Chemical Inhibition of Supragingival Dental Plaque Control Question And Answers

Plaque Control

Question 1. Write short note on chemical inhibition of plaque.
Or
Write short note on chemical plaque control.
Or
Write short note on chemical plaque inhibition.
Answer.

Chemical Plaque Inhibition

Chemical plaque control is used as an adjunct for controlling gingival inflammation and preventing progression of periodontal disease.

Chemical methods are very effective during phase I therapy for patients with recurrent problems.

According to ADA, two agents are accepted for plaque inhibition, i.e. chlorhexidine digluconate and essential oil rinse.

Chemicals Used for Supragingival Plaque Control (Addy’s Classification)

• Antibiotics:
  • Penicillin
  • Vancomycin
  • Kanamycin
  • Erythromycin
  • Spiramycin
  • Metronidazole.
• Enzymes:
  • Mucinase
  • Protease
  • Lipase
  • Amylase
  • Elastase
  • Lactoperoxidase
  • Hypothiocyanate
  • Mutanase.

Read And Learn More: Periodontics Question And Answers

• Quaternary ammonium compounds:
  • Cetylpyridinium chloride
  • Benzethonium chloride
  • Benzalkonium chloride
  • Domiphen bromide.
• Bisbiguanides:
  • Chlorhexidine
  • Alexidine
  • Octenidine/bispyridines.
• Metallic salts:
  • Copper
  • Tin
  • Zinc.
• Herbal extracts:
  • Sanguinarine.
• Fluorides:
  • Strontium fluoride.
• Oxygenating agents:
  • Hydrogen peroxide.
• Phenolic compounds:
  • Thymol
  • Menthol
  • Eucalyptol.
• Other antiseptics:
  • Iodine
  • Povidone-iodine
  • Sodium hypochlorite
  • Hexetidine
  • Triclosan.

Classification of Antimicrobial Agents Used as Chemical Inhibitor of Plaque.

Depending on antimicrobial efficacy and substantivity.

First Generation Agents

• Reduces plaque scores by 20–50%.
• For example, antibiotics, quaternary ammonium compounds, phenols and sanguinarine.
• Efficacy is limited by their poor retention, hence used 4 to 6 times daily.

Second Generation Agents

• These are retained longer in the oral cavity reduce plaque score by 70–90% used 1 to 2 times daily.
• For example, bisbiguanides.

Third Generation Agents

They should be effective against specific periodontopathic organisms. They are yet to be developed clinically.

Description of Chemical Plaque Control Agents

Triclosan

• Triclosan is a phenol derivative, it is synthetic and is nonionic.
• It has a broad-spectrum of activity against gram-positive and gram-negative bacteria.

Mechanism of Action

• It acts over the microbial cytoplasmic membrane and it induces leakage of cellular constituents and leads to bacteriolysis.
• It also delays plaque maturation and inhibit formation of prostaglandin and leukotrienes which are the mediators of inflammation.

Metallic Ions

Salts of zinc and copper are most commonly used metal ions.

Mechanism of Action

They reduce glycolytic activity in microorganisms and inhibit bacterial as well as crystal growth.

Quaternary Ammonium Compounds

• These are the cationic antiseptics as well as surface active agents which are more active against gram-positive as compared to gram-negative organisms.
• Quaternary ammonium compounds are benzethonium chloride, benzalkonium chloride and cetylpyridinium chloride.

Mechanism of Action

Positively charged molecule along with negatively charged cell membrane phosphates disrupts cell wall structure of microorganisms.

Sanguinarine

• It is effective against wide variety of gram-negative microorganisms.
• It undergoes retention with plaque when used as mouthwash.

Antibiotics

• Vanacomycin, erythromycin, nidamycin and kanamycin are used as antibiotics.
• As there are chances of bacterial resistance and hypersensitivity reactions their use is restricted.

Enzymes

• These are mucinase, dehydrated pancreas, dextranase and thiocyanate synthetase.
• Various proteolytic enzymes are bactericidal and are effective when applied in the mouth.
• Enzymes act as active agents and they breakdown already formed matrix of plaque and calculus.

Povidone-Iodine

• It does not show significant plaque inhibition activity when used as 1% mouthwash.
• Various studies shows that it reduces inflammation and progression of periodontal disease.

Bisbiguanides

• Chlorhexidine is a bisbiguanide
• It has most positive antibacterial result
• Two daily rinses with 10 mL of 0.2% aqueous solution of chlorhexidine digluconate almost completely inhibit the development of dental plaque, calculus and gingivitis.

Mechanism of Action

• It has a broad spectrum of antibacterial activity.
• Gram-positive bacteria are more susceptible than gramnegative
• In relatively high concentration, it is bactericidal but in low concentration it may be bacteriostatic
• Cationic molecules of chlorhexidine bind readily to the oppositely charged cell wall and interfere with the membrane transport initiating a leakage of low molecular weight substances
• In high concentration, chlorhexidine penetrates the cell and causes precipitation of cytoplasm (Bactericidal action).

Delmopinol

• It is a low molecular weight amino alcohol.
• Inhibits growth of plaque and reduce the chances of gingivitis.

Mechanism of Action

• It target dextran in extracellular matrix by blocking the synthesis, reducing the viscosity and selectively inhibiting dextran-producing streptococci.
• It also undergoes interference with plaque matrix formation and reduces bacterial adherence. It causes weak binding of plaque to tooth surface and aid in easy removal of plaque

Question 2. List the tools for plaque control. Describe the Stillman modified method of tooth-brushing.
Answer. Plaque control is defined as the removal of microbial plaque and prevention of its formation on teeth. Basically, there are two types of plaque control methods.

• Mechanical plaque control.
  • Toothbrushes.
  • Powered toothbrushes.
  • Interdental cleansing aids.
    • Interdental brushes.
    • Single tufted brushes.
    • Dental floss.
  • Wooden tips
  • Gum stimulator
  • Oral irrigation devices
  • Dentifrices
• Chemical Plaque Control.

Stillman Modified Method of Tooth-brushing

• In modified Stillman method, brush is placed with bristle ends resting partially on the cervical portion of teeth and partially on the adjacent gingiva pointing in an apical direction and at an oblique angle of long axis of teeth.

• Apply pressure against the gingival margin to produce a percepitable blenching.
• Then move the brush in 20 back and forth strokes while simultaneously moving it coronally along the attached gingiva and on gingival margin and tooth surface.
• A soft or medium multitufted brush should be used with this technique to minimize trauma to gingiva.
• To reach the lingual surface of maxillary and mandibular incisors the handle of the brush can be held in vertical position.
• The occlusal surface of molars and premolar are cleaned with the bristles placed perpendicular to the occlusal plane and penetrating into the grooves and interproximal embrasures.
• The modified Stillman method may be recommended for cleaning in areas with progressing gingival recession and root exposure to minimize abrasive tissue destruction.

Question 3. Write short note on interdental cleaning aids.
Answer. The brushing method used does not completely remove interdental plaque.

• Interdental plaque removal is crucial because majority of dental and periodontal diseases originates in interproximal area.
• Other condition formed in periodontal and gingival diseases also demands interproximal cleansing.
• The purpose of interdental cleaning is to remove plaque. Among the numerous aids available dental floss and interdental cleaners such as wooden or plastic tips and interdental brushes are commonly recommended.
• Criteria of selection of these aids depends on type of embrasures
  Type 1: Interdental papilla completely fills embrasure space. Dental floss can be used.
  Type 2: Mild loss of interdental papilla due to slight spacing between the teeth, interdental brushes can be advised.
  Type 3: No proximal contact between the teeth like diastema where there is no interdental papilla. Unitufted brushes are advised.

Dental Floss

• It is used for cleaning in narrow gingival embrasures that are occupied by intact papilla and border by tight contact zones. It is most effective dental hygiene aid.
• There are various types of dental floss, i.e.
  • Twisted or non-twisted
  • Bonded or non-bonded
  • Waxed or unwaxed
  • Thick or thin
• Dental floss should contact the proximal surface from line angle to line angle to clean effectively.

Interdental Brushes

• It is used in area of moderate papillary recession, proximal tooth surface adjacent to open embrasure, orthodontic appliances, fixed prosthesis, dental implant and other area that are hard to reach with regular toothbrush.
• They are single-tufted brushes or small conical brushes.
• These brushes should be inserted in inter-proximal spaces and are activated by short back and forth strokes in between the teeth.

Unitufted Brushes

• It is used in accessible areas such as lingual surface of mandibular molars, abutment teeth, distal surface of most posterior teeth, crowded teeth, open interproximal areas and in deep recessions. It is also indicated in fixed dental prosthetics.
• They are mainly used in Type III gingival embrasures

Wooden Picks

• It is used for plaque removal at or just underneath gingival margin, for concave proximal tooth surface and for exposed furcation area.
• Soft triangular wooden picks should be placed in the interdental space in the manner that base of triangle rest over gingiva and sides contact the proximal tooth surfaces and now the pick is move in and out of embrasure which remove soft deposits.
• Wooden tooth picks should be attached to the handle and then used on facial and lingual surfaces of tooth in oral cavity.
• They are the substitute for dental floss in type III embrasures.

Gauze Strips

It is used for the cleaning of proximal surface of widely spaced teeth, for the surface of teeth which lies next to edentulous space and fixed appliances.

Irrigation device or Waterpik Device

• They are composed of built in pump and a reservoir.
• These devices remove the unattached plaque and debris.
• When these devices are used adjunct to toothbrushing, they enhance the periodontal health by decreasing plaque and calculus formation.

Question 4. Write short note on gingival massage.
Answer. Massaging the gingiva can be performed with a toothbrush, rubber-tip stimulator or interdental cleaning device.

• It produces epithelial thickening, increased keratinization and increased mitotic activity by the epithelium and connective tissue.
• The increased keratinization occurs only on the gingiva facing the oral cavity (oral epithelium), but not on the areas more vulnerable to microbial attack, which are the sulcular epithelium and the interdental areas where the gingival col is present.
• It has never been demonstrated that epithelial thickening, increased keratinization, and blood circulation provide protection against microorganisms and other local irritants and thus are beneficial or necessary for gingival health.
• These method (rubber tip, brushes) also provide plaque control, hence, the plaque removal effect is far more important to periodontal health.

Question 5. Write short note on toothbrush.
Answer. Toothbrush is a mechanical plaque control device.It may be manual or powered.

Types of Toothbrush

Toothbrushes are of following types, i.e.

• Manual toothbrushes.
• Powered toothbrushes.
• Sonic and ultrasonic toothbrushes.
• Ionic toothbrushes.
• Orthodontic toothbrushes:
• Manual toothbrushes: It requires manual regulation.
• Powered toothbrushes: Automated battery-driven toothbrushes with bristles moving in a side-to-side or rotary or reciprocating motion.
• Sonic and ultrasonic toothbrushes: Toothbrushes that produce high frequency vibrations that leads to the mechanism of acoustic streaming and cavitation similar to ultrasonic scalers. These vibrations disrupt bacterial cell wall and remove plaque.
• Ionic toothbrushes: These brushes are designed to release positively charged ions that change the surface charge of a tooth.
• Orthodontic toothbrushes: They are designed especially for patients with orthodontic appliances. The bristles in the centre of the brush are shorter than those present at the periphery allowing it to pass over the appliance without causing abrasion of the teeth.

Manual Toothbrushes

• A toothbrush consists of handle, shank and head.
• According to ADA, specification of toothbrush a head of the brush should be:
• 1” to 1/4” long (Brushing surface).
• 5/16” to 3/8” (7.9 to 9.5 mm) wide.
• 2–4 rows of bristles.
• 5–12 tufts per row.
• 80 to 86 bristles per tuft.
  The extreme end of head is toe and close to the handle is heel.
  Size: Large, medium and small.
  Lateral profile: Flat, convex, concave and scalloped.
  Bristles: Two kind of bristle materials are used in toothbrush.
  • Natural from hog.
  • Artificial by nylon.

Hardness

Depends on material, diameter and length

Soft: 0.007” to 0.009” (No. 7, 8, 9)

Medium: 0.010” to 0.012” (No. 10, 11, 12)

Hard: 0.013” to 0.014” (No. 13, 14)

Extrahard: 0.015” (No. 15).

Handle Design

• Handle should be fit comfortably in the palm of the hand
• It may be straight or angled.
• It may be thick or thin.

Bristles

• Bristles are of two types, i.e. nylon and natural.
• Nylon bristles are preferable brushes.
• Natural bristles are more susceptible for breakage, their contamination chances by bacteria are very high.

Powered Toothbrushes

• Electrically powered toothbrushes were invented in 1939.
• Various types of motion in powered toothbrushes are:
  • Back and forth reciprocal.
  • Circular.
  • Elliptical or combination.

Powered Toothbrushes are Indicated for:

• Children and adolescents.
• Children with physical or mental disability.
• Hospitalized patient, including older adults who need to name their teeth cleaned.
• Patient with fixed orthodontic appliances.
• They are particularly useful for cleaning proximal surfaces and for people with limited dexterity.
• Toothbrushes are used with dentifrices.

Advantages of Powered Toothbrushes

• Increases the patient motivation.
• Cleaning in interproximal areas and on lingual surfaces is increased.
• Apply less brushing force when compared to manual toothbrush.

Question 6. What is plaque control? Describe various brushing techniques along with advantage.
Answer. Plaque control is the removal of dental plaque on a regular basis and the prevention of its annulations on the teeth and adjacent gingival surfaces.

• Effective removal of plaque is essential to dental and periodontal health throughout life
• Dental plaque accumulation results in development of gingivitis with 7 to 21 days
• Daily removal of plaque led to resolution of the gingival inflammation
• Plaque removal plays an important role in treatment and prevention of periodontal diseases.

Plaque Control

• Mechanical methods
  • Toothbrushes
  • Interdental aids
  • Dental floss, interdental brushes, wooden or rubber tips
  • Irrigation devices.
• Chemical methods
  • Chlorhexidine
  • Essential oil mouth rinse-menthol, thymol eucalyphor.

Question 7. Write short note on dentifrices.
Answer. Dentifrices are widely used as aid in oral hygiene consisting either soluble pyrophosphate or zinc compounds which have demonstrated 10% to 50% reduction in calculus.

According to American Dental Association Council on Dental Therapeutics “A dentifrice is a substance used with a tooth brush for purpose of cleaning accessible surfaces of teeth.”

Webster describe the term dentifrice and it is derived from dens (tooth) and fricare (to rub).

Uses of Dentifrices

• Maintains oral hygiene
• Helps in prevention of dental caries
• Prevents gingivitis
• Prevent periodontal diseases
• Prevents halitosis
• Removes stains from the teeth
• Helps in suppressing hypersensitivity of the teeth.
• They are also used for cosmetic whitening of teeth.

Question 8. Write short note on dental floss.
Answer. Dental floss was developed by Levi Spear Parmly, a New Orleans dentist.

Dental floss is the most widely recommended tool for removing plaque from proximal tooth surfaces.

Type of Dental Floss

• Twisted or non-twisted
• Bonded or non-bonded
• Waxed or unwaxed
• Thick or thin.

Factors Determining the Choice of Dental Floss

• Lightness of tooth contact
• Roughness of proximal surface
• Patients manual dexterity.

Technique

• Spool technique: Recommended for teenagers and adults who have acquired the level o neuromuscular coordination and mental maturity to use floss.
• Loop or circle technique: It is suited for children as well as adults with less nimble hands or handicaps such as poor muscular coordination or arthritis
• The floss must contact the proximal surface from line angle to line angle to clean effectively
• It must clean the entire proximal surface, not just slipped apical to the contact area.

Procedures

• The floss should be at least 12 to 18” long
• It is wrapped around the fingers or ends may be tied together in a loop
• After stretching the floss between thumb and fingers, it gently through each contact area in a back and forth motion
• Once the floss is apical to contact area, move it up along the tooth, till the contact area and down into the sulcus again, this is repeated several times
• Same is repeated on the proximal surfaces of other teeth.

Floss Holder

• Flossing can be made easier by using a floss holder.
• Floss holder is indicated in patient with low manual dexterity for handicapped and hospitalized patient.
• Disadvantages of floss holders. They are more time consuming.

Dental Tape

It is a flat and wider dental floss, it is recommended for cleaning of Class 1 and Class 2 embrasures.

Power Flosser

They remove the biofilm, reduce gingivitis and bleeding and is similar to manual floss.

Specialized Floss

• These flosses consist of thin, stiff and soft, flat sections within the 1% length.
• Thin flosses are used in the areas of tight contact and where sharp edges of filling are absent.
• Wide ribbon-like flosses provide greater contact surface with enamel for removing plaque.
• Wax floss slide easily between tight contacts.
• Unwaxed dental floss is better than waxed as its diameter is small and is passed easily through tight contacts. It makes squeaking noise when it is used over clean tooth surface

Functions of Dental Floss

• Removal of adherent plaque and food debris from interproximal areas.
• Polishing of the tooth surface after the oral prophylaxis
• Stimulating and massaging interdental papillae.
• It helps to locate the subgingival calculus deposit, overhanging margins of restoration and the proximal carious lesions.
• It improves oral hygiene.
• It also act as vehicle for application of polishing or therapeutic agents to interdental and subgingival area and decreases the gingival bleeding.

Question 9. Write short note on disclosing agents.
Answer. Disclosing solutions are capable of staining bacterial deposits on the surfaces of teeth, tongue and gingiva which might otherwise be invisible to naked eye.

Disclosing agents are prepared in form of mouthrinse, wafer, chewing gum, aerosol, spray or lozenges which consists of dye and various other coloring agents.

Purpose of Disclosing Agents

• For patient education and motivation.
• For evaluation of effectiveness of maintenance of oral hygiene by patient.
• For preparing the plaque indices.
• In research studies.

Properties of Disclosing Agents

• Color intensity: It should distinctly stain the deposit so that it should be in contrast with normal color of oral cavity.
• Duration of intensity: Color should not rinse of immediately by ordinary rinsing method.
• Taste: Disclosing agent should have a pleasant taste.
• Irritation to mucous membrane: If there is any allergy reported in patient from disclosing agent it should be mentioned in the permanent history record of patient.
• Diffusibility: Disclosing agent should be thin enough so that it can be applied readily to exposed teeth surface. It should also be thick enough to impart color to bacterial plaque.
• Astringent and anti-septic properties: Disclosing agents should possess both astringent and anti-septic properties.

Various Plaque Disclosing Agents

• Iodine preparation:
  • Skinner’s iodine solution
  • Diluted tincture of iodine
• Bismarck brown
• Erythrosine: FD & C Red No. 3/No. 28
• Fast green: FD & C Green No. 3
• Fluorescein: FD & C Yellow No. 8
• Two-tone dye:
  • FD and C Green No.3
  • FD and C Red No.3
• Basic fuschin

Methods of Application

• Dry the teeth of patient by compressed air, retract cheek or tongue.
• Small swab or cotton pellet is used for application of disclosing agent to crowns of teeth.
• Patient is directed to spread the agent over all surfaces of teeth with tongue.
• Distribution of disclosing agent should be examined.
• If rinsing type of disclosing agent is used, patient is instructed to rinse with appropriate dilution of concentrated solution and the solution is swished over all the tooth surfaces.
• Disclosing agent should not be swallowed. If swallowed, then patient is asked to rinse with water.

Recent Advancement in Disclosing Agents

Recently, a toothbrush is designed which dispense plaque disclosing agent via a reservoir designed and constructed which consists of dental plaque, disclosing agent.

Question 10. Write short note on chlorhexidine.
Or
Discuss chlorhexidine in detail.
Or
Write short answer on chlorhexidine.
Answer. It has most positive antibacterial result.

Two daily rinses with 10 mL of 0.2% aqueous solution of chlorhexidine digluconate almost completely inhibit the development of dental plaque, calculus and gingivitis.

Mechanism of Action

Antiplaque Action

• Superior anti-plaque activity of chlorhexidine is because of its property of sustained availability.
• It involves reservoir of chlorhexidine, slowly dissolving from all the oral surfaces which result in bacteriostatic milieu in oral cavity.
• Following are the three mechanisms of plaque inhibition by chlorhexidine:
  • It prevents pellicle formation by blocking the acidic groups on salivary glycoprotein thereby decreasing glycoprotein adsorption on to tooth surface.
  • It prevents adsorption of bacterial cell wall onto tooth surface by binding the bacteria.
  • It prevents the binding of mature plaque precipitating agglutination factors in saliva and displacing calcium from plaque matrix.

Chlorhexidine is effective in inhibiting plaque formation on a clean surface but has little effect over the pre-existing plaque.

Antibacterial Action

• It has a broad-spectrum of antibacterial activity.
• Gram-positive bacteria are more susceptible than gramnegative
• In relatively high concentration, it is bactericidal but in low concentration, it may be bacteriostatic.
• Cationic molecules of chlorhexidine bind readily to the oppositely charged cell wall and interfere with the membrane transport, initiating a leakage of low molecular weight substances
• In high concentration, chlorhexidine penetrates the cell and causes precipitation of cytoplasm (Bactericidal action).

Indications

• In initial periodontal therapy, it is used as adjunct to mechanical oral hygiene.
• After surgeries, immediately after the removal of pack complete plaque control is achieved without use of proximal cleaning aids.
• In handicapped patients whose oral hygiene status is not compatible.
• In medically compromised patient who suffer from recurrent infections.
• Control plaque in patients with gingival enlargement.
• In patients having high risk of caries, chlorhexidine produces synergistic effects with fluoride to prevent caries.
• It is useful in patients undergoing orthodontic treatment, patients admitted in hospital for long time, elderly patients and terminally ill patients.

Disadvantages

• Locally reversible side effects to chlorhexidine use may occur, primarily brown staining of the teeth, tongue and silicate as well as resin restorations
• Transient impairment of taste perception
• Painful, desquamative lesions on the oral mucosa may be associated with burning sensation.

Question 11. Write short note on modified Stillman brushing technique.
Answer.

Stillman Brushing Technique

• The soft or medium brush is placed with bristle ends partly on gingiva and partly on cervical portion of teeth, positioning in apical position.
• Pressure is applied laterally against the gingival margin to produce a perceptible blanching.
• The brush is activated with 20 short back and forth strokes and is simultaneously moved in a coronal direction. This process is repeated in all the teeth.
• To reach lingual surface of anterior teeth, the handle of the brush is held in a vertical direction; engaging the heel of the brush. Penetration of bristles into the gingival sulci is avoided.

Stillman Brushing Advantages

• Gingiva is mechanically stimulated.
• Gingival third of the tooth is contacted with a short vibratory motion and plaque is removed between the gingival margin and the exposed area of tooth surface. Hence, advised only in areas of gingival recession.
• The tips of the bristles tend to reach the interproximal areas to clean and stimulate the inter-dental papilla without injury.

Stillman Brushing Disadvantages

• Patient might miss the gingiva and cervical areas of teeth thus, leaving behind plaque.
• Patient might not apply sufficient pressure to produce blanching of tissue.

Stillman Brushing Indications

• Removal of dental plaque from the cervical areas below the height of contour of enamel and from the exposed proximal areas.
• For regular cleaning of teeth and massaging the gingiva.
• Clean the areas with progressive gingival recession and root exposure.

Question 12. Write short note on oral irrigation.
Answer. Oral irrigation is the generic term that covers the two separate treatment modalities, i.e. professionally delivered (Chair side) and home (Self-applied) irrigation for the prevention and treatment of periodontal disease.

• Professional irrigation is of limited value, regardless of agent used in enhancing the outcomes of scaling and root planning. Use of chlorhexidine may reduce pain and shorten healing time.
• Home irrigation has a stronger body of supportive evidence than professional irrigation and is safe and effective for a wide range of patients, including those receiving periodontal maintenance and those with calculus build up, gingivitis, orthodontic appliances, etc.

Oral Irrigation Devices

• They are of several types—one can use water faucet to irrigate between and around the teeth.
• The water pressure is steady and is controlled by turning the faucet handle. Others use an intermittent water jet.
• Oral irrigators clean non-adherent bacteria and debris from the oral cavity.
• It has been shown to disrupt and detoxify subgingival plaque and can be useful in delivering antimicrobial agents into periodontal pockets (subgingival irrigation).
• Currently, there are two types of irrigator tips useful for subgingival irrigation. One is the cannula type tip recommended for office use and other is a soft rubber tip for patient’s use at home.

Question 13. Classify toothbrushes and various techniques.
Answer. Toothbrushes are of following types, i.e.

• Manual toothbrushes.
• Powered toothbrushes.
• Sonic and Ultrasonic toothbrushes.
• Ionic toothbrushes.
• Orthodontic toothbrushes.
• Manual toothbrushes: It requires manual regulation.
• Powered toothbrushes: Automated battery-driven toothbrushes with bristles moving in a side-to-side or rotational or reciprocating motion.
• Sonic and ultrasonic toothbrushes: Toothbrushes that produce high frequency vibrations that lead to the mechanism of acoustic streaming and cavitation similar to ultrasonic scalers. These vibrations disrupt bacterial cell wall and remove plaque.
• Ionic toothbrushes: These brushes are designed to release positively charged ions that change the surface charge of a tooth.
• Orthodontic toothbrushes: They are designed especially for patients with orthodontic appliances. The bristles in the center of the brush are shorter than those present at the periphery allowing it to pass over the appliance without causing abrasion of the teeth.

Techniques

• Roll technique: Modified Stillman method and rolling stroke method.
• Vibratory technique: Stillman, Charter and Bass method.
• Circular technique: Fones’ method.
• Vertical technique: Leonard method.
• Horizontal technique: Scrub method.
• Physiologic technique: Smith method.

Question 14. Write short note on oral physiotherapy.
Answer. Oral physiotherapy is defined as the collective procedures properly performed for the maintenance of personal hygiene of the mouth, those procedures necessary for cleanliness, tissue stimulation, tone and preservation of the dentition.

Uses of Oral Physiotherapy

In OSMF

• Oral physiotherapy includes mouth opening and ballooning of the mouth.
• Oral physiotherapy in oral submucous fibrosis put pressure on fibrous bands and provides relief.
• Forceful opening have been tried with mouth gag and acrylic surgical screw.

Gingival Massage

• Massaging the gingiva can be performed with a tooth brush, rubber tip stimulator or interdental cleansing aids.
• It produces epithelial thickening, increased gelatinization and increased mitotic activity by the epithelium and connective tissue.
• It also provides plaque control, hence the plaque removal is more important for periodontal health.

Interdental Physiotherapy Aids

The use of a tooth brush, interdental stimulator, floss, irrigation devices or other adjunctive aids used in oral physiotherapy to maintain the oral health.

Question 15. Write short note on Bass method of brushing.
Answer. It is also known as intrasulcular method.

Technique

• Head of the soft brush is placed parallel to occlusal plane with brush head acquiring three teeth which begins at most distal tooth in arch.
• Bristles are placed at gingival margin and are established at angle of 45° to long axis of tooth.
• Patient should apply gentle vibratory pressure by using back and forth motions without dislodging tip of bristles. This causes the forcing of bristle ends in sulci. Minimum of 20 strokes are given in same position.
• Brush should be lifted and move anteriorly and process is repeated for next three teeth.
• For lingual surfaces of anterior teeth brush is inserted vertically. Heel of the brush is pressed in gingival sulci and proximal surfaces at 45° angle to long axis of teeth. Brush is activated by 20 short vibratory strokes.
• For cleaning of occlusal surfaces, bristles are firmly pressed in pit and fissure areas. Brush is activated by 20 short back and forth strokes.
• For reaching the distal surface of last tooth, mouth should be opened wide and the tip of brush is vibrated 20 times for each tooth.

Indications

• Recommended in routine patients with or without periodontal diseases.
• For removing dental plaque in proximal areas and provides gingival stimulation.

Question 16. Write short note on modified bass technique.
Answer. This technique combines the vibratory and circular movements of bass technique with the sweeping motion of Roll technique.

• Toothbrush should be held in such a way that bristles is 45° to the gingiva.
• Bristles are gently vibrated by moving the brush handle in back and forth motion.
• The bristles are then swept over the sides of the teeth towards their occlusal surfaces in a single motion.

Indications

• As routine oral hygiene method.
• For intrasulcular cleansing.

Question 17. Define plaque control. Write in detail about mechanical plaque control. 
Or
Write short answer on mechanical plaque control.
Answer. Plaque control is the removal of dental plaque on a regular basis and the prevention of its annulations on the teeth and adjacent-gingival surfaces.

Mechanical Plaque Control

Mechanical plaque control is achieved by following methods:

• Toothbrush: Manual or powered
• Interdental aids:
  • Dental floss
  • Triangular tooth picks
  • Inter – dental brushes
  • Gauze strips
• Others:
  • Rubber-tip stimulators
  • Water irrigator

Toothbrush

Toothbrush is a mechanical plaque control device.

• It may be manual or powered.

Types of Toothbrush

Toothbrushes are of following types, i.e.

• Manual toothbrushes.
• Powered toothbrushes.
• Sonic and ultrasonic toothbrushes.
• Ionic toothbrushes.
• Orthodontic toothbrushes:
  • Manual toothbrushes: It requires manual regulation.
  • Powered toothbrushes: Automated battery-driven toothbrushes with bristles moving in a side-to-side or rotary or reciprocating motion.
  • Sonic and ultrasonic toothbrushes: Toothbrushes that produce high frequency vibrations that leads to the mechanism of acoustic streaming and cavitation similar to ultrasonic scalers. These vibrations disrupt bacterial cell wall and remove plaque.
  • Ionic toothbrushes: These brushes are designed to release positively charged ions that change the surface charge of a tooth.
  • Orthodontic toothbrushes: They are designed especially for patients with orthodontic appliances. The bristles in the centre of the brush are shorter than those present at the periphery allowing it to pass over the appliance without causing abrasion of the teeth.

Manual toothbrushes

• A toothbrush consists of handle, shank and head.
• According to ADA, specification of toothbrush a head of the brush should be:
  • 1” to 1/4” long (Brushing surface).
  • 5/16” to 3/8” (7.9 to 9.5 mm) wide.
  • 2–4 rows of bristles.
  • 5–12 tufts per row.
  • 80 to 86 bristles per tuft.
    The extreme end of head is toe and close to the handle is heel.
    Size: Large, medium and small.
    Lateral profile: Flat, convex, concave and scalloped.
    Bristles: Two kind of bristle materials are used in toothbrush.

• • • Natural from hog.
    • Artificial by nylon.

Hardness

Depends on material, diameter and length

Soft: 0.007” to 0.009” (No. 7, 8, 9)

Medium: 0.010” to 0.012” (No. 10, 11, 12)

Hard: 0.013” to 0.014” (No. 13, 14)

Extrahard: 0.015” (No. 15).

Handle design

• Handle should be fit comfortably in the palm of the hand
• It may be straight or angled.
• It may be thick or thin.

Bristles

• Bristles are of two types, i.e. nylon and natural.
• Nylon bristles are preferable brushes.
• Natural bristles are more susceptible for breakage, their contamination chances by bacteria are very high.

Powered toothbrushes

• Electrically powered toothbrushes were invented in 1939.
• Various types of motion in powered toothbrushes are:
  • Back and forth reciprocal.
  • Circular.
  • Elliptical or combination.

Powered toothbrushes are indicated for:

• Children and adolescents.
• Children with physical or mental disability.
• Hospitalized patient, including older adults who need to name their teeth cleaned.
• Patient with fixed orthodontic appliances.
• They are particularly useful for cleaning proximal surfaces and for people with limited dexterity. Toothbrushes are used with dentifrices.

Advantages of powered toothbrushes

• Increases the patient motivation.
• Cleaning in interproximal areas and on lingual surfaces is increased.
• Apply less brushing force when compared to manual toothbrush.

Interdental Aids

Interdental plaque removal is crucial because majority of dental and periodontal diseases originates in interproximal area.

• Other condition formed in periodontal and gingival diseases also demands interproximal cleansing.
• The purpose of interdental cleaning is to remove plaque. Among the numerous aids available dental floss and interdental cleaners such as wooden or plastic tips and interdental brushes are commonly recommended.
• Criteria of selection of these aids depends on type of embrasures
  Type 1. Interdental papilla completely fills embrasure space. Dental floss can be used.
  Type 2. Mild loss of interdental papilla due to slight spacing between the teeth, Interdental brushes can be advised.
  Type 3. No proximal contact between the teeth like diastema where there is no interdental papilla. Unitufted brushes are advised.

Dental Floss

• It is used for cleaning in narrow gingival embrasures that are occupied by intact papilla and border by tight contact zones. It is most effective dental hygiene aid.
• There are various types of dental floss i.e.
  • Twisted or non-twisted
  • Bonded or non-bonded
  • Waxed or unwaxed
  • Thick or Thin
    • Dental floss should contact the proximal surface from line angle to line angle to clean effectively.
    • Wax dental floss leave a coating on inter proximal surfaces to which debris may stick. Thick floss causes difficulty to floss in tight contact areas.

Interdental Brushes

• It is used in area of moderate papillary recession, proximal tooth surface adjacent to open embrasure, orthodontic appliances, fixed prosthesis, dental implant and other area that are hard to reach with regular toothbrush.
• They are single-tufted brushes or small conical brushes.
• These brushes should be inserted in inter-proximal spaces and are activated by short back and forth strokes in between the teeth.

Unitufted brushes

• It is used in accessible areas such as lingual surface of mandibular molars, abutment teeth, distal surface of most posterior teeth, crowded teeth, open interproximal areas and in deep recessions. It is also indicated in fixed dental prosthetics.
• They are mainly used in Type 3 gingival embrasures

Wooden Picks

• It is used for plaque removal at or just underneath gingival margin, for concave proximal tooth surface and for exposed furcation area.
• Soft triangular wooden picks should be placed in the interdental space in the manner that base of triangle rest over gingiva and sides contact the proximal tooth surfaces and now the pick is move in and out of embrasure which remove soft deposits.
• Wooden tooth picks should be attached to the handle and then used on facial and lingual surfaces of tooth in oral cavity.
• They are the substitute for dental floss in Type 3 embrasures.

Gauze Strips

It is used for the cleaning of proximal surface of widely spaced teeth, for the surface of teeth which lies next to edentulous space and fixed appliances.

Irrigation Device or Water Pik Device

• They are composed of built in pump and a reservoir.
• These devices remove the unattached plaque and debris.
• When these devices are used adjunct to toothbrushing they enhance the periodontal health by decreasing plaque and calculus formation.

Question 18. Define plaque. Write in detail about plaque control.
Answer. Dental plaque is defined as an adherent intercellular matrix consisting primarily of proliferating microorganisms along with a scattering of epithelial cells, leucocytes and macrophages.

Plaque Control

• Plaque control is the regular removal of dental plaque and prevention of its deposit on the teeth as well as adjacent gingival surface.
• Plaque control is carried out by two methods, i.e. chemical methods and mechanical methods

Chemical Method of Plaque Inhibition

Chemical plaque control is used as an adjunct for controlling gingival inflammation and preventing progression of periodontal disease.

Chemical methods are very effective during phase 1 therapy for patients with recurrent problems.

According to ADA, two agents are accepted for plaque inhibition, i.e. chlorhexidine digluconate and essential oil rinse.

Chemicals Used for Supragingival Plaque Control (Addy’s Classification)

• Antibiotics:
  • Penicillin
  • Vancomycin
  • Kanamycin
  • Erythromycin
  • Spiramycin
  • Metronidazole.
• Enzymes:
  • Mucinase
  • Protease
  • Lipase
  • Amylase
  • Elastase
  • Lactoperoxidase
  • Hypothiocyanate
  • Mutanase.
• Quaternary ammonium compounds:
  • Cetylpyridinium chloride
  • Benzethonium chloride
  • Benzalkonium chloride
  • Domiphen bromide.
• Bisbiguanides:
  • Chlorhexidine
  • Alexidine
  • Octenidine/bispyridines.
• Metallic salts:
  • Copper
  • Tin
  • Zinc.
• Herbal extracts:
  • Sanguinarine.
• Fluorides:
  • Strontium fluoride.
• Oxygenating agents:
  • Hydrogen peroxide.
• Phenolic compounds:
  • Thymol
  • Menthol
  • Eucalyptol.
• Other antiseptics:
  • Iodine
  • Povidone-iodine
  • Sodium hypochlorite
  • Hexetidine
  • Triclosan.