Toothbrushing Flashcards
Earliest evidence if toothbrushes
Chew sticks made of various types of crushed wood spread out like a brush
Toothbrushes eventually evolved to the use of horsehair
Nylon bristles replaced the use of horse hair in
1938
The first powered toothbrush appeared in
1960
Characteristics of an Effective Manual Toothbrush
• Conforms to individual patient requirements in size, shape, and texture.
• Easily and efficiently manipulated.
• Readily cleaned and aerated; impervious to moisture.
• Durable and inexpensive.
• Soft bristles.
• Multilevel or angled bristles.
• End-rounded filaments free of sharp or jagged edges.
• Designed for utility, efficiency, and cleanliness.
• In the United States, look for the ADA (American Dental Association) Seal of Acceptance, and in Canada, look for the CDA (Canadian Dental Association) Seal.
What are the parts of a toothbrush?
• Handle: The part grasped in the hand during toothbrushing.
• Head: The working end; consists of tufts of bristles or filaments.
• Shank: The section that connects the head and the handle.
Length of the toothbrush head should
cover two to three posterior teeth.
Width of the toothbrush head should
cover the intercuspal distance of the first molar.
What are the preferred characteristics of the handle?
Preferred characteristics
• Easy to grasp. A handle of larger diameter may be useful for patients with limited dexterity, such as children, aging patients, and those
• Does not slip or rotate during use.
• No sharp corners or projections.
• Lightweight, consistent with strength.
• Variations
• A twist, curve, offset, or angle in the shank with or without thumb rests may assist the patient in adaptation of the brush to difficult-to-reach areas.
The length of the brush head may be
5-12 tufts long and 3-4 rows wide
What are the variations in brush planes/design?
flat, rippled, tapered, bi-level, multilevel, and angled.
Most toothbrush filaments are made of
Nylon
A variety of filament designs are available and may include, but are not limited to,
end-rounded, feathered, microfine, and conical shaped.
Some evidence suggests end-rounded bristles are
less abrasive to gingival damage than bristles that are non-end-rounded
What is the purpose of power toothbrushes?
Recommended for physically able patients with ineffective manual biofilm removal techniques.
• Facilitate mechanical dental biofilm control or removal of food debris from the teeth and the gingiva.
• Reduce calculus and extrinsic dental stain buildup.
What are the indications for use of a power toothbrush?
Those with a history of failed attempts at more traditional biofilm removal methods.
• Those undergoing orthodontic treatment.
• Those undergoing complex restorative and prosthodontic treatment.
• Aggressive brushers: Many models of power toothbrushes will shut off automatically it too much pressure is applied during brushing, which can be a benefit for those who have a tendency to apply too much pressure.
• Patients with disabilities or limited dexterity: The large handle of a power brush can be of benefit. Handle weight needs to be considered for these patients.
• When a parent or caregiver must brush for the patient.
What are the motions of a power toothbrush?
Rotational
Counterrotational
Oscillating
Pulsating
Cradle or twist
Side to side
Translating
Combination
Ultrasonic/ sonic
What are the speeds of power brushes?
Low to high
What are the brush head designs for power brushes?
The filaments or bristles of power tooth brushes should be
Soft End rounded nylon
What are the types of power source of a power tooth brushes should?
Direct, replaceable battery, rechargeable, disposable
What are the influencing factors in selection of a toothbrush?
Ability of the patient to use the brush and remove dental biofilm from tooth surfaces without damage to the soft tissue or tooth structure.
Manual dexterity of the patient.
The age of the patient and the differences in dentition and dexterity.
Status and Anatomic configurations of gingival and periodontal health.
Position of Teeth: Crowded teeth, Open contacts
Patient preference and compliance
Specific Factors to Consider for Selection of Power Toothbrush
• Replaceable brush head.
• Features that include a timer and pressure sensor.
• Patient affordability.
• Battery-operated models are often less expensive and may be a good way for the patient to try out a power toothbrush before investing in a more expensive rechargeable model.
Brush head selection is dependent on
the patient’s ability to maneuver and adapt the brush correctly to all facial, lingual, palatal, and occlusal surfaces for dental biofilm removal.
Some research suggests ___designs of manual toothbrush heads and ____power brush heads are most effective.
angled tufted; rotating, oscillating round
Toothbrush bristles are typically classified as
hard, medium, soft, or extra soft.
Filaments must have adequate stiffness to
remove plaque biofilm and do no harm to oral soft and hard tissues.
What are the methods of manual brushing?
Sulcular: Modified Bass.
• Roll: Rolling stroke, modified Stillman.
• Vibratory: Stillman, Charters, Bass.
• Horizontal (or scrub).
• Circular: Fones.
• Vertical: Leonard.
What is the purpose of the bass and modified bass method of brushing?
Dental biofilm removal adjacent to and directly beneath the gingival margin.
• Open embrasures, cervical areas beneath the height of contour of the enamel, and exposed root surfaces.
• Adaptation to abutment teeth or implants, under the gingival border of a fixed partial denture.
What is the procedure for the bass and modified bass method?
Direct the filaments apically (up for maxillary, down for mandibular teeth).
• First, position the sides of the filaments parallel with the long axis of the tooth.
• From that position, turn the brush head toward the gingival margin to make approximately a 45° angle to the long axis of the tooth.
• Direct the filament tips into the gingival sulcus.
• Press lightly so the filament tips enter the gingival sulci and embrasures and cover the gingival margin. Do not bend the filaments with excess pressure.
• Vibrate the brush back and forth with very short strokes without disengaging the tips of the filaments from the sulci.
• Count at least 10 vibrations.
• In the modified Bass method, the vibratory, sulcular brush stroke is followed by rolling the toothbrush down over the crown of the tooth to clean the rest of the tooth surface.
Apply the brush to the next group of two or three teeth. Take care to overlap placement.
The entire stroke (steps A-C) is repeated at each position around the maxillary and mandibular arches, on both facial and lingual tooth surfaces.
Tilt the brush handle somewhat vertically for the anterior components. The bristles are directed into the sulci.
What are the limitations of the bass and modified bass method?
• The toothbrush bristles extend only 0.9 mm below the gingival margin, so plaque removal in the sulcus is limited.
• An individual who is an aggressive brusher may interpret “very short strokes” into a vigorous horizontal scrubbing motion, causing injury to the gingival margin.
• Dexterity requirement for the vibratory stroke may be difficult for certain patients.
What is the purpose of stillman and modified stillman method?
As originally described by Stillman, the method is designed for massage and stimulation, as well as for cleaning the cervical areas. The modified Stillman method adds a rolling stroke to the Vibratory stroke to clean the crown of the tooth.
• Dental biofilm removal from cervical areas below the height of contour of the crown and from exposed proximal surtaces.
• General application for cleaning tooth surfaces and massage of the gingiva.
What is the procedure for the stillman and modified stillman method?
Place side of brush on the attached gingiva: The filaments are directed apically
When the plastic portion of the brush head is level with the occlusal or incisal plane, generally the brush is at the proper height.
The brush ends are placed partly on the gingiva and partly on the cervical areas of the tooth and directed slightly apically.
Press to flex the filaments: The sides of the filaments are pressed lightly against the gingiva, and blanching of the tissue occurs
• Angle the filaments: Turn the handle by rotating the wrist so that the filaments are directed at an angle of approximately 45° with the long axis of the tooth.
• Activate the brush: Use a slight rotary motion. Maintain light pressure on the filaments, and keep the tips of the filaments in position on the tooth surface. Count to 10 slowly as the brush is vibrated by a rotary motion of the handle.
• Roll and vibrate the brush: Turn the wrist and work the vibrating brush slowly down over the gingiva and tooth. Make some of the filaments reach interdentally.
Reposition the brush by rotating the wrist. Avoid dragging the filaments back over the free gingival margin by holding the brush slightly away from the tooth.
• The entire stroke (steps A-C) is repeated at least five times for each tooth or group of teeth. When moving the brush to an adjacent position, overlap the brush position.
• Position the brush somewhat vertically using the toe of the brush head for the anterior components.
• Press and vibrate, roll, and repeat.
What are the limitations of the stillman method?
Careful placement of a brush with end-rounded filaments is necessary to prevent tissue laceration. Light pressure is needed.
Patient may try to move the brush into the rolling stroke too quickly, and the vibratory aspect may be ineffective for biofilm removal at the gingival margin.
What is the purpose of The Roll or Rolling Stroke Method?
• Removing biotim, materia alba, and food debris from the teeth without emphasis on gingival sulcus.
• Used in conjunction with a vibratory technique such as modified Bass, Charters, and Stillman methods.
• Can be particularly helpful when there is a question about the patient’s ability to master and practice a more complex method.
What is the procedure for the rolling stroke method?
• Filaments: Direct filaments apically (up for maxillary, down for mandibular teeth).
• Place side of brush parallel to and against the attached gingiva: The filaments are directed apically. When the plastic portion of the brush head is in level with the occlusal or incisal plane, generally the brush is at the proper height.
Press to flex the filaments: The sides of the filaments are pressed lightly against the gingiva. The gingiva will blanch.
• Roll the brush slowly over the teeth: As the brush is rolled, the wrist is turned slightly. The filaments remain flexed and follow the contours of the teeth, thereby permitting cleaning of the cervical areas.
Some filaments may reach interdentally.
• Repeat the entire stroke: The entire stroke (steps A and B) is repeated at least five times for each tooth or group of teeth.
• Rotate the wrist: When the brush is removed and repositioned, the wrist is rotated.
• Stretch the cheek: The brush is moved away from the teeth, and the cheek is stretched facially with the back of the brush head. Be careful not to drag the filament tips over the gingival margin when the brush is returned to the initial position.
• When moving the brush to an adjacent position, overlap the brush position.
E. Position Brush for Anterior Lingual or Palatal Surfaces
• Tilt the brush slightly vertically and use the toe of the brush head to access the lingual surfaces of the anterior teeth.
• Press (down for maxillary, up for mandibular) until the filaments lie flat against the teeth and gingiva.
• Press and roll (curve up for mandibular, down for maxillary teeth).
What are the limitations of the rolling stroke method?
Brushing too high during initial placement can lacerate the alveolar mucosa.
• Minimal plaque removal interproximally or in sulcular areas.
• Tendency to use quick, sweeping strokes results in failure to adequately remove plaque biofilm from the cervical third of the tooth because the brush tips pass over rather than into the area, likewise for the interproximal areas.
Purposes and indications for the charters method
• Loosen debris and dental biofilm.
• Stimulate marginal and interdental gingiva.
• Aid in biofilm removal from proximal tooth surfaces when interproximal tissue is missing creating open embrasures (e.g., following periodontal surgery).43
• Remove dental biofilm from abutment teeth and under the gingival border of a fixed partial denture (bridge) or implant-supported bridge or partial denture.
What is the procedure for the the charters method?
• Filaments: Direct bristles at 90° angle to the teeth.
• Place side of brush at right angles (90% to the long axis of the teeth.
• Note the contrast with position for the Stillman method.
• Press the bristles gently between the teeth, being careful not to injure the gingiva.
• With the bristles between the teeth, use as little pressure as possible and make three to four small rotary movements with the bristles.
• The sides of the bristles should come into contact with the gingival margin to massage or stimulate them.
• Remove the brush from the interproximal area and move to the next area.
Repeat steps for strokes described previously three to four times in each area on the maxillary and mandibular arches.
• Move the distance of one embrasure and repeat the process to overlap strokes.
What are the limitations of the charter method?
Brush ends do not engage the gingival sulcus to disturb subgingival bacterial” accumulations.
• In some areas, the correct brush placement is limited or impossible; modifications become necessary, consequently adding to the complexity of the procedure.
Purpose of Horizontal or scrub method
• Research suggests the horizontal toothbrushing method is appropriate for children younger than 6 years for use on occlusal and lingual surfaces; however, the method should be combined with other techniques.
• Once the child reaches the late mixed dentition stage, modification to another technique can be initiated as the horizontal method has limitations in terms of thorough plaque biofilm removal.
Procedure for the horizontal method
Filaments: Direct bristles at right angle to the tooth.
• Place toothbrush head at a 90° angle to the long axis of the teeth on both buccal and lingual posterior surfaces.
• For anterior teeth, the head of the toothbrush is held parallel to the long axis of the tooth and the toe of the brush is used.
• Bristles are moved in a gentle back and forth motion on the posterior surfaces, buccal, lingual, and occlusal.
• Bristles are moved in an up and down motion on the anterior teeth using the toe of the toothbrush.
Limitations for the horizontal method
Although this method can remove plaque biofilm on buccal and lingual surfaces, it does not reach interproximal areas.
There are also concerns about this method resulting in cervical abrasion if excessive pressure along with an abrasive toothpaste is used in adults.”
What is the purpose of the fones method?
This method is easy for children to learn and may be easier than the horizontal method to switch to more appropriate techniques as the child ages.
Procedure of fones method
Place toothbrush at 90° to the long axis of the teeth, buccal and lingual, and press bristles gently against the teeth.
Bristles are moved in a circular motion several times in each area and then the brush is moved to a new area
Limitations of fones method
Efficiency of plaque removal was the lowest as compared to sulcular and horizontal brushing methods.
Leonard’s (or Vertical) Method procedure
Place toothbrush at 90° to the long axis of the teeth, buccal and lingual, and press bristles gently against the teeth.
The teeth are edge to edge.
Bristles move in an up and down motion with light pressure on the tooth
surfaces. Move systematically from area to area around the mouth.
Leonard method purpose
May work well for small children.
Limitations of leonard’s method
Much like the rolling stroke, there is minimal plaque removal interproximally and in the sulcular areas.
Procedure for power toothbrushing
• Place bristles at a 45° to 90° angle to the long axis of the tooth, then turn the brush on.
• Move the brush over the buccal (or lingual) and interproximal surfaces of each tooth (or area depending on the size of the brush head) for about 5 seconds.
• Reposition the brush on the next tooth and repeat both on the buccal and lingual surfaces in a systematic approach.
• Many powered toothbrushes have a built-in 2 minute timer which can signal to the patient the minimum brushing time.
Limitations of power toothbrushing
• Cost for the rechargeable models can be an economic hardship for some patients.
• Some people may not like the sound or vibration of the powered toothbrushes, especially those with oral hyposensitivity. However, desensitization may allow for power toothbrushes to be used and they have been shown to be effective in those with autism.
What is the purpose of occlusal brushing?
• Loosen food debris and biofilm microorganisms in pits and fissures.
• Remove biofilm from the margins of occlusal restorations.
• Clean pits and fissures to prepare for sealants.
What is the procedure for occlusal brushing ?
• Place brush head on the occlusal surfaces of molar teeth with filament tips pointed into the occlusal pits at a right angle.
• Position the handle parallel with the occlusal surface.
• Extend the toe of the brush to cover the distal grooves of the most posterior tooth
• Strokes: The two acceptable strokes include:
• Vibrate the brush in a slight circular movement while maintaining the filament tips on the occlusal surface throughout a count of 10. Press moderately so filaments do not bend but go straight into the pits and fissures.
• Force the filaments against the occlusal surface with sharp, quick strokes; lift the brush off each time to dislodge debris; repeat 10 times.
• Overlap previous stroke by moving the brush to the premolar area.
Gradually progress around each maxillary and mandibular arch until all occlusal surfaces have been thoroughly debrided.
While teaching the brushing methods, Hands-on demonstration of toothbrushing by the patient is essential so the clinician can
assess dexterity and ability of the patient to reach difficult areas. This also allows the clinician to determine if a different oral hygiene aid may be more effective.
What are some areas for special attention during brushing?
Distal surfaces of posterior teeth
Facially displaced teeth, especially canines and premolars
Lingually inclined teeth such as the maxillary anterior teeth.
Exposed root surfaces: Cemental and dentinal surfaces.
Overlapped teeth or wide embrasures, which may require use of vertical brush position
Surfaces of teeth next to edentulous areas.
Tongue coating is a
white-brownish layer on the dorsum of the tongue and is made up of desquamated epithelial cells, blood cells and metabolites, food debris, and bacteria.
Purpose of tongue brushing
Remove or reduce tongue coating.
• Reduces bacterial load.
• Reduces potential for halitosis .
• Improves taste sensation in smokers and nonsmokers.
Brushing tongue Procedure
• Hold the brush handle at a right angle to the midline of the tongue and direct the brush tips toward the throat.
• With the tongue extruded, the sides of the filaments are placed on the posterior part of the tongue surface.
• With light pressure, draw the brush forward and over the tip of the tongue. Repeat three or four times.
• A power brush should only be used for tongue cleaning when the switch is in the “off” position.
Types of Tongue Cleaners and Scrapers
Tongue cleaners or scrapers are typically made of plastic or a flexible metal strip. A variety of tongue cleaners and scrapers are available and may include the following:
• Loop with a single handle
• Curved with two ends to hold.
• Raised, textured rubber pad on the back side of the toothbrush head.
Procedure for tongue scrubbing
• Place the cleaner toward the most posterior area of the dorsal surface
• Press with a light but firm stroke, and pull forward.
• Repeat several times, covering the entire surface of the tongue.
• Wash the tongue cleaner under running water to remove debris.
The grasp of a toothbrush should be
Light and controlled
Grasp the toothbrush handle in the palm of the hand with the thumb against the shank.
near the head so it can be controlled effectively.
• Position according to the brushing method to be used.
• Adapt grasp for the various positions of the brush head on the teeth throughout the procedure; adjust to permit unrestricted movement of the wrist and arm.
• Apply appropriate pressure for removal of the dental biofilm avoiding excessive pressure
The brushing sequence should be approached in a
systematic way to ensure complete coverage for each tooth surface. Technique based on sequence creates habit, which may increase effectiveness.
How frequent should brushing be?
Twice a day
The average times for brushing range from
60 to 80 seconds in the literature.
what are some way to ensure brushing duration?
The count system, the clock system or a combination of the two and built in timers
(PB)
When should toothbrushing be changed for special conditions?
1. Acute Oral Inflammatory or Traumatic Lesions
When an acute oral condition precludes normal oral self-care, instruct the patient to:
• Brush all areas of the mouth not affected and if tolerable clean the affected area with an extra-soft toothbrush. Reducing the bacterial load is essential to aid in healing.
• Rinse with a warm saline solution to encourage healing and debris removal.
• Consider prescribing an antimicrobial rinse like chlorhexidine to aid in the reduction of bacterial load until normal oral self-care can resume.
• Resume regular biofilm control measures on the affected area as soon as possible.
II. Following Periodontal Surgery
Provide specific instructions concerning brushing while sutures and/or a dressing are in place.
• Perform oral self-care in the areas not involved in the surgery as usual.
• Follow directions provided by the periodontal office for care of the surgical area.
• Rinsing and brushing the surgical area may not be recommended until at least 24 hours after surgery, at which time care should be taken to avoid the gingival areas when brushing.
• If gingival grafting was done, no brushing may be allowed until the postoperative follow-up appointment.
• An antimicrobial rinse like chlorhexidine may be prescribed to aid with reducing the bacterial load and to aid in healing while the oral self-care process is modified.
III. Following Dental Extraction
• Clean the teeth adjacent to the extraction site the day following surgery.
• Brush areas not involved in the surgery as usual to reduce biofilm and promote healing.
• Beginning 24 hours after surgery, rinse the mouth with a warm, mild saline solution after each meal or snack to help remove food debris from the extraction site.
IV. Oral Self-Care of the Neutropenic Patient
Neutropenia or a low white blood cell count (<500 absolute neutrophil count) occurs during treatment such as chemotherapy, radiotherapy, and bone marrow transplant associated with many cancers. Neutropenia puts the patient at increased riskfor life-threatening
infection.Oral complications can significantly impact the patient’s quality of life and ability to recover primarily due to the impact on adequate nutrient intake.
A. Oral Complications
• Mucositis (inflammation and ulceration of the mucous membranes of the mouth and throat).
• Xerostomia (dry mouth).
• Dysgeusia (changes in taste).
• Fungal and viral infections such as Candida and herpetic lesions.
• Trismus (reduce opening of the mouth).
• Diffuse pain.
• Aggravation of existing periodontal diseases.
B. Oral Care Recommendations
• Ongoing interprofessional collaboration with the oncology team by the dental team is essential to maintain the patient’s oral health.
• Prevention of infection in the oral cavity is needed to minimize the risk of systemic infection during this immune-compromised state. The following recommendations have been made by the MASCC/ISSOO guidelines:
• Brush a minimum of two times/day with an extra-soft or soft toothbrush with the bristles softened in hot water.
• If mucositis is present, a topical anesthetic mouthrinse, such as morphine 0.2%, may be necessary for brushing to help minimize oral pain.
• Replace the toothbrush regularly.
It is suggested to replace the brush prior to each neutropenic cycle, meaning it should be replaced prior to the beginning of each chemotherapy or radiotherapy treatment cycle.
• Use a fluoride toothpaste; non-mint flavored may be more comfortable if the patient is experiencing mucositis. A prescription fluoride gel,
toothpaste, or rinse may also be recommended depending on the patient’s caries risk and ability to be compliant with oral self-care.
• The use of chlorhexidine for preventive measures of oral mucositis is not recommended.
• Interproximal cleaning should be done regularly using aids the patient is familiar with to avoid self-injury.
• Clean the tongue by either brushing or using a tongue cleaner/scraper.
• Any dental prostheses should be cleaned according to instructions found in Chapter 30.
What can be the adverse effect of toothbrushing?
Soft tissue lesions, hard tissue lesions and bacteremia
How do you care for toothbrushes?
Have 2; Replaced every 2-3 months, tap to get out excess water, needs to be kept in open air
