Mechanical plaque control

The mechanical plaque control by humans is as old as the history of mankind. Dental literature is full of reports stressing the importance of maintaining oral hygiene. It has been known for centuries that a good oral hygiene is a primary requirement for healthy teeth and periodontium. However, the scientific literature came into the picture later, when various studies established an association between plaque and periodontal inflammation. In one of the initial studies, cause and effect relationship between supragingival plaque and gingivitis was demonstrated by Löe and his colleagues in 1965 1. In this experimental study, the plaque was allowed to accumulate, which resulted in the development of gingivitis within 21 days. When plaque control was initiated using brushing and flossing, gingivitis was reversed to clinical gingival health. Further investigations 2-5 provided more evidence for this association and plaque control was established as a primary measure to prevent the development of periodontal diseases.

Plaque control is defined as the removal of microbial plaque and food debris from the oral cavity 6. This can be accomplished either mechanically or chemically or a combination of the two procedures. In the present discussion, we shall discuss the self-performed mechanical plaque control methods.

Rationale of mechanical plaque control

The periodontal pathogens inhabiting periodontal pockets are primarily responsible for the  inflammatory and destructive periodontal diseases. Various epidemiological studies have demonstrated a  very strong  correlation  between  the  localization  of  dentogingival  plaque  and  periodontal  disease 7, 8. The periodontal pathogens are present in a well-organized structure of dental plaque. Dental plaque formation starts with the formation of dental pellicle, which matures by incorporating various Gram-positive and Gram-negative bacteria. If plaque is not removed regularly, the microorganisms and their products start damaging the periodontal tissue, thereby initiating host-bacterial interactions. These interactions lead to the damage of periodontal tissues supporting the teeth (bone and connective tissue) 9, 10. Due to the continued presence of bacterial biofilm, certain bacteria invade into the periodontal tissue, which cause further intensification of the inflammation, resulting in tissue destruction 11, 12. Due to all these reasons, the regular removal of bacterial biofilm from the teeth becomes an important component of measures in the maintenance of good periodontal health.

History of mechanical plaque control

Throughout the history of mankind, various cleansing aids have been used to remove deposits around the teeth. Primitive man used figure nails and splinters of wood to remove deposits in between the teeth. The first known toothpick which belongs to Sumerian civilization was made from gold and dates back to about 3000 B.C. The Chinese were amongst the first people to use the chewstick as a toothpick and toothbrush to clean the teeth and massage the gingival tissues. The Chinese designed gold and silver toilet sets which included stiletto-like toothpicks. Toothpicks were used by Greeks, Romans, and Hebrews also. The toothpicks used by the Romans were made up of bronze, gold or silver. Hippocrates (460 B.C.) recommended cleaning the teeth with a ball of wool soaked in honey. Toothbrushes during early civilization were made from various materials such as sponges, shredded ends of certain sticks and lint.

Although, the exact origin of the toothbrush is not known, the earliest toothbrushes have been recorded from China, dating back to 1498. These toothbrushes were made up of bone or ivory handles with natural bristles attached perpendicular to the long axis of the handle. The mass production of toothbrushes started in Europe during late 18th and early 19th century and since then toothbrushes are one of the most commonly available items in all parts of the world.

The first mechanical toothbrush was probably designed by Frederick Wilhelm Tornberg, a watchmaker in Stockholm in 1885 13. The invention was a new design of a toothbrush which allowed easy cleaning of teeth on the inner side as on the other side. The new introductions in toothbrushes include the electric toothbrushes, ionic toothbrushes, chewable toothbrushes etc. (discussed below).

Classification of mechanical plaque control aids

In the present context, various means of oral hygiene measures are used to aim at the removal of plaque and other deposits. These mechanical plaque control measures can be classified as,

Toothbrushes:

  • Manual Toothbrush
  • Electric Toothbrush
  • Ionic toothbrushes
  • Chewable toothbrush
  • Ecological toothbrushes
  • End-tuft brushes
  • Sulcabrushes
  • Beam toothbrush

Interdental Aids:

  • Dental Floss
  • Triangular Tooth Picks
  • Interdental Brushes
  • Yarn
  • Superfloss
  • Perio-Aid

Aids for gingival stimulation:

  • Rubber Tip Stimulator
  • Balsa Wood wedge

Tongue cleaners

Others:

  • Gauze Strips
  • Oral Irrigation Device

Aids for completely or partially edentulous patients:

  • Denture and partial clasp brushes
  • Cleansing solutions

In the following sections, we shall discuss in detail these mechanical plaque removal aids,

Toothbrushes

Manual toothbrushes:

The manual toothbrush is widely used as an oral hygiene aid and is often the sole means of plaque removal for many people. When performed correctly, for an adequate duration of time, manual brushing is highly effective for most patients.

Brief History:

Although the tooth brushing tools date back to 3500-3000 BC, when the Babylonians and the Egyptians made a brush by fraying the end of a twig, the Chinese are believed to be the inventors of the first natural bristle toothbrush in the 15th century. It was made from the bristles from pigs’ necks. The bristles were attached to a bone or bamboo handle. This toothbrush design was adopted by European people who modified it by using softer horsehairs or feathers as bristles.

The design of a modern toothbrush can be attributed to William Addis of Clerkenwald, England around 1780. In fact, he was put in jail for inciting a riot………………………

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The first 3-row bristle brush was designed in 1844. During the 1900s, celluloid handles gradually replaced bone handles in toothbrushes. The first American to patent a toothbrush was H N Wadsworth, (patent number 18,653) on Nov. 7, 1857. Soon after the invention of nylon by DuPont laboratories in 1938, the bristles were replaced with this new material. The first nylon toothbrush was called Doctor West’s Miracle Tuft Toothbrush. By 1938, the truly modern toothbrushes came into the picture and within few decades were extensively manufactured and used. Although, the first electric toothbrush was made in 1939 in Switzerland, first electric toothbrush introduced in the US was marketed by the Squibb company under the name Broxodent in 1960. It was designed by Dr. Philippe-Guy Woog. General Electric introduced a rechargeable cordless toothbrush in 1961. Interplak was the first rotary action electrical toothbrush introduced in 1987 for home use.

Design of toothbrush:

The toothbrush is the fundamental tool for the mechanical removal of plaque and other deposits. The requirements of a toothbrush are,

  • A toothbrush should be durable so that it can be used by the patient for a long duration of time.
  • The brush head should be small enough to be manipulated effectively, yet large enough to cover tooth surfaces.
  • The bristles should be of an even length so that they can function simultaneously. Too long bristles will not be able to clean the tooth surfaces properly and too short bristles will fail to reach the interdental sites.
  • The texture of the bristles should be smooth so that they do not injure the gingiva.
  • It should be flexible and light-weight for easy manipulation.
  • It should have strong bristles which are not too rigid.
  • The toothbrush should be easily cleanable. The nylon bristles are more hygienic than the natural bristles.
  • The toothbrush should be able to meet individual requirements.

Toothbrushes vary in size, design, length, hardness, and arrangement of bristles. According to American Dental Association (ADA), the method and toothbrush choice depends on patient oral health, manual dexterity, personal preference, ability and their desire to learn and follow the prescribed procedures. The ADA specification 14 for toothbrush is as follows,

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The bristles used to make the bruising surface may be made up of natural bristles from hogs or artificial bristles primarily made of nylon (Figure 45.1). Presently, artificial bristles made up of nylon predominate in the market and have been shown to have superior properties. The tufts of the bristles are arranged in 3 to 4 rows on the brushing surface. The ends of the bristles are made round so that gingiva is not hurt during brushing. The diameter of the bristles ranges from 0.007 inches for soft brushes to 0.012 inches for medium brushes to 0.014 inches for hard brushes. Soft brushes are most commonly used. Use of hard brush and abrasive dentifrice may lead to cervical abrasion of the teeth and recession of gingiva. Bass recommended the use of soft nylon bristles with a diameter of 0.007 inches and a length of 0.406 inches with rounded ends arranged in 3 rows of tufts, six evenly spaced tufts per row with 80 to 86 bristles per tuft. The brush recommended for children is smaller and has thinner (0.005 inches or 0.1 mm) and shorter (0.344 inches or 8.7 mm) bristles. The bristles are commonly colored with dyes which fade with use. The fading dye on the bristles acts as a reminder to replace the brush.

Figure 45.1 A toothbrush with 5 rows of nylon bristles with rounded ends. Each tuft is made up of 80-86 bristles.

Structure of toothbrush

The stiffness of the bristles depends on the diameter and length of the bristle filament and its elasticity. It also depends on whether the brush is used dry or wet and if wet, the temperature of water. A soft toothbrush typically has around 1600 filaments with 0.008 inches diameter and approximately 11 mm length, arranged in around 40 tufts in three or four rows.

Toothbrushes are available with different designs of handle and neck (Figure 45.2). The handle of the toothbrush may be straight or angled and thick or thin. Single or double angulation in the neck of the handle is provided so that the brush can reach the most distal surfaces of the posterior teeth. Toothbrushes recommended for most of the patients have a short head, soft or medium bristles with rounded ends arranged in three or four rows of tufts.

Figure 45.2 A few toothbrushes with different shapes and designs of heads and bristle tuft arrangement.

Designs of toothbrush head

Electric toothbrushes:

The electric toothbrushes provide a brush head, which is capable of a variety of movements driven by a power source (Figure 45.3). The first electric toothbrush was designed to mimic the back and forth motion which is commonly used in manual tooth brushing method. Presently, many powered toothbrushes use circular or elliptical motion and still others use a combination of motions.

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Since then a lot of modifications have been done in the electric toothbrushes such as oscillating or rotating toothbrushes and brushes with increased frequency. However, it was again emphasized in the World Workshop in Periodontics, 1996 that there was a little evidence suggesting an additional benefit of electric toothbrushes over manual brushes 17.

Figure 45.3 Electric toothbrush with head having circulatory and the back and forth vibratory motion.

Electrical tooth brush

The initial powered toothbrushes were not so user-friendly because of their cumbersome size, power source unreliability, and a lack of concurrence regarding effectiveness. After extensive work on designing a powered toothbrush, Oral-B (Procter & Gamble Company, Cincinnati, OH, USA) came up with “D-1”, the first mass-produced power toothbrush. The brush was designed to perform side to side motion with a manual-like brush head. Following the introduction of D-1, electric brushes with rotary or circular-like movements (e.g., Rotadent® [Zila, Fort Collins, CO, USA]) and head tufts rotating in a counter-rotational fashion (e.g., Interplak® [Conair, East Winslow, NJ, USA]) were introduced. Another major development in powered toothbrushes was the introduction of Oral-B Plaque Remover ‘D5’ in 1991. The brush was equipped with the prophylaxis-inspired oscillating-rotating mode of action 18. The brush had a cup-shaped head which oscillated at 5600 oscillations per minute. This was the first powered toothbrush which was clinically proven to clean the teeth better than a manual toothbrush 19.

The electric toothbrushes work by performing oscillating or rotatory action of bristles which is driven by a motor. Most of the presently available powered toothbrushes are equipped with a timer and pressure sensors which improve the efficacy of brushing. The electric toothbrushes can be divided into three classes according to the speed of bristle movement as,

  • Standard power toothbrushes
  • Sonic toothbrushes
  • Ultrasonic toothbrushes

Technically speaking, every electric toothbrush is a power toothbrush. It can be classified as a sonic toothbrush when its frequency of rotation is 20 Hz to 20,000 Hz or ultrasonic when it is more than that. Certain toothbrushes available in the market such as Megasonex and the Ultreo, have both sonic and ultrasonic movements. Sonic toothbrushes generated sonic waves create high-speed scrubbing strokes that can remove plaque from subgingival and interdental areas. They may also create the cavitational effect, fluid streaming, and acoustic vibrations which may cause hydrodynamic stresses that also aid in dislodging microbial plaque.

The ultrasonic toothbrushes have a piezoelectric ultrasonic emitter (transducer) embedded in the brush head. The transducer undergoes dimensional changes when connected to the power supply, thus producing ultrasonic waves. When these waves are transmitted to the bristles, they vibrate with a microscopic amplitude which does not provide any tactile feedback to the user. The dentifrice is used to conduct these ultrasonic waves to the teeth and gingiva. These ultrasonic waves may be conducted into the subgingival environment through the gingival crevicular fluid.  UltraSonex®, an ultrasonic toothbrush operates at a frequency of 1.6 MHz.

The vibration frequency of these toothbrushes also affects the fluid dynamics and creates a mild cavitation effect. The acoustic vibrations produced in vitro have been shown to have significant effects in reducing the abilities of oral bacteria to adhere to hard surfaces 20.

Ionic toothbrushes:

The concept, based on which ionic toothbrushes work has been utilized in dentistry in the form of iontophoresis, electrophoresis, and electrolyzing for years. Ionic brushes work on the principle of changing the surface charge of the tooth to repel plaque even from inaccessible areas of teeth (Figure 45.4). Another mechanism by which they remove plaque is by inhibiting coupling between the pellicle and bacteria, mediated by calcium bridges. Bonding between the pellicles and bacteria is mediated by Ca2+ ion bridge formation. The lithium battery in the toothbrush supplies anions which inhibit the bonding between the bacteria and Ca2+ ions, thus preventing the bacteria from adsorbing to the pellicles. The plaque removal is enhanced by both ionic exchanges, along with the normal mechanical action of the bristles on the tooth surface.

Figure 45.4 Ionic toothbrush

ionic tooth brush

Chewable toothbrush:

These are miniature plastic molded toothbrushes which can be used when no water is available, commonly during traveling. They are most commonly available from bathroom vending machines and are available in different flavors. After using they should be disposed off. Some chewable brushes have a breakable toothpaste plastic ball on the bristles which again can be used without water (Figure 45.5).

Figure 45.5 Chewable toothbrush

Chewable tooth brush

Ecological toothbrushes:

The plastic which is used to make traditional toothbrushes is a small source of environmental pollution. To reduce this pollution, some manufacturers have come up with biodegradable materials to manufacture toothbrushes. Also, the replaceable heads of toothbrushes have been introduced to be used with the same handle.

End-tuft brushes:

The end-tuft brush is a small round brush composed of a head with seven tufts of tightly packed soft nylon bristles (Figure 45.6). They are trimmed in such a way that the bristles in the center can reach deeper into small spaces. These brushes are primarily used to clean areas such as posterior surfaces of last molars, orthodontic braces and tooth surfaces next to missing teeth. These brushes are also useful in cleaning bridges, dental implants, and other fixed appliances.

Figure 45.6 End tufted brush

Unitufted interdental brush

Sulcabrushes:

Sulcabrushes are specifically designed to clean the teeth along the gingival margin. Its bristles are trimmed in such a way that they closely adapt to the gingival margin. These are used to clean difficult to reach areas such as last molars, interdental areas in between crowded teeth, bridges, and fixed orthodontic appliances.

Beam toothbrush:

In this toothbrush, a sensor is attached to the brush to…………………

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“Collis curve” brush:

It is a specially designed brush which has curved bristles (Figure 45.7). These curved bristles surround the tooth, allowing both, inside and outside of the tooth, cleaned at the same time.

Figure 45.7 “Collis curve” brush

 “Collis curve” brush

Suction toothbrushes:

These are the toothbrushes in which a small suction machine is attached to the toothbrush. The suction machine allows the care provider to brush the resident’s teeth where the suction removes debris and saliva during brushing.

Toothbrushes using solar power:

Researchers have developed toothbrushes which clean teeth by………………………………..

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Interdental Aids

Before we discuss in detail the interdental aids, let’s first discuss the types of the embrasure. As already discussed in chapter 39 “Art of history taking in periodontics”, Nordland and Tarnow have given the classification of interdental papillary height as follows,

Normal: The interdental papilla occupies the entire embrasure space apical to the interdental contact point / area.

Class I: The tip of the interdental papilla is located between the interdental contact point and the level of the CEJ on the proximal surface of the tooth.

Class II: The tip of the interdental papilla is located at or apical to the level of the CEJ on the proximal surface of the tooth but coronal to the level of the CEJ mid-buccally.

Class III: The tip of the interdental papilla is located at or apical to the level of CEJ mid-buccally.

Dental Floss:

Dental floss is a cord of thin filament used to remove food debris and plaque from the interdental areas where bristles of the toothbrush cannot reach. It is one of the most commonly recommended oral hygiene aids by the health professionals. However, it has been observed that client compliance with dental flossing is low as compared to tooth brushing because it is challenging to use 21. Dental floss is very effective in removal of interdental plaque and according to the American Dental Association; it can remove up to 80% of plaque in the interdental areas 21.

Historical aspect:

Anthropologists have found evidence that dental floss was used by prehistoric humans. The teeth recovered have been shown to have groove marks which are characteristics of using dental floss like material. It was Dr. Levi Spear Parmly, who is credited as the inventor of modern dental floss in early 1800’s. He advised his patients to floss between their teeth using a silk thread. But, this new concept of cleaning the teeth was not very well accepted by patients. In 1882 a company called the Codman and Shurtleft Company, based in Randolph, Massachusetts started mass production of dental floss. In 1898, New Jersey based Johnson & Johnson secured a patent for dental floss made from silk. A nylon based dental floss was developed by Dr. Charles C Bass in 1940’s. Nylon quickly replaced silk because of its consistent texture and resistance to shredding. In 1950’s dental tape was developed. Because of its efficacy in removing interdental plaque, dental floss is currently made from various materials and is available in various forms.

Types of dental floss:

There are various types of dental floss available currently which include,

  • Waxed and unwaxed floss
  • Teflon floss
  • Thread floss
  • Flavored and unflavored floss
  • Tape floss (also known as ‘dental tape’)

Waxed and unwaxed floss:

As the name indicates, waxed floss is coated with wax and is used in closely spaced teeth because it can easily slide between contacts. The waxed flosses are available with various flavors, which are preferred by many patients. The example of waxed dental floss is Oral-B waxed dental floss. On the other hand, unwaxed floss can be routinely used to clean the interdental areas. However, it is not as sturdy as waxed floss and is difficult to pass through the closely spaced teeth. The unwaxed floss typically has no flavor. Many patients find unwaxed floss easy to grip between the fingers.

Teflon floss:

This floss is made up of Teflon, which makes it easy to slide between the teeth. Teflon is shred-resistant material and is stronger and more durable than many other types of floss. It does not usually stick in between the teeth, but if it does, it comes out easily. An example of this type of floss is Crest ‘Glide’.

Thread floss:

This is made from nylon and works in the same way as any other type of floss.

Flavored and unflavored floss:

Many dental flosses are available in different flavors such as mint or cinnamon. Many patients find them more pleasant to use as they leave a nice, clean taste in the mouth. Dental floss coated with fluoride is also available which may protect teeth against decay. As the name indicates, unflavored floss does not contain any flavor.

Tape floss (also known as ‘dental tape’):

The dental tape has a wider and flatter design as compared to conventional floss and is recommended for those individuals who have a larger area of the tooth surface to clean 22. This floss is suitable for patients new to flossing and has an advantage of not breaking or fraying. An example of this is Colgate Dental Tape.

 

 

Know more…………..

Floss threader:

The floss threader has a loop of fiber, which has been designed in such a way that it can be used to clean small, hard to reach sites around the teeth. These are…………

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Figure 45.8 Use of floss threader

Floss threader

 

Powered flosser:

The powered flosser is provided with an electric motor. It has a bow type tip and single filament nylon cord (Figure 45.9). It is recommended for physically challenged individuals or persons who cannot master traditional string floss.

Figure 45.9 Powered flosser

Powered flosser

Floss holder/ Floss pick:

It is made up of plastic body with two prongs extending from the body. A single piece of floss is attached at the end of two prongs which runs between them. Various companies have designed floss holders in the shape of “V” or “F” (Figure 45.10). The body of the floss holder is broad which provides adequate grip for the operator. Most of the floss holder’s body tapers off into a pick. Floss holders are available in a variety of shapes, colors, and sizes for adults and children.

 Figure 45.10 Floss holders with “Y” and “F” shape

 Floss holders with “Y” and “F” shape

Triangular Tooth Picks:

The triangular-shaped wooden or plastic toothpicks are suitable for cleaning the interdental areas. Wooden sticks are made of balsa or birch wood (Figure 45.11) and are more pliable than plastic sticks. Another advantage of wooden toothpicks is that they soften in the mouth by moistening with saliva. The soft and pliable toothpick is more effective in cleaning interdental areas and is less harmful to the gingiva.  As the shape of triangular toothpicks approximates the shape of the interdental embrasure, they can slide into the interdental areas. These can be used to clean Type II and Type III embrasures.

Figure 45.1 1 Wooden toothpicks

Wooden tooth pick

Interdental aids used for different embrasures

Interdental cleansing aid
Types
Indicated in (Embrasure Type)
Uses
FlossUnwaxed, waxed, tape, polytetra-uoroethylene (PTFE),
braided
Class ICleaning in between teeth that have healthy, normal gingiva and type I embrasure space
Waxed floss- indicated for the tight contacts
Unwaxed floss- recommended for normal tooth contact
Tufted dental flossRegular diameter ¬floss and threader combination, wider tufted portion which looks like yarnClass II and Class IIICleaning the abutment of teeth under the pontic of a fixed partial denture
Under the wires in orthodontic appliances
Floss holder with dental floss
Handle with two prongs in Y or F shapeClass IPeople with poor manual dexterity
Using only one hand
People with big hands
Floss threaderDifferent designs that resemble a needle with a large opening to thread the flossClass ITo floss under tight contacts, and orthodontic fixed appliances.
Used under pontics and the abutments of bridges.
Floss is pulled through the interproximal space to allow cleaning of the proximal surface
Toothpick or Toothpick holderRound
Or triangular
Class II and Class III Cleaning in between exposed roots
Interdental brushBristle inserts are tapered or conicalClass II and Class IIICleaning in between exposed roots
Orthodontic fixed appliance and accessible furcations
Single-tufted brush (end-tuft, unituft)Bristles are attached at the end of plastic or wooden handleClass IIIOpen spaces between teeth
Difficult to reach areas
Fixed dental prostheses
A fixed partial denture
Pontic/abutment
Orthodontic appliance
Interdental TipHandle with soft, absorbent tip or plastic filamentClass II and Class III Can be used to clean root concavities, furcations, and orthodontic appliances

Interdental Brushes:

The interproximal or interdental brushes are made up of bristles which are mounted on the angled plastic handle (Figure 45.12). They are used to clean areas in between the teeth and between the wire of dental braces and the teeth. According to ISO 16409, they are color coded from 1-7 according to the width of the brush. Interdental brushes are classified according to ISO standard 16409:2006. This classification also specifies the passage hole diameter which is the minimum diameter of the interdental hole which will allow its passage.

Figure 45.12 Interproximal or interdental brush

Interdental cleansing aids

Classification of interdental brushes according to ISO standard 16409:2006

Brush Color (coded as per ISO 16409)
Brush Size
Wire Size
Passage Hole Diameter (PHD)
Pink00.4 mm
Orange10.45 mm< or = 0.8 mm
Red20.5 mm0.9 mm-1.0 mm
Blue30.6 mm1.1 mm-1.2 mm
Yellow40.7 mm1.3 mm-1.5 mm
Green50.8 mm1.6 mm-1.8 mm
Purple61.1 mm>1.9 mm
Gray71.3 mm
Black71.5 mm

Yarn:

The yarn is rarely used these days to clean interdental areas. Its usage and functions are similar to that explained for dental floss. It is primarily used in interdental areas where the interdental papillae have receded and interdental embrasures are extremely large. Only synthetic yarn should be used because the wool fibers irritate the gingiva and may cause trauma. It can be put into the interdental embrasure with the help of floss by attaching a piece of dental floss in the center of yarn and doubling the yarn back on itself. The dental floss acts as a leader for yarn to bring it into the interdental area. Once the yarn is in place, the procedure for cleaning is same as that for floss.

Superfloss:

It is a special kind of dental floss which is supplied in pre-cut segments. The ends of the floss are thin and stiff whereas the middle portion is tufted and fuzzy which helps in plaque removal. The superfloss can be inserted under the bridge or between orthodontic fixed appliances to clean plaque deposits.

Perio-Aid ®:

It is a toothpick holder which……………..

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Aids for gingival stimulation

Rubber tip stimulator:

It is primarily used for gingival stimulation, but can also be used to remove plaque biofilm by rubbing the tip against exposed surfaces. It is used by placing the rubber tip interdentally and in a coronal direction. Using an in-and-out motion, the tip is rubbed against the teeth and into contact areas.

Balsa Wood wedge:

Balsa wood is softer and more compressible in comparison to the hardwood. After getting moistened with saliva, the wedge becomes soft and conforms readily to contours bordering interproximal spaces between the teeth. However, some problems associated with fabrication and use of balsa wood wedge include uncertain source and supply, and a variance of properties, such as density, compressive strength, flexural strength, and cleanliness.

Tongue cleaners

The dorsum of the tongue provides a large area for the accumulation of various microorganisms, food debris, and dead cells. Furthermore, the tongue is inhabited by Candida species which is the cause of severe infections in immunocompromised patients 23.  These micro-organisms along with food debris, dead cells, and salivary components form the so-called ‘tongue coating’. It has been shown that…………………

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The tongue cleaning procedure was practiced by the Romans and was recorded in Europe in the 18th and 19th centuries. Ayurveda, the practice of Indian traditional medicine, suggests the daily use of the tongue cleaner in association with the cleaning of teeth to remove toxic substances from the dorsum of the tongue.  In the Koran (Mohammedan’s holy book), the Prophet Mohammed said ‘you shall clean your tongue for that is the way to praise God’. The end stage of oral cleansing procedures in Mohammedans involved vigorous tongue cleaning. In the 19th century, tongue cleaners were handcrafted and were made from sterling silver, ivory, and tortoise shell. Presently, a variety of tongue cleaners are available in the market. These may be made up of stainless steel, plastic (Figure 45.13) or wood.

Figure 45.13 Tongue cleaner

Tongue cleaner

Assessment of tongue coating:

Winkel tongue coating index (WTCI) 35 is used to assess tongue coating. In this index, dorsum of the tongue is divided into 6 areas (3 posterior, 3 anterior). The tongue coating is assessed as follows,

0 = no coating,

1 = light coating,

2 = severe coating.

All the scores from six areas are added and the final score is given with a possible range of 0–12.

Using a tongue cleaner:

The tongue cleaner is used by placing it as far as possible on the tongue. It should be pressed with gentle pressure to ensure full contact of the tongue cleaner with the tongue. Then it is pulled forward slowly, maintaining the tongue cleaner and tongue contact. The raised middle portion is used to clean the dorsum of the tongue. The smooth surface of the tongue cleaner is used to clean the lateral parts of the tongue. This procedure is repeated a number of times followed by mouth rinsing. One of the problems associated with the usage of tongue cleaner is stimulation of gag reflex, especially in persons who have just started practicing it. Patients should be instructed to place the tongue cleaner as back as possible without the stimulation of gag reflex.

Others

Gauze strips:

The gauze strips can be easily used to clean plaque deposited on the teeth. It is specifically useful when a broad surface has been exposed due to loss of tooth, making plaque accumulation easy in that area. It may also be used to clean those areas which are not accessible to the toothbrush. It is readily available at home and can be used by moistening it and rubbing it gently around the gingival margin.

Oral Irrigation Device:

The microbial accumulation in subgingival areas is the primary cause of initiation of periodontal diseases. The supra and subgingival irrigation with water or antimicrobial agents have been demonstrated to reduce the microbial load in the periodontal sulcus or pocket, thus reducing gingival inflammation 36-39. The most important rationale of using intraoral irrigation devices is

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The device consisted of a plastic container to store water, a motor and tubing designed by a dentist and hydraulic engineer to generate water jet with pressure. Since then, many oral irrigation devices have been introduced for both professional and home use.

Mechanism of action:

When a stream of water is applied in the subgingival area, it expels bacteria and debris out from the sulcus, thus helping in reducing bacterial load in the periodontal environment. The two basic properties utilized in irrigation devices are pressure and pulsation. The initial devices were designed to deliver a continuous stream of the water jet. Early studies showed a reduction in gingivitis but not in the plaque index. For this reason, the use of oral irrigators was restricted to orthodontic patients for many years until new irrigator devices with pulsating water jet were introduced. The pulsation of water jet results in the phases of compression and decompression of the tissue which not only helps in better removal of bacteria and debris from the pocket but also helps in the stimulation of gingival tissue 54-56. It has been demonstrated that  pulsating devices were three times more effective than continuous stream devices 54, 55. Bhaskar et al. (1971) have shown that healthy gingiva can withstand a water jet pressure up to 160 psi for up to 30 seconds without any irreversible damage 54. The recommended pressure for an intraoral irrigator device on healthy gingiva is 90 psi whereas on inflamed gingiva is 50 to 70 psi 54.

Another important factor which has been studied in subgingival irrigation by oral irrigators is the depth of delivery or irrigation solution. When water or any irrigation solution jet is put on the oral tissue surface, it created two different zones of hydrokinetic activity. One is the zone of impact where the solution initially makes contact with oral tissue and other is flushing zone, where the solution widens out in concentric circles and penetrates subgingivally 57. The depth of penetration of irrigation solution also depends on the kind of tip used for irrigation. The standard tip which is used for irrigation has been found to result in around 50% penetration of complete pocket depth. However, the depth of penetration of the solution also depends on the pocket depth and angle of tip placement 58, 59.

Depth of penetration of irrigation solution with standard jet 58

Tip placement
90-degree angulation of the tip
45-degree angulation of the tip
Pocket depthMean Percent Pocket
Penetration
Incidence of 75%
Pocket Penetration
Mean Percent Pocket
Penetration
Incidence of 75%
Pocket Penetration
0-3 mm71%42.9%54%30.8%
4-7 mm44%25%46%29.9%
>7 mm68%60%58%34.4%

Although, many tips are available in the market today, a tip that can be very helpful for periodontal patients is the Pik Pocket™ subgingival irrigation tip by Waterpik technologies. It is a soft latex-free rubber tip designed to fit Waterpik oral irrigators. One study has shown penetration of irrigation solution up to 90% of the pockets with this tip where pocket depth was up to 6 mm. In pockets 7 mm or more, the depth of penetration was 64% 60. Another company, Ora-tec also designed a unique tip that can be used for both standard and sulcus irrigation with their Via-Jet home irrigator. Presently, some companies are supplying cannula tips with their irrigation device, however, their efficacy has not been evaluated yet.

Use of antimicrobial solutions in oral irrigation:

The efficacy of various antimicrobial solutions has been compared with that of plain water in reducing plaque and gingival inflammation. A wide variety of solutions have been advocated for home irrigation, including chlorhexidine, acetylsalicylic acid, hydrogen peroxide, sodium hypochlorite, metronidazole and magnetized water 41, 44, 61-70. The regular home usage of chlorhexidine irrigation is not recommended because it may result in staining of teeth. One study has demonstrated that irrigation with diluted (0.5%) sodium hypochlorite solution resulted in significantly greater and longer-lasting reduction in plaque and gingivitis as compared to irrigation with water 65. However, patients may not comply with regular usage of sodium hypochlorite solution due to its bad taste.

It must be understood that the plaque elimination by intraoral irrigators is primarily because of their…………….

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Reduction in subgingival pathogens:

The reduction in subgingival pathogens by subgingival irrigation has been suggested as the primary biological mechanism involved in reducing periodontal inflammation. A lot of research has been done to evaluate the qualitative and quantitative changes in microflora in the periodontal pocket before and after application of intraoral subgingival irrigation devices. In one study, Newman et al. (1990) 74 compared the effects of rinsing with 0.12% chlorhexidine (CHX) gluconate, irrigating with 0.06% CHX, and irrigating with water on the marginal and subgingival microflora in the subjects with gingivitis. All the subjects involved in the study used sodium fluoride dentifrice to brush their teeth. The data were collected at baseline, 3 months and 6-month intervals. All the groups were compared for Gram-positive cocci and rods, Gram-negative rods, and Gram-negative anaerobic rods and black-pigmented Bacteroides for logarithmic transformation (log10) of colony-forming units (CFU) and proportions (percent). The results of the study demonstrated that the reduction in CFU10 log, the percentage of Gram-negative anaerobic rods and the percentage of black-pigmented Bacteroides was maximum in chlorhexidine group. There was no significant difference found between water irrigation group and other groups in reducing the CFU log at 6 months. In contrast to these findings, Sanders et al. (1986) 67 found no significant difference between most of the organisms measured from the irrigated and non-irrigated sites. The study compared supragingival irrigation with 0.02% CHX, 0.05% metronidazole, 0.01% quinine sulfate inactive control, and non-irrigated sites for measurements of micro-organisms in pockets ≥ 4 mm.  However, some isolated differences were found between the groups for cocci at certain time points, favoring the irrigation sites.

In another study 71, levels of Prevotella intermedia were found to be significantly reduced from baseline in the water irrigation group at 6 months and the 0.04% CHX irrigation group at 3 months interval after subgingival irrigation. Hurst and Madonia (1970) 49 analyzed salivary samples from patients with fixed orthodontic appliance to measure the levels of micro-organisms. They found that water irrigation was 80% more effective at reducing the total aerobic flora and 60% more effective at reducing lactobacillus counts.

Effect on inflammation:

Multiple studies have reported a reduction in gingival inflammation after adding a dental water jet to tooth brushing as compared to tooth brushing alone 44, 45, 48, 51-53, 72. In one study, Al-Mubarak et al. (2002) 51 studied the effects of subgingival irrigation in chronic periodontitis patients with type 1 or type 2 diabetes. 52 patients were included in the study. It was a single-center, single-blind, 3-month clinical and laboratory study. Scaling and root planing treatment was done on all the subjects who were then randomly assigned to either normal oral hygiene group (a manual toothbrush and any interdental device they used before the study) or the irrigation group with a subgingival tip plus normal oral hygiene. The results of the study demonstrated that the irrigation group showed significantly better improvement in measures, including gingivitis, plaque, and bleeding on probing, as compared to the controls. Further, the serum levels of interleukin-1 beta (IL-1β) and prostaglandin E2 (PGE2) were significantly reduced from baseline in the irrigation group. The authors attributed these results to the host modulation effect of subgingival irrigation.

In another study, Cutler et al. (2000) 45 evaluated the changes in inflammatory parameters following daily irrigation with water in conjunction with routine oral hygiene measures. The pro-inflammatory mediators in the gingival crevicular fluid (GCF) were evaluated at 14 days along with clinical parameters, including periodontal probing depths, bleeding on probing, gingival index, and plaque index. The results of the study demonstrated a significant reduction in clinical parameters of inflammation as well as down-modulation of pro-inflammatory mediators in GCF.

Fixed orthodontic appliances:

The patients undergoing orthodontic treatment are more prone to gingival inflammation due to food debris and plaque accumulation around orthodontic brackets. Intraoral irrigation helps in dislodgement of these deposits, thereby promoting periodontal health. Various studies have investigated the effects of dental jet devices on periodontal health in patients undergoing fixed orthodontic treatment 46-49. In one study, dental water jet as an adjunct to tooth brushing was found to be 80% more effective than tooth brushing and rinsing in reducing the total aerobic flora and 60% more effective in reducing  the lactobacillus count in orthodontic patients 49. In another 2 months study, it was observed that the orthodontic patients who used dental water jet in addition to manual or powered tooth brushing demonstrated less plaque accumulation, reduced gingival inflammation and gingival bleeding as compared to patients using only tooth-brushing 47.

Sharma et al. (2008) 48 did a study on 105 adolescents undergoing orthodontic treatment, comparing plaque removal efficacy and the reduction in gingival bleeding with the application of a specifically designed orthodontic water jet tip + manual tooth brushing, brushing  +  flossing via a floss threader and manual tooth brushing alone. The results of the study demonstrated that the orthodontic waterjet tip + brushing was significantly more effective at plaque removal than brushing + flossing with a floss threader or brushing alone. The reduction in gingival bleeding from baseline for orthodontic waterjet tip group was 84.5%, which was 26% better than the results achieved with dental floss.

Bacteremia following subgingival irrigation:

The subgingival irrigation with oral irrigator devices is expected to result in bacteremia due to high pressure with which the irrigant is delivered. Studies have shown that incidences of bacteremia with the application of pulsating oral irrigators range from 7% in people with gingivitis 75 to 50% of people with periodontitis 76 However, the incidences are almost similar to that observed with routine oral hygiene measures such as tooth brushing and flossing (20% to 68%) and use of wooden toothpicks (20% to 40%) 77, 78. Hence, oral subgingival irrigation can be used as an adjunct to standard oral hygiene procedures without any added risk of bacteremia.

Home use intra-oral irrigation:

The home use self-care devices for oral irrigation are widely available in the market these days. Most common of these devices are pulsed flow irrigators. One irrigator device for home use is pulsed flow, magnetized irrigator (Hydro Floss®). It is hypothesized that charged water decreases calculus formation as well as achieves the benefits found with non-magnetic irrigators 62. Some newer intraoral irrigators have been designed to water stream with micro air bubbles (Oral B OxyJet). They are proposed to help in better removal of plaque from the tooth surfaces. There are a variety of tips available for intraoral irrigation. Most commonly used tip is the standard tip which has been designed for supragingival placement.

While using, the patient is instructed to direct the tip of the irrigator at a 90⁰ angle to the long axis of the tooth, placed approximately 3 mm from the gingival margin. After starting the irrigator, the tip is moved along the gingival margin and stopped at each interproximal area for five or six seconds, irrigating both the lingual and buccal aspects of the teeth.

Professionally applied intra-oral irrigation:

Intra-oral irrigation with various anti-microbial solutions has been shown to reduce plaque significantly greater than plain water. To take an advantage of these beneficial effects of intra-oral irrigation, many dental offices have incorporated irrigation to deliver antimicrobials subgingivally, especially after periodontal treatments. The antimicrobial solutions should be applied for an adequate time duration and frequency to achieve maximum benefit. Following subgingival irrigation, the bacterial counts return to baseline within one to eight weeks. For this reason, regular application of intra-oral irrigation is recommended in patients with periodontal diseases. The most widely investigated agent for intra-oral irrigation is chlorhexidine followed by 10% povidone-iodine solution (Betadine).

The intra-oral subgingival irrigation in the dental office can be achieved by various methods. One method utilizes power scalers which utilize water or anti-microbial solution for irrigation. Another method is in-office oral irrigators specifically designed for this purpose. Via-jet manufactured by Ora-tec which is composed of a heated reservoir and a handpiece which facilitates delivery of antimicrobial agents subgingivally with a cannula.

Brushing techniques

Various brushing techniques have been advised for appropriate cleaning of teeth and removal of plaque and debris. The tooth brushing techniques which are recommended currently have been proposed in the early half of the twentieth century by various researchers. The oldest tooth brushing method was described in 1913 by………………

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Classification of brushing techniques based on the direction of toothbrush movement

Horizontal Reciprocating Motion:

  • Horizontal Scrub Technique

Vibratory Motion:

  • Bass (Sulcular) brushing technique
  • Stillman’s brushing technique
  • Charters brushing technique

Vertical Sweeping Brushing Technique:

  • Modified Bass brushing technique
  • Modified Stillman’s brushing technique
  • Leonard brushing technique
  • Hirchfeld’s brushing technique
  • Smith-Bell (Physiologic) brushing technique

Rotary Brushing Technique:

  • Fones Technique

In the following sections, we shall discuss in detail various brushing techniques,

Horizontal Reciprocating Motion

Horizontal Scrub Technique:

This is the most commonly used brushing technique due to ease of using. In this technique the bristles are placed at a right angle to the long axis of the tooth and gentle horizontal scrubbing movement of the brush is performed. The main advantage of this brushing technique is its simplicity. However, a major disadvantage of this brushing technique is cervical abrasion of teeth, which is particularly seen in patients who do vigorous brushing and/or use hard toothbrushes.

Vibratory Motion

Bass (Sulcular) brushing technique:

In this brushing technique, Bass put emphasis on the removal of plaque from the area above and just below the gingival margin 81. The brush is placed at an angle of 45⁰ to the long axis of the teeth, directed apically. The bristles are then gently pressed so that they enter the gingival sulcus and interdental embrasure. This action should produce perceptible blanching of the gingiva. The brush is then vibrated gently back and forth with short strokes. At each position, 20 strokes are given and then the brush is moved to the next position. In one position 2-3 teeth are cleaned. Firm but gentle strokes are given without removing the bristles out of the sulcus. The occlusal surfaces are cleaned by placing the bristles on the occlusal surface and gentle back and forth vibratory movements are made.

Indications:

  • This tooth brushing technique is indicated in all patients for bacterial plaque removal adjacent to the areas directly beneath the gingival margin.
  • Open interproximal areas, cervical areas beneath the height of contour of enamel and exposed root surfaces.
  • For patients who had periodontal surgery, but not immediately after surgery.

Advantages:

The main advantage of this technique is that short back and forth motion is easy to master because most of the patients usually use the scrub brushing technique. Also, this brushing technique concentrates the cleaning action on the cervical and interproximal portion of teeth, which have maximum plaque and debris accumulation.

Disadvantages:

The disadvantage of this brushing technique is that the patient has to place the brush in many different positions to cover the full dentition. Hence, the patient may lose patience while performing this brushing technique. To overcome this problem, the patient should be instructed to brush in a controlled and systematic sequence for optimum plaque removal.

Stillman’s brushing technique:

This technique is similar to the Bass technique except that the bristles are placed partly over the cervical portion of the teeth and partly on the adjacent gingiva. As compared to Bass technique where the bristle ends enter the gingival sulcus, the Stillman’s technique uses sides rather than the ends of the bristles and penetration of the bristles into the gingival sulci is avoided. The brush is placed in the same manner as described for Bass technique, i.e., at 45⁰ angle apically to the long axis of the teeth. The brush is activated with 20 short back-and-forth strokes and is simultaneously moved in a coronal direction along the attached gingiva, gingival margin, and tooth surface.

Indications:

  • For spongy gingival tissue where massaging is valuable.
  • For cleansing areas with the progressive gingival recession and root exposure to minimize abrasive tissue destruction 82.

Advantages:

The advantage of this brushing technique is that it provides gingival stimulation along with plaque and debris removal from cervical margins of the teeth and wide embrasures.

Disadvantages:

Similar to the Bass technique of tooth-brushing, this technique requires patience for placing the toothbrush in many different positions throughout the dentition.

Charter’s brushing technique:

This brushing technique of tooth-brushing was recommended by Charter in 1848 83. It is a very useful technique for patients having……………….

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Indications:

  • This brushing technique aids in cleansing fixed orthodontic appliances.
  • It helps in loosening of debris and bacterial plaque.
  • It massages and causes stimulation of marginal and interdental gingiva.
  • This brushing technique is indicated following periodontal surgery.
  • This brushing technique is useful in removing bacterial plaque from the abutment teeth and under the gingival border of fixed partial denture or from the under surface of sanitary bridges.
  • This brushing technique is also suitable for cervical areas below the height of contour of the crown and to the exposed root surface.

Figure 45.14 Charter’s brushing technique where the brush is placed at an angle of 45°to the long axis of the teeth in an occlusal/incisal direction

Charter's brushing technique

Advantages:

This technique is specifically indicated in patients having fixed prosthodontic and orthodontic appliances because it efficiently removes plaque and debris from these appliances. After periodontal surgeries, this technique gently massages the area of wound healing and promotes healing.

Disadvantages:

The main disadvantage of this brushing technique is that it does not efficiently clean the interdental areas due to angulation of the bristles in a coronal direction. Also, this technique is difficult to learn and good patient compliance is required for appropriate cleaning of teeth.

Vertical Sweeping Brushing Technique

Modified Bass brushing technique:

The modified Bass technique is same as the Bass technique with one additional movement of the bristles.  After the vibratory motion has been completed in each area, the bristles are swept in rolling motion towards the occlusal surface (Figure 45.15). The indications are same as discussed earlier under Bass technique.

Figure 45.15 Modified Bass brushing technique. The bristles are placed at an angle of 45°to the long axis of the teeth in an apical direction pressing them gently into the gingival sulcus (a). The brush is then vibrated gently back and forth making around 20 short strokes. After that the bristles are swept in rolling motion towards the occlusal surface. The placement of bristles on the palatal surface of upper anterior teeth (b) and lingual surfaces of mandibular anterior teeth (c). The occlusal surface is cleaned by placing the bristles on the occlusal surface and making gentle back and forth vibratory movements.

Modified Bass brushing technique

Advantages:

This technique allows the removal of plaque and debris from the sulcular and interdental areas. Along with this, the rolling motion completely cleans the buccal and lingual surfaces of the teeth without damaging the base of the gingival sulcus. This technique is recommended for patients with healthy gingiva without the recession of gingival margins.

Disadvantages:

This technique is difficult to master and repeated patient reinforcement is required.

 

 

Know more…………

Common errors during performing modified Bass technique of tooth-brushing:

  • While performing this brushing technique (especially in a patient who are learning the technique), the hand becomes tired after sometime. As a result, there is a tendency to relax and let the brush slides down, creating an angle between the occlusal plane and the long axis of the brush. It causes inadequate adaptation of the bristles into the interdental embrasures and gingival sulci, resulting in inefficient plaque removal. This error can be eliminated by raising the elbow as far as necessary.
  • Careful positioning of the bristles in necessary in this technique. If the bristles are placed on the attached gingiva, it may result in the inadequate cleaning of the tooth surfaces and unwanted trauma to attached gingiva and alveolar mucosa.
  • If the bristles are placed sideways against teeth, it may result in the inadequate cleaning of the interdental areas. This error can be corrected by appropriate positioning of the brush.
  • If the brush is ‘scrubbed’ across the teeth with long horizontal strokes rather than short back and forth vibratory strokes, it may result in toothbrush trauma to teeth (notching) and gingival

 

Modified Stillman’s brushing technique:

The technique is same as described in Stillman’s technique with the addition of a sweeping movement of the bristles in a coronal direction (Figure 45.16).  The technique is indicated in patients with gingival recession, as it provides good gingival massage. Indications are same as discussed in Stillman’s technique.

Figure 45.16 Modified Stillman’s brushing technique. The brushing technique is similar to the modified Bass technique, except that the sides of the bristles are used for cleaning rather than bristle ends and the bristles are placed partially on gingival and partially on teeth surfaces, thus providing gingival massage along with tooth cleaning.

Modified stillman brushing technique

Advantages:

This technique offers good gingival massage and interproximal cleaning.

Disadvantages:

The technique is difficult to learn and implement.

Leonard brushing technique:

It is a vertical tooth brushing technique where the brush is moved up and down across the teeth. The maxillary and mandibular teeth are brushed separately. After bringing the upper and lower teeth in edge to edge contact, the bristles are placed at a right angle to the long axis of the teeth and are moved in up and down stroke motion. It must be noted that…………….

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Hirshfeld’s brushing technique:

This brushing technique is essentially the same as the Charter’s technique except that the maxilla and mandible are kept occluded. It provided additional stability and control for those patients who lack manual dexterity. The cheeks help in exerting pressure required to flex the bristles.

Smith-Bell (Physiologic) brushing technique:

This is also known as the physiological technique of tooth-brushing because the brushing method is the same as that taken by the food during mastication. The bristles are placed at the height of the incisal edge or occlusal surfaces at an angle of 90 degrees and moved in the gingival direction. This brushing technique produces frictional action similar to that obtained from mastication of fibrous food. This brushing technique is suitable for patients having anatomically normal dentition. It stimulates the gingiva and improves blood circulation in the connective tissue. However, in the existing pockets, this brushing technique tends to strip the tissue away from the teeth and facilitates packing of debris into the open pocket.

Rotary Brushing Technique

Fones Technique:

This method is usually recommended for young children with minimal manual dexterity. The technique is quite easy to learn and provides good gingival stimulation. In this technique, the brush is placed against a set of teeth and is moved in a circular motion 4-5 times for each set of teeth. The maxillary and mandibular teeth are kept in occluded position while performing this brushing technique. This technique is simple to use, but is less effective than modified Bass and modified Stillman’s technique in plaque and debris removal.

Sequence of brushing

The recommended procedure for brushing is to start brushing from molar region of one arch and then moving towards the opposite molar of the same arch. Then the lingual surfaces of the same arch are cleaned. The same procedure is followed on the opposite arch until all the accessible areas of the dentition are cleaned. The last surfaces to be brushed are the occlusal surfaces.

Frequency of tooth-brushing

There has been no consensus so far regarding the frequency of tooth-brushing. Studies designed to evaluate the association between frequency of brushing and development of gingivitis have not come up with any consensus on a particular daily frequency of brushing which may prevent the development of gingivitis 84-87. It has been emphasized that the development of gingival inflammation is more related to the quality of tooth brushing rather than the frequency of tooth brushing 88.

However, brushing teeth twice daily has been recommended as a measure for maintaining good oral hygiene 89. Three or more cleanings per day did not produce significantly better periodontal conditions. It has been suggested that one of the two brushings done in a day should be performed very thoroughly to maintain a good periodontal health. Tooth-brushing should be performed most preferably after taking meals. A dry brush without debris between the bristles should be used. Keeping two separate brushes for morning and night time brushing is recommended because it allows complete drying of the brushes and permits bristles to return to an upright position. Brushing should be performed before a mirror under good light so that one can check the placement of the brush and bristles in an accurate position. At night time, before going to bed the patient should brush the teeth and should not eat or drink anything after brushing.

Brushing duration

The length of time for which one brushes teeth varies from person to person depending on the technique of brushing and the manual dexterity. Initially, when a tooth-brushing technique is instructed to a patient, usually 10-20 minutes brushing time is required until the patients learn the technique. Once the patient adapts to the technique, 3-5 minutes are sufficient for brushing.

How to clean and store a toothbrush

A clean toothbrush is a primary requirement for the maintenance of good oral health. The toothbrush should be rinsed with hot water before and after brushing the teeth. The thumb should be placed over the bristles and moved………………………

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Many toothbrush sanitizers have been introduced which utilize UV light, antibacterial rinses and even some toothbrushes with antibacterial bristles have been designed. However, their efficacy in toothbrush sanitization still needs to be established.

Dentifrices

Dentifrices are an integral component of plaque control and are used to deliver various chemical agents to control plaque. A detailed description of dentifrices has been given in the next chapter on chemical plaque control.

Assessment of home care:

The assessment of plaque control by the patient plays an important role in the maintenance of good oral hygiene. The most effective tool in the assessment of plaque control is disclosing agents.

Disclosing agents

Disclosing agents are the solutions or wafers capable of staining bacterial deposits on the surface of teeth, tongue or gingiva (Figure 45.17). These are very effective tools in patient education and motivation, helping them to perform adequate plaque control. The disclosing agents in solution form are applied on the teeth either in concentrated form with cotton swabs or in diluted form as mouthwashes. Disclosing agents available in wafer form are crushed between the teeth and swished around the mouth for a few second, followed by spitting.

Figure 45.17 Two-tone disclosing solution, showing the newly formed plaque as red and older plaque as blue

Disclosing agents

Uses:

  • Acts as an effective motivational tool for the patient for maintenance of good oral hygiene.
  • Facilitates self-evaluation of plaque control by the patient on a regular
  • The plaque control procedures used may be revised, if the patient is not able to maintain a good oral hygiene.
  • To study the long-term plaque control by the patient during successive maintenance appointments.
  • Used in plaque indices.
  • Used in research work evaluating plaque accumulation on the tooth surfaces.

Properties of a disclosing agent:

An ideal disclosing agent should have following properties,

  • Adequate staining: The disclosing agent should be able to adequately stain the bacterial deposits with a color which is in contrast with the normal color of the oral tissues.
  • Stability of staining: Following staining, the color of the disclosing agent should not disappear immediately with saliva or simple rinsing.
  • Taste: The taste of the disclosing agent should be acceptable to the patient.
  • Non-irritant: The disclosing agent should be non-irritant to the mucous membrane.
  • Diffusibility: The disclosing agent should be thin enough to easily diffuse and be applied readily and easily, to the exposed surfaces of teeth. At the same time, it should have enough thickness to impart an intense color to the bacterial plaque.
  • Astringent and antiseptic: The disclosing agent should have astringent and antiseptic properties

Before applying any disclosing agent, the patient should be asked about any history of an idiosyncratic reaction to any of the components of that particular disclosing agent. If it is there, then some other disclosing agent should be considered. Various dyes are utilized to detect plaque include,

  • Iodine preparations
    • Skinner’s iodine solution
    • Diluted tincture of iodine
  • Mercurochrome preparations
    • Mercurochrome solution 5
    • Flavored mercurochrome disclosing solution
  • Bismark brown (Easlick’s disclosing solution)
  • Mebromin
  • Basic Fuchsin
  • Erythrosine (FDC red # 3)
  • FDC green # 3 (fast green, brilliant green)
  • FDC yellow # 8 (fluorescein)
  • Two tone solutions

Iodine preparations:

The iodine preparations such as Skinner’s solution or diluted tincture of iodine are used as plaque disclosing agents. Iodine solution (21 ml of tincture Iodine of 15 ml of water) is formally the most classic disclosing solution used for staining the plaque. The primary advantage of using iodine is that its effects are dramatic on plaque staining. Plaque is stained deep brown or black with associated inflamed gingiva. The staining disappears within a few minutes. Another advantage is the low cost of iodine. Primary disadvantages of using iodine as a disclosing agent are, its objectionable taste and some patients may be allergic to iodine.

Mercurochrome preparations:

The mercurochrome preparations have been used primarily due to their antiseptic properties. These have been used as plaque disclosing agents but are rarely used these days.

Bismark brown (Easlick’s disclosing solution):

It is used as a plaque disclosing agent characterized by its brown color and licorice flavor. It is a diazo dye which is primarily used to stain histological sections.

Erythrosine (FDC red No.3):

Erythrosine is also known as FDC red No.3 and is an organoiodine compound, primarily derived from fluorone. It is available in tablet or solution form and is the most widely used disclosing agent. It can be dissolved……………..

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The main disadvantage of erythrosine dye is that it tends to stain soft tissues, making a post-application evaluation of gingiva difficult.

Merbromine:

It is a disodium salt of 2,7-dibromo-4-hydroxymercurifluorescein. It has been primarily used as an antiseptic agent, but also has staining properties similar to those of eosin and phloxine. It forms a red aqueous solution. Mercurochrome is a trade name of merbromin.

Basic Fuchsin:

Basic Fuchsin is a cationic triphenylmethane dye. This dye is magenta in color with a chemical formula of C20H19N3·HCl. It is primarily used to stain histological sections.

FDC green # 3 (fast green, brilliant green):

FDC green #3 gives a brilliant, blue-green color to dental plaque. Many disclosing agents use this dye for staining plaque.

Fluorescein (FDC yellow # 8):

Fluorescein is a coloring agent that, when excited with blue light, fluoresces yellow-green in the range of 500 nm 90. The fluorescence of fluorescein is affected by the pH value. Fluorescence if more intense in acidic pH. Optimum fluorescence is achieved at pH 5.5 91. Plaque Test manufactured by Ivoclar Vivadent comprises the fluorescein, which exposes plaque on the teeth as a yellow color and on gingiva as a green color, when viewed under a blue light source. It is more expensive to use, but has the advantage of not interfering with the gingival assessment or leaving a visible stain on the oral tissues. Examples of this disclosing agent include GUM Plak-Check by Sunstar Butler and Plak-Lite® by Brilliant Enterprises, Inc. (Philadelphia).

Two tone dye:

A two-tone dye test comprises of a combination of the erythrosin with either FDC green #3, FDC blue #1 or Hercules green shade 3 in order to obtain differential staining, i.e. thick old plaques stain blue and thin new plaques stain red.  The red and blue colors are because of the acidic or basic environment. The older plaque has an orderly architecture of organisms and has basic environment, whereas the newly formed plaque has an acidic environment. Hence, the newer thin plaque stains red, whereas the older thick plaque stains blue.

Application methods for disclosing agents:

The disclosing agents in a solution form are applied with a cotton swab and the tablets are chewed and swished. The patient is instructed to rinse and expectorate the disclosing agent. These agents do not stain biofilm-free tooth surfaces unless roughness (i.e., decalcification, pitting) is present. The precautions followed during the application of disclosing agents include,

  • To avoid staining the lips, a light coat of non-petroleum or water-based lubricant should be applied.

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Limitations of disclosing agents:

  • Disclosing solutions cannot selectively stain bacterial plaque, but stain debris and dental pellicle.
  • Disclosing solutions may stain restorations, especially silicate cements and resin restorations.
  • These can stain exposed cementum free of plaque.
  • The alcohol present in the disclosing agents evaporates slowly, rendering the solution too highly concentrated.

Advising self-performed mechanical plaque control measures

Before advising mechanical plaque control measure to a patient, the oral health care professional should be well versed with all the mechanical plaque control aids available in the market. The most commonly used oral hygiene measure is tooth brushing. So, a dental professional should be well aware of the various sizes, shapes, texture and other properties of toothbrushes. Out of all the oral hygiene aids available in the market, a few should be selected for a particular patient and a correct method of using them should be instructed to the patient. The oral hygiene status of the patient should be evaluated on a regular interval so that patient compliance may be assessed. If any improvisation is required, it may be suggested to the patient.

Conclusion

The home used preventive and therapeutic procedures play a key role in the prevention of dental and periodontal diseases and in promoting oral health care among the population. A well motivated and instructed patient can very well take care of his or her oral health. An accurate brushing technique is fundamental to achieve good plaque control. However, it must be remembered that inappropriate brushing is one of the many etiological factors which may damage the hard and soft tissue in the oral cavity. Powered toothbrushes may be used to minimize these effects. The use of interdental cleansing aids helps in the removal of plaque and deposits from the interdental and interproximal areas, which may not be accessed by a toothbrush. Appropriate use of these aids along with tooth-brushing can be very useful in reducing periodontal inflammation, thus preventing the development of periodontal diseases.

Periobasics: A textbook of Periodontics and Implantology
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Periobasics: A textbook of periodontics and implantology

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