Plaque Control

Periodontium

Dental plaque
A biofilm consists of complex communities of bacterial species that reside on tooth surfaces or soft tissues 400-1000 species

Etiology of gingivitis and periodontitis

Biofilm concept
matrix-enclosed bacterial populations adherent to each other and/or to surfaces of interfaces

Plaque as etiologic factor

Experimental gingivitis study
(1965 Le et al. )

Plaque as etiologic factor

Oral hygiene study
(1973 Lang et al.)

3 hypothesis in etiology of periodontal disease

Non-specific plaque hypothesis Ecological plaque hypothesis
Specific plaque hypothesis

Non-specific plaque hypothesis (1986 Theilade)

The bacterial dental plaque that accumulates to around teeth is a relatively homogenous mass that causes periodontal disease when it accumulates to the point of overwhelming the hosts defense mechanisms A result of the overall interaction of the microflora with the host

Non-specific plaque hypothesis

Experimental gingivitis Effect of mechanical removal of plaque

Ecological plaque hypothesis (1994 Marsh)

Change in a key environmental factor will trigger a shift in the balance of the resident plaque microflora and that this change might predispose a site to disease

Ecological plaque hypothesis

Specific plaque hypothesis (1976 Loesche)

The diverse collection of microorganisms constituting the resident plaque microflora, only a very limited number are actively involved in causing disease Meet Kochs postulate(modification)

Current suspected pathogens of destructive periodontal diseases

Actinobacillus actinomycetemcomitans Porphyromonas gingivalis Bacteroides forsythus 1996 American Academy of Periodontology Spirochetes Prevotella intermedia Fusobacterium nucleatum Campylobacter rectus Eikenella corrodens Peptostreptococcus micros Eubacterium species Selenomonas species
Others

Definition
Plaque control: the removal of dental plaque on a regular basis and the prevention of its accumulation on the teeth and adjacent gingival surfaces. Position: supra- & sub-gingival plaque control Methods: mechanical & chemical

Experimental gingivitis
Dental plaque was allowed to accumulate in the absence of any plaque control procedures, resulting in the development of gingivitis in all subjects within 7-21 days.

1965 Le

Self-performed plaque control

Brushing Interdental cleaning

Brushing
Toothbrush Methods of toothbrushing Frequency and effectiveness of toothbrushing Toothbrush wear and replacement Electric toothbrushes

Interdental cleaning
Dental floss and tape Toothpicks Interproximal brushes Single-tufted brush

Adjunctive aids
Dental irrigation devices Tongue scrapers Dentifrices

Effects and sequelae of the incorrect use of mechanical plaque removal devices
Gingival erosion Gingival recession Cervical abrasion Toothbrush stiffness Method of brushing Brushing frequency

Mechanical plaque control

The toothbrush Powered toothbrushes Dentifrices Toothbrushing methods Interdental cleaning aids Gingival massage Oral irrigation devices

Toothbrush
American Dental Association (ADA) Brush length: 1-1.25 inches Brush width: 5/16-3/8 inches 2-4 rows 5-12 tufts per row

Toothbrush bristles
Natural: hog Artificial filaments: nylon

Bristle hardness
Proportional to the square of the diameter and inversely proportional to the square of bristle length Soft brush: 0.007 inch(0.2 mm) Medium brush: 0.012 inch(0.3 mm) Hard brush: 0.014 inch(0.4 mm)

Bass soft brush

Straight handle Nylon bristle 0.007 inch(0.2 mm) in diameter 0.406 inch(10.3 mm) in length Rounded ends 3 rows of tufts 6 evenly spaced tufts per row 80-86 bristles per tuft

 For most patients, short-headed brushes with straight-cut, round-ended, soft to medium nylon bristles arranged in three or four rows of tufts are recommended.

Powered toothbrushes
Powered toothbrushes are not generally superior to manual ones Powered toothbrushes have been shown to improve oral health:
Children and adolescents Children with physical or mental disabilities Hospitalized patients Patients with fixed orthodontic appliances

Dentifrices
Dentifrices aid in cleaning and polishing tooth surfaces Paste, powder and gel

Dentifrices
Abrasive: silica, alumina, dicalcium phosphate, and calcium carbonate Detergent: sodium lauryl sulfate Thickeners: silica and gums Sweeteners: saccharine Humectants: glycerine and sorbitol Flavors: mint, peppermint Actives: fluorides, triclosan and stannous fluoride

Abrasion
Upper arch > lower arch Left side > right side Abrasive: powder > paste, gel (5 times) Cementum > dentin > enamel 35 25 1

Toothbrushing methods
Horizontal brushing (scrub) Leonard method (vertical) Bass method Modified Bass methods Stillman methos (vibratory) Modified Stillman method (roll) Charters method Methods of cleaning with powered toothbrushes

Bass method

The efficacy of brushing with regard to plaque removal is dictated by three main factors: The design of the brush The skill of the individual using the brush The frequency and duration of use
1986 Frandsen

Interdental cleaning aids

Dental floss Interdental brushes Wooden or rubber tips

Dental floss
Multifilament vs. monofilament Twisted vs. untwisted Bonded vs. unbonded Waxed vs. unwaxed 12-18 inches for use Stretch: thumb and forefinger Up-and-down stroke

Interdental brush

Gingival massage
Epithelial thickening, increased keratinization, and increased mitotic activity in epithelium and connective tissue Emphasizing the importance of altering or removing plaque rather than stimulating or thickening the keratinized surface in the plaque control program

Oral irrigation devices

Supragingival irrigation

Subgingival irrigation

Caries control for the periodontal patient

Periodontal patients require appropriate use of topical fluorides in the daily plaque control regimen to protect and remineralize both exposed root surfaces and coronal surfaces of teeth

Chemical plaque control

Antiadhesive Antimicrobial Plaque removal Antipathogenic

Vehicles for the delivery of chemical agents

Toothpaste Mouthrinses Spray Irrigators Chewing gum Varnishes

Mouthrinse
ADA has accepted two agents for treatment of gingivitis: Prescription solutions of chlorhexidine digluconate mouthrinse Nonprescription essential oil mouthrinse

 Chlorhexidine: plaque reduction 45-61%, gingivitis reduction 27-67% Essential oil mouthrinse: plaque reduction 20-35%, gingivitis reduction 25-35%

Chlorhexidine
In the US: 0.12 % solution

In Europe: 0.2 % solution

Chlorhexidine-side effects
Brown discoloration Taste perturbation Oral mucosal erosion Parotid swelling Enhanced supragingival calculus formation
1971 Flotra

Disclosing agents
Solutions or wafer capable of staining bacterial deposits on the surfaces of teeth, tongue, and gingiva Erythrosine, fuchsin Fluoresceincontaining dye

Frequency of plaque removal

Cleaning once a day with all necessary tools is sufficient if it is performed meticulously. Emphasis must be placed on the efficiency of complete plaque removal at least once per day, rather than the frequency of brushing alone

Plaque control instruction

Motivation for effective plaque control Education Instruction Encouragement Reinforcement

Plaque control
Mechanical plaque control is necessary and not replaceable by chemical plaque control Mechanical plaque control >>>>>> chemical plaque control