plaque control: toothbrushing and interdental cleaners Flashcards
What’s the most important part of any dental appointment?
Prevention is the most important part of any dental appointment!
why is plaque control importnat?
an effective way of treating and preventing gingivitis
critical part of all the procedures involved in the treatment & prevention of periodontal disease.
key element of the practice of dentistry.
permits each patient to assume responsibility for his or her own oral health on a a daily basis. Without it, optimal oral health cannot be attained.
every patient in every dental practice should be educated about plaque control and be encouraged to perform a personalized program on a daily basis.
Should we use natural bristle toothbrushes?
Should be avoided:
More porous
Collect moisture,
odours & bacteria.
What type of toothrbush should we use?
Soft, nylon bristle toothbrushes clean effectively(when used properly), remain effective for a reasonable time, and tend not to traumatize the gingiva or root surfaces
what are the parts of a toothbrush?
Handle - plastic, straight variations ,thickened -sometimes helpful to those who have arthritis or other disabilities.
Head - working end holds bristles (straight & even) bristles are in tufts
Shank - connects head to handle
What’s the correct manual toothrbush size?
The length of the brush head should fit the length of the 4 mandibular incisors on the lingual surface
What brushing sequence should you use?
Begin brushing from the buccal molar region of 1 arch and work to the opposite side
Continue back around on the lingual
Repeat in the opposing arch
Each brush placement should overlap the previous one
Brush the occlusal/incisal surfaces
What frequency of brushing should be use?
A minimum of 2 brushings, accompanied by interdental cleaning per day
Brushing before bed is strongly recommended
Children-after meals
3 minutes is recommended
What are the 7 manual toothrbushing methods?
Bass Modified Bass Rolling Stroke Modified Stillman Charters Fones Scrub
What is the bass method? When is it recommended?
Recommended for patients with: Biofilm adjacent to & directly beneath gingival margin Open embrasures, exposed root surfaces Orthodontic appliances Crowns/bridges Perio surgery
Hold the toothbrush using a palm grasp
Position the toothbrush filaments:
Apically
Parallel to long axis of tooth
Turn brush toward gingival margin to make a 45 degree > to long axis of tooth
Direct filament tips into gingival sulcus
Lightly press filament tips to enter gingival sulci, embrasures and cover gingival margins
Do NOT use excess pressure
Vibrate toothbrush bristles back/forth without moving the filaments from the sulci
Be careful the vibration does NOT turn into a scrub method
results in DAMAGE
Count 10 vibrations minimum
Reposition brush to the next 2-3 teeth-overlapping placement
Repeat at each position around Max/Mand arches on facials/lingual
What is the bass method for anterior teeth lingual/palatal?
Utilize heel of the brush head
Direct filament tips into sulci
what’s the modified bass method/
Identical to the Bass method
The modification incorporates a rolling stroke after the vibratory phase at the gingival sulcus
what’s the rolling stroke method?
Recommended for :
Removal of biofilm, material alba & food debris
Cleaning gingiva without emphasis on gingival sulcus
Meant for children with healthy
gingiva/normal tissue contour
Useful to prepare for Modified
Stillman instruction
Hold the toothbrush using a palm grasp Position the toothbrush filaments: Apically Place side of brush on attached gingiva Plastic portion of brush head level with occlusal/incisal plane of teeth
Flex side of filaments lightly against the gingiva
Gingiva will blanch
Slowly roll the brush over the teeth, rotating the wrist
Filaments remain flexed and follow the contour of the teeth
Repeat stroke 5 times minimum for each group of teeth
Reposition brush to the next 2-3 teeth, overlapping placement
for the lingual and palatal of anterior teeth
Use the heel of the brush head
Place filaments against teeth and gingiva
Press filaments and roll the brush-up for mand/down for max
Repeat 5X for each brush width
what’s the modified stillman method?
Recommended for:
Removal of biofilm on tooth surfaces and massaging of the gingiva
Hold toothbrush using a palm grasp Position the toothbrush filaments: Apically Place side of brush on attached gingiva Plastic portion of brush head level with occlusal/incisal plane of teeth
Flex side of filaments against the gingiva
Gingiva will blanch
Angle the filaments by rotating the wrist
Filaments should be directed at a 45 degree < with long axis of tooth
Activate brush - using a slight rotary motion
- keep filament tips in constant contact
- use light pressure on filaments
Roll and vibrate brush-turn wrist, working the vibrating brush over gingiva and teeth
Be careful the vibration does NOT turn into a scrub method results in DAMAGE
Repeat stroke 5X minimum for each group of teeth
Reposition brush to the next 2-3 teeth, overlapping placement
for anterior teeth lingual/palatal
Use the heel of the brush head
Place filaments against teeth and gingiva
Press filaments, vibrate and roll the brush-up for mand
-down for max
Repeat 5X for each brush width
What ais the charters method?
Recommended for: Loosening debris and biofilm Massage/stimulation of gingiva Removal of biofilm on proximal surfaces, when interproximal tissue is missing following perio surgery Crowns/bridges Orthodontic appliances
Patient to use a basic rolling stroke first, for general cleaning
Grasp toothbrush with a palm grasp
Direct filaments toward the occlusal/incisal plane of teeth to be brushed-i.e. down for max & up for mand
Insert brush inside mouth
Place sides of filaments against tooth with brush tips toward occlusal/incisal plane
Angle filaments at 45 degree < to occlusal/incisal plane
Using light pressure:
Flex the filaments
Force filament tips between the teeth
Press sides of filaments against gingiva
Vibrate brush gently, keeping filament tips in contact with tooth surface
Count to 10 slowly as the brush is vibrated
Reposition brush to the next 2-3 teeth, overlapping placement
The Charters method of toothbrushing is very difficult to position on lingual surfaces
Recommend a Modified Stillman technique
What’s the fones method?
Recommendation:
An easy-to-learn 1st technique for young children
Considered detrimental for adults-especially by a vigorous brusher
Select a soft toothbrush
Keep teeth closed
Place brush inside cheek, with filament tips contacting gingiva over last max. molar
Use light pressure
Use a fast, wide, circular motion, sweeping from maxillary gingiva to mandibular gingiva
Use light pressure
Use a fast, wide, circular motion, sweeping from maxillary gingiva to mandibular gingiva
Bring anterior teeth in end-to-end contact-continue with circular strokes
With jaws apart-use smaller circular sweeping motion to clean on the lingual surfaces of maxilla and mandible
Occlusal surfaces are brushed in an anteroposterior direction
what’s the scrub-brush method?
Recommendations:
Acceptable method initially for very young children
Generally not recommended-encourages gingival recession, tooth abrasion
Does not clean gingival margins/sulci or interproximal surfaces well
critical areas are missed
Select a soft toothbrush
Hold toothbrush using a palm grasp
Place filament tips perpendicular to long axis of teeth
Use a combination of vertical, horizontal and circular strokes
what are power toothbrushes?
Also known as power-assisted, automatic, mechanical or electric
Move in various speeds + motions not duplicated by manual toothbrushing
Research indicates power brushes to be more effective than manual toothbrushes
what should you consider for power toothbrushes?
Design-size + shape
Brushing method
Cost
when are power toothbrushes recmmmended?
Recommended for:
The removal of dental biofilm and food debris
The reduction of calculus and stain
When to recommend a Power Toothbrush:
Patients who have difficulty removing biofilm
Aggressive toothbrushers
Orthodontic patients
Dental implants
Major restorative/prosthodontic treatment
Patients with limited dexterity
Patients with disabilities
Patients who are unable to brush e.g. a parent or caregiver
What are the power sources for the power toothbrushes?
Power sources can be: Direct-connects to electrical outlet Replaceable batteries Rechargeable batteries Disposable-batteries are not replaceable or rechargeable
**NOTE: power brushes with replaceable batteries move slower than
those with rechargeable batteries
what’s the power brush procedure?
Provide patient with video instructions or demonstration model of the brush
Instruct patient to floss 1st
Use a dentifrice with minimum abrasivity -apply a small amount on the brush
Place brush inside mouth before turning on power prevents splashing
Move brush from most posterior teeth toward the anterior, quadrant by quadrant
Use light pressure
How should you care for toothbrushes?
Replace toothbrushes every 2-3 months before filaments become splayed
Clean thoroughly after each use by holding the brush head under a strong stream of warm water to remove debris, toothpaste and bacteria from between the filaments
Store brush in open air, toothbrush head in an upright position and not in contact with other brushes
what are some negative effects of toothbrushing?
Acute lacerations/ulcerations/trauma-most frequent on facial surfaces over canines/premolars
Dental abrasion-wearing away of tooth structure, resulting from a repetitive mechanical habit e.g. incorrect tooth brushing with an abrasive toothpaste
what are the contraindications for toothbrushes?
The use of a hard bristled toothbrush , vigorous horizontal brushing and the use of a very abrasive dentifrice, may lead to cervical abrasion of teeth and recession of gingiva.
what’s the purpose of tongue cleaning?
Purpose: Reduces number of microorganisms Slows biofilm formation Reduces potential for halitosis Contributes to total mouth cleanliness
how to tongue brush?
Extrude the tongue
Place head of toothbrush on the midline of the tongue
The sides of the filaments are placed on the posterior of the tongue
The filament tips are directed toward the throat
Use light pressure and draw the brush forward toward the tip of the tongue
Repeat 3-4 X
Do NOT scrub the papillae
**NOTE: Gagging can be a problem
what are tongue cleaners?
Made of plastic, rubber, stainless steel or other flexible metals
May be curved, raised, textured
Position the cleaner toward the most posterior area of the tongue surface
Pull forward, using a light but firm stroke
Cover the entire surface of the tongue
Repeat several times
Rinse tongue cleaner under running water
why do we need interdental cleaners and what should the selection consider?
Tooth brushing does not remove biofilm on proximal surfaces
Interdental cleaning is essential for a patient’s self care program
Things to consider:
History of patient’s oral care-what are they currently using for self care
Position of the teeth
Shape of embrasures
Probing depths
Fixed or removable prostheses
Personal factors e.g. disability/handicap that limit ability to perform self care
what are the 4 types of dental floss/tape?
Types of Floss:
Waxed -slides easily through contact points, less shredding
Unwaxed –thinner-better for tight contact points, tends to shred
Tape-wider ribbon, easier to grasp
Tufted floss e.g. super floss or NUFloss-for wide embrasures, abutment teeth, under pontics of a fixed bridge, ortho appliances
When should you floss?
Best results are obtained before brushing
When flossing is accomplished first, biofilm is removed
Fluoride from a dentifrice used while brushing reaches the proximal surfaces=dental caries prevention
If brushing occurs before flossing, patient may not have time to floss or may feel mouth is clean and that flossing is not necessary
how should you floss?
Use approx. 18” of floss
Wrap loosely around middle finger
Firmly grasp ½” of floss between the fingertips
Tuck excess floss in the palm of the hand
For maxillary teeth: hold floss between thumb + index finger
For mandibular teeth: direct floss down by holding the index fingers
on top of the floss
Guide the floss between the contact points using a controlled, short
sawing motion- do NOT snap the floss between the contact points
onto the gingiva
Curve the floss around the tooth in a “C” shape
Press the floss firmly against the tooth
Slide the floss up and down the side of 1 tooth, moving gently beneath the gingiva
Move the floss to the top of the papilla and reposition the floss on
the next tooth
Remove the floss by using the same controlled, short sawing motion or unwrap the floss from the fingers and pull through the teeth
Slide to a new, unused portion of floss for succeeding proximal surfaces
what are floss cuts or floss clefts?
Occur on facial/lingual surfaces
Appear as straight-line cuts from the gingival margin
Caused by: Using a piece of floss that is too long Snapping the floss through the contact Not curving the floss around the teeth Holding the floss straight Using undue pressure
what are flossing aids?
Floss Threader-threads floss under ortho appliances, fixed bridges
Floss Holder/Floss Wand/Floss Picks-patient with disability
Knitting Yarn-distals of posterior teeth, isolated teeth, diastemas,
abutments/pontics of fixed bridges
Gauze Strip-proximal surfaces of widely spaced teeth, teeth next to
edentulous areas, abutments of fixed bridges, under a
cantilevered bridge
what is superfloss?
Under bridges (abutments) small diastemas orthodontic flossing furcation Type III (through and through) Dental implants
what is sulcabrush?
A uni-tuft , firm bristled brush angled for “outside” (buccal) and
“inside” (lingual)
Tips are replaceable
Used for cleaning the gingival margin and sulcus
Ideal for ortho appliances, crowns, bridges, dental implants
Travel size available
Place the angled tuft on the distal surface of the last tooth
The tip should be 1-2 mm beneath gingival margin
Follow the outline of the gingival margin
Add a circular motion in-between the teeth
Use the end labeled “outside” for all buccal surfaces and for lingual posterior
Use the end labeled “inside” for maxillary and mandibular anterior lingual
whats an interdental tip?
Flexible rubber tip attached to a handle or to the end of a toothbrush handle
Removes biofilm at and below gingival margin
Trace the tip along the gingival margin
Tip should be positioned 1-2 mm beneath the margin
For proximal surfaces-rub the tip against the teeth, moving it in & out
of the embrasure and under the contact point
what is a toothpick in holder?
Known as a Perio-Aid
Round toothpick is inserted into a plastic handle with contra-angled ends
Used for patients with periodontitis-removes biofilm at & under gingival margin, interdental cleaning, concave proximal surfaces, exposed furcations
Insert round, tapered toothpick into end of holder
Break off the long end of the toothpick cleanly so that there are no sharp edges
Apply toothpick slightly under the gingival margin at a slant
Using moderate pressure, outline the gingival margin around each tooth
what is a wooden interdental cleaner?
For cleaning proximal surfaces where tooth surfaces are exposed & interdental gingiva are missing
Made of basswood or birch wood
Triangular cross-section
Instruct patient to use a fulcrum on cheek/chin
Soften pointed end by placing in mouth & moisten with saliva
Insert the flat base of the triangle on the gingival side
Clean the tooth surface by moving the wedge in & out
Apply moderate pressure
what are soft-picks?
76 soft rubber bristles in a wire-free, tapered design
Safe for crowns, bridges, dental implants, orthodontic appliances
Difficult to access lingual surfaces
Used like a toothpick
what is oral irrigation?
A home care device that delivers a pulsating or steady stream of water/therapeutic agent
Used to remove loosely attached supragingival and subgingival biofilm
Reduces gingivitis and bleeding
Provides subgingival delivery of antimicrobial agents
Variety of tips available-monojet, soft rubber tip, cannula
how do you use a water pik?
Fill reservoir with lukewarm water
Insert tip-tapered plastic tip is
designed to be placed at the
gingival margin
Adjust pressure to lowest setting for first time use
Lean over sink and place tip in mouth, directing the tip at the teeth
turn it on
Direct tip at 90 degree < to gum line
Slightly close lips to avoid splashing, but still allow water to flow from mouth into sink
Start in molar region working to the front teeth
Glide tip along gum line, pausing between teeth
Gradually increase the pressure over a period of time-i.e. 1 notch every 2 weeks
What are subgingival tips for oral irrigators-pikpocket?
Soft rubber tip is designed to be placed 2 mm below gingival margin
What is a dentrifice?
Substance applied with a toothbrush for the removal of food debris, biofilm, stain from the gingiva and tooth surfaces
Variety of active ingredients to help prevent caries, sensitivity, biofilm, gingivitis, calculus formation and halitosis
what are the active ingredients in dentrifices?
anti-biogilm/anti-gingivits - triclosan, zinc citrate, stannous fluoride
anti-calculus - Pyrophosphate salts, zinc chloride, zinc citrate, Triclosan, Sodium Hexametaphosphate
de-sensitizer - Potassium Nitrate, Strontium Chloride, Stannous Fluoride
malodour - Chlorine Dioxide, Essential Oils, Zinc Chloride, Triclosan
what are examples of toothaste?
Anti-biofilm/Anti-gingivitis (Triclosan) E.g. Colgate Total
Anti-calculus (Disodium Pyrophosphate) E.g. Crest Tartar Control
Desensitizer (Potassium Nitrate) E.g. Sensodyne
Malodour (Chlorine Dioxide) E.g. CloSYS
Xerostomia (Enzymes/Fluoride) E.g. Biotene
what are mouthrinses for?
Formulated for a variety of oral benefits: Mouth freshening Caries prevention Control biofilm Contol oral malodour
Classified as: preventive, cosmetic, therapeutic
what are therapeutic mouthrinses?
FLUORIDE-stannous or sodium fluoride e.g. Crest Pro-Health Complete
dental caries prevention
reduce hypersensitivity
reduce gingivitis
Disadvantage: stannous fluoride may stain teeth
CHLORHEXIDINE (CHX) e.g. Peridex
Pre-procedural rinse to reduce bacterial aerosols
Before, during & after perio debridement
Post-surgery wound healing
CHLORHEXIDINE (CHX)
Disadvantages:
staining of teeth, pits & fissures
may cause an increase in supragingival calculus
altered taste perception
interacts with & is inactivated by the toothpaste ingredient sodium lauryl
sulfate when occurs immediately after brushing **must wait 30 min after
brushing before rinsing with CHX
TRICLOSAN e.g. Colgate Total
Reduces biofilm and biofilm accumulation
Reduces gingivitis
Reduces supragingival calculus formation
PHENOL-RELATED ESSENTIAL OILS e.g. Listerine
Reduces biofilm
Reduces gingivitis
PHENOLIC-RELATED ESSENTIAL OILS
Disadvantages:
Burning sensation
Bitter taste
Contraindicated for current/recovering alcoholics due to alcohol content
QUATERNARY AMMONIUM COMPOUNDS e.g. Cepacol, Scope
Disadvantages:
Staining of teeth
Increased supragingival calculus
Burning sensation/desquamation
OXYGENATING AGENTS- 1.5% hydrogen peroxide or 10% carbamide peroxide
Debriding agent
Recommended for short-term use to reduce symptoms of ANUG &
pericoronitis
e.g. amosan, Colgate Peroxyl
OXIDIZING AGENTS-chlorine dioxide e.g. Crest 3D White
Short-term use to control oral malodour-cosmetic
What are dentricife recommendations for the pediatric patient?
BIRTH -1ST TOOTH ERUPTION
-parents should clean child’s gums with a soft cloth + H2O or finger brush
ERUPTION OF 1ST TOOTH
-start brushing 2X/day with a soft, infant toothbrush and a
non-fluoridated child toothpaste
2-5 YEAR OLDS
-parents should dispense a “pea-sized” amount of a fluoridated
toothpaste and perform/assist the child with brushing
what shoul you do for removable partial denture care?
Plaque forms on natural teeth and partial denture surfaces
Partial dentures need to be brushed/cleaned as well
Toothbrushing and interdental cleaning must be emphasized around abutment teeth
what should you do for edentulous/denture care?
Tissue under denture must be cared for: Remove denture daily
Stimulate tissue with soft toothbrush or a facecloth
Any deposit that can form on natural teeth can also form on denture surfaces. Immersion will not remove plaque, still requires mechanical friction
what should you do with dental implant care?
Use caution not to scratch titanium on implant.
No sulcus but plaque and calculus can form.
WHAT YOU CAN RECOMMEND TO YOUR IMPLANT PATIENTS FOR HOME CARE:
Dental tape or tufted floss e.g. Superfloss
Nylon coated interdental brushes (no metal wire) e.g. Proxabrush
Sulcabrush
Rubber tip stimulator
Perio-aid
Soft picks
Water irrigator e.g. waterpik
how sholud you floss for dental implants?
FLOSSING TECHNIQUE FOR AN IMPLANT:
Insert dental tape or Superfloss on both sides (mesial/distal) of the implant.
Wrap the floss around the implant and crisscross in front.
Move floss in a sawing or shoe-shine motion.
what should you do for orthodontic plaque control?
Complicating factors: Age Hormonal imbalances Exaggerated gingival response to local irritants Gingival enlargement Position of the teeth Problems with the appliances Self-care is difficult and tedious
what about toothrbushing bonded brackets?
Power brushes a very effective
Select a brush with bi-level filaments i.e. middle row is shorter so that it can be applied directly over the brackets
Insert brush above, over, and below brackets Additional recommendations: floss threader, interdental brushes, sulcabrush, rubber tip, oral irrigation
what is xerostomia and what should you do for the xerostomia patient?
XERSTOMIA:
-dryness of the mouth caused by a lack of normal secretions
CAUSES: Pharmacologically induced-side effect Sjogren’s syndrome Surgical removal of salivary glands Radiation treatment to head/neck
USE OF A SALIVA SUBSTITUTE
-preparation with chemical/physical properties similar to saliva
-contains CMC-carboxymethycellulose and the minerals calcium,
phosphorous & fluoride
Instruct patient to place a small amount in their mouth
Distribute the solution over all surfaces with the tongue
Use as needed for comfort
what should you do to help patients with dental caries?
Dietary survey may be needed
Explain the relationship between plaque, sucrose and dental caries
Fluoride in toothpastes, rinses, professional applications important
e.g. PreviDent toothpaste
what are disclosing agents?
Is a liquid/tablet preparation containing dye
Used to identify biofilm deposits for evaluation/instruction
how do you use disclosing agents?
SOLUTION:
Gingival tissue examination must be completed before disclosing agent is applied because disclosing agents mask tissue colours
Apply lubricant to lips to prevent staining
Retract the lips/cheek/tongue, and dry teeth with compressed air
Use a cotton tip applicator & generously paint the crowns of the teeth
with the solution
Rinse mouth with 3-way syringe/suction
RINSE:
Place a few drops of concentrated disclosing agent in a paper cup and dilute with water
Instruct the patient to rinse/swish the solution over the teeth
TABLET:
Instruct patient to chew ½-1 tablet and swish the dissolved solution for 30-60 seconds, covering the teeth
Rinse with water
