patient education, motivation & oral hygiene instructions

PRESENTED BY :SHILPA SHIVANAND

II MDS

PATIENT EDUCATION, MOTIVATION AND

ORAL HYGIENE INSTRUCTIONS

3

Patient education Methods of patient education Motivation Theories of motivation Oral hygiene instructions Disclosing agents Toothbrushes and brushing techniques Dentifrices Interdental aids Oral hygiene after regenerative procedures Conclusion

CONTENTS

4

The background to oral health education The term Dental Health Education (DHE) has been

gradually superseded in recent years by Oral Health Education (OHE), reflecting a wider concern than health only of the teeth.

Problems with oral health education Previous inadequacies in OHE delivery have been

attributed to two main faults. The message which has been contained within the dental

health advice has not always been correct and has at times been totally misleading.

PATIENT EDUCATION

5

Domains of learning In education it is accepted that there are three do mains of

learning

1. Cognitive domain: this relates to the acquisi tion of knowledge.

2. Skills domain: this is the learning of practical skills.

3. Affective domain: this involves the creation of attitudes and motivation.

THE LEARNING PROCESS

6

The prevention and control of the two major dental diseases inflammatory periodontal dis ease and dental caries, depend to a large extent on a change in the behavior of the patient.

Changing behavior The following are the steps which must be followed to

establish behavioral changes

Factual education.

Practical demonstration.

Motivation.

Reinforcement.

BEHAVIORAL CHANGE

7

Information is a necessary but not on its own sufficient condition for changing behavior.

The information supplied should be accurate and comprehensible to lay-people.

Part of this information should include realistic goals that the patient can achieve.

For example, with some patients it would be preferable to concentrate solely on the improvements achiev able by brushing before progressing to inter dental cleansing.

FACTUAL EDUCATION

8

The teaching of the physical skills involved in dental health includes disclosing, brushing, interdental cleansing and the cleaning of dentures and appliances.

Educator should use 'tell-show-do' approach.

The action should first be explained, then demonstrated to the patient, possibly at first on models, then in the mouth.

Finally, the patient should carry out the procedure with the instructor supervising, correcting and giving encouragement.

Do not overload the patient. It is better to teach a little at a time.

PRACTICAL TRAINING

9

Refers to 'that which induces a person to act'.

In dentistry, the phrase 'patient motivation' is often misused, implying that one can cause a third person to co-operate, comply or perform in some desired manner.

This would be a very useful ability, but unfortunately not possible.

Motivation must come from within an individual.

MOTIVATION

10

In order to become motivated to alter a behavioral pattern an individual must be able to identify the following:

1. A problem exists which affects the individual personally

for example the existence of period ontal disease in the mouth.

2. The problem will have an unwanted personal outcome

such as the premature loss of teeth.

3. There is a practical solution

such as adequate plaque control.

4. The problem is serious enough to justify the in convenience of the solution.

THE ESSENTIALS FOR MOTIVATION

11

In relation to dental health education, people may be divided into three broad groups:

- those who are already motivated,

- those with latent motivation,

- those lacking the necessary motivation to change their behavior

Motivated have their own drive and simply require guidance and reinforcement from time to time.

Latent motivation is possessed by a majority of patients.

This is indicated by studies which show that approxi mately 60% of patients attend a dentist at least every second year, usually for a preventive check-up.

This latent motivation requires a trigger to activate or release it.


12

Patients without the desired motivation are intractable problem.

Various forms of threat or sanction may produce an

improved short-term behavioral change, but no long-term alteration.

However, even these patients may not be lost for ever, as research suggests that the priority of motives may change with time and circumstances, even in adults, and this will give rise to behavioral changes.


13

The process of encouraging or establishing a belief or pattern of behavior.

Once the progression of the disease has been controlled, then most patients require a regular (possibly 3 monthly) maintenance programme of visits.

This can be coupled with reinforcement of the oral hygiene regimen.

The frequency of reinforcement will vary from person to person and will depend to a large extent on their attitudes and the type of problem present.

REINFORCEMENT

14

A. Learning is more effective when an individual is physiologically and psychologically ready to learn.

B. Individual differences must be considered if effective learning is to take place.

C. Motivation is essential for learning.

D. What an individual learns in a given situation depends on what is recognized and under stood.

E. Transfer of learning is facilitated by recognition of similarities and dissimilarities between past experiences and the present situation.

F An individual learns what is actually used.

G. Learning takes place more effectively in situa tions from which the individual derives feelings of satisfaction.

H. Evaluation of the results of instruction is essential to determine whether learning is taking place.

PRINCIPLES OF LEARNING E M WILKINS 2005

15

The learning ladder illustrates the six steps from learner unawareness to habit formation.

When beginning to help a patient learn about oral health and what the individual's needs are, one must determine where the patient stands on the ladder and start from there.

THE LEARNING LADDER

16

A. Unawareness

Many patients have little concept of the new informa tion about dental and periodontal infections and how they are

prevented or controlled.

B. Awareness

Patients may have a good knowledge of the scientific facts, but they do not apply the facts to personal action.

C. Self-interest

Realization of the application of facts/knowledge to the well-being of the individual is an initial motivation.

THE LEARNING LADDER

17

D. Involvement

With awareness and application to self, the response to action is forthcoming when attitude is influenced.

E. Action

Testing new knowledge and beginning of change in behavior may lead to an increased awareness that a real

health goal is possible to attain.

F. Habit

Self-satisfaction in the comfort and value of sound teeth and healthy periodontal tissue helps to make certain

practices become part of daily routine Ultimate motivation is finally reached.

THE LEARNING LADDER

18

Periodontal health is important teeth are worth keeping for life.

The patients must believe this; otherwise any change in habit as an immediate response will be short-lived.

Several arguments may be employed and the experienced practi tioner can tailor these to the patient's perceived needs.

Adolescents and adults may respond to different arguments

CHANGE IN ATTITUDE TO DENTAL HEALTH DM ELEY, JD MANSON 2OO4

19

Impaired function No appliance can function as efficiently as the natural

and healthy dentition Full dentures may be an extremely poor substitute for

the patient's own teeth.

ATTITUDE TO DENTAL HEALTH

20

Personal hygiene. These days most people are concerned about personal

cleanliness and yet there may be a marked contrast between the patient's general appearance and the state of his mouth.

This usually represents a lack of awareness of oral hygiene and when the true state of affairs is demonstrated the individual who is truly concerned about personal hygiene will be ready to change his habits.

The patient is given a hand-mirror to witness the examination of the mouth, and deposits of plaque and calculus can be pointed out.

The use of a disclosing agent is valuable.


21

Social handicap Periodontal disease produces halitosis, inflamed gingiva

and eventually tooth loss due to mobility

The idea of possessing offensive breath or an ugly smile is often sufficient incentive for patients to improve their home care.

General health The fact that periodontal disease can have an adverse

effect on general health should be explained to the patient.


22

Based on the concept that one's beliefs direct behavior; model is used to explain and predict health behaviors and acceptance of health recommendations; emphasis is placed on perceived world of individual, which may differ from objective reality

Components

1. Susceptibility-individuals must believe that they are susceptible to a particular disease or condition

2. Severity-individuals must believe that if they get the particular disease or condition, the conse quences will be serious

3. Asymptomatic nature of disease-individuals must believe that the disease may be present without their full awareness

4. Behavior change will be beneficial-individuals must believe that there are effective means of pre venting or controlling the potential or existing problem and that action on their part will produce positive results

HEALTH BELIEF MODEL M L DARBY 1998

23

Theory regarding human nature that is used to explain the motivational process

Maslow suggested that inner forces, or needs, drive a person to action

He classified needs in a pyramid according to their importance to the individual, his or her ability to motivate, and the importance placed on their satisfaction

Only when an individual's lower needs are met, will the individual become concerned about higher level needs

Once needs are met, they no longer function as motivators

"MASLOW'S HIERARCHY OF NEEDS

24

HIERARCHY OF NEEDS

self-realization needs that drive the individual to reach the very top of his or her field

components necessary for body homeostasis, such as food, water, oxygen, temperature regulation etc

Social needs

25

The first task of the practitioner is to establish rapport with the patient, which then makes pos sible further development of communication, learning, and motivation.

Despite their importance, history taking, clinical examination, and diagnosis must all wait be cause, according to Meares 1957, while they may all occur concurrently with rapport, rapport must come first.

ESTABLISHMENT OF COMMUNICATION : RAPPORT

H E GOLDMAN 1980

26

Rapport is an emotional state in which logical, intellectual, or verbal factors may play only a small role.

Expressions, gestures, and other non verbal communication, however small, may as sume symbolic value to the patient as the initial meeting with the doctor takes place.

On the sur face the patient may be reciting his symptoms and concerns, but underneath this veneer he is assessing the competence and trustworthiness of the doctor.

Meanwhile the doctor should be establishing the emotional relationship with the patient that we know as rapport.

RAPPORT….

27

In considering obstacles to rapport the dentist should note the difference between sympathy and empathy.

Empathy, a great gift for a professional to possess, means that although we do not share the emotional feelings with the patients as in sympathy, we do appreciate how he is feeling.

Empathy is a blend of interest and objectivity. Many times the more sensitive the individual happens to

be, the more apt he is to possess a capacity for empathy. Lack of this qualification by professional is an obstacle

to formation of rapport with his patients or clients.

SYMPATHY / EMPATHY

28

Cinotti and Grieder advocate methods that may prove to be effective and more efficient.

These are conditioning and insight learning.

Conditioning The dental patient is conditioned by past experiences to

expect pain and discomfort before he visits the dental office. In our society, the dentist is often portrayed in cartoon and

lay articles as a threatening mutilator of the mouth who is to be feared.

It has been stated by many that the most feared figure in our society is the psychiatrist and that the dentist is possibly a close second

Friedman

METHODS OF PATIENT EDUCATION

29

In attempting to reeducate such patients many practitioners perform no treatment per se on the first visit but use it to establish rapport and com munication and to commence the unlearning of old ideas and fears and the learning of old ideas and fears and the learning of new values.

If sev eral visits elapse without pain the former trau matic association is weakened, and the patient is conditioned to become less fearful in the dental situation.

The dentist may then proceed with the full treatment that is needed.


30

Insight learning. If every patient came to the dentist with no previous dental

experience or knowledge, patient education would be not only easy but almost effortless because no previous erroneous concepts would have to be unlearned.

There would be no negative conditioning or avoid ance reactions already established.

Treatment could be started immediately, and insight learning could be instituted as treatment proceeded.

In sight occurs when there is an instantaneous as sociation between formerly unknown or poorly understood events and present happenings.

In the process the individual avoids trial and error and the long-term building up of associations re quired in conditioning.


31

Education of the patient con tinues throughout the examination.

A useful list of objectives to be accomplished by the dentist in consultation would include the following:

1. Determine the patient's needs, motives, and desires.

2. Make the patient feel important and ac cepted .

3. Give the patient some recognition and attention as an active partner in treatment plan.

4. Use visual aids (especially the patient’s own mouth).

5. Be a good listener, especially in the earlier stages of consultation.


32

The term "motivation" means conveying to the patient, through a series of words, gestures, and examples, the importance that self-performed oral hygiene has in the health of the oral cavity.

A T Botticelli 2002 In order to achieve this goal, dentists must possess:

- Technical skill- Communication skill- Psychologic insight

Dentist may have great technical skill, but will not succeed in their profession if they are unable to communicate with their patients in order to motivate them

MOTIVATION

33

OUR YOUTH - ORIENTED SOCIETY

OUR DESIRE TO BE PHYSICALLY ATTRACTIVE

SUPERSTITIONS AND FOLKLORE

SELF-DISCIPLINE

FACTORS THAT INFLUENCE PATIENT

MOTIVATION

34

Our so ciety is a youth oriented one and those things that enable us to prolong our youth and retain our youthful appearance are much sought after and valued.

Teeth are the most important physical facial feature that, if lost almost single handedly give the impression of the onset of old age.

Old age has been portrayed for centuries as a period of toothlessness with a collapse of vertical dimension in the face, subsequent characteristic changes in speech and facial form, and an increase in wrinkling.

Therefore from the aesthetic standpoint teeth are important, not purely for a superficial attractiveness, but also from more deep-seated fear of aging.

OUR YOUTH - ORIENTED SOCIETY.

35

Teeth are a major factor in preserving a pleasant facial expression that helps us retain our attractiveness to the opposite sex.

Attractiveness in men and women is aided immeasurably by the presence of teeth —hopefully natural teeth.

OUR DESIRE TO BE PHYSICALLY ATTRACTIVE

36

Many times facts regarding teeth and the pathology associated with them are warped slightly in correct to the extent of preventing patients from receiving proper advice on retaining their teeth and preventing dental disease.

Practitioners have repeatedly heard about the "soft" teeth or the familial susceptibility to decay or pyorrhea.

Folk lore also contributes its share of distortion to the truth.

H E Goldman 1980

SUPERSTITIONS AND FOLKLORE

37

Tonge (1965) indicates that this reputation is no doubt due to the fact that teeth are the most lasting parts of our bodies, as demonstrated by skeletal remains from all parts of the world.

In present-day life some evidence of' our respect for teeth still remains.

We still use eruption of teeth as a measure of maturity in the child.

SUPERSTITIONS AND FOLKLORE….

38

Both caries and periodontal disease are by nature chronic and thereby slowly progressive.

The practice of preventive measures to prevent future disease and discomfort requires considerable self-discipline by the patient.

Age. Another factor that may be a barrier to successful motivation is the fact that most periodontal patients are adults.

Adults are more difficult to change from their habits of neglect because their previously held concepts must be overcome before learning can take place.

On the other hand an adult can learn from another's experience and can accept long-range goals better than a younger patient can.

SELF-DISCIPLINE

39

DARBY , WALSH 1995

1.Self-efficacy Theory Self-efficacy, also known as self-confidence, is the belief in

one's ability to perform specific behaviors. Self-efficacy theory maintains that self-confidence about

being able to perform a behavior has a strong influence on the ability to perform that behavior.

Based on self-efficacy theory, motivation to brush and floss should be stronger when clients feel confident that they know how to floss and have the skill to do so.

An important role of the dental hygienist is to help clients acquire this confidence by training them to perform personal oral hygiene skills and by providing them with ongoing support and encouragement.

THEORIES OF MOTIVATION

40

2.Attribution Theory

Attributions are the explanations individuals give for their

performance. Attribution theory is a cognitive theory that emphasizes the

importance of content of thoughts. What people attribute to their success or failure deter mines

their feelings about themselves, their predictions of success at accomplishing the task, and the probability that they will try harder or not as hard at a task in the future.

For example, when people attribute their failure to low ability, they feel depressed, predict that they will fail again, and use less effort in the future. therefore attributions affect expectations of success, emotional (affective) reactions, and persistence at future tasks.

THEORIES OF MOTIVATION

41

Some clients may blame someone or something else for their poor performance in maintaining oral health.

Those people believe that external aspects or their environment have control over their failure (or their suc cesses)

The counterpart to these individuals is those who believe they hold their fates in their own hands and are responsible for their own actions.

They are focused on the internal aspects of themselves and how they can influence their environment.

Psychologists categorize such internal and external personality dispositions under the construct locus of control.

LOCUS OF CONTROL

42

He developed a 23-item internal-external locus of control scale for classification of individuals.

Three examples of items on Rotter's scale allow the respondent to read each statement and select the statement he or she most agrees with.

1a. Many times I feel that I have little influence over things that happen to me. (external)

1b. It is impossible for me to believe that chance or luck plays an important role in my life (internal)

2a. Getting a good job depends mainly on being in the right place at the right time (external)

2b. Becoming a success is a matter of hard work; luck has little or nothing to do with it. (internal)

3a. Without the right breaks one cannot be an effective leader (external)

3b. Capable people who fail to become leaders have not taken advantage of their opportunities (internal)

SOCIAL LEARNING THEORY OF ROTTER

44

SOURCES OF INFORMATION ON PERIODONTAL THERAPY.

(H E GOLDMAN 1980)

Dentist is not the sole source of information about dental disease

and its treatment. Before a Patient makes a dental visit oriented toward

prevention, he must have already been informed to some degree about the dangers of neglecting his dental health.

He might have been informed by any one of great number of sources , some of which are listed as follows:

1. Family or friends

2. Mass media-television, radio, magazines

3. Past experiences —personal and family

4. Fear of future pain and discomfort

5. Other authorities —physicians, school teach ers, nurses

6. Social and cultural background

45

At this point he may not be aware of the status of his periodontal health but be concerned only about the problems associated with dental caries.

The major source of information about peri odontal disease should be the private practitioner of dentistry.

We must assume that the patient has come to a dental office for some definite reason.

The dental practitioner may then take steps to inform him through a suitable means of communication to arouse in him a need for the required periodontal therapy.

SOURCES OF INFORMATION ON PERIODONTAL THERAPY.

46

Actions that dentists and the dental profession may take to improve the milieu in which the patient will motivate himself can be considered as either extramural or intramural procedures (Katz et al 1972)

Extramural procedures Because most periodontal patients are adults, and adults

have beliefs that are often difficult to change, the profession should concentrate on informing patients when they are children.

Extramurally this could be done by the dental profession through a more active participation in the health program at the elementary school level.

It could be accomplished by supplying attractive audio visual materials to the school, by participating in school functions, and by cultivating and edu cating the teachers, who are very powerful opinion makers in the child's life.

Parents may be ap proached by other dentally educated opinion makers such as physicians and nurses.

SUGGESTIONS FOR MOTIVATING PATIENTS

47

Intramural procedures Once the patient makes an appointment with the dentist,

he has evidenced a certain amount of need, or the appointment would never have been made.

After he arrives, stronger motivation is evidenced. Even though the patient has not come to the office for

relief of pain, you may as sume that he has come for the relief of some other anxiety (disquiet of mind).


48

Kegeles (1963) has suggested a procedure for dealing with such a patient.

He indicates that the following format is a useful framework in which to educate the patient relative to dental disease.

For a patient to make a dental visit and to undergo treatment that is oriented toward prevention he must believe the following:

1. That he is susceptible to periodontal disease

2. That periodontal disease is personally serious

3. That there is something he can do to treat or correct the condition

4. To a lesser degree that the condition oc curred due to natural causes


49

A patient must first believe that he is suscep tible to periodontal disease before he can possibly consider the personal seriousness of it.

Likewise he must accept his susceptibility and its serious ness before he can be required to consider whether any action that he may take will be beneficial in treating the problem.

If the patient accepts the fact that periodon tal disease is serious for him, but does not ac cept the fact that he is susceptible to it., he will never take any beneficial action.

Similarly, if he believes that he is susceptible, but that it is of no consequence, he will never agree to treat ment.

In like manner he may accept his suscep tibility and its seriousness for him and yet not believe that periodontal therapy and oral hygiene will help him.

He still will not take beneficial action.


50

Therefore Kegeles outlines must be followed. The dentist must develop a suitable presentation that will

convince the patient that he has every right to expect that, as a member of the human race, he is susceptible to periodontal disease

If the dentist is aware of some of the motives that compel men to action, he may similarly pre sent the patient with factual information on the seriousness of tooth loss from the financial, hy gienic, functional, esthetic, or psychological as pects.

The choice of approach depends on the patient's values in relation to his teeth.


51

Once the patient has truly accepted both his susceptibility and the serious nature of periodontal disease he will probably ask the dentist what he can do about treating the condition.

At this point a personal disease control program is outlined.

The individual dentist and his complete office staff should have their dental disease under control and should enthusiastically teach such a program to all patients (Kutz et al 1972).

Kegeles' last point states that the patient must believe that periodontal disease has occurred in his mouth due to natural causes.

This means that the patient should accept his condition as a natural biologic sequence of events and not as a punish ment evoked by God for some past sins.

Occa sionally, successful patient motivation is blocked by such a belief.


53

Patients can reduce the incidence of plaque and gingivitis with repeated instruction and encouragement much more effectively than with self-acquired oral hygiene habits

Gravelle et al 1967, Suomi et al 1969 However, instruction in how to clean teeth must be more

than a cursory chair side demonstration on the use of a tooth brush.

It is a painstaking procedure that requires patient participation, careful supervision with correction of mistakes, and reinforcement during return visits, until the patient demonstrates that he or she has developed the necessary proficiency

Anderson JC 1972, Less W 1972


54

Any strategy for introducing plaque control to the periodontal patient includes several elements.

At the first instruction visit, the patient should be given a new toothbrush, an interdental cleaner, and a disclosing agent.

The patient’s plaque should be disclosed because dental plaque otherwise is difficult for the patient to see

Newman et al 2006


55

A - Because bacterial plaque is relatively invisible and many tooth surfaces are not easily accessed, teaching patients the skills necessary for disease control can be difficult.

B -Agents that make supragingival plaque visible can enhance the teaching-learning process by

i) Demonstrating a relationship between the presence of supragingival plaque and the clinical signs of disease.

ii) Guiding skill development when applied before plaque removal.

iii) Allowing evaluation of skill effectiveness when ap plied after plaque removal.

BACTERIAL PLAQUE DETECTION M L DARBY 1998

56

C - Presence of subgingival plaque cannot be demon strated by the use of disclosing agents.

D - Plan for disease control education should include es tablishing the association between the presence of plaque and clinical signs of disease, such as bleeding.

E - Subgingival plaque detection by the client is best managed when there is an understanding of the gingival sulcus and/or pocket and the clinical changes that will occur when bacterial plaque removal is not effective

BACTERIAL PLAQUE DETECTION

57

I. Purposes A disclosing agent clearly demarcates soft deposits that might

otherwise be invisible and therefore facilitates the following:

a. Personalized patient instruction in the location of soft deposits and the techniques for removal.

b. Self assessment by the patient on a daily basis during initial instruction and periodic checks thereafter.

c. Continuing evaluation of the effectiveness of the instruction for the patient.

i) Determining the need for revision of the biofilm control procedures.

ii) Studying the long term effects over successive maintenance appointments.

DISCLOSING AGENTS E M WILKINS 2005

58

d. Preparation of biofilm indices.

e. Conducting research studies to gain new information about the incidence and formation of deposits on the teeth, the effectiveness of the specific diseases for dental biofilm control, and anti biofilm agents and to evaluate clinical and instructional group health programs.

DISCLOSING AGENTS

59

II. Properties of an acceptable disclosing agent

A. Intensity of Color : A distinct staining should be evident, color should contrast with normal colors of oral cavity.

B. Duration of Intensity: should not rinse off immediately with ordinary rinsing methods, neither should it be removable by the saliva for the period of time required to complete the instruction or clinical service.

C. Taste: The patient should not be made uncomfortable by an unpleasant or highly flavored substance

D. Irritation to the mucous membrane: The patient should be questioned concerning the possibility of an idiosyncrasy to an ingredient.

DISCLOSING AGENTS

60

E. Diffusibility: A solution should be thin enough so it can be applied readily to the exposed surfaces of the teeth, yet thick enough to impart an intense color to dental biofilm.

F. Astringent and Antiseptic Properties : These properties may be highly desirable in that the disclosing agent may contribute other factors to the treatment procedures

DISCLOSING AGENTS

61

III. Formulae A variety of disclosing agents has been used. Skinner’s iodine solution was formerly the most classic

and widely used. In general, iodine solutions are less desirable because of

their unpleasant flavor. Aniline dyes have been shown to have carcinogenic

potential. Therefore, the use of basic fuchsine and beta rose

(flavored basic fuchsine) has been discouraged. Other well-known agents are Buckley’s Berwic’s, Talbot’s

iodo-glycerol, and Metaphen solutions.

DISCLOSING AGENTS

63

1V Methods for application

A. Solution for Direct Application

(Painting)

1. Have patient rinse to remove food particles and heavy saliva.

2. Apply water-based lubricant generously to pre vent staining of the lips.

3. Dry the teeth with compressed air, retracting cheek or tongue

4. Use swab or small cotton pellet to carry the solution to the teeth

5. Apply solution generously to the crowns of the teeth only.

6. Direct the patient to spread the agent over all surfaces of the teeth with the tongue

7. Examine the distribution of the agent and request the patient to rinse if indicated.

DISCLOSING AGENTS

64

B. Rinsing A few drops of a concentrated preparation are placed in

a paper cup and water is added for the appropriate dilution.

Instruct the patient to rinse and swish the solution over all tooth surfaces.

C. Tablet or Wafer The patient chews the wafer (one half may be sufficient

for some patients), swishes it around for 30 to 60 seconds, and rinses.

DISCLOSING AGENTS

65

V. Interpretation

A. Clean tooth surfaces do not absorb the coloring agent; when pellicle and dental biofilm are pres ent, they absorb the agent and are disclosed

B. Pellicle stains as a thin, relatively clear covering whereas dental biofilm appears darker, thicker, ' and more opaque.

C. Two-Tone

1. Red Biofilm. Newly formed, thin, usually supragingival.

2. Blue Biofilm. Thicker, older, more tena cious; usually it is seen at and just below gingival margin, especially on proximal surfaces and where brush or floss is not easily applied; may be associated with calculus deposits.

DISCLOSING AGENTS

66

DISCLOSING AGENTS

Applying Disclosing Solution.mp4

68

VI. Patient instruction

A. Explain Dental Plaque

B. Show Location and Distribution of Plaque

C. Demonstrate Methods for Daily Plaque Removal

DISCLOSING AGENTS

69

A. Iodine solutions

- Skinner’s solution, Diluted Tincture of Iodine

B. Mercurochrome preparation

- Mercurochrome Solution (5%), Flavored Mercurochrome Disclosing Solution

C. Bismarck brown (Easlick’s Disclosing Solution)

D. Merbromin

E. Erythrosin

- Concentrate for Application by rinsing , For Direct Topical Application , Tablet

F. Fast Green

G. Fluorescein (Lang et al 1972)

H. Two-Tone (Block et al 1972)

DISCLOSING AGENTS

70

The bristle toothbrush appeared about the year 1600 in China, was first patented in America in 1857.

Generally tooth brushes vary in size and design, as well as length, hardness, and arrangement of the bristles. Silverstone LM , Featherstone MJ 1988

The American Dental Association has described the range of dimensions of acceptable brushes:

- Length : 1 to 1.25 inches

- Width : 5/16 to 3/8 inches

- Surface area : 2.54 to 3.2 cm

- No. of rows : 2 to 4 rows of brushes

- No. of tufts : 5 to 12 per row

- No. of bristles : 80 to 85 per tuft

TOOTH BRUSHES Newman et al

71

Never advice hard toothbrush gingival laceration, recession, tooth abrasion

Bristles of children's toothbrush always soft (0.1-0.15mm)

Fransden 1972 Adult brush head : 2.5 cm, children 1.5cm Bristle even length Bristle should penetrate gingival crevice without causing

damage Brush easy to clean Toothbrush handle should rest comfortably in hand Non-toxic, hygienic

TOOTH BRUSHES

72

A. Sequence

1. A methodical, systematic approach will enhance effectiveness

2. Suggested sequence: begin systematic overlapping strokes at the facial aspect of the maxillary right or left terminal tooth and continue around the arch to the terminal tooth on the opposite side; switch to the lingual aspect and begin working back to ward the starting side; use the same pattern for the mandible, then brush the occlusal surfaces.

FACTORS IN TOOTHBRUSHING EFFECTIVENESS

M L DARBY 1998

73

B. Duration

1. Each time the brush is moved, the time spent in an area should be monitored by counting strokes or seconds

2. Total manual brushing time of 3 to 5 minutes has been suggested; powered brushes may be used for 2 minutes


74

C. Frequency

1. Thorough bacterial plaque removal once a day is the minimum requirement for maintaining periodon tal health; it may not, however, be the optimum regimen for some individuals

2. Frequency should be increased when gingival or periodontal conditions warrant it or when caries risk or activity is high

3. Brushing removes residual food debris as well as bacterial plaque and is one method for self application of topical fluoride


75

D. Skill level

1. Careful attention should be given to evaluating skill development in all components of brush ma nipulation, including grasp, placement, activa tion, wrist movement, and amount of pressure applied

2. Control of brush placement and motion is essential for effectiveness


76

Roll: Roll method or modified Stillman technique

Vibratory: Stillman, Charters, and Bass techniques

Circular: Fones technique

Vertical: Leonard technique

Horizontal: Scrub technique Scrub technique: probably the simplest and most common

method of brushing. Patients with periodontal disease are most frequently taught

a sulcular brushing technique using a vibratory motion to improve access in the gingival areas.

The method most often recommended is the Bass technique because it emphasizes sulcular placement of bristles.

TOOTHBRUSHING METHODS

77

Place the head of a soft brush parallel with the occlusal plane, with the brush head covering three to four teeth, beginning at the most distal tooth in the arch.

Place the bristles at the gingival margin, pointing at a 45-degree angle to the long axis of the teeth.

Exert gentle vibratory pressure, using short, back and forth motions without dislodging the tips of the bristles.

This motion forces the bristle ends into the gingival sulcus area as well as partly into the interproximal embrasures.

The pressure should be firm enough to blanch the gingiva Complete several strokes in the same position. Lift the brush, move it to the adjacent teeth, and repeat

the process for the next three or four teeth.

BASS TECHNIQUEBASS CC 1954

78

BASS TECHNIQUE

• Place the toothbrush so that the bristles are angled approximately 45 degrees from the tooth surfaces.

• Start at the most distal tooth in the arch, and use a vibrating, back-and forth motion to brush.

79

A. Proper position of the brush in the mouth aims the bristle tips toward the gingival margin.B. Diagram shows the ideal placement, which permits slight subgingival penetration of the bristle tips.

BASS TECHNIQUE

80

MODIFIED BASS TECHNIQUE

Tooth Brushing- Modified Bass Technique.mp4

81

Brush is placed with bristles resting partly on cervical portion of tooth and partly on adjacent gingiva, pointing in an apical direction at an oblique angle to long axis of tooth

Pressure is applied laterally towards gingival margin to produce blanching

Brush is activated with 20 short back and froth strokes and is simultaneously moved in coronal direction along attached gingiva, gingival margin and tooth surface.

Recommended in patients with progressing gingival recession and root exposure to prevent abrasive tissue destruction

STILLMAN METHODSTILLMAN PR 1932

82

Brush is placed with bristles pointed towards the crown at 45 degree angle to long axis of the teeth

Sides of the bristles are flexed against the gingiva, and the back and froth vibratory motion is used to massage the gingiva

Bristle tips should not move across the gingiva Suitable for gentle plaque removal and gingival massage Indicated in healing wounds after periodontal surgery

CHARTERS METHODCHARTERS WJ 1932

83

Method Bristle placement Motion Advantage/disadvantage

Scrub Horizontal on gingival margin Scrub in anterior position direction keeping brush horizontal

Easy to learn & best suited fro children

BASS Apical towards gingival into sulcus at 450 to tooth surface

Short back and forth vibratory motion while bristles remain in sulcus.

Cervical plaque removalEasily learned Good gingival stimulation

Charter's Coronally 45o, sides of bristles half on teeth and half of gingiva

Small circular motions with apical movements towards gingival margin

Hard to learn and position brush Clears inter proximalGingival stimulation

Fones Perpendicular to the tooth With teeth in occlusions, move brush in rotary motion over both arches and gingival margin

Easy to learn Inter proximal areas not cleaned May cause trauma

Roll Apically, parallel to tooth and then over tooth surface

On buccal and lingual inward pressure, then rolling of head to sweep bristle over gingiva & tooth

Doesn't clean sulcus area Easy to learn good gingival stimulation

Stillman's On buccal and lingual, apically at an oblique angle to long axis of tooth. Ends rest on gingiva and cervical part.

On buccal and lingual slight rotary motions with bristle ends stationary

Excellent gingival stimulationModerate dexterity required Moderate cleaning of interproximal area

Modified stillman's

Pointing apically at and angle of 45o to tooth surface

Apply pressure as in stillmans's method but vibrate brush and also move occlusally

Easy to master Gingival stimulation

84

Each of these methods can be modified to add a roll stroke.

The brush is positioned similarly to the Bass/Stillman technique.

After activation of the brush head in a back-and-forth direction, the head of the brush is rolled over the gingiva and tooth in the occlusal direction, making it possible for some of the filaments to reach interdentally.

MODIFIED BASS/STILLMAN TECHNIQUE

85

A. Brushes should be rinsed clean after each use, allowed to air-dry in an upright position

B. Rotating use of more than one brush during 24 prolongs brush life

C. Brushes should be replaced when bristles splay resiliency, generally no longer than 3 to 4 months.

D. Some brushes have color indicator bristles to monitor replacement time

E. Brushes should be replaced after an illness such or flu or disinfected with a household bleaches

TOOTHBRUSH MAINTENANCE

86

In 1939 powered tooth brush invented to make plaque

control easier.

Its mainly recommended for

(a) Individual lacking motor skills

(b)Hospitalized patients whose teeth are cleaned by the

caregivers.

(c)Special needs patient ( physical and mental disability)

(d) Patient with orthodontic applied

(e) Whosoever wants to use

ELECTRIC TOOTHBRUSH ( POWERED)

87

Powered toothbrushes rely primarily on mechanical contact between the bristles and the tooth to remove plaque.

The addition of low-frequency acoustic energy generates

dynamic fluid movement and provides cleaning slightly

away from the bristle tips.

Forgas-Brockmann LB et al 1998

POWERED TOOTHBRUSHES

88

No evidence of a statistically significant difference between powered and manual brushes. However, rotation oscillation powered brushes significantly reduce plaque and gingivitis in both the short and long-term

C. Deery et al 2003 Electric toothbrush have

not been shown to provide benefits routinely for patients with RA, children who are well-motivated brushers , or patients with chronic periodontitis.

Heasman, 1999

89

Definition

Substance used with a tooth brushes are accessible tooth surfaces; available in gel, paste or powder form.

Purposes

1. Cosmetic – Tooth surfaces are cleaned and polished, breath is freshened.

2. Therapeutic – Certain non drug substances augment the efficiency of the brush in removal of plaque debris and stain; Vehicle for transporting biologically active ingredients to the tooth and its environment; fluoride dentifrices inhibit tooth demineralization

DENTIFRICES

90

A. Products selected should carry the American dental Association (ADA) seal

B. All ADA accepted dentifrices have safe levels of abrasiveness

C. Dentifrices containing fluoride are granted acceptance based on their caries-reduction properties

GUIDELINES FOR DENTIFRICE SELECTION

91

D. Dentifrices that carry the ADA seal have gained acceptance for the proven efficacy of the fluoride mechanism

E. Desensitizing dentifrices that carry the ADA seal have gained acceptance for proven efficacy in the control of dentinal hypersensitivity

F. Dentifrices that claim therapeutic benefits other than dental caries reduction (from fluoride) or control of hypersensitivity have not been awarded the ADA seal for such claimed benefit

GUIDELINES FOR DENTIFRICE SELECTION

92

A. Daily use of fluoride dentifrice should be recom mended for all individuals, regardless of caries risk, because these products promote tooth remineralization

B. Young children (under age 6) should be supervised when using fluoride dentifrice

C. Use of a small pea-sized amount of toothpaste gel containing no more than 1100 ppm fluoride is recommended swallowing should be avoided dental fluorosis has been associated with use of more than a pea sized amount of toothpaste by young children living in fluoridated communities

Pendrys DG 1995

GUIDELINES FOR DENTIFRICE USE ADA 1995

93

Any toothbrush, regardless of the brushing method used does not completely remove interdental plaque

This is true for all brushers even periodontal patients with wide open , embrasures. Gejermo et al1970, Schmidet al 1976

Daily interdental plaque removal is crucial to augment the effects of tooth brushing because most dental and periodontal diseases originate in interproximal areas

Addy et al 1998 Tissue destruction associated with periodontal disease

often leaves large, open spaces between teeth and long, exposed root surfaces with anatomic concavities and furcation's.

These areas are both difficult for patients to clean and poorly accessible to the toothbrush Kinane 1998

INTERDENTAL CLEANING AIDS

94

Many tools are available for interproximal cleaning. They should be recommended based on the patient's

interdental architecture (e.g., size of interdental spaces), Presence of furcation's, tooth alignment, and presence, of orthodontic appliances or fixed prostheses.

Also, ease of use and patient cooperation are important considera tions. Common aids are dental floss and interdental cleaners such as wooden or plastic tips and interdental brushes.

INTERDENTAL CLEANING AIDS

95

Type I The gingival papilla fills up the embrasure space completely

floss

Type II The gingival papilla partially fills the embrasure space due to papillary recession

tufted dental floss/super floss , interdental brushes/proxy-brushes

Type III The embrasure space is not filled. The gingival papilla has receded extensively or it is completely lost

interdental brush/proxy-brushes, single tufted brushes

Norland , Tarnow 1998

CLASSIFICATION OF EMBRASURE

96

Dental floss is the most widely recommended tool for removing plaque from proximal tooth surfaces.

Floss is available as a multifilament nylon yarn that is twisted or nontwisted, bonded or nonbonded, waxed or unwaxed, and thick or thin.

Some prefer monofilament flosses made of a nonstick material because they do not fray.

Clinical research has demonstrated no significant differences in the ability of the various types of floss to remove dental plaque

they all work equally well. Grossman 1979, Keller 1969 Waxed dental floss was thought to leave a waxy film on

proximal surfaces, thus contributing to plaque accumulation and gingivitis.

Robert H. Beaumont 1990

DENTAL FLOSS

97

Dental floss should be held securely in the fingers or tied in a loop. (12-18 “)

Dental floss technique. The floss is slipped between the contact area of the teeth, is wrapped around the proximal surface, and removes plaque by using several up-and-down strokes.

98

DENTAL FLOSS

How to use Dental Floss. Dr Kuljeet MEHTA-Periodontist. www.kmperio.co.uk.mp4

99

INTERDENTAL BRUSH (PROXY BRUSH)

Interdental brush are conical shape brushes made of bristles mounted on a handle / single tufted brushes.

Suitable for cleaning large, irregular, or concave tooth surfaces adjacent to wide interdental spaces.

Inserted inter-proximally and are activated with short back and forth strokes in between the teeth.

101

The dorsum of the tongue harbors a great number of microorganisms. These bacteria may serve as a source of bacterial dissemination to other parts of the oral cavity.

Therefore, tongue brushing has been advocated as part of daily home oral hygiene together with tooth brushing and flossing, since this might reduce a potential reservoir of microorganisms contributing to plaque formation Christen & Swanson 1978

The bacterial accumulations on the dorsum of the tongue may also be the source of bad breath.

TONGUE CLEANER

102

Massaging the gingiva with a toothbrush or an inter dental cleaning devices produces epithelial thickening. increased keratinization, and increased mitotic activity .

Canter et al1965, Castenfelt 1952, Glickman et al 1965 The increased keratinization occurs only on the oral

gingiva and not the areas more vulnerable to microbial attack the sulcular epithelium and the interdental areas where the gingival col is present.

Improved gingival health associated with interdental stimulation is much more likely the result of plaque removal than gingival massage.

GINGIVAL MASSAGE

103

Chemical plaque control can augment mechanical plaque control procedures.

Fluoride preparations are essential for caries control in periodontal patients.

Antimicrobial oral rinses will reduce gingivitis in periodontal patients.

CHEMICAL PLAQUE CONTROL WITH ORAL RINSES NEWMAN ET AL

105

1st generation agents Decrease plaque by 20-50% Good antimicrobial activity but

poor substantivity Antibiotics: Penicillin , Erythromycin, Metronidazole Quaternary ammonium compounds: Cetylpyridium chloride ,

Benzylchonium chloride Phenolic compounds: Phenol, thymol Essential oils: Eucalyptol, benzoic acid Herbal extracts: Sanguinarine Oxygenating agents: Peroxides

CLASSIFICATION OF CHEMICAL PLAQUE CONTROL AGENTS

Lindhe et al

106

2nd Generation Agents Decrease plaque by 60-90% Good antimicrobial activity and

excellent substantivity Bisbiguanides: Alexidine , Chlorhexidine Bispyridines: Octenidine

3rd Generation Agents They prevent plaque formation by inhibiting the pellicle

attachment. Amine alcohol: Delmopinol

CLASSIFICATION

107

To replace mechanical tooth brushing when this is not possible in the following situation:

- After oral or periodontal surgery and during the healing period

- After inter-maxillary fixation used to treat jaw fractures or following cosmetic surgery.

- With acute oral mucosal or gingival infections when pain and soreness prevents mechanical oral hygiene.

- For mentally or physically handicapped patients who are unable to brush their teeth themselves.

ID Mandel 1972

USES OF ANTI-PLAQUE MOUTHWASH

108

As an adjunct - to normal mechanical oral hygiene in situations where this may be compromised by discomfort or inadequacies.

Following sub gingival scaling and root planning when the gingival may be sore for days.

Following scaling when there is cervical hypersensitivity due to exposed root surface. Its use needs to be combined with measures to treat the hypersensitivity.

Following scaling in situations when the patients oral hygiene remains inadequate.

SG Ciancio 1986

USES OF ANTI-PLAQUE MOUTHWASH

109

Dispense the prescribed amount of mouthwash

Pour it into the mouth. Close your mouth to create a seal Do not swallow the mouthwash

Swish it through your teeth for 30 seconds

to a minute and then spit

HOW TO PRESCRIBE A MOUTHRINSE

110

HOW TO PRESCRIBE A MOUTHRINSE

How To Use A Mouthwash.3gp

113

Colgate Colgate Plax Peppermint Mouthwash (Rs 85 – Rs 99 /250ml)

Colgate Plax Complete Care Mouthwash (Rs 100 – Rs 112/250ml)

Colgate Plax Sensitive Mouthwash (Rs 105 – Rs 112 / 250ml)

Colgate Plax Fresh Tea (Rs 105 – Rs 112 /250ml)

MOUTHWASHES AVAILABLE IN INDIA

114

Listerine Listerine Fresh Burst Mouthwash (Rs 95 – Rs 100 /250ml)

Listerine Original Mouthwash (Rs 98 – Rs 100 /250ml)

Listerine Cool Mint Mouthwash (Rs 100 – Rs 102 /250ml)


115

• Colgate® PerioGard® Rinse

• Acclean® Chlorhexidine gluconate 0.12% oral rinse

• Rexidine mouth wash

CHLORHEXIDINE MOUTHWASHES AVAILABLE

IN INDIA

116

Pepsodent Pepsodent Germi Check Fresh Mint Mouthwash (Rs 115 – Rs 122 /300ml)

Pepsodent Germi Check Herbal Fresh Mouthwash (Rs 115 – Rs 122 / 300ml)


117

Oral-B Oral B Mouthwash Alcohol Free Multi-Protection (Rs 150 – Rs 165 for 500ml)

Crest Crest Pro-Health Complete Fresh Mint Fluoride Mouthwash

(Rs 425 – Rs 525 for 1Litre)

Crest Pro Health Clinical Deep Clean Mint (Rs 375 – Rs 450 for 975ml)


118

Himalaya Himalaya HiOra-K Mouthwash

(Rs 75 – Rs 80 for 215ml)

Aquafresh Aqua Fresh Tingling Mint Mouthwash

(Rs 280 – Rs 305 for 500ml)


119

Oral irrigators for daily home use by patients work by directing a high-pressure, steady or pulsating stream of water through a nozzle to the tooth surfaces.

Most often, a device with a built-in pump generates the pressure Oral irrigators clean non-adherent bacteria and debris from the

oral cavity more effectively than toothbrushes and mouth rinses. Irrigators are particularly helpful for removing debris from

inaccessible areas around orthodontic appliances and fixed prostheses.

When used as adjuncts to tooth brushing, these devices can have a beneficial effect on periodontal health

Both supra and sub-gingival irrigators are available

ORAL IRRIGATORS

120

A, The most common oral irrigators have a built-in pump and reservoir. B, Conventional plastic tips are used for daily supragingival irrigation at homeby the patient. Left, Tip for gingival irrigation. Right, Tip for cleaning dorsal surface of thetongue C, Soft rubber tip is used for daily subgingival irrigation by the patient at home.

121

Coarse fibrous foods As part of the plaque control program patients should be advised to

include hard fibrous foods in their diet, particularly at the end of meals. Although some investi gators disagree (Lindhe et al 1969) it is the

consensus that hard fibrous foods reduce plaque accumula tion and gingivitis on tooth surfaces ex posed to their mechanical cleansing action during mastication

Bear et al 1961, Stewart et al 1960 Coarse fibrous foods functional stimu lation to the periodontal

ligament and al veolar bone. Soft diets increased plaque accu mulation and calculus formation,

gingivitis and periodontal disease Plezer et al 1940 Animals fed soft diets enriched with vitamins and min erals develop

severe periodontal disease with loosening of the teeth, which does not occur when the diet includes lengths of bone and adherent meat which require vigorous chewing King et al 1945

DIETGLICKMAN 1972

122

Limiting sucrose-containing foods The fact that the ingestion of sucrose in creases plaque

formation is of great clinical importance. The polysaccharide dextran is a major component of the

plaque matrix. It is a sticky substance which envelops the plaque

bacteria and attaches the plaque to the tooth surface. The bacteria form the dextran from carbohydrates,

particularly sucrose. Limiting the intake of sugar and sugar-sweetened foods

assists in reducing plaque formation (Carlson et al 1965) and patients should be instructed accordingly.

DIET

123

No therapeutic intervention is without adverse effects, including oral hygiene practices.

Tooth abrasion and gingival recession are both alleged to be caused by traumatic brushing.

Tooth Abrasion Evidence implicating the toothbrush in cases of abrasion

comes primarily from in vitro studies, case reports, and cross-sectional studies.

Some studies have implicated a horizontal scrubbing stroke as a more important risk factor for tooth abrasion than bristle stiffness.

Other studies have indicated that abrasive toothpastes are the primary cause of tooth abrasion.

Vander et al 1996

ADVERSE EFFECTS OF ORAL HYGIENE AIDS

124

Gingival Recession Gingival recession is the result of an interaction between

precipitating factors, such as trauma to the gingival tissues, and predisposing factors,, such as a thin tissue complex.

Gingival recession, particularly that occurring on the buccal surface, is often presumed to be the result of toothbrush trauma.

It seems logical to assume that the thin gingival biotype might be more easily traumatized.

There is evidence suggesting that thin tissue is more prone to recessionOlsson1993


125

Possible Adverse Effects of Home Irrigation A number of investigators have examined the effect of pulsating

water jet devices on gingiva and mucosa and most have concluded there is little risk for tissue damage when such devices are used according to manufacturer's instructions

Rethman et al 1994 In one investigation, the use of an irrigator at 60 psi in

untreated periodontal pockets created no more tissue damage than was found in the "no irrigation" control groupCobb et al 1988

Some investigators have reported no bacteremia after irrigation, whereas others have reported that this does occur. Because this could have implications for individuals at risk for endocarditis, some authorities have recommended that the devices not be used by individuals at risk.

Page et al 1997


126

Thorough plaque removal may enhance the results of regenerative surgical therapy and may help provide stability to the gains in clinical attachment achieved Tonetti et al 1996

In the immediate postoperative period plaque control is accomplished by means of chemotherapeutic agents such as chlorhexidine gluconate rinses, and mechanical plaque removal is generally avoided.

Some tissue maturation should occur before resumption of normal oral hygiene

Critical to the regenerative outcome is wound stability and the preservation of the delicate fibrin forms on the root surface.

The presence of this fibrin clot may prevent the down growth of the epithelium, there by permitting regeneration of the attachment apparatus

ORAL HYGIENE AFTER REGENERATIVE PROCEDURES

127

It is often recommended that professional subgingival debridement and probing be avoided for 6 months after regenerative surgery, but little is said about the resumption of oral hygiene measures

Slots et al 1999 Do not brush or floss the surgical area for the first 7-10

days

Bruce B. Wiland

ORAL HYGIENE AFTER REGENERATIVE PROCEDURES

128

The foundation of a preventive health-oriented dental practice is an effective hygiene department.

We are responsible for delivering not only quality restorations with which patients can prevent dental disease, but also a structured program to aid them in taking care of their health and investment.

It is the quality of the dentist's restorations and the effectiveness of his or her hygiene program that determine whether he or she is practicing true preventive dentistry or simply functioning in a reparative manner-always "putting out fires."

CONCLUSION

129

1. Carranza’s clinical periodontology - 10th edition

2. Clinical practice of the dental hygienist - Esther M Wilkins

3. Dental maintenance for patients with periodontal disease – Thomas G Wilson

4. Periodontics – BM Eley , JD Manson

5. A handbook for the dental hygienist – W Collins, TF Walsh

6. Arnim, S.S.: Use of Disclosing Agents for Measuring Tooth Cleanliness, J. Periodontol., 34, 227, May, 1963

7. Glickman I, Petralis R, Marks R: The effect of powered toothbrushing plus interdental stimulation upon the severity of gingivitis, J Periodontol 35:519, 1964

REFERENCES

130

8. Glickman I, Petralis R, Marks R: The effect of powered toothbrushing and interdental stimulation upon microscopic inflammation and surface keratinization of the interedental gingiva, J Periodontol 3:108, 1965.

9. Lindhe, J., and Wicen, P.O.: The Effects on the Gingivae of Chewing Fibrous Foods. J. Periodont. Res., 4:193, 1969.

10. Loe H, Anerud A, Boysen H: The natural history of periodontal disease in man: prevalence, severity, and extent of gingival recession, J Periodontol 63:489-495, 1992.

patient education, motivation & oral hygiene instructions

Health & Medicine

mds patient education

oral health education

phrase patient motivation

dental health advice

learning of practical

dental caries

skills domain

domains of learning