Mechanical plaque control in periodontics

2. 1. Introduction
2. Mechanical plaque control
(a) Toothbrush
(b) Dentifrice
(c) Interdental cleaning aids
- Dental floss
- Interdental brushes
- tooth pick
(d) Oral irrigation
(e) Salvadora persica

3.  Mechanical plaque control, as measured by the oral hygiene
effort of the individual patient, is the most important predictive
factor in determining the overall prognosis of the treatment
therapy.
 Mechanical plaque control is the removal of microbial plaque
and the prevention of accumulation on the teeth and
adjacent gingival surface by the use of tooth brush and other
mechanical hygiene aids.
 It is very critical in every phase of therapy that plaque control
must be maintained .
 It is an effective way of treating and preventing gingivitis,
periodontitis, .. ect.

4.  The cause and effect relationship between supragingival
plaque and gingivitis was demonstrated by Loe and his
colleagues in 1965.
 When plaque was allowed to accumulate, gingivitis
developed within 21 days. When plaque control was
initiated, the gingivitis was reversed (by means of efficient
plaque control, i.e., brushing and flossing) to clinical gingival
health
 The removal of microbial plaque leads to cessation of
gingival inflammation, and cessation of plaque control
measure leads to recurrence of inflammation

5.  The removal of plaque also decreased the rate of formation of
calculus. ( Sanders , 1962)
 Thus eliminating the plaque is the key to prevent the
occurrence of periodontal disease or halting the progression
of the disease.
 Masses of plaque first develop in Molar , Premolar areas ,
followed by proximal surfaces of the antrier teeth , and the
facial surfaces of the molar and premolar( Lang,1973)

6.  complete daily removal of dental plaque with a minimum of
effort, time, and devices, using the simplest methods possible.

7. 1. Mechanical plaque
control
(a) Toothbrush
(b) Dentifrice
(c) Interdental
cleaning aids
- dental floss
- toothpick
- interproximal brush
(d) Oral irrigation
(e) Salvadora persica

8.  The bristle tooth brush
appeared about the year
of 1600 in China and later
was patented in America
in 1857.
 Originally, they are varied
in size, length, hardness of
the bristle, and even in the
arrangement of the bristle

9. - Generally toothbrushes very in size, design as well as in length
and arrangements of bristles hardness to overcome this
variation ADA given specification of toothbrushes.
- ----------------------------------------------------------
› Length : 1 to 1.25 inches
› Width : 5/16 to 3/8 inches
› Surface area : 2.54 to 3.2 cm
› No. of rows : 2 to 4 rows of brushes
› No. of tufts : 5 to 12 per row
› No. of bristles : 80 to 85 per tuft

10.  Soft, nylon bristle toothbrush clean effectively
( when used properly),remain effective for a
reasonable time , Soft bristle are more flexible,
clean beneath the gingival margin, and reach
farther into the proximal tooth surfaces.
 soft toothbrush is utramatic , eliminates gingival
recession, tooth surface abrasion (classical wedge
shape defect in the cervical area of root surfaces),
trauma to soft tissue.

11.  The use of hard
toothbrush , vigorous
horizontal brushing, the
use of extremely abrasive
dentifrices may lead to
cervical abrasion of teeth
and recession of the
gingiva.( Jepson ,1998)
 Toothbrushs need to be
replaced every 3 months

12.  Today, there are three methods that are widely accepted:
the bass method, the modified stillman method( stillman
1932), and the charters method( Carter’s 1948) .
 Controlled studied evaluating the most common brushing
technique have shown that no one method is superior
 The method which is often recommended is Bass technique ,
because it emphasize sulcular placement of the bristles.
 Dentist should be noted that a plaque control devices should
be tailored to the individual, similarly to his or her plaque
control program

13.  Patient is instructed to start with molar region of one arch
around the opposite side than continue back around the
lingual or facial surfaces of the same arch
 Last surface to be brush are occlusal.
 Patient instructed to stroke each area ten time of spend 10
seconds per area then move on to next area.
 Time : 2 minutes ( 30 sec per quadrent )

14. Method Bristle placement Motion Advantage/
disadvantage
Scrub Horizontal on gingival margin Scrub in anterior position direction Easy to learn & best suited
keeping brush horizontal fro children
BASS Apical towards gingival into sulcus at Short back and forth vibratory Cervical plaque removal
450 to tooth surface motion while bristles remain in Easily learned
sulcus. Good gingival stimulation
Charter's Coronally 45o, sides of bristles half Small circular motions with apical Hard to learn and position
on teeth and half of gingiva movements towards gingival margin brush
Clears inter proximal
Gingival stimulation
Fones Perpendicular to the tooth With teeth in occlusions, move Easy to learn
brush in rotary motion over both Inter proximal areas not
arches and gingival margin cleaned
May cause trauma
Roll Apically, parallel to tooth and then On buccal and lingual inward Doesn't clean sulcus area
over tooth surface pressure, then rolling of head to Easy to learn
sweep bristle over gingiva & tooth good gingival stimulation
Stillman's On buccal and lingual, aplically at an On buccal and lingual slight rotary Excellent gingival
ablique angle to long axis of tooth. motions with bristle ends stimulation
Ends rest on gingiva and cervical stationary Moderate dexterity
part. required
Moderate cleaning of
interproximal area
Modified Pointing apically at and angle of 45o Apply pressure as in stillmans's Easy to master
stillman's to tooth surface method but vibrate brush and also Gingival stimulation
move occlusally

15. Method Bristle placement Motion Advantage/
disadvantage
Scrub Horizontal on gingival margin Scrub in anterior position direction Easy to learn & best suited
keeping brush horizontal fro children
BASS Apical towards gingival into sulcus at Short back and forth vibratory Cervical plaque removal
450 to tooth surface motion while bristles remain in Easily learned
sulcus. Good gingival stimulation
Charter's Coronally 45o, sides of bristles half Small circular motions with apical Hard to learn and position
on teeth and half of gingiva movements towards gingival margin brush
Clears inter proximal
Gingival stimulation
Fones Perpendicular to the tooth With teeth in occlusions, move Easy to learn
brush in rotary motion over both Inter proximal areas not
arches and gingival margin cleaned
May cause trauma
Roll Apically, parallel to tooth and then On buccal and lingual inward Doesn't clean sulcus area
over tooth surface pressure, then rolling of head to Easy to learn
sweep bristle over gingiva & tooth good gingival stimulation
Stillman's On buccal and lingual, aplically at an On buccal and lingual slight rotary Excellent gingival
ablique angle to long axis of tooth. motions with bristle ends stimulation
Ends rest on gingiva and cervical stationary Moderate dexterity
part. required
Moderate cleaning of
interproximal area
Modified Pointing apically at and angle of 45o Apply pressure as in stillmans's Easy to master
stillman's to tooth surface method but vibrate brush and also Gingival stimulation
move occlusally

16. Bass method
Charters method

17.  O’Leary in 1970 studied the deposition of particlulate matter
in the crevicular tissue by toothbrushing using the roll and the
bass technique.
 Brushes presoaked in solution containing carbon particle
were used.
 The result showed that no carbon particles were observed in
the crevicular epithelium or underlying connective tissue of
any test section on either technique.
 However, the result of this study does not eliminate the
possibility that bacteria can be introduced into the crevicular
tissue since the bacteria is smaller in size than the carbon
particle used in this study

18.  Waerhaug 1981. reported on the effect of tooth brushing on
subgingival plaque formation.
 Results: during brushing, it could be noticed that the bristles
penetrate as far as 0.9 mm below the gingival margin ( Bas
technique)

19.  MacGregor ( 1984) , conducted a study to determine
whether smokers have more plaque than non-smokers , and
whether it could be explained by dif. In brushing time, quality
and frequency
 Results:
› In both genders, smokers have higher plaque scores.
› No association btw tobacco consumption and frequency
of tooth brushing
› Poorer oral cleanliness level in smokers both before and
after tooth brushing may be explained by their shorter
brushing time.

20. • In 1939 powered tooth brush invented to make plaque control
easier.
• Its mainly recommended for
(a) Individual lacking motor skills
(b) Hospitalized patients whose teeth are cleaned by the caregivers.
(c) Special needs patient ( physical and mental disability)
(d) Patient with orthodontic applied
(e) Whosoever wants to use
 There are many powered tooth brushes some with reciprocal of
back and back motions and some with combination of both
some are circular and elliptical motion.
 Powered tooth cleaner resembles a dental prophylaxis and
hand piece with rotary rubber cap.
 Patient should be lustrated for proper use.

22.  No evidence of a statistically significant difference between
powered and manual brushes. However, rotation oscillation
powered brushes significantly reduce plaque and gingivitis in
both the short and long-term
 (C. Deery , et al 2003)
 electric toothbrush have not been shown to provide benefits
routinely for patients with RA, children who are well-
motivated brushers , or patients with chronic periodontitis.
 ( Heasman, 1999)

23.  Long and Killoy in 1985 evaluated the effectiveness of the
electric toothbrush versus manual toothbrushing using
modified Bass technique in 14 orthodontic patients.
 The results showed the electric toothbrush is significantly
better in toothbrusing efficiency.
 Similar result was found in Youngblood et al. in 1985, when
they examine the effectiveness of electric toothbrush
compared to manual toothbrushing using modified Bass
technique in removing subgingival and interproximal plaque

24.  On the other hand, using electric
tooth brush versus manual tooth brush
had no significant difference in a
group of 123 children in a two months
period.
Crawford 1975

25.  Any thooth brush , regardless of the brushing method, does
not completely remove interdental plaque. Even for patients
with wide-open dental embrassures. ( Gjermo, 1970, Schmid
1976).
 The majority of dental and periodontal disease's originate in
interproximal area, interdental plaque removal is necessary
 Tissue distruction associated with perio. Disease often leave
large ,open spaces, btween teeth and exposed roots with
anatomic concavities and furcations which are difficult to
clean and access with the toothbrush.
 The purpose of Interdental cleaning aids is to remove plaque,
not to dislogde food wedged btween teeth.

26.  Dental floss is the most
widely recommended
mehtod for removing
proximal plaque.
 The floss is wrapped around
each proximal surface and
is activated with repeated
up and down stroke.
 Floss should pass gently
through the contact area.
Do not snap the floss pass
the contact area as it may
injure the interdental
papilla.

27.  Floss is available in many types:
unwaxed, waxed, tape floss,
ePTFE floss, and Superfloss.
› Waxed floss contained wax to
facilitate passing the floss the
floss through the contact and
alleviate fraying.
› Tape floss contain criss-cross fiber
and eliminate fraying.
› PTFE floss (Glide floss) is the teflon
floss which allow passing through
very tight contact easily without
fraying.
› Superfloss is the web-like material
which improved proximal
cleaning efficiency.

28.  There are no significat diffrence between various types of
floss to remove dental plaque , they all work equally well
( Grossman 1979, Keller 1969).
 Graves et al. in 1989 evaluated in a 2 week clinical trial the
efficacy of unwaxed dental floss, dental tape, waxed floss,
and tooth brushing alone in reduction of interproximal
bleeding.
 The result showed that the dental tape and dental floss were
equally effective in reducing interproximal bleeding and
twise effective as toothbrushing alone.

29.  Lambert et al. in 1982 compare the waxed and unwaxed
floss to determine the efficacy to remove plaque and their
effect on gingival health during a home oral program.
 The results showed there was no statistical difference
between the types of floss in regards to their ability to remove
plaque or prevent gingivitis.
 Wunderlich et al. in 1982 reported there is no difference
between wax and unwaxed floss in maintaining gingival
health.

30.  Wong and Wade study
in 1985, which they
compared the
effectiveness of Super
floss and waxed dental
floss as proximal surface
cleansing agent in 34
subject.
 Superfloss was found to
be superier (50%) to
waxed dental floss(45%)
in removing proximal
plaquem but neither was
100% efffective.

31.  Flossing can be made easier by using a floss holder –
 Floss holder should have –
1. One or two fork that enough to keep the floss tent
even when its moved pass tight contact area
2. An effective and simple mounting mechanisms

32.  Interdental brush are
conical shape brushes
made of bristles
mounted on a handle,
single tufted brushes, or
small conical brushes.
 They are suitable for
cleaning large, irregular,
or concave tooth
surfaces adjacent to
wide interdental spaces.
 They are inserted
interproximally and are
activated with short
back and forth strokes in
between the teeth.

33.  Waerhaug in 1976 evaluated the effec tof interdental brushes
on 67 teeth which scheduled for extraction.
› Teeth were cleaned prior to extraction and then stained
and examined after extraction.
› The results indicated that plaque can be removed from 2
to 2.5mm subgingivally using the interdental brush
 A comparision study between dental floss and interdental
brush in patients with sever to moderate periodontitis ,
showed that interproximal brushs remove slightly more
interproximal plaque and that the patients found them easier
to use.
 No diffrence was found in PD reduction and BI.
( Christou,1998)

35.  Studies have been conducted to compare the efficacy of
tooth pick, dental floss, and multi-tufted brush.
 Dental floss removed more plaque at lingual interproximal
surface than toothpicks.
 Toothpicks combined with multi-tufted brush used on oral
surfaces were as effective in removing interproximal plaque
as dental floss.
 The use of floss or tooth pick combined with single tufted
brush may reduce the amount of plaque adhering to the
proximal surfaces by an average of 50%

36.  Oral irrigation device include the
use of water picks.
 The high pressure, pulsating stream
of water through a nozzle is
directed to the tooth surface and
subgingivally, washing away debris
and plaque containing bacteria.
 They are helpful surrounding
orhtodontic appliance, and when
used as an adjucntive treatment in
shallow pocket depth.
 Patients reqiure antibiotic
premidication should not use oral
irrigation.

37.  When used as adjuncts to
toothbrushing , irrigation
devises, can have a
beneficial effect on
periodontal health by
reducing the accumulation
of plaque and calculus and
decreasing inflammation
and pocket depth.
 ( Robinson and Hoover,
1971)

38.  Eakle et al. in 1986 showed that the oral irrigator deliver an
aqueous solution into the periodontal pocket and will
penetrate an average to approximately half the depth of the
periodontal pockets.
 Penetration of 90 degree angle stream of water is about 70%
for pocket less than 3mm, 44% for moderate pocket (4 to 7
mm) and 68% for deep pocket ( greater than 7mm).
 For 45 degree angle, the result is 54%, 45%, and 58%
respectively.

39.  Ciancio in 1989 evaluate the efficacy of an antimicrobial
rinse delivered by an oral irrigation device twice daily.
 The results showed that irrigation with or without an
antimicrobial agent was effective in reducing the plaque,
suggesting that oral irrigation may be beneficial on oral
health and the use of the chemotherapeutic agent will lead
to greater reduction in plaque and gingival bleeding and to
moderate decreases in total bacteria counts detected by
phase contrast microscopy

40.  Miswak (chewing stick) in the Islamic countries.
 Miswak use is as effective , tooth brushing for
reducing plaque and gingivitis.
 antimicrobial effect
 association with Islam, maximum benefits may be
achieved by encouraging optimum use of the
miswak
 Oral hygiene may be improved by complementing
traditional miswak use with modern technological
developments such as tooth brushing
Al-Otaibi 2004

41.  A clinical trial study on Ethiopian schoolchildren comparing
mefaka (Miswak) with conventional toothbrush, found
Miswak to be as effective as the toothbrush in removing oral
deposits.
 In a clinical trial among adolescents in Nigeria, the
- results showed that the Massularia acuminata chewing
stick was as effective in controlling and removing dental
plaque as the toothbrush and paste

42.  Danielsons, et al-showed that there was a reduction of plaque
on the front teeth more than the posterior teeth and
recommended Miswak as a tool for oral hygiene.
( Danielsons B, et al 1989)
 Cross-sectional studies show conflicting results. A cross- sectional
study in Ghana among adults revealed higher plaque and
gingival bleeding in chewing stick users as compared with
toothbrush users.
(Norman S , 1989)
 Another retrospective study showed that Miswak users had
deeper pockets and more prevalence of periodontal diseases
(Gazi M,1990)

43.  Regardless the means to achieve the goal, mechanical plaque
control is the key to the success of periodontal therapy and
achieving dental health.
 Good mechanical plaque control program should be included
in the first phase of therapy and reinforced through the entire
therapy.
 The clinician must evaluated patient plaque control by means of
gingival and plaque indices to motivate the patient toward the
common goal, the optimal periodontal health.
 Common devices to be recommended to the patient are soft
bristle tooth brush, floss, interproximal brushes, and optional
intraoral irrigation devices.
 With good oralphysiotherapy, gingivitis can be prevented and
periodontal disease with bacterial as the main etiological factor
can be erradicated.

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 2. Sanders, WE. Robinson, HBG. The effect of toothbrushing on deposition of calculus. Journal of
Periodontology 33: 386, 1962.
 3. O’Leary, Shafer W., Swenson H, Nesler D. Possible penetration of crevicular tissue from oral hygiene
procedure. Use of the toothbrush. J. Periodontology, 41:163, 1970 A.
 4. Caranza, Newman. Textbook of clincal periodontology. Eighth edition. WB Saunders, 1996.
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 7. Killoy, W. Love J., Fedi, P. Tira, D. The effectiveness of a counterrotary action powered toothbrush and
conventional toothbrush on plaque removal and gingival bleeding. Journal of Periodontology, 60: 473, 1989.
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 9. Graves, R. Disney J. Stamm J. Comparative effectiveness of flossing and brushing in reducing interproximal
bleeding. Journal of periodontology, 60: 243, 1989.
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device on plaque, gingivitis, and subgingival microflora. Journal of Periodontology, 60: 310, 1989.
 11. Eakle, W. Ford, C., Boyd, R. Depth of penetration in periodontal pockets with oral irrigation. Journal of
clinical Periodontology, 13: 39, 1986.
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Odontol Scand 1989; 47:121-25
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 14. . Gazi M, Saini T, Ashri N and Lambourne A. Meswak chewing stick versus conventional tooth- brush as an
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