
- Patients receive an explanation that plaque is the initiator in the development of periodontal diseases
- Patients should be informed about their susceptibility to periodontal diseases
- Patients are informed that for periodontal treatment to be effective they must keep their plaque levels below their own disease threshold.
what were the different methods of mechanical plaque removal through the ages?
- Woodsticks
- Finger and abrasive
- Siberian wild bore bristles attached to bone or bamboo!
- Horsehair bristles attached to bone handles (used by Napoleon), pig and badger hair was also used
what do we use now for mechanical plaque removal?
nylon filaments
For the majority of patients, is mechanical or chemical plaque controlled required?
mechanical plaque control
what is only recommended in particular situations?
Mouthwash
however 31% of adults report to use mouthwash
what does mouthwash not get through?
Mouthwash does not get through biofilm- needs to be mechanical
what can be used on clinic to highlight plaque presence while delivering oral hygiene instruction to patients?
Disclosing tablets/ solution
what are the colourations of plaque using disclosing tablets?
Blue- where the plaque has been there for around 2 weeks
pink- for plaque that has not been there as long
what are the current oral hygiene recommendations at DDH? (at home)
• Toothbrushing x2 daily ideally using ‘Bass Technique’
• A systematic brushing technique is advised to ensure cleaning of all
areas
• Fluoride-containing toothpaste advised
• Spit out excess toothpaste but do not rinse out
• Cleaning of approximal surfaces once daily after brushing
• Do not use mouthwashes at the same time as brushing
what is the bass technique?
- Angle of brisles is 45degrees to the gingival margin, brissels not directly on teeth or on gum
- back and forth motion over gingival margin
what negative effects can mouthwash have?
It can’t distinguish between pathogens and commensals and so it messes up the commensal (its a cosmetic product )
what are the patients advised/shown about plaque removal?
• Advise patients that bleeding on brushing may occur initially
• Brushing will remove plaque from buccal, lingual and palatal surfaces
but is relatively ineffective inter-proximally
• When OHI is given it should always be instructed in the patient’s mouth
• Patient must be given opportunity to practice in the clinic and demonstrate OHI skills back to clinician.
what was the evidenced base -psychological interventions of OHI?
Only four studies met the inclusion criteria but demonstrated that psychological approaches to behaviour management can improve oral hygiene related behaviours
How do we change patients behaviour?
- talk
- Instruct
- Practice
- Plan
- Support
Describe what you tell your patient in the “talk”.
- Cause of disease
- Brushing frequency
- Brushing technique
- Type of brush
- Toothpaste use
- Interdental cleaning
what do you “instruct” your patients to do?
Instruct Your patient by demonstrating in their mouth (not on a plastic model)
Describe how the patients “practices”.
- Let your patient practice while you observe
- Correct their technique as required
- Ask patient for their feedback
- Address concerns regarding bleeding on brushing/flossing etc
Describe the “plan”.
Best times of day for your patient to clean
Describe the “support”.
Follow up advice on next appointment
what toothbrushing approach is to be used?
systemic approach (decide with patient what their approach is gonna be)
what is the evidence summary of frequency of brushing?
• Effective plaque removal every 2 days to prevent/resolve experimental gingivitis
• Optimum frequency not determined
• Consensus that x2 daily brushing is consistent with
gingival health
what are the evidence findings of brushing duration and technique?
- Brushing time under-estimated
- Most use simple horizontal brushing action
- Most spend too little time on brushing lingual areas
- Most fail to effectively remove plaque from approximal surfaces of molars/premolars
what is to be emphasised durning recommendations?
Emphasise a systematic approach to maximise plaque removal
what are the recommendations of a manual toothbrush?
- be medium hardness
- have a simple straight handle
- be multi-tufted
- have a small head size
- should be replaced every 6-8 weeks on average
what is the evidence summary of manual toothbrushes?
- Handle size appropriate to user age/dexterity
- Head size appropriate to user’s mouth
- Compact arrangement of medium, end rounded nylon filaments not >0.009 inches diameter
- Bristle patterns which enhance plaque removal in IP sites & along gum margin
why are toothbrushes with filaments arranged at different heights and angles more effective and there fore what is recommended?
- more effective at plaque removal/reducing gingivitis than flat trim brushes
- Use small headed brush with rounded filaments, a compact angled arrangement of long & short filaments & comfortable handle
what type of powered toothbrush resulted in reduced gingivitis scores?
rotation oscillation powered brushes
what was not statistically significant in powered toothbrushes evidence?
They also removed more plaque compared to manual brushes but this improved plaque removal was not statistically significant.
what are the modes of action of power brushes?
- Side to side
- Counter oscillation
- Rotation oscillation
- Circular
- Ultrasonic/sonic
What are the 2 main advances in design of powered toothbrushes?
- Small circular head which performs oscillating, rotating or counter-rotational movements. Said to improve efficiency of IP cleaning
- Increased frequency of brush vibration. Said to improve cleaning by 2 biophysical actions – Cavitation & Acoustic Microstreaming.
what is the role of cavitation effect?
Successfully used to remove stain & calculus from root surfaces
what range of bubble behaviour is used in the cavitation effect?
- gentle linear pulsations of gas-filled
bodies (stable cavitation) - violent and highly destructive formation and collapse of vapour-filled voids and cavities (transient cavitation)
why do tradition powered brushes unlikely to generate destructive transient cavitation ?
Traditional powered brushes operate at low frequencies – unlikely to generate destructive transient cavitation
what is the main effect of powered brushes?
aeration of water
what effect may more expensive powered brushes have?
have a higher operating frequency and may produce some cavitation effect
Describe acoustic microstreaming.
• Occurs around the bristles of a powered brush and this is accompanied by large hydrodynamic shear stresses
• These forces may dislodge plaque but are not strong enough to disrupt cells and tissues
( movement of stare between anything that is vibrating)
What effect may acoustic microstreaming have?
May have a synergistic effect with anti-plaque irritant (chemical and mechanical effects working together)
Is the effects of microstreaming in the oral cavity as dramatic as seen in model lab systems?
No - in the mouth a powered brush operate in as all fluid volume of toothpaste and salvia
what are the timers on powered brushes?
Powered toothbrushes often incorporate two-minute timers to encourage brushing for the recommended time
What did two studies report using powered brushes?
improved compliance
what should clinicians tell patients about powered brushes?
clinicians should provide advice & instruction in their use
who will benefit most from powered brushes ?
For some individuals unable to maintain effective plaque control and periodontal health, powered brushes with oscillating/rotating action may be more effective than manuals
what are the recommendations for interproximal cleaning?
- should not be demonstrated until smooth surfaces are maintainable by the patient
- should always be done after brushing
- should be done x1 daily (night is best)
- aids are primarily chosen according to the size of the interproximal space
what are the choices for inter proximal cleaning?
- Dental floss/tape
- TePe brushes
- Superfloss
- Flossette/ dental harp
- Single tufted brushes can clean the approximal surfaces of lone standing teeth
what do some patients use for interproximal cleaning which are ineffective and not recommended?
toothpicks or woodsticks
what technique should be used for flossing?
wrap between middle fingers so only two fingers int he mouth wrap around tooth in C shape
what are the different tepe for interproximal cleaning?
Different colours for different sizes and a patient should be given 2/3 (to fit in all parts of the mouth)
what can be used for interproximal cleaning in tight contact with normal papillae?
flossette
what is considered when choosing interproximal aid?
- The size of the space
- The interdental papillae
- Tooth anatomy
- Patient’sability
what are the recommendations in perio clinic when reviewing oral hygiene?
- It is essential to review the patient a short time (ideally 2/52) after OHI to check whether plaque control is effective
- modifications of technique may be suggested after the clinician assesses current OHI practice as performed by the patient
- Plaque charts may help monitor patient’s progress
what is the outcome if OH consistently remains inadequate (ie. periodontal disease is not controlled – presence of bleeding on probing and pockets >3.5mm deep)?
-Treatment is very unlikely to be successful irrespective of the professional care given
• Palliative care is the most suitable option.
What are the OHI key points?
• Teach patients according to evidence- use OH TIPPS
• Advise toothbrushing twice daily, fluoride toothpaste
• SpitDon’tRinse
• Change brush every 2-3 months, same timescale for
head on power brush
• Teach interproximal cleaning after patient has mastered toothbrushing
• Interproximal aid depends on patient ability and anatomy of area
• Interproximal cleaning once daily after brushing
• Review the patient and monitor OH
• Mouthwash is NOT recommended.
