Dr :Hawa Beayou

University of Benghazi

Faculty of Dentistry

Department Of Preventive Dentistry and Dental Public Health

Plaque control

Plaque control : is the removal of microbial plaque and the prevention of its
accumulation on the teeth and the adjacent gingival.

The major part in plaque control must be played by the individual, the
responsibility of professional personnel are:

 To provide information about dental health.

 To provide information and guidance about the technique of plaque control.

 To attempt to change the individual’s evaluation of dental health (motivate the

patient).

There are two basic approach in plaque control :

*Mechanical plaque control:

- Individual

- Professional—for sub gingival plaque control, e.g. scaling, polishing and root
planning.

*Chemical plaque control

 Mechanical Plaque Control:

1- Tooth brushes:
 Manual
 Electrical
 Ionic toothbrushes
 Sonic and ultrasonic
2-Interdental oral hygiene aids:

 Dental floss

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  Toothpicks
 Interproximal brushes
 Single tuft brushes
 Pipe cleaner
 Wedge stimulators
3- Adjunctive aids:
 Tooth paste ,and mouth rinses
 Irrigation devices (water- pik)
 Tongue cleaner
 Rubber tip stimulator
 Denture brush

 Chemical Plaque Control ,such as:

 Antibiotics
 Enzymes
 Quaternary ammonium compounds
 Essential oils
 Bis biguanides (Chlorhexidine mouth rinses)

 Mechanical Plaque Control

Toothbrushes

Although different cleaning devices have been used in different cultures (toothbrush, chewing
stick, etc.) .the conventional toothbrush is the instrument most frequently used to remove dental
plaque.

The efficacy of brushing with regards to plaque removal depends upon main factors:

 The design of the brush.

 The skill of the individual using the brush.
 The frequency and duration of use.
If a properly designed brush is used with an effective technique and for a sufficient duration of
time, plaque control can be achieved on a long-term basis.

Objectives of tooth brushing:

o To clean teeth from food, stains and debris.

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o To disturb and remove plaque formation.
o To stimulate and message the gingival tissue.
o To apply fluoride dentifrice.
o Cleaning of tongue.

Ideal requisites of manual tooth brush:

1- Handle size appropriate to user age and dexterity.

2- Head size appropriate to size of the patient ‘s mouth.
3- Use of soft rounded –end nylon or polyester filaments.
4- Bristle pattern which enhances plaque removal.
5- Should be easy to keep and clean.
6- Should be have a reasonable life span
*Adults and children should be change their toothbrush every 1 or 3 months or
whenever the bristles become fray, worn out and ineffective.

 Power or electrical toothbrushes:

The electrical toothbrush designs are categorized by the type of the brush head’s shape
and movement:

• The first generation of power toothbrushes had a head looking like the one of
manual toothbrushes, and moving back and forth to simulate manual brushing. Only
few low cost power toothbrushes use, this is not efficient mode today

• Rotary toothbrushes: The next generation moved to a design with a circular head
that is rotating in one direction

• Counter-rotational toothbrushes with different tufts of bristles rotating in opposite

directions

• Rotating-oscillating toothbrushes in which a circular head spins back and forth in

quick bursts

• Oscillating-pulsating toothbrushes have in addition a pulsating motion to enhance

the cleaning action.

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  Advantages of electrical toothbrushes:
1- Only minimal skill level is needed to brush
2- Minimum effort is needed to remove dental plaque
3- Less brushing force is required ,so less likely to cause damage to tooth and
gum.

 Indications of electrical toothbrushes:

1. Those with physical or learning disability.
2. Fixed orthodontic appliances
3. Young children
4. Aged persons
5. Institutionalized patients who depend upon care providers for brushing
6. Poorly motivated patients.

 Sonic and ultrasonic toothbrushes:

The cleaning action generated by a sonic toothbrush is actually based on
two separate mechanisms:

 The primary mode of cleaning is scrubbing action.

 The vibratory motion is considered secondary cleaning action, that motion has
able to impart energy to the fluids that surround teeth (such as saliva). The
motion of these fluids is capable of dislodging dental plaque.

 Ionic toothbrushes:
Principle of ionic tooth brush:

 inhibit the bonding between the bacteria and Ca2+ and prevent the bacteria
from absorbing to the pellicles.

 ionic technology changes the polarity of tooth surfaces from -ve to +ve. As
brushing is done, plaque material is actively repelled by teeth and drawn to the
negatively charged of bristles.

Tooth brushing techniques

 According to the direction of brushing strokes:

 Vibrating technique (Bass method ,Stillman’s method, and Charter’s method).

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  Roll technique (Modified bass /Modified Stillman 's method/ modified
charter's technique)
 Vertical technique (Leonard’s method).
 Horizontal technique
 Fone's technique ( Circular)

The Bass method: sulcular brushing

Indications:

1. For plaque removal adjacent to and directly beneath the gingival margin in all
individuals
2. For sulcus cleansing, which is recommended in remove the plaque in sub
gingival area.
3. Particularly useful in open interproximal areas, cervical areas beneath the
height of contour of the enamel and exposed root surfaces.
Technique:

Bristles are directed apically at 45 degree to long axis of tooth, with gentle force in to
sulcus, then vibratory strokes (back and forth motion) ,and without removing bristle
from sulcus

The Stillman’s method:

Indications:

As the bristle ends are not directed into sulcus, this method can recommended for
individuals with periodontal disease ,progressive gingival recession, and post
periodontal surgery.

Technique

This method was originally developed to provide gingival stimulation. The brush is
positioned with bristles inclined at a 45 degree angle to the long axis of the tooth, with
the bristles placed partly on the gingiva and partly on the cervical portion of the tooth .
The strokes are activated in a short back and forth (vibratory) motion, with slight
pressure to stimulate the gingiva. Approximately 5 to 10 strokes are completed in each
region.

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 The Charter's method:

Bristles are directed toward crown of tooth with 45 degree, and then apply vibratory
strokes.

Indications:

For patient with orthodontics and fixed prosthetic appliance.

Rolling stroke technique:

Used in conjunction with vibratory technique, i.e. Bass, Stillman’s, or Charter’s

method.
Technique:

Bristles are directed apically and parallel to the axis of the tooth. The brush is then
rotated deliberately down in the upper jaw and upward in the lower jaw ,so that bristle
sweep across the gum and tooth in an occlusal direction with rolling motion.

 Modified bass technique

 Modified stillman's technique
 Modified charter's technique

Fone's technique (Circular):

This method may be recommended as an easy to learn technique for young children.

Indication:

Young children with primary teeth.

Technique:

The brush is placed inside the mouth. With the teeth closed and brush tips contacting
the gingiva over the last maxillary molar, bristles are activated in circular motion that
sweeps from the maxillary gingiva to the mandibular gingiva.

Vertical technique (Leonard): vertical strokes are used when teeth in edge-to-edge
position (not recommended).

Horizontal technique : bristle are activated in a gentle, horizontal scrubbing motion

(not recommended).

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 A toothpaste (dentifrice)

It is defined as a semi-aqueous material for removing naturally occurring deposits from teeth and
is supposed to be used as adjunctive aid with a toothbrush.

The dentifrice can either be:

 Cosmetic :which cleans and removes plaque biofilm, food debris and stains from tooth
surfaces and polishes.

 Therapeutic: which transports the drug substance to the tooth surface, to reduce some
disease process in the mouth as anti- plaque agent.

Composition of a typical dentifrice:

Ingredients Percent

 Abrasive as silicon or aluminim oxide 40-50

 Humectant as glycerine 20-30

 Water as solvent 20-30

 Binding agent as starch 1-2

 Foaming agent as sodium lauryl sulphate 1-3

 Flavoring agent.as peppermint 1-2

 Preservative as sodium benzawate 0.05-0.5

 Therapeutic agent 0.5-2

Therapeutic agents are:

 Anti-caries agents (Fluoride toothpaste) as :sodium fluoride and sodium mono

fluorophosphates

 Anti –plaque: sodium lauryl sulphate , triclosane, zinc, stannous ions

 Anti- calculs: pyro phosphat

 Anti-dentine hypersensitivity (Dsensitizing toothpaste) : potasssium salts

 Whitening agents: papain, dimethicones , sodium

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 Interdental oral hygiene aids

 As the interdental region is the most common site of plaque retention and the most inaccessible
to the toothbrush, special methods of cleaning are needed.

Factors effecting on selection of interdental aids :

1. Contour and consistency of gingival tissue.

2. The size of the interproximal embrasure.

3. Tooth position and alignment.

4. Ability and motivation of the patient.

5. Condition and type of restorative work present.

1- Dental floss
Uses of dental floss:

1. Removes plaque and debris adherent to the teeth, restorations, orthodontic

appliances, fixed prosthesis and gingival in the interproximal embrasure.

2. It polishes the surfaces as it removes the plaque.

3. Massaging of the interdental papilla.

4. Helps to identify the presence of sub gingival calculus deposits, overhanging

restorations and interproximal carious lesions.

5. Maintenance of general oral hygiene and control of halitosis.

6. Reduces gingival bleeding.

Disadvantages of dental floss:

1. Not easy to perform specially in posterior areas.

2. Requires good manual dexterity.

3. Time consuming.

4. Risk of tissue damage if improperly used.

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 Types of dental floss:

1. Twisted or non-twisted.
2. Bonded or non-bonded.
3. Waxed or un-waxed.
4. Thin or thick.

Methods of using dental floss:

1 -Spool Method :
It is recommended for teenagers and adults who have acquired the required the level of
neuromuscular coordination and mental maturity to use floss correctly.

Method:

A piece of floss approximately 18 inch long is taken. The bulk of the floss length is
lightly wound around the middle finger. The rest of the floss is similarly wound around the same
finger of opposite hand. Space should be left between wraps to avoid cutting off circulation to the
fingers. The last three fingers are clenched and both hands are moved apart, pulling the floss taut.
The thumb and index finger of each hand are free. The floss is then secured with the index finger
and thumb of each hand by grasping a length of about 1 inch in each hand. The finger of opposite
hand can wind the floss as it becomes soiled or frayed to permit access to an unused portion.

2- Loop Method:

This method is particularly suited for children as well as adults with less nimble hands
or handicaps such as poor muscular coordination or arthritis

Method:

A piece of 18 inch long is made into a circle and tied securely with three knots . All
fingers except the thumbs are placed within the loop. The floss is guided with the two
index fingers for mandibular teeth and with two thumbs or one index finger and one

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thumb for maxillary teeth. As teeth are flossed, the loop is rotated so that, each
proximal area receives unused floss for proper cleaning

- To be effective the floss should be pulled around the tooth curvature so that, close contact
with tooth surface is made patients with tight contact areas need thin un waxed floss that
can be slipped easily between the contact areas, whereas in patients with crowded teeth,
heavy calculus deposits, or defective and overhanging restorations, a bonded un waxed
floss or waxed floss is the dental floss of choice because they do not fray as easily as un
waxed floss. Dental tape is recommended when there is considerable interdental space
resulting from gingival recession and bone loss.
 Super Floss:
It is a type of floss that incorporates a rigid plastic portion that can be introduced under fixed
bridge. Distal to rigid plastic portion is a spongy region that is ideal for plaque removal

 Floss holder:
Indications:

1. Patient with physical disabilities.

2. Individuals with large hands.

3. Individuals with strong gag reflex.

4. Caregivers.

5. Type I embrasures.

Floss holder is a flossing aid. The majority of floss holders consist of a device with a
handle with two prongs in Y shape or C shape .

Disadvantages:

1. More time consuming.

2. Unable to maintain tension of floss.

3. Must be rethreaded when the floss becomes soiled or frayed.

4. Need to set fulcrum to avoid floss cuts.

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2- Toothpicks:
Toothpicks are usually made of softwood and have a triangular, round or rectangular shape.
Triangular are said to be superior to the rest, as they are ineffective on lingual aspect of
proximal surfaces.

Indications

1. Type II and Type III embrasures from facial aspect only.

2. Accessible furcation.
3. Small root concavities.
4. Interproximal open spaces.
Disadvantages:

1- Wearing down of papilla and marginal tissues from incorrect usage.

2- Wood ends may cause tissue trauma/ cuts or abrasion.

3- Enamel abrasion in use.

4- Can force bacteria or debris into gingival attachment if used improperly.

5- May cause opening of the embrasure.

Contraindications:

1. Type I embrasures.
2. Healthy gingiva

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3-Interproximal brushes :

Also called as interdental brushes, proxa brush. They are available in various sizes
and shapes. The most common are conical or tapered and designed to be inserted into
a plastic or metal reusable handle that is angled to facilitate interproximal adaptation .

Indications

1. Type II and Type III embrasures.

2. Exposed root furcations.

3. Orthodontic and fixed appliances.

4. Application of fluoride, antimicrobial or desensitizing agents.

Technique

Inserted inter proximally and activated with short back and forth strokes in between
the teeth .

Disadvantages

1. Different types may be needed to fit different open interproximal spaces.

2. Trauma to tooth or gingiva from sharp wire center of some.

4-Single tuft brushes:

Single tuft or end tuft brushes are small brushes with nylon bristles that are
attached to a plastic handle. There are variations in the shape of the tufts and the
width and length of the handles.

Indications

1- The single tuft brush is for patients who prefer a longer handle
2- Patients who are not able to change the refills of the interproximal brush.
3- Patients who cannot control the interproximal brush due to manual dexterity or
disabilities.

5-knitting yarn:
It is used to clean proximal tooth surfaces adjacent to wide embrasure spaces. Yarn is
used similar to floss.

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Indications

1. Type II and Type III embrasures.

2. Isolated teeth.
3. Diastemas.
4. Abutments of partial dentures.
5. Under sanitary pontics .
6. Distal of posterior most teeth in arch.

Disadvantage

Yarn may catch on appliances and become stuck on rough appliances and removing a
stuck yarn may damage the appliance.

6-Pipe cleaner:

They are another useful adjunct to dental flossing for the removal of plaque and
debris. A pipe cleaner with soft covering and with a minimum exposed wire should be
selected. It used by passing between exposed root's furcation and a bucco- lingual
movement is used for cleaning.

Indications

1. Type III embrasures.

2. Exposed root furcation.

3. Exposed proximal surfaces.

Disadvantage

Sharp wire center can damage the cementum or can cause trauma to gingiva.

7-Wedge stimulator: Wooden and plastic sticks or wedge stimulators reduce

bleeding and inflammation when used to reduce plaque. They are wooden or plastic
oral hygiene devices designed for interdental cleansing and stimulation.

Indications:

1- Type II and Type III embrasures from facial aspect only.

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 2- Accessible furcations.
3- Application of fluoride, antimicrobial or desensitizing agents.
Disadvantages:

1- Wearing down of papilla and marginal tissues from incorrect use.

2- Enamel abrasion from incorrect use.
3- Splaying of wood ends may cause tissue trauma or abrasions.
4- Improper use can force bacteria or debris into gingival attachment leading to
abscess formation.

Adjunctive aids

1- Power dental Irrigation Devices (Water-Pik):

- These are used to eliminate plaque and soft debris through the mechanical action of
a jet stream of water (may used with water or antimicrobial agent)

- Type I embrasure.

2- Tongue Scrapers:
The dorsum surface of tongue harbors a great number of bacteria. This may serve as a
source of bacterial dissemination to other parts of oral cavity. It may also be the
source of bad breath. Therefore, tongue brushing and the use of tongue scrapers
should be recommended as part of daily home oral hygiene together with tooth
brushing and flossing.

3-Rubber tip stimulator:

It consists of a conical, flexible, rubber or plastic tip attached to a handle or to the end
of a toothbrush. Rubber or plastic tips are recommended for gingival stimulation and
for plaque removal in open embrasures. Reshape or re contour the gingiva following
periodontal surgery.

Indications:

1. Type II and Type III embrasures

2. Exposed furcation.

3. To increase epithelial keratinization of the interdental tissue.

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Contraindications:

1-Type I embrasures.
2-Healthy gingiva.

Disadvantages:

It can cause tissue trauma specially when used with excessive pressure.

4-Denture brush:

These have been designed with firm nylon filaments to clean dentures. Because the
prosthesis is removable and cleaned outside the mouth, the firmer filaments do not
cause destruction of gingival tissues. Some of denture brushes have double-end, flat
side is used for cleaning the tooth side of the denture and the pointed bristle end for
tissue side. Preferably used with nonabrasive denture paste to avoid scratching .

 Chemical plaque control

Chemical agents are used to control the plaque in number of ways:

1. Suppression of the oral flora.

2. Inhibition of bacterial colonization of the tooth surface.
3. Inhibition of plaque-forming factors, e.g. dextran
4. Dissolution of established plaque.
5. Prevention of mineralization of plaque.

Vehicles for delivery chemical agents:

1-Mouth rinses is designed to reduce oral bacteria, remove food particles, temporary
reduce bad breathe and provide a pleasant taste. Most chemical plaque control agents
are formulated as mouth rinse.

2- toothpaste
3- Spray (Chlorhexidine sprays)

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4-Irrigators (are design to spray water under pressure around teeth that to remove
debris)
5-Chewing gum (sugar –free chewing gum)
6-Varnishes (mainly used to prevent root caries).

Classification of anti-plaque agents:

 1st generation agents (antibiotics, phenol, quaternary ammonium
compounds, and Sanguarine)
=Plaque reduction of 20-50%
=Poor retention in mouth.
 2nd generation agents- effectively retained in the oral tissue
=Slow release
=Plaque reduction of 70-90%
=Eg: Bis biguanides .

 Antibiotics such as penicillin:

Despite evidence for efficacy in preventing caries and gingivitis, antibiotics should
not be used either topically or systemically as preventive agents against these diseases
(the risk-to-benefit ratio is high). Antibiotics have their own side effects not all of
which can be avoided by topical application. Most important among those is the
development of bacterial resistance and hypersensitivity reactions.

 Enzymes:
E.g: dextranase, mutanase, and protease remove dental plaque through have
antimicrobial effect.

 Quaternary ammonium compounds:

Benzyl conium chloride and cetyl pyridinium chloride are the most studied of this
family of antiseptics. Cetyl pyridinium is used in a variety of antiseptic mouth rinse
either alone or in combination at a concentration of 0.05 percent. The substantively
cetyl pyridinium chloride appears to be only 3 to 5 hours.

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 Natural products (Sanguinarine):
The activity of sanguinarine is attributed to its ability to interfere with bacterial
glycolysis and bind to plaque to prevent adherence of microorganisms. It is less active
than chlorhexidin.

 Metal salts:
A number of metal ions have been studied for their effect on plaque ,such as zinc,
copper and tin . These metal ions have shown to possess plaque inhibitory effects but
are dependent on its concentration. Zinc and other metal ions have shown synergistic
effect when combined with other antiseptics like triclosan and sanguinarine.

 Amine alcohols:
Several substituted amine alcohols have been shown to inhibit plaque such as :
Octapinol - delmopinol .
Delmopinol at 0.1 percent and 0.2 percent in mouth rinse was shown to be effective
plaque inhibitor. The mode of action of delmopinol appears to be the inhibition in
formation or disruption of the matrix of early plaque forming bacteria. Side effects
include tooth discoloration, transient numbness of the mucosa (particularly tongue)
and burning sensation of the mouth.

 Oxygenating Agents:
Oxygenating agents such as hydrogen peroxide , buffered sodium peroxy borate and
peroxycarbonate in mouth rinses have a beneficial effect on acute ulcerative
gingivitis.

 Phenols and essential oils:

- Phenols and essential oils have been used in mouth rinses and lozenges for
many years.
- Triclosan is a non -cationic, chlorinated phenol. (0.2%) triclosan has moderate
plaque inhibitory action.

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The activity of triclosan appears to be enhanced by the addition of zinc citrate or the
copolymer. The copolymer appears to enhance the retention of triclosan whereas the
zinc is a highly substantive antimicrobial agent and citrate reduce metallic taste.
- Listerine is an essential oil mouth rinse.
 Administration and Use:
It is recommended that a person rinse for 30 seconds with half ounce of listerine after
brushing and flossing twice a day
 Indications:
- It is advised to the patients with extensive fixed prosthesis, implants, over dentures,
splinting, and orthodontics.
- individuals with poor manual dexterity.
 Contraindications:
should not be recommended for person with xerostomia, children, or persons on
medications.
 Fluorides:
Stannous Fluoride:
It has more antiplaque properties than sodium fluoride. Tin from the stannous ion
enters the cell, impairs the metabolism and affects the growth and adherence
properties of bacteria. Increased tooth staining and weak antiplaque activity
significantly limit the potential application of stabilized stannous fluoride
formulations.
 Bis biguanides:
Chlorhexidine is most effective antiseptic for plaque inhibition and the prevention of
gingivitis .

-It is preventing the plaque accumulation on a clean tooth surface. Other bis
biguanides such as alexidine and octenidine have similar role.

-The effectiveness of these mouthwashes is based on the dose of chlorhexidine

delivered. 10 ml of 0.2 percent solution delivers or 15 ml of 0.12 percent solution
delivers (both have equally effective).

- It is recommended that the individual should rinse for 60 seconds after brushing and
flossing twice a day .

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The person should allow at least 30 minutes between tooth brushing and use of mouth
washing.

 Side effects of chlorhexidine :

1- Brown discoloration of the teeth, margins and surface of composite and glass
ionomer restorations
-Brown discoloration of dorsum of tongue.
2- Unpleasant taste and disturbance in taste sensation.
3- Unilateral or bilateral parotid swelling [mechanical obstruction of parotid duct.
(rare (
4- Desquamative lesion of oral mucosa in some individuals. (rare)
5- Enhanced supra gingival calculus formation. (by increase precipitation of
inorganic salts n the pellicle layer)
 Chlorhexidine products:.
- Gel: now available as 0.2 percent and 0.12 percent gels.

- Sprays: 0.1 percent and 0.2 percent chlorhexidine in sprays are available .

- Toothpaste: Difficult to formulate into toothpaste, but 1 percent chlorhexidine

toothpaste has been formulated.

- Varnishes.

- Chewing gum.

Good luck

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