Dentistry has come a long way toward reaching this treatment ratio. At the core of this preventive foundation is home oral hygiene and plaque control.
The main objectives of the oral hygiene are:-
To consider the patient as a whole entity.
To maintain a healthy mouth for as long as possible.
To stop progression of disease and to provide appropriate rehabilitation.
To provide patient with the necessary knowledge, skills, and motivation.
Plaque Formation
Dental Plaqueis defined clinically as a structured, resilient, yellow – grayish substance that adheres tenaciously to the intraoral hard surfaces, including removable and fixed restoration.Plaque is primarily composed of bacteria in a matrix of salivary glycoproteins and extracellular polysaccharides. This matrix makes it impossible to remove the plaque by rinsing or the use of sprays. Plaque can thus be differentiated from other deposits that may be found on the tooth surface, such as materia alba and calculus. Materia alba refers to soft accumulations of bacteria and tissue cells that lack the organized structure of dental plaque and it is easily displaced with a water spray. Calculus is a hard deposit that forms by mineralization of dental plaque, and it is generally covered by a layer of unmineralized plaque.
Dental plaque is composed primarily of micro organization. One gram of plaque ( wet weight) contains approximately 1011 bacteria. The number of bacteria in supragingival plaque on a single tooth surface can exceed 109. In a periodontal pocket, counts can range from 103 bacteria in a healthy crevice to greater than 108 bacteria in a deep pocket. More than 500 distinct microbial species are found in dental plaque. New molecular approaches for bacterial identification, which rely on analysis of ribosomal dexyribonuclie acid (DNA) sequences, suggest that as much as 30% of the micro- organisms associated with gingivitis may represent uncultivated species. Thus it is apparent that substantial numbers of plaque micro organism have yet to be identified. One individual may harbor 150 or more different species. Nonbacterial micro organisms that are found in plaque include Mycoplasma species, yeast, protozoa, and virus. The micro organization exists within an intercellur matrix that also contains a few host cells, such as epithelial cells, macrophages and leukocytes.
Dental plaque is broadly classified assupragigivalorsupragigivalbased on its position on the tooth surface towards the supragingival margin as follows.
- Supragingival plaque is found at above the gingival margin when in direct contact with the gingival margin, it is referred to as marginal plaque.
- Supragingival plaque is found at or above the gingival margin, between the tooth and the gingival pocket epithelium.
Supragingival plaque typically demonstrates a stratified organized of a multilavered accumulation of bacterial morphotypes. Gram – positive cocci and short rods predominate at the tooth surface, whereas gram- negative rods and filament as well as spirochetes, predominate in the outer surface of the mature plaque mass.
In general, the subgingival microbiota differs in composition from the supragingival plaque, primarily because of the local availability of blood products and a low oxidation – reduction (redox) potential, which characterizes the anaerobic environment.
MECHANICAL METHODS OF PLAQUE CONTROL
Mechanical methods of plaque control are the most widely accepted techniques for plaque removal. Tooth brushing and flossing are the essential elements of these mechanical methods; adjuncts include disclosing agents, oral irrigators, and tongue scrapers.
MANUAL TOOTHBRUSH
The toothbrush is the most common method for removing plaque from the oral cavity. A number of variables enter into the design and fabrication of toothbrushes. These include the bristle material; length, diameter, and total number of fibers; length of brush head; trim design of brush head; number and arrangement of bristle tufts; angulation of brush head to handle; and handle; design. In addition, many features, such as the use of neon colors or familiar cartoon caricatures, are designed to attract the attention of potential purchasers
Today, most commercially available brushes are manufactured with synthetic (nylon) bristles. Brushes are classified as soft, medium, or hard based on the diameter of these bristles. The diameter ranges for these classifications are 0.16 to 0.22mm for soft, 0.23 to 0.29 mm for medium, and 0.30 mm and higher for hard. Of the three types of bristle ends coarse-cut, enlarged bulbous, and round, the round end is the bristle type of choice because it is associated with a lower incidence of gingival tissue irritation. However, even the coarse-cut bristles round off eventually with normal use
The soft brush is preferable for most uses in pediatric dentistry because of the decreased likelihood of gingival tissue trauma and increased interproximal cleaning ability. In evaluating the best toothbrush head and handle for children, Updyke concludes that it is best to use a brush with a smaller head and a thicker handle than on the adult-size brush to aid in access to the oral cavity and facilitate the child’s grip of the handle.
The cleansing effectiveness of toothbrushes is maintained until pronounced toothbrush wear has occurred. This implies that patients are much more likely to dispose of a brush well before its clinical usefulness actually ends than to continue to use a toothbrush that no longer cleans effectively. In this regard, one manufacturer claims that their commercial toothbrush indicates when the brush should be replaced by means of centrally located tufts of bristles dyed with food colorant. When the blue band fades to halfway down the bristle, it is time to replace the brush. The company states that on average this occurs after 3 months but that the time varies depending on the individuals brushing habits.
The best advice is to replace the brush when it appears well worn. This can present some problems for parents, because some children, especially toddlers, chew their brushes when brushing, which rapidly gives the bristles a well-worn appearance.
Floss
Although tooth brushing is the most widely used method of mechanical plaque control, tooth brushing alone cannot adequately remove plaque from all tooth surfaces. In particular, it is not efficient in removing interproximal plaque, which means that interproximal cleaning beyond brushing is necessary. Many devices have been suggested for interproximal removal of plaque, such as interdental brushes, floss holders and floss, and end tuft brush.
floss holders for children.
there appears to be no substantial difference between these devices in their ability to remove plaque and their tendency to produce gingival inflammation effects when they are used properly; however, floss is the standard device to which other devices are most often compared. The other devices are more often recommended in certain unique circumstances, for example the interdental brush may be recommended for orthodontic, patients.
Several different types of floss are available; flavored and unflavored, waxed and unwaxed and thin tape and meshwork. Almost all commercially available floss is made of nylon although floss made of Teflon material (polytetrafluoroethylene) is also available. The manufacturer claims that, because the material has a lower coefficient of friction than nylon, this floss does not shred, slides easily between tight contacts, and minimizes snapping of the floss.
Based on the work of Bass, unwaxed nylon –filament floss has generally been considered the floss of choice because of the ease of passing the floss between tight contacts, the lack of a wax residue, the squeaking sound effect produced by moving the floss over a clean tooth, and the fiber spread, which results in increased surface contact and greater plaque removal.
From the perspective of patient acceptance, flavored waxed floss may be the most effective type. In addition, many parents complain that their fingers are too large for their child’s mouth. Floss- holding devices (see Fig. 11_4 ) are an excellent alternative for parents when this complaint is voiced or when the dexterity of the parent or child prevents hand – holding of floss. For orthodontic patients flossing is a tedious process but is nonetheless essential to maintenance of oral health.
POWERED MECHANICAL PLAQUE REMOVAL
The rationale for using powered brushes is that many patients remove plaque poorly because they lack adequate manual dexterity in manipulating the brush. The powered brushes should decrease the need for dexterity; by automatically including some movement of the brush head.
use of the latest power brushes, such as the Sonicare or the Braun Oral B Kids, Power Toothbrush (D10), May prove to be more beneficial than use of other brushes. The Sonicare uses sonic technology in the form of acoustic energy to improve the plaque removal ability of traditional toothbrush bristles. The brush has an electromagnetic device that drives the bristles motions at 261 Hz or 31, 320 brush strokes per minute.
Powered toothbrushes removed significantly more plaque than the manual toothbrushes for children.
Power brushes with a rotation-oscillation action design removed more plaque and reduced gingivitis more effectively than manual brushes in both the short and the long term.
Braun Oral –B Interclean. This electrically powered cleaning device requires only singlel-handed usage while its filament rotates to undergo an elliptical movement disrupting plaque attached to adjacent and proximate teeth.
DENTIFRICES
Dentifrices serve multiple functions in oral hygiene through the inclusion of a variety of agents. They act as plaque and stain-removing agents through the use of abrasives and surfactants. Pleasant flavors and colors encourage their use. They have tartar control properties because of the addition of pyrophosphates. Finally, dentifrices have anticaries and desensitization properties through the action of fluoride and other agents. A child’s dentifrice should contain fluoride, rank low in abrasiveness, and carry the ADA seal of acceptance.
Child is more likely to practice oral hygiene procedures if the tools to be used are pleasing to the child. Although the caries-preventive efficacy of fluoride toothpastes in children
children tend to use larger amounts of dentifrice, brush for a longer period, and rinse and expectorate less when using a children’s dentifrice than when using an adult dentifrice.
Manufacturers should market a low-fluoride dentifrice for intents or reduce the diameter of the tube orifice. Parents should be advised to delay the use of fluoride dentifrice until the child is older than 36 months and to use small, pea-sized quantities of toothpaste.
Dentifrice for children called Baby Orajel Tooth and Gum Cleanser. The manufacturer states that it is nonabrasive, nonfoaming without fluoride, safe for infants, and ideal for babies aged 4 months to 3 years. It contains a mild surfactant and simethicone, is sugar-free and comes in vanilla and fruit flavors.
DISCLOSING AGENTS
In an effort to increase the patient’s ability to remove plaque, several agents have been developed to allow for patient visualization of plaque. These include iodine, gentian violet, erythrosin, basic fuchsin, fast green, food dyes, flourescein, and a two-tone disclosing agent. Use of these agents is particularly helpful in teaching children toothbrushing techniques and educating them on the rationale for oral hygiene. FDC red No. 28 is a plaque-disclosing agent commonly used either as a liquid to be dabbed onto the teeth with a cotton swab or in the form of a chewable tablet this dye stains the oral soft tissues and dental pellicle, as well as plaque, leaving an objectionable pink discoloration that lasts up to several hours after use. Most younger children do not appear to be bothered by the discoloration, but as children approach adolescence it can become a problem. Fluorescein disclosing agents were developed to address this problem because fluorescein is not visible under normal light. Their use does, however, require special equipment.
Disclosing agents have some antimicrobial activity, according although short-term quantitative inhibition of plaque growth has not been observed clinically; long-term home use of disclosing agents may contribute to qualitative differences in plaque composition.
Several other devices, such as oral irrigators and tongue scrapers, have been suggested for routine oral hygiene. Oral irrigators use pulsed water or chemotherapeutic agents to dislodge plaque from the dentition. Tongue scrapers, which are flat, flexible plastic sticks, are used to remove bacterial and food deposits that accumulate within the rough dorsal surface of the tongue. In addition, gauze or special dental washcloths are useful in infants to massage the gums and to remove plaque on newly erupted teeth. Although these adjuncts add to our basic hygiene tools, toothbrushes and floss remain the most effective means of mechanical plaque removal. Professional recommendation of these adjuncts should be to suggest them as supplements to and not substitutes for the basic tools
TECHNIQUES
As with toothbrush design, several different types of tooth brushing techniques for children have been advocated over the years. The more predominant techniques are the roll method, the Charters method, the horizontal scrubbing method, and the modified Stillman method
Roll Method.The brush is placed in the vestibule, the bristle ends directed apically, with the sides of the bristles touching the gingival tissue. The patient exerts lateral pressure with the sides of the bristles, and he brush is moved occlusally. The brush is placed again high in the vestibule, and the rolling motion is repeated. The lingual surfaces are brushed in the same manner, with two teeth brushed simultaneously.
Charters Method- The ends of the bristles are placed in contact with the enamel of the teeth and the gingiva, with the bristles pointed at about a 45-degree angle toward the plane of occlusion. A lateral and downward pressure is then placed on the brush, and the brush is vibrated gently back and forth a millimeter or so.
Horizontal Scrubbing Method: The brush is placed horizontally on buccal and lingual surfaces and moved back and forth with a scrubbing motion.
Modified Stillman Method- The modified Stillman method combines a vibratory action of the bristles with a stroke movement of the brush in the long axis of the teeth. The brush is placed at the mucogingival line, with the bristles pointed away from the crown, and moved with a stroking motion along the gingiva and the tooth surface. The handle is rotated toward the crown and vibrated as the brush is moved.
The Bass methodis used on 2-3 teeth at a time. The brush is placed at 450 angle to the tooth surface and is moved back and forth, allowing the bristles to remain in the same place.
Horizontal scrubbing method exhibited a more significant plaque-removing effect than the roll, Charters, and modified still man methods.
The horizontal scrub technique removes as much or more plaque than the other techniques, regardless of how old the child is and whether the brushing is performed by the parent or the child. In addition, it is the technique most naturally adopted by children.
Forflossing, the following technique is recommended
1. A 46-to 61-cm (18-to 24-inch) length of floss is obtained, and the ends are wrapped around the patient’s or parent’s middle fingers. Floss should be long enough to allow the thumbs to touch each other when the hands are laid flat.
2. The thumbs and index fingers are used to guide the floss as it is gently sawed between the two teeth to be cleaned. Care must be taken not to snap the floss down through the interproximal contacts to a void gingival trauma.
3. The floss is then manipulated into a c shape around each tooth individually and moved in a cervical-occlusal reciprocating motion until the plaque is removed. In between cleaning each pair of teeth the floss is repositioned on the fingers so that fresh, unsoiled floss is used at each new location.
Some children and their parents prefer to make a loop of floss. Tying the two ends of the floss together, instead of wrapping it around their fingers, assists them in holding and controlling the flossing and other plaque removal activities are added to this time. If should be the last thing the child does before bedtime at night. Because the flow of saliva and its buffering capacity are reduced during sleep, it is addition, the development in children of a learned behavior performed at a specific time of day, each and every day, will prove beneficial throughout childhood and into adulthood.
Chemotherapeutic Plaque Control
FONES METHOD OR CIRCULAR SCRUB METHOD (1934)
Indication:
Indicated for young children who want to do their own brushing, but do not have the muscle development for techniques which requires more co-ordinations
Technique:
The child is asked to stretch his/her arms such that they are parallel to the floor. The child is then asked to make big circles using the whole arm to draw circles in the air. The circles are reduced in diameter until very small circles are made in front of the mouth. The child is now ready to make circles on the teeth with the toothbrush, making sure that the teeth and gums are covered.
Advantages
This technique has equal or better potential than Bass technique for plaque removal and prevention of gingivitis.
- It is easy to learn
- Shorter time
- Physically or emotionally, handicapped individuals
- Patients who lack dexterity for a more technical brushing method
- Gingiva is provided with good stimulation
Disadvantages
- Possible trauma to gingiva
- Interdental areas are not properly cleaned
- Detrimental for adults especially who use the brush vigourously
Chemotherapeutic PLAQUE CONTROL
Although the use of mechanical therapy for plaque control can provide excellent results, it is clear that many patients are unable, unwilling or untrained to practice routine effective mechanotherapy. In addition, certain patients with dental diseases (e. g. immunocompromised conditions) require additional assistance beyond mechanotherapy to maintain a normal state of oral health. Because of this, chemotherapeutic agents have been developed as adjuncts in plaque control.
Van der ouderaa has stated that the ideal chemother apeutic plaque control agent should have the following characteristics.
Specificity only for the pathogenic bacteria
Substantivity, the ability to attach to and be retained by oral surfaces and then be released over time
without loss of potency .
Chemical stability during storage .
Absence of adverse reactions, such as staining or mucosal interactions .
Toxicologic safety .
Ecologic safety so as not to adversely alter the microbiotic flora
Ease of use
No agent has yet been developed that has all of these characteristics.
There are several main routes of administration of antiplaque agents designed for home use. They are mouthwashes, dentifrices, gels, irrigators, floss, chewing gum lozenges, and capsules. All of these are designed for local, supragingival administration, except the irri-gator and capsule delivery methods. The irrigators can provide both supragingival and subgingival delivery. The capsules are designed for systemic distribution
Both van der Ouderaa and Mandel have provided excellent reviews of the various chemotherapeutic agents and their uses.
ANTISEPTIC AGENTS
Positively Charged Organic Molecules:
Quaternary ammonium compounds—cetylpyridinium
chloride
Pyrimidines—hexedine Bis-biguanides—chlorhexidine, alexidine
Noncharged Phenolic Agents: Listerine (thymol,
eucalyptol, menthol, and methylsalicylate),
triclosan, phenol, and thymol
Oxygenating Agents: Peroxides and perborate
Bis-Pyridines: Octenidine Halogens: Iodine, iodophors, and fluorides
Heavy Metal Salts: Silver, mercury, zinc, copper, and tin
ANTIBIOTICS
Niddamycin, kanamycin sulfate, tetracycline hydrochloride, and vancomycin hydrochloride
ENZYMES
Mucinases, pancreatin, fungal enzymes, and protease
PLAQUE-MODIFYING AGENTS
Urea peroxide
SUGAR SUBSTITUTES
Xylitol, mannitol
PLAQUE ATTACHMENT INTERFERENCE AGENTS
Sodium polyvinylphosphonic acid, perfluoroalkyl
ANTISEPTIC AGENTS
The antiseptic agents used in chemotherapeutic plaque control have been shown to exhibit little or no oral or systemic toxiaty in the concentrations used. Virtually no drug resistance is induced, and in most instances these agents have a broad antimicrobial spectrum.
Chlorhexidine, a positively charged organic antiseptic aoent. has batter ability to reduce plaque and gingivitis scores.
Chlorhexidine binds with anionic glycoproteins and phosphoproteins on the buccal, palatal, and labial mucosa and the tooth-borne pellicle its antibacterial effects include binding well to bacterial cell membranes, increasing their permeability, initiating leakage, and precipitating intracellular components.
Several studies have demonstrated the use and efficacy of chlorhexidine therapy in children as young as 8 years of age. Studies have examined its use in the form of a rinse, a spray, a varnish, and a chlorhexidine gel used in flossing.
Lang et al investigated the effects of supervised rinsing with chlorhexidine in 158 schoolchildren, aged 10 to 12 years. The children were divided into four groups. Group A rinsed with a 0.2% solution of chlorhexidine digluconate (CHX) six times weekly. Group B rinsed with 0.2% CHX two times weekly. Group C rinsed with a 0.1% CHX solution six times weekly . Group D rinsed six times weekly with a placebo solution. All rinsing was performed under supervision, and no effort was made to change the children's oral hygiene habits.
Graph shows the results of the study All three experimental groups, A. B. and C, exhibited statistically significant reductions in the gingival index compared with the control group. Group D. The investigators concluded that gingivitis can be controlled successfully in children by regular rinsing with a chlorhexidine solution over an extended period.
Chlorhexidine spray has stimulated interest regarding its use in disabled populations because of its effectiveness and ease of administration.
Burtner et al demonstrated a 35% reduction in plaque levels with use of the spray compared with placebo use in a study of 16 institutionalized adult males with severe and profound mental retardation.
Chikte et al conducted a 9-week, doubleblind, randomized crossover clinical trial involving 52 institutionalized mentally disabled individuals 10 to 26 years of age. By the end of the trial, plaque and gingival indices had been reduced by 48% and 52%, respectively, in the group treated with a stannous fluoride spray.
Ferretti et al found that the prophylactic use of chlorhexidine mouthrinse produced reductions in gingivitis and mucositis and oral microbial burden in patients undergoing bone marrow transplantation.
The use of a chlorhexidine mouthrinse as an antiplaque and antigingivitis agent in bone maarrow transplant patients to augment their oral hygiene.
Finally, chlorhexidine varnish has been shown by Fennisle et al and by Petersson etal tosuppress the level of mutans streptococci.
The use of positively charged antiplaque agents has been hampered by adverse reactions such as staining of teeth, impaired taste sensation, and increased supragingival calculus formation. Different attempts have been made to decrease these side effects, such as alteration of dietary habits, increase in mechanical plaque removal efforts, and use of hydrogen peroxide solutions in conjunction with the antiseptic agent.
The most widely known noncharged phenolic antiseptic agent is Listerine. it was the first mouthrinse to be accepted by the Council of Dental Therapeutics for its help in controlling plaque and gingivitis. Despite its long history of use, studies by Clark et al and by Brownstone et al have shown chlorhexidine tobesignificantly more effective than Listerine in reducing plaque and gingivitis indices.
Listerine tends to give patients a burning sensation, and it has a bitter taste
Lang and Brecx have summarized the changes in plaque index, gingival index, and discoloration index scores resulting from the use of four well-known chemotherapeutic plaque control agents.
- The effects of two daily 10-mL rinses with either 0.12% chlorhexidine digluconate, the quaternary ammonium compound cetylpyridinium chloride, the phenolic compound Listerine, or the plant alkaloid sanguinarine were compared with those of rinses with a placebo.
All rinses were supervised by registered dental hygienists during these 21-day studies.
The subjects were divided into five groups of eight individuals each and were instructed to refrain from oral hygiene during the21days.
Mean indices in five groups of eight individuals refraining from oral hygiene for 21 days rinsing with either 0.12% chlorhexidine digluconate (CHX), 0.075% cetylpyridinium chloride (CPC), Listerine, sanguinarine, or placebo. A, Mean plaque index (PLI). B, Mean gingival index (Gl). C, Mean discoloration index (Dl).
Although the sanguinarine, Listerine, and cetylpyridinium chloride inhibited plaque formation to some extent, they did not prevent gingivitis significantly more than the placebo.
Unfortunately, all of the antiseptics demonstrated higher discoloration index scores than the placebo. As can be seen in graph C, chlorhexidine had the second highest discoloration score of the four agents.
Listerine has one of the highest alcohol contents of any mouthwash, approximately 25%.
Alcohol intoxication is use has been investigated, alcohol intoxication is more relevant to pediatric dentistry. The relationship of alcohol containg mouthwashes to oral carcinomas is equivocal.
Alcohol intoxication of children and adolescents from mouthwashes is a concern because of the products’ availability. Most parents do not recognize the potential harm from these rinses.
The use of fluoride as a halogen antiseptic plaque control agent are appropriate.
The fluoride ion inhibits carbohydrate utilization of oral organisms by blocking enzymes involved in glycolytic pathway.
As mentioned earlier, stannous fluoride can produce reduction in plaque an gingivatis scores approaching those of chlorhexidine, but this effect is caused by the tin content of this salt, not the fluoride content.
it is interesting to note that two antiseptic agents, chlorhexidine and triclosn have been incorporated into dentifrice formulations.
ENZYMES, PLAQUE – MODIFYING AGENTS, AND PLAQUE ATTACHMENT INTERFERENCE AGENTS
Enzyme system intended to alter plaque architecture and adherence, as well as enzymes designed to generate antibacterial products, have been investigated.
Problems associated with the long term stability of enzyme molecules in environments with potentially high concentrations of alcohol or surfactants have yet to be addressed.
The use of urea peroxide as a plaque modifying agent has been investigated because of its increased stability over hydrogen peroxide and the protein denaturation effect of urea.
SUGAR SUBSTITUTES
The use of sugar substitutes such as xylitol, mannitol, sucrose and aspartate has been advocated.
Park et al have shown that sugar substitutes can have a positive influence on plaque pH, the intrinsic antiplaque activity is much lower than that of other plaque control agents.
These agents have been suggested for use in chewing gum to decrease plaque accumulation and pH.
Hoerman et al demonstrated that in a less oral hygiene environment plaque accumulation was lower when gum with sucrose or sorbitol was chewed than when gum was not chewed.
The study demonstrated that the combination of xylitol gum chewing and fluoride usage resulted in a significantly lower incidenc
