Plaque control is the regular removal of dental plaque and the prevention of its accumulation on the teeth

and adjacent gingival surfaces.

Carefully performed daily home plaque control, combined with frequent professionally delivered plaque
removal, has been demonstrated to
1. Reduce supragingival plaque.
2. Decrease the total number of microorganisms in moderately deep pockets, including furcation areas.
3. And greatly reduce the number of subgingival sites with Porphyromonas gingivalis, a significant periodontal
Pathogen.
Thus, plaque control is an effective way of treating and preventing gingivitis and is a critical part of all the
procedures involved in the treatment and prevention of periodontal diseases, the daily use of a toothbrush and
other oral hygiene aids is the most dependable way of achieving oral health benefits for all patients. Plaque
growth occurs within hours and must be completely removed at least every 48 hours in periodontally healthy
subjects to prevent inflammation.
The plaque control is divided to:
A) Mechanical plaque control B) Chemical plaque control
A) Mechanical plaque control: scaling instrument, toothbrush, interdental aids.
B) Chemical plaque control: mouthwashes, dentifrices.
Chemical plaque control is a rapidly growing field and will become even more significant for periodontal
patients and practices in the future as increasingly effective products become available.
A) Mechanical plaque control:

The Toothbrush
Toothbrushes vary in size and design as well as in length, hardness, and arrangement of the bristles.

Type of toothbrush: Manual and powered toothbrushes

Manual TOOTHBRUSHES

Toothbrush Design
1) Toothbrush bristles are grouped in tufts that are usually arranged in three or four rows. Rounded bristle
ends cause fewer scratches on the gingiva than flat-cut bristles with sharp ends.
Two types of bristle material are used in toothbrushes:
Natural bristles from hogs and artificial filaments made of nylon. Both types remove plaque, but:artificial filaments
Natural bristles
vastly predominate in the market
rare
To be replaced about every 3 months.
Can sterilize it.
Homogeneity of material
heterogeneity
Uniformity of bristle size, elasticity, resistance to
Susceptible to fray, break, soften, and lose their
Fracture
elasticity quickly
Contamination with diluted microbial debris
Bristle hardness is proportional to the square of the diameter and inversely proportional to the square of bristle
length.
Diameters of common bristles range from 0.007 inch (0.2 mm) for soft brushes to 0.012 inch (0.3 mm) for
medium brushes and 0.014 inch (0.4 mm) for hard brushes.
Note:Soft bristle brushes of the type have gained wide acceptance.
Softer bristles are more flexible, clean slightly below the gingival margin when used with a sulcular brushing
technique, and reach farther onto the proximal surfaces.
Hard bristled toothbrushes is associated with more gingival recession, Bristle hardness does not significantly
affect wear on enamel surfaces.
Toothbrushes must also be replaced periodically, although the amount of visible bristle wear does not
Appear to affect plaque removal for up to 9 weeks.

2) Handle and Head of toothbrush

The preference of handle characteristics is a matter of individual taste. The handle should fit comfortably in
the palm of the hand; it may be straight or angled, thick or thin.
Some clinical evidence supports that slightly bent brush handles improve posterior access for plaque removal

under supervised brushing conditions.

One study described a toothbrush with a double angulation of the neck of the handle and demonstrated
significantly more plaque reduction, especially on the buccal and lingual surfaces of posterior teeth.
The clinical significance of these findings has not been determined, but modifications improving access may
help some patients to brush more effectively for most patient.
Head size appropriate to the size of the patient's mouth
Short-headed brushes with straight-cut, rounded-ended, soft to medium nylon bristles arranged in three or
four rows of tufts are recommended.

Note the variation in brush head and handle design.

Recommendations
Soft, nylon bristle toothbrushes clean effectively (when used properly); remain effective for a reasonable time,
and tend not to traumatize the gingiva or root surfaces.
Toothbrushes need to be replaced about every 3 months.
If patients perceive a benefit from a particular brush design, they should use it.

POWERED TOOTHBRUSHES
Electrically powered toothbrushes designed to mimic back and- forth brushing techniques.
Subsequent models featured circular or elliptic motions, and some with combinations of motions. Currently,
Powered toothbrushes have oscillating and rotating motions, and some brushes use low- frequency

Acoustic energy to enhance cleaning ability.

Powered toothbrushes rely primarily on mechanical contact between the bristles and the tooth to remove
Plaque. The addition of low- frequency acoustic energy generates dynamic fluid movement and provides
cleaning slightly away from the bristle tips. The vibrations have also been shown to interfere with bacterial
adherence to oral surfaces; Hydrodynamic shear forces created by these brushes disrupt plaque a short distance
from the bristle tips, providing additional interproximal plaque removal.
Powered toothbrushes have been shown to improve oral health for
(1) Children and adolescents,
(2) Children with physical or mental disabilities,
(3) Hospitalized patients, including older adults who need to have their teeth cleaned by caregivers,
(4) Patients with fixed orthodontic appliances.
Powered brushes have not been shown to provide benefits routinely for patients with rheumatoid arthritis,
children who are well-motivated brushers, or patients with chronic periodontitis.

Recommendations
Powered toothbrushes remove plaque as well as, if not slightly better than, manual toothbrushes.
Patients who want to use powered toothbrushes should be encouraged to do so.
Patients need to be instructed in the proper use of powered devices.
Patients who are poor brushers, children, and caregivers may particularly benefit from using powered
toothbrushes.

Toothbrushing Methods
Many methods for brushing the teeth have been described and promoted as being efficient and effective.
Horizontal brushing (scrub): is the most widespread technique and despite the efforts of the dental profession
to instruct patients to adopt other more convenient brushing techniques, most individuals use such a technique
since it is the simplest. The head of the brush is positioned at a 90 angle to the tooth surface and then
movement is applied horizontally. The occlusal, lingual / palatal surfaces of the teeth are brushed with the
mouth open and the vestibular surfaces are cleaned with the mouth closed.
Vertical brushing (Leonard technique): is similar to the horizontal brushing technique, but the movement is
applied in vertical direction using an up-down motion.
Vibratory technique (Stillman technique): the head of the brush is positioned in an oblique direction toward
the apex, with the bristles placed partly in the gingival margin and partly on the tooth surface. Light pressure
together with a vibratory movement is then applied to the handle, without moving the brush from its original
position.
Roll technique (modified Stillman technique): the brush is positioned in a similar manner to the Stillman
technique, but after applying a small vibratory pressure, the head of the brush rotates progressively in an
Occlusal direction.

Stillman technique

modified Stillman technique

Charters technique: the head of the brush is positioned in an oblique direction to the tooth surface, with the
bristles directed towards the oclusal surface. The brush is then moved back and forth with a rotatory motion.
This method is particularly effective in cases with receded interdental papillae, since with this particular
situation the brush bristles can penetrate the interdental space.

Bass technique: the head of the brush is positioned in an oblique direction towards the apex, in order to
Introduce the bristles into the gingival sulcus. The brush is then moved in an anterior-posterior direction using
short strokes. This brushing technique is particularly useful in removing plaque not only at the gingival margin,
but also subgingivally. this brushing method the cleaning efficiency could reach a depth of about 0.5 mm
subgingivally.

Modified Bass technique: the brush is positioned similarly to the Bass technique, but after applying the
small movement in anterior-posterior direction, the head of the brush is rotated applying a movement in
Occlusal direction. It is a combination of the Bass and the modified Stillman techniques.
Although each of these toothbrushing methods can be effective regarding plaque removal, their
implementation must be made according to patient needs.
(modified Stillman technique): recommended for cleaning in areas with progressing gingival recession and
root exposure to minimize tissue destruction.
Charters technique: recommended for cleaning in areas of healing wounds after periodontal surgery.
Bass technique and Modified Bass technique: recommended for cleaning in person with or without
periodontal disease.

Bass Technique:
1. Place the head of a soft brush parallel with the occlusal plane, with the brush head covering three to four
teeth, beginning at the most distal tooth in the arch.
2. Place the bristles at the gingival margin, pointing at a 45-degree angle to the long axis of the teeth.
3. Exert gentle vibratory pressure, using short, back and- forth motions without dislodging the tips of the
bristles. This motion forces the bristle ends into the gingival sulcus area (see the Figure), as well as partly
into the interproximal embrasures. The pressure should be firm enough to blanch the gingiva as in picture.
4. Complete several strokes in the same position. The repetitive motion cleans the tooth surfaces, concentrating
on the apical third of the clinical crowns, the gingival sulci, and as far onto the proximal surfaces as the bristles
can reach.
5. Lift the brush, move it to the adjacent teeth, and repeat the process for the next three or four teeth.
6. Continue around the arch, brushing about three teeth at a time. Then, use the same method to brush the
lingual surfaces.
7. After completing the maxillary arch, move the brush to the mandibular arch, and brush in the same organized
way to reach all the teeth.
8. If the brush is too large to reach the lingual surfaces of the anterior teeth, it should be turned vertically to
press the end of the brush into the gingival sulcus area.
9. Brush the occlusal surfaces of three or four teeth at a time by pressing the bristles firmly into the pits and
fissures and brushing with several short, back-and forth strokes.
The Bass technique requires patience and placement of the toothbrush in many different positions to cover
the full dentition. Patients need to be instructed to brush in a controlled and systematic sequence.

This in occlusal portion for all method

Brushing with Powered Toothbrushes

The various mechanical motions built into powered toothbrushes do not require special techniques. The patient
need only concentrate on placing the brush head next to the teeth at the gingival margin and proceeding
systematically around the dentition. Additional placement adjustments can be made to clean difficult areas,
such as the distal surfaces of the third molars, furcations, or gingival clefts. A systematic method of brushing all
the teeth, similar to the method described for manual brushing, should be used with powered toothbrushes

Positioning the powered toothbrush head and bristle tips

Recommendations
The principles of the Bass method have two advantages over other, more complex techniques:
1. Short, back-and- forth motion is easy to master because it is similar to the scrubbing that most patients
normally perform.
2. Cleaning action is focused on the cervical and interproximal portions of the teeth, where plaque accumulates
first.
Brushing with a powered toothbrush requires a systematic routine to reach all areas, even though the brush
head does most of the work.
Patients will modify any technique to their needs, with the goal of brushing until the teeth are free of plaque.
Frequency and effectiveness of toothbrushing:
How often and how much plaque has to be removed in order to prevent gingivitis and loss of attachment has not
been determined. Disease is more related to quality of cleaning than to its frequency, a general recommendation
to brush the teeth twice daily is generally accepted.
INTERDENTAL CLEANING AIDS
Any toothbrush, regardless of the brushing method used, does not completely remove interdental plaque.
Daily interdental plaque removal is crucial to augment the effects of toothbrushing because most dental and
periodontal diseases originate in interproximal areas.
Tissue destruction associated with periodontal disease often leaves large, open spaces between teeth and long,
exposed root surfaces with anatomic concavities and furcations. These areas are both difficult for patients to
clean and poorly accessible to the toothbrush.
Many tools are available for interproximal cleaning, they should be recommended based on
1) The patients interdental architecture (e.g., size of interdental spaces),
2) Presence of furcations,
3) Tooth alignment and presence of orthodontic appliances or fixed prostheses.
4) Ease of use and patient cooperation are important considerations.
Common aids are dental floss and interdental cleaners, such as wooden or plastic tips and interdental brushes.
Dental Floss
Dental floss is the most widely recommended tool for removing plaque from proximal tooth surfaces.
Floss is available as a multifilament nylon yarn that is twisted or nontwisted, bonded or nonbonded, waxed or
unwaxed, and thick or thin. Some prefer monofilament flosses made of a nonstick material because they are
slick and do not fray, but no significant differences in the ability of the various types of floss to remove dental
plaque; they all work equally well.
Waxed dental floss was thought to leave a waxy film on proximal surfaces, thus contributing to plaque
accumulation and gingivitis.
But if that wax is not deposited on tooth surfaces, and that improvement in gingival health.
Factors influencing the choice of dental floss include:
1) The tightness of tooth contacts.
2) Roughness of proximal surfaces.
3) The patients manual dexterity, not the superiority of any one product.
Therefore, recommendations about type of floss should be based on ease of use and personal preference.

Technique: The floss must contact the proximal surface from line angle to line angle to clean effectively. It
must also clean the entire proximal surface, not just be slipped apical into the contact area. The following
description is a primer in floss technique:
1. Start with a piece of floss long enough to grasp securely; 12 to 18 inches is usually sufficient. It may be
wrapped around the fingers, or the ends may be tied together in a loop.
2. Stretch the floss tightly between the thumb and forefinger, or between both forefingers, and pass it gently
through each contact area with a firm back-and-forth motion. Do not snap the floss past the contact area because
this may injure the interdental gingiva. In fact, zealous snapping of floss through contact areas creates proximal
grooves in the gingiva.
3. Once the floss is apical to the contact area between the teeth, wrap the floss around the proximal surface of
one tooth, and slip it under the marginal gingiva. Move the floss firmly along the tooth up to the contact area
and gently down into the sulcus again, repeating this up-and-down stroke two or three times. Then, move the
floss across the interdental gingiva, and repeat the procedure on the proximal surface of the adjacent tooth.
4. Continue through the whole dentition, including the distal surface of the last tooth in each quadrant. When
the working portion of the floss shreds or becomes dirty, move to a fresh portion of floss.

Flossing is facilitated by using: ~

A floss holder Floss holders are helpful for: 1) patients lacking manual dexterity. 2) Caregivers assisting
handicapped. 3) hospitalized patients in cleaning their teeth.
A floss holder should be rigid enough to keep the floss taut when penetrating into tight contact areas, and it should
be simple to string with floss.
The disadvantage is that floss tools are time-consuming because they must be rethreaded frequently when the floss
shreds.
Disposable, single-use floss holders with prethreaded floss are also available.
Powered flossing devices are also available; these devices have a single bristle that moves in a circular motion.
The devices have been shown to be safe and effective, but no better at plaque removal than finger flossing.

Reusable floss

Disposable floss tools

Powered flossing devices

Recommendations
The benefits of interproximal cleaning using dental floss are undisputed.
Floss ing tools work as well as flossing with the traditional method.
The flossing habit is difficult to establish, so the patient should keep trying.
Interdental Cleaning Devices
Concave root surfaces and furcations and recession are not as thoroughly cleaned with dental floss alone.
interproximal cleaning aids that are easy to handle and adaptable to irregular and long, exposed root surfaces can be
recommended for proximal cleaning of teeth when interdental spaces permit access.
Embrasure spaces vary greatly in size and shape. in the Figure provides a representation of the size and anatomy
of three types of embrasures and the type of interdental cleaner often recommended for each.

Interproximal embrasure spaces vary greatly in patients with periodontal disease. In general,
A, embrasures with no gingival recession are adequately cleaned using dental floss.
B, larger spaces with exposed root surfaces require the use of an interproximal brush.
C, single tufted brushes clean efficiently in interproximal spaces with no papillae.
A wide variety of interdental cleaning devices are available for removing soft debris from between the teeth.
The most common types are:
1) Conical or cylindrical brushes. 2) Tapered wooden toothpicks that are round or triangular in cross section.
3) single-tufted brushes.
Many interdental devices can be attached to a handle for convenient manipulation around the teeth and in posterior
areas.

(Figure C and D), single-tufted brushes (Figure E), or small cylindrical brushes (Figure F).
Interdental brushes are particularly suitable for cleaning large, irregular, or concave tooth surfaces adjacent to wide
interdental spaces.
Interproximal cleaning devices include wooden tips (A and B), interproximal brushes (C through F), and rubber tip
stimulators (G).

Wooden or Rubber Tips

Wooden toothpicks are used either with or without a handle (Figure A and B). Without handles, primarily in the
anterior and bicuspid areas. With handles improve access to all
areas Triangular wooden tips are also available; this design is
most useful in the anterior areas when used from the buccal
surfaces of the teeth.
The tip is inserted between the teeth, with the triangular
portion resting on the gingival papilla. The tip is moved in and
out to remove plaque; however, it is very difficult to use on
posterior teeth and from the lingual aspect of all teeth.

Rubber tips are conical and are mounted on handles or the ends of toothbrushes; they can be easily adapted to all
proximal surfaces in the mouth.
Plastic tips that resemble wooden or rubber tips are also available and are used in the same way.
Both rubber and plastic tips can be rinsed and reused and are easily carried in a pocket or purse.

Recommendations
Often a toothbrush and dental floss are not sufficient to clean interdental spaces adequately, so it is extremely
important to find an interdental device that the patient likes and will use.
Many interdental cleaning aids are available for patients. The clinician might need to try several devices before
finding one that works for the individual patient.
In general, the largest brush or device that fits into a space will clean most efficiently

Dental floss (A)

an interdental brush (B)
Cleaning of concave or irregular proximal tooth surfaces. Dental floss (A) may be less effective than an interdental
brush (B) on long root surfaces with concavities.
Tongue scrapers
The dorsum of the tongue harbors a great number of microorganisms.
These bacteria may serve as a source of bacterial dissemination
to other parts of the oral cavity; therefore, tongue brushing has been
advocated as part of daily home oral hygiene together with
toothbrushing and flossing.
The bacterial accumulations on the dorsum of the tongue may also be
the source of bad breath.

B) Chemical plaque control

1) DENTIFRICES
Dentifrices aid in cleaning and polishing tooth surfaces.
The form of dentifrices: ~ Paste, powder, and gel.
They are used mostly in the form of pastes.
Dentifrices: Are made up of abrasives (e.g., silicon oxides, aluminium oxides, granular polyvinyl chlorides),
water, humectants, soap or detergent, flavoring and sweetening agents ,
therapeutic agents (e.g., fluorides, pyrophosphates), coloring agents, and preservatives.
Composing 20% to 40% of dentifrices, abrasives are insoluble inorganic salts that enhance the abrasive action of
toothbrushing as much as 40 times.
Tooth powders are much more abrasive than pastes and contain about 95% abrasive materials. The abrasive
greater concern for patients with exposed roots.
Dentifrices are useful for delivering therapeutic agents to the teeth and gingiva. The pronounced caries preventive
Effect of fluorides incorporated in dentifrices has been proved beyond question. Fluoride ion must be available in
the amount of 1000 to 1100 parts per million (ppm) to achieve caries reduction effects.
Calculus control toothpastes, also referred to astartar control toothpastes,
contain pyrophosphates and have been shown to reduce the deposition of new supragingival calculus on teeth and do
not affect subgingival calculus formation or gingival inflammation but will not affect existing calculus deposits.
These ingredients interfere with crystal formation in calculus but do not affect the fluoride ion in the paste or
increase tooth sensitivity.

Recommendations
Dentifrices increase the effectiveness of brushing but should cause a minimum of abrasion to root surfaces.
Products containing fluorides and antimicrobial agents provide additional benefits for controlling caries and
gingivitis.
Patients who form significant amounts of supragingival calculus benefit from the use of a calculus control
dentifrice.
2) ORAL IRRIGATION
Irrigation can be supragingival or subgingival.
Oral irrigators for daily home use, work by directing a high-pressure, steady or pulsating stream of water through a
nozzle to the tooth surfaces. Most often, a device with a built-in pump generates the pressure Oral irrigators clean
1) non adherent bacteria and debris from the oral cavity more effectively than toothbrushes and mouth rinses
2) removing debris from inaccessible areas around orthodontic appliances and fixed prostheses.
When used as adjuncts to toothbrushing, these devices can have a beneficial effect on periodontal health and
decreasing inflammation and pocket depth.
Oral irrigation has been shown to disrupt
and detoxify subgingival plaque and can be useful in
delivering anti-microbiala gents into periodontal
pockets, useful in reductions of bleeding.
Oral irrigation. A, The most common oral
irrigators have a built-in pump
and reservoir. B, Conventional plastic tips
are used for daily supragingival irrigation
at home by the patient. Left, Tip for
gingival irrigation. Right, Tip for cleaning
dorsal surface of thetongue C, Soft rubber
tip is used for daily subgingival irrigation by
the patient at home.

Recommendations
A

Supragingival irrigation reduces gingival inflammation and is easier for some patients than using mechanical
interdental aids.
Subgingival irrigation with specialized tips for deep pockets and furcation areas is effective when used daily as part
of the home care routine.
Patients requiring antibiotic premedication for dental procedures should not use subgingival irrigation devices.

Supragingival Irrigation Supragingival irrigation performed at home by the patient,

Subgingival Irrigation Subgingival irrigation performed both in the dental office and at home by the patient,
It is performed by aiming or placing the irrigation tip into the periodontal pocket, attempting to insert the tip at least
3 mm, using a soft rubber tip (Figure C).
Irrigation performed in the dental office, also called lavage or flushing of the periodontal pocket,
Subgingival irrigation performed with an oral irrigator using chlorhexidine diluted to one-third strength, performed
regularly at home and after scaling, root planing, and in-office irrigation therapy, has produced significant gingival
improvement compared with controls.
3) CHEMICAL PLAQUE CONTROL WITH ORAL RINSES
Chlorhexidine Rinse
Nonprescription Essential Oil Rinse
Other Products

A preparation containing triclosan has shown some effectiveness in reducing plaque and gingivitis. It is available in
toothpaste form, and the active ingredient is more effective in combination with zinc citrate or a copolymer
of methoxyethylene.
Other oral rinse products on the market have shown some evidence of plaque reduction, although long-term
improvement in gingival health has not been substantiated. These include stannous fluoride,
cetylpyridinium chloride (quaternary ammonia compounds),and sanguinarine. Evidence suggests that these and other
available mouth rinse products do not possess the antimicrobial potential of either chlorhexidine products or
essential oil preparations.
One type of agent has been marketed as a pre-brushing oral rinse to improve the effectiveness of toothbrushing.
The active ingredient is sodium benzoate.
Chemical plaque control has been shown to be effective for both plaque reduction and improved wound healing after
periodontal surgery.
Both chlorhexidine and essential oil mouth rinses have significant positive effects when prescribed for
use after periodontal surgeryfor 1 to 4 weeks.

Recommendations
Chemical plaque control can augment mechanical plaque control procedures.
Fluoride preparations are essential for caries control in periodontal patients.
Antimicrobial oral rinses will reduce gingivitis in periodontal patients.
Chlorhexidine rinses can be used to augment plaque control during Phase I therapy, for patients with recurrent
problems, for ineffective plaque control for any reason, for some uncommon oral mucous membrane diseases, and
for use after periodontal or oral surgery.
Essential oil rinses are effective but to a lesser degree than chlorhexidine. They may be advantageous because they
have fewer side effects and are available without a prescription.
Oral irrigators used with dilute solutions of effective antimicrobial agents reduce gingivitis.
Oral rinse preparations are also available with no alcohol content, which may be preferable to some clinicians and
patients.
The use of cosmetic oral rinses and prebrushing rinses should not be used to replace proven mechanical and
chemical.
Means of plaque removal but can be useful if patients perceive benefits from them.