periodontics 3

8/14/2019 Periodontics 3

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Plaque Control for the Periodontal Patient

The reference for this lecture is chapter 44 in the 11th

edition of the book(Carranza's clinical periodontology), or chapter 50 in the 10thedition.

The doctor was merely reading the slides aloud; so they might be enoughby themselves.

Patient motivation and oral hygiene instructions are basic in the

periodontal clinic. Without these, the treatment cannot succeed.

Plaque controlis the regular removal of dental plaque and the prevention

of its accumulation on the teeth and adjacent gingival surfaces.

Rationale: In the absence of bacteria in gnotobiotes (germ-free animals) gingivitis

and periodontitis do not develop.

Accumulation of plaque on teeth induces an inflammatory response in

adjacent gingival tissues while plaque removal results in resolution of

gingival inflammation.

Optimal oral hygiene, preventing re-growth of bacterial deposits, is

critical in the long-term success of periodontal therapy.

Le et al (1965) andTheilade et al (1966), conducted studies on dentalstudents, whom they asked to stop brushing their teeth. (This is

considered unethical nowadays!)

It was found that:

All of the subjects rapidly formed supragingival plaque. Gingivitis developed within 7-21 days. When oral hygiene was resumed, the condition was reversed and

health was reestablished (within one week).

This is a classic study that provides evidence for the importance of oral

hygiene.

In a three-year study by Axelsson&Lindhe(1978), regular OHI andprophylaxis were given to stimulate adults to adopt proper oral hygiene

habits:

Persons who utilized proper oral hygiene techniques had:

Negligible signs of gingivitis. No loss of periodontal tissue attachment. No new carious lesions.


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Control patients who merely received traditional dental care(symptomatic treatment) suffered from:

Gingivitis. Lost periodontal tissue support. New and recurrent carious lesions.

The results of this study indicate the importance of oral hygiene at

home. Dental treatment alone is highly ineffective in curing caries

and periodontal diseases.

The initiating factor of periodontal disease is mainly plaque. And sothe goal of oral hygiene is the physical and chemical disruption of

the biofilm on a frequent basis.

Microbial plaque growth occurs within hours, and it must be

completely removed at least once every 48 hours to prevent

inflammation.

The ADA recommends that individuals brush their

teethtwice& use floss or other interdental cleaners onceper

day.

So if the inflammation only occurs after 48 hours, why brush twice

and floss once a day? Because you can't remove all the plaque at

once; brushing your teeth a second time improves the results.

There are two approaches to plaque control: mechanical andchemical. Both can be performed either by the individual

himself/herself, or by the dental professional.

The following diagram summarizes the techniques in which home

care can be performed.


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Tooth brushing:

Carries dentifrice to tooth surface. Removes dental plaque, and disrupts its reformation. Cleans teeth of food debris and stains. Massages the gingival tissue.

Ideal toothbrush:

Handle size is appropriate to age and dexterity. Head size is appropriate to the size of the individual patients

requirements.

Use of end-rounded nylon or polyester filaments(not larger than 0.23 mm in diameter).

Has soft filament configurations as defined by the acceptableinternational industry standards (ISO).

Has filament patterns which enhance plaque removal in theproximal spaces and along the gum line.

Inexpensive, durable. Impervious to moisture, easily cleaned.

The ADA's specifications for the heads of toothbrushes:

1 inch to 1 inches long. 2-4 rows of bristles. 5/16 inch to 3/8 inches wide. 5-12 tufts per row.


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Claydon N andAddy Mcompared four commercially available

toothbrushes for total plaque removal at a single brushing. All

toothbrushes removed plaque equally. Plaque removal

depends on the brushing technique rather than the design.

Toothbrush care:

Keep on a clean surface. Clean after use. Store in open air in no contact with other brushes. Replace when worn. Disinfect or replace after illness. Replace every 3 to 4 months.

The usual recommendation to brush twice daily is reasonable, not

only to remove plaque but also to apply fluoride through the use of

dentifrice in order to prevent caries.It is likely that the thoroughness and duration of the oral hygiene

session, rather than the frequency, are the critical factors.Theoptimum tooth-brushing duration is 2 minutes.

Brushing techniques:

Diameter

Varies depending on

portion of bristletaken, age & life of

animal

Range from soft at

0.2mm to medium at0.3 mm & hard at

0.4mm

End shape

Deficient, irregular,

frequently open-

ended

End rounded to ensure

fewer trauma

Advantage,

Disadvantage

1) Cannot bestandardized

2) Wear rapidly& irregularly

3) Hollow endsallow micro-organisms &

debris tocollect inside.

4) Rinse, clean,dries rapidly.

5) Durable &maintain longer.

6) End rounded &closed, repel

debris & water.7) More resistant to

accumulate

micro-organisms


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Circular brushing technique

It can be learned and mastered by small children.

The Bass brushing technique

The bristles are angled into the sulcus at a 45-degree angle.

Horizontal

Scrub

techni

que

Vertical

Leonar

d

techni

que

(1939)

Circular

Fones

techni

que

(1934)

Vibratory

Stillman,

Bass,

and

Charte

rs

techni

ques

Roll

Roll

method

or

modified

Stillman

technique


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And then they are moved in a short vibratory stroke that has a

circular pattern.


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The modified Bass technique (picture above) is the most often

recommended, because it emphasizes sulcular placement of bristles

to reach supragingival plaque and access subgingival plaque as

much as possible.

The Charters brushing technique

The bristles are held perpendicular to the long axis of the teeth and

are forced into the interproximal spaces. Then bristles of the brush

deflect toward the occlusal surface. This technique is recommended

when the patient has firm gingival biotype with recession or a high

risk of recession; because here the bristles are not held towards the

gingiva, but towards the occlusal surface.


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The Modified Stillman or Roll" Technique

The bristles are angled into the sulcus at a 45-degree angle and

overlap onto the facial gingiva. The head of the brush is then

"rolled" so that the bristles move occlusally.


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Summary of brushing techniques:

Electrical brushes

They are indicated for children and adolescents, patients withphysical or mental disabilities, hospitalized patients including older

adults who need to have their teeth cleaned by care givers, and

patients with fixed orthodontic appliances.

They are easy to use. Their main disadvantage is that they are a bitexpensive.

Different designs for electrical brushes:

Charters bristles on cervical crown obliquely

pointing coronally, horizontal motion

with rotations

Bass bristles in sulcus 45 pointing apically,

horizontal back & forward motion

Modified

Bass

bristles in sulcus 45 pointing apically,

horizontal motion with rotations to

occlusal

Leonard bristles 90 to tooth surface, up &

down motions

Stillman bristles in gingival margin obliquely

towards the apex. Vibratory movementswithout moving the brush

Modified

Stillman

bristles in gingival margin obliquely

towards the apex. Vibratory movementswith rotations towards occlusal


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The brush should reach the gingival margin, as shown below.

The result of a study by Heanue et al. (2003) that comparedelectrical toothbrushes to manual ones is that "powered

toothbrushing is at least as effective as manual brushing and

there is no evidence that it will cause any more injuries to the

gums than manual brushing."

So if your patient can afford an electrical toothbrush, advise them to

one.

DentifricesDentifrices can be in the form of powder, gel, or paste (which is the

commonest).

It has the following ingredients:


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Calculus control toothpastes

Also called tartar control toothpastes, they contain

pyrophosphatesnthat interfere with crystal formation in calculus.They reduce the formation of new supragingival calculus by 30% or

more. They do not affect subgingival calculus formation or gingival

inflammation. They reduce the deposition of new supragingival

calculus but do not affect existing calculus deposits.

Interdental cleaning aidsA toothbrush, regardless of the method in which it's used, does not

remove interdental plaque. That's why these aids (floss, interdental

brushes, unitufted brushes, and toothpicks) are used.

Most dental and periodontal diseases originate in the proximal area,

and so it's very important to clean them well.

The choice of which aid to use depends on:

The size and shape of the interdental embrasure and thedegree to which soft tissue fills the space. Presence of furcations, tooth alignment.


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Presence of Orthodontic appliances or fixed prostheses. Ease of use and patient cooperation.

Interdental space (soft tissue) classification and choice of interdental

cleaning aid:


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Dental flossCan be twisted or non-twisted, bonded or non-bonded, waxed or

unwaxed, thick or thin.

Instructions: 12 to 18 inches should be taken Floss is slipped between contact area and wrapped around

tooth surface- up and down strokes


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SuperflossIt has the following parts:

It has a stiff end for ease of insertion under the bridge. The stiff endis inserted first, and then the tufted floss is used for cleaning.

Floss holdersThey are used to assist patients who have difficulty flossing.


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Interdental brushesThey are used in open embrasures with low papillary height where

the brush can fit easily in the available space without causing trauma

to the papilla.

The ones shown below are called proxy brushes.

The interdental brush is inserted into the interdental area and used toremove the plaque. The aim of interdental aids is not to remove fooddebris, but to remove plaque.


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In open contact areas, or furcation areas, the interdental brush is

used (and not the floss), because it can reach all surfaces (picturebelow).

Single-tufted brushThe tuft can be 3-6 mm in diameter, and it can be tapered or flat.


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It's used to: Improve access to distal surfaces of posterior molars, tipped,

rotated or displaced teeth.

To clean around and under fixed partial dentures, orthodonticappliances, or precision attachment.

To clean teeth affected by gingival recession and irregulargingival margin or furcation involvement.

Tongue cleaner

It has a raised edge for cleaning the middle and it's smooth on the

sides.

Tongue cleaning is an important part of oral hygiene instructions,

because the tongue is considered a reservoir for microorganisms.

Chemical plaque controlIt will be covered in more detail in a forthcoming lecture.

Remember: mechanical plaque removal remains the primary

preventive method to control dental diseases. However, chemical

plaque control could be an adjunct to mechanical plaque control.


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The ADA has accepted just two types (agents) of chemical plaque

control:

1. Prescription solutions of Chlorhexidinedigluconate oral rinse(2 daily rinses with 10 ml of a 0.2%).

(Plaque reductions of 45% to 61% and more importantly, gingivitis

reductions of 27% to 67 %.)The patient is advised to use the Chlorhexidine mouth rinse 30

minutes after brushing and not immediately afterwards, because the

toothpaste contains sodium laurate, which might intereact withChlorhexidine. The patient is also advised not to eat or drink for 30

minutes after rinsing.

2.Nonprescription essential oil mouthrinse.(Plaque reductions of 20% to 35% and gingivitis reductions of 25%to 35 %.)Mechanism of action of Chlorhexidine:

One charged end of Chlorhexidine (dicationic) molecule binds to the

tooth surface whereas the other remains available to initiate the

interaction with the bacterial membrane as the microorganism

approaches the tooth surface, and thus it destroys bacteria.


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Side effects of Chlorhexidine: Primarily brown staining of the teeth, tongue, and

silicate and resin restorations.

Transient impairment of taste perception. Oral mucosal erosion. Unilateral, bilateral parotid swelling rare,

unexplainable.The following pictures illustrate these effects.


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Oral hygiene instruction

Oral hygiene instruction can be achieved either by personal (one-to-

one) instruction, or through other self-instructional approaches (e.g.

videos, booklets). Both approaches are equally effective.

A formal plaque-reduction protocol should be part of all dentalpractices, regardless of the method used.Compliance is the degree to which a patient follows a regimen

prescribed by a healthcare practitioner.


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Disclosing agents

Erythrosine dye is applied to teeth and it discolors plaque (pink areas

in picture below). This helps show the patient where plaque is, and

how to remove it.

Cases in which the patient fails to perform dental home care (and

ways to improve their performance) are illustrated in the picture

below.


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The following two pictures show the adverse effects of incorrectly

used (interdental) plaque-control techniques.

Incorrect use of floss can cause a cleft in the gingiva.

Forceful tooth-brushing can cause abrasion and sensitivity.

best to find an alternative

method (e.g., an EMB) that will

enhance her efforts. It may also be necessary to see

her more frequently for

maintenance.

The patient

knows what to

do, but is unableto perform

(lacks

dexterity)

Reinstruction is indicated.

If continued efforts at instruction

and feedback are ineffective, analternative might be considered,

such as another brushing

technique or an EMB.

The patient does

not know what todo

(lacks

knowledge)

motivation is missing

The key is to focus on the

problem: the presence ofunacceptable amounts of plaque

and the associated biologic

response to the plaque, such as

bleeding on probing.

The patient knowswhat to do, is able

to do it, but simplydoesn't comply

with the regimen

(lacks

motivation)


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Reinforcement of daily plaque control practices and routine visits to

the dental office for maintenance care are essential to successful

microbial plaque control and long-term success of therapy

Please excuse the higgledy-piggledy manner in which this script is

written; circumstances hadarisen that made it very difficult to do it

properly.

periodontics 3

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