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PRESENTED BY :
SHILPA SHIVANAND
II MDS
PATIENT EDUCATION,
MOTIVATION AND ORAL
HYGIENE INSTRUCTIONS
 Patient education
 Methods of patient education
 Motivation
 Theories of motivation
 Oral hygiene instructions
 Disclosing agents
 Toothbrushes and brushing techniques
 Dentifrices
 Interdental aids
 Oral hygiene after regenerative procedures
 Conclusion
CONTENTS
3
The background to oral health education
 The term Dental Health Education (DHE) has been gradually superseded
in recent years by Oral Health Education (OHE), reflecting a wider
concern than health only of the teeth.
Problems with oral health education
 Previous inadequacies in OHE delivery have been attributed to two main
faults.
 The message which has been contained within the dental health advice has
not always been correct and has at times been totally misleading.
PATIENT EDUCATION
4
Domains of learning
 In education it is accepted that there are three domains of learning
1. Cognitive domain: this relates to the acquisition of knowledge.
2. Skills domain: this is the learning of practical skills.
3. Affective domain: this involves the creation of attitudes and
motivation.
THE LEARNING PROCESS
5
 The prevention and control of the two major dental diseases 
inflammatory periodontal disease and dental caries, depend to a large
extent on a change in the behavior of the patient.
Changing behavior
 The following are the steps which must be followed to establish
behavioral changes
Factual education.
Practical demonstration.
Motivation.
Reinforcement.
BEHAVIORAL CHANGE
6
 Information is a necessary but not on its own sufficient condition for
changing behavior.
 The information supplied should be accurate and comprehensible to lay-
people.
 Part of this information should include realistic goals that the patient can
achieve.
 For example, with some patients it would be preferable to concentrate
solely on the improvements achievable by brushing before progressing to
interdental cleansing.
FACTUAL EDUCATION
7
 The teaching of the physical skills involved in dental health includes
disclosing, brushing, interdental cleansing and the cleaning of dentures and
appliances.
 Educator should use  'tell-show-do' approach.
 The action should first be explained, then demonstrated to the patient,
possibly at first on models, then in the mouth.
 Finally, the patient should carry out the procedure with the instructor
supervising, correcting and giving encouragement.
 Do not overload the patient.
 It is better to teach a little at a time.
PRACTICAL TRAINING
8
 Refers to 'that which induces a person to act'.
 In dentistry, the phrase 'patient motivation' is often misused, implying that
one can cause a third person to co-operate, comply or perform in some
desired manner.
 This would be a very useful ability, but unfortunately not possible.
 Motivation must come from within an individual.
MOTIVATION
9
 In order to become motivated to alter a behavioral pattern an individual
must be able to identify the following:
1. A problem exists which affects the individual personally
for example the existence of periodontal disease in the mouth.
2. The problem will have an unwanted personal outcome
such as the premature loss of teeth.
3. There is a practical solution
such as adequate plaque control.
4. The problem is serious enough to justify the inconvenience of the
solution.
THE ESSENTIALS FOR
MOTIVATION
10
 In relation to dental health education, people may be divided into three broad
groups:
- those who are already motivated,
- those with latent motivation,
- those lacking the necessary motivation to change their behavior
 Motivated  have their own drive and simply require guidance and reinforcement
from time to time.
 Latent motivation is possessed by a majority of patients.
 This is indicated by studies which show that approximately 60% of patients attend
a dentist at least every second year, usually for a preventive check-up.
 This latent motivation requires a trigger to activate or release it.
THE ESSENTIALS FOR MOTIVATION
11
 Patients without the desired motivation are intractable problem.
 Various forms of threat or sanction may produce an improved short-term
behavioral change, but no long-term alteration.
 However, even these patients may not be lost for ever, as research
suggests that the priority of motives may change with time and
circumstances, even in adults, and this will give rise to behavioral changes.
THE ESSENTIALS FOR MOTIVATION
12
 The process of encouraging or establishing a belief or pattern of behavior.
 Once the progression of the disease has been controlled, then most
patients require a regular (possibly 3 monthly) maintenance programme of
visits.
 This can be coupled with reinforcement of the oral hygiene regimen.
 The frequency of reinforcement will vary from person to person and will
depend to a large extent on their attitudes and the type of problem
present.
REINFORCEMENT
13
A. Learning is more effective when an individual is physiologically and
psychologically ready to learn.
B. Individual differences must be considered if effective learning is to take place.
C. Motivation is essential for learning.
D. What an individual learns in a given situation depends on what is recognized
and understood.
E. Transfer of learning is facilitated by recognition of similarities and
dissimilarities between past experiences and the present situation.
F An individual learns what is actually used.
G. Learning takes place more effectively in situations from which the individual
derives feelings of satisfaction.
H. Evaluation of the results of instruction is essential to determine whether
learning is taking place.
PRINCIPLES OF LEARNING
E M WILKINS 2005
14
 The learning ladder illustrates the six steps from learner unawareness to
habit formation.
 When beginning to help a patient learn about oral health and what the
individual's needs are, one must determine where the patient stands on the
ladder and start from there.
THE LEARNING LADDER
15
A. Unawareness
Many patients have little concept of the new information about dental and
periodontal infections and how they are prevented or controlled.
B. Awareness
Patients may have a good knowledge of the scientific facts, but they do not
apply the facts to personal action.
C. Self-interest
Realization of the application of facts/knowledge to the well-being of the
individual is an initial motivation.
THE LEARNING LADDER
16
D. Involvement
With awareness and application to self, the response to action is forthcoming
when attitude is influenced.
E. Action
Testing new knowledge and beginning of change in behavior may lead to an
increased awareness that a real health goal is possible to attain.
F. Habit
Self-satisfaction in the comfort and value of sound teeth and healthy
periodontal tissue helps to make certain practices become part of daily routine
Ultimate motivation is finally reached.
THE LEARNING LADDER
17
 Periodontal health is important  teeth are worth keeping for life.
 The patients must believe this; otherwise any change in habit as an
immediate response will be short-lived.
 Several arguments may be employed and the experienced practitioner can
tailor these to the patient's perceived needs.
 Adolescents and adults may respond to different arguments
CHANGE IN ATTITUDE TO DENTAL HEALTH
DM ELEY, JD MANSON 2OO4
18
Impaired function
 No appliance can function as efficiently as the natural and healthy
dentition
 Full dentures may be an extremely poor substitute for the patient's own
teeth.
ATTITUDE TO DENTAL HEALTH
19
Personal hygiene.
 These days most people are concerned about personal cleanliness and yet
there may be a marked contrast between the patient's general appearance
and the state of his mouth.
 This usually represents a lack of awareness of oral hygiene and when the
true state of affairs is demonstrated the individual who is truly concerned
about personal hygiene will be ready to change his habits.
 The patient is given a hand-mirror to witness the examination of the
mouth, and deposits of plaque and calculus can be pointed out.
 The use of a disclosing agent is valuable.
ATTITUDE TO DENTAL HEALTH
20
Social handicap
 Periodontal disease produces halitosis, inflamed gingiva and eventually
tooth loss due to mobility
 The idea of possessing offensive breath or an ugly smile is often sufficient
incentive for patients to improve their home care.
General health
 The fact that periodontal disease can have an adverse effect on general
health should be explained to the patient.
ATTITUDE TO DENTAL HEALTH
21
 Based on the concept that one's beliefs direct behavior; model is used to
explain and predict health behaviors and acceptance of health
recommendations; emphasis is placed on perceived world of individual,
which may differ from objective reality
Components
1. Susceptibility-individuals must believe that they are susceptible to a
particular disease or condition
2. Severity-individuals must believe that if they get the particular disease or
condition, the consequences will be serious
3. Asymptomatic nature of disease-individuals must believe that the disease
may be present without their full awareness
4. Behavior change will be beneficial-individuals must believe that there are
effective means of preventing or controlling the potential or existing
problem and that action on their part will produce positive results
HEALTH BELIEF MODEL
M L DARBY 1998
22
 Theory regarding human nature that is used to explain the motivational
process
 Maslow suggested that inner forces, or needs, drive a person to action
 He classified needs in a pyramid according to their importance to the
individual, his or her ability to motivate, and the importance placed on
their satisfaction
 Only when an individual's lower needs are met, will the individual become
concerned about higher level needs
 Once needs are met, they no longer function as motivators
"MASLOW'S HIERARCHY OF NEEDS
23
HIERARCHY OF NEEDS
24
self-realization  needs that
drive the individual to reach the
very top of his or her field
components necessary for body
homeostasis, such as food, water,
oxygen, temperature regulation etc
Social needs
 The first task of the practitioner is to establish rapport with the patient, which
then makes possible further development of communication, learning, and
motivation.
 Despite their importance, history taking, clinical examination, and diagnosis must
all wait because, according to Meares 1957, while they may all occur concurrently
with rapport, rapport must come first.
ESTABLISHMENT OF COMMUNICATION : RAPPORT
H E GOLDMAN 1980
25
 Rapport is an emotional state in which logical, intellectual, or verbal
factors may play only a small role.
 Expressions, gestures, and other nonverbal communication, however small,
may assume symbolic value to the patient as the initial meeting with the
doctor takes place.
 On the surface the patient may be reciting his symptoms and concerns, but
underneath this veneer he is assessing the competence and trustworthiness
of the doctor.
 Meanwhile the doctor should be establishing the emotional relationship
with the patient that we know as rapport.
RAPPORT….
26
 In considering obstacles to rapport the dentist should note the difference
between sympathy and empathy.
 Empathy, a great gift for a professional to possess, means that although we
do not share the emotional feelings with the patients as in sympathy, we
do appreciate how he is feeling.
 Empathy is a blend of interest and objectivity.
 Many times the more sensitive the individual happens to be, the more apt
he is to possess a capacity for empathy.
 Lack of this qualification by professional is an obstacle to formation of
rapport with his patients or clients.
SYMPATHY / EMPATHY
27
 Cinotti and Grieder advocate methods that may prove to be effective and
more efficient.
 These are conditioning and insight learning.
Conditioning
 The dental patient is conditioned by past experiences to expect pain and
discomfort before he visits the dental office.
 In our society, the dentist is often portrayed in cartoon and lay articles as a
threatening mutilator of the mouth who is to be feared.
 It has been stated by many that the most feared figure in our society is the
psychiatrist and that the dentist is possibly a close second
Friedman
METHODS OF PATIENT
EDUCATION
28
 In attempting to reeducate such patients many practitioners perform no
treatment per se on the first visit but use it to establish rapport and com-
munication and to commence the unlearning of old ideas and fears and the
learning of old ideas and fears and the learning of new values.
 If several visits elapse without pain the former traumatic association is
weakened, and the patient is conditioned to become less fearful in the
dental situation.
 The dentist may then proceed with the full treatment that is needed.
METHODS OF PATIENT EDUCATION
29
Insight learning.
 If every patient came to the dentist with no previous dental experience
or knowledge, patient education would be not only easy but almost
effortless because no previous erroneous concepts would have to be
unlearned.
 There would be no negative conditioning or avoidance reactions already
established.
 Treatment could be started immediately, and insight learning could be
instituted as treatment proceeded.
 Insight occurs when there is an instantaneous association between
formerly unknown or poorly understood events and present happenings.
 In the process the individual avoids trial and error and the long-term
building up of associations required in conditioning.
METHODS OF PATIENT EDUCATION
30
 Education of the patient continues throughout the examination.
 A useful list of objectives to be accomplished by the dentist in
consultation would include the following:
1. Determine the patient's needs, motives, and desires.
2. Make the patient feel important and accepted .
3. Give the patient some recognition and attention as an active
partner in treatment plan.
4. Use visual aids (especially the patient’s own mouth).
5. Be a good listener, especially in the earlier stages of consultation.
METHODS OF PATIENT EDUCATION
31
 The term "motivation" means conveying to the patient, through a series of
words, gestures, and examples, the importance that self-performed oral hygiene
has in the health of the oral cavity.
A T Botticelli 2002
 In order to achieve this goal, dentists must possess:
- Technical skill
- Communication skill
- Psychologic insight
 Dentist may have great technical skill, but will not succeed in their profession
if they are unable to communicate with their patients in order to motivate them
MOTIVATION
32
 OUR YOUTH - ORIENTED SOCIETY
 OUR DESIRE TO BE PHYSICALLY ATTRACTIVE
 SUPERSTITIONS AND FOLKLORE
 SELF-DISCIPLINE
FACTORS THAT INFLUENCE
PATIENT MOTIVATION
33
 Our society is a youth oriented one and those things that enable us to prolong
our youth and retain our youthful appearance are much sought after and
valued.
 Teeth are the most important physical facial feature that, if lost almost single
handedly give the impression of the onset of old age.
 Old age has been portrayed for centuries as a period of toothlessness with a
collapse of vertical dimension in the face, subsequent characteristic changes
in speech and facial form, and an increase in wrinkling.
 Therefore from the aesthetic standpoint teeth are important, not purely for a
superficial attractiveness, but also from more deep-seated fear of aging.
OUR YOUTH - ORIENTED
SOCIETY.
34
 Teeth are a major factor in preserving a pleasant facial expression that
helps us retain our attractiveness to the opposite sex.
 Attractiveness in men and women is aided immeasurably by the presence
of teeth —hopefully natural teeth.
OUR DESIRE TO BE
PHYSICALLY ATTRACTIVE
35
 Many times facts regarding teeth and the pathology associated with them are
warped slightly incorrect to the extent of preventing patients from receiving
proper advice on retaining their teeth and preventing dental disease.
 Practitioners have repeatedly heard about the "soft" teeth or the familial
susceptibility to decay or pyorrhea.
 Folklore also contributes its share of distortion to the truth.
H E Goldman 1980
SUPERSTITIONS AND
FOLKLORE
36
 Tonge (1965) indicates that this reputation is no doubt due to the fact that
teeth are the most lasting parts of our bodies, as demonstrated by skeletal
remains from all parts of the world.
 In present-day life some evidence of' our respect for teeth still remains.
 We still use eruption of teeth as a measure of maturity in the child.
SUPERSTITIONS AND
FOLKLORE….
37
 Both caries and periodontal disease are by nature chronic and thereby
slowly progressive.
 The practice of preventive measures to prevent future disease and
discomfort requires considerable self-discipline by the patient.
 Age. Another factor that may be a barrier to successful motivation is the
fact that most periodontal patients are adults.
 Adults are more difficult to change from their habits of neglect because
their previously held concepts must be overcome before learning can take
place.
 On the other hand an adult can learn from another's experience and can
accept long-range goals better than a younger patient can.
SELF-DISCIPLINE
38
 DARBY , WALSH 1995
1.Self-efficacy Theory
 Self-efficacy, also known as self-confidence, is the belief in one's ability to
perform specific behaviors.
 Self-efficacy theory maintains that self-confidence about being able to perform
a behavior has a strong influence on the ability to perform that behavior.
 Based on self-efficacy theory, motivation to brush and floss should be stronger
when clients feel confident that they know how to floss and have the skill to do
so.
 An important role of the dental hygienist is to help clients acquire this
confidence by training them to perform personal oral hygiene skills and by
providing them with ongoing support and encouragement.
THEORIES OF MOTIVATION
39
2.Attribution Theory
 Attributions are the explanations individuals give for their performance.
 Attribution theory is a cognitive theory that emphasizes the importance of
content of thoughts.
 What people attribute to their success or failure determines their feelings about
themselves, their predictions of success at accomplishing the task, and the
probability that they will try harder or not as hard at a task in the future.
 For example, when people attribute their failure to low ability, they feel
depressed, predict that they will fail again, and use less effort in the future.
therefore attributions affect expectations of success, emotional (affective)
reactions, and persistence at future tasks.
THEORIES OF MOTIVATION
40
 Some clients may blame someone or something else for their poor
performance in maintaining oral health.
 Those people believe that external aspects or their environment have
control over their failure (or their successes)
 The counterpart to these individuals is those who believe they hold their
fates in their own hands and are responsible for their own actions.
 They are focused on the internal aspects of themselves and how they can
influence their environment.
 Psychologists categorize such internal and external personality
dispositions under the construct locus of control.
LOCUS OF CONTROL
41
 He developed a 23-item internal-external locus of control scale for
classification of individuals.
 Three examples of items on Rotter's scale allow the respondent to read each
statement and select the statement he or she most agrees with.
 1a. Many times I feel that I have little influence over things that happen to me.
(external)
 1b. It is impossible for me to believe that chance or luck plays an important
role in my life (internal)
 2a. Getting a good job depends mainly on being in the right place at the right
time (external)
 2b. Becoming a success is a matter of hard work; luck has little or nothing to do
with it. (internal)
 3a. Without the right breaks one cannot be an effective leader (external)
 3b. Capable people who fail to become leaders have not taken advantage of their
opportunities (internal)
SOCIAL LEARNING THEORY
OF ROTTER
42
43
SOURCES OF INFORMATION ON PERIODONTAL THERAPY.
(H E GOLDMAN 1980)
 Dentist is not the sole source of information about dental disease and its
treatment.
 Before a Patient makes a dental visit oriented toward prevention, he must have
already been informed to some degree about the dangers of neglecting his
dental health.
 He might have been informed by any one of great number of sources , some of
which are listed as follows:
1. Family or friends
2. Mass media-television, radio, magazines
3. Past experiences —personal and family
4. Fear of future pain and discomfort
5. Other authorities —physicians, school teachers, nurses
6. Social and cultural background44
 At this point he may not be aware of the status of his periodontal health
but be concerned only about the problems associated with dental caries.
 The major source of information about periodontal disease should be the
private practitioner of dentistry.
 We must assume that the patient has come to a dental office for some
definite reason.
 The dental practitioner may then take steps to inform him through a
suitable means of communication to arouse in him a need for the required
periodontal therapy.
SOURCES OF INFORMATION ON
PERIODONTAL THERAPY.
45
 Actions that dentists and the dental profession may take to improve the
milieu in which the patient will motivate himself can be considered as either
extramural or intramural procedures (Katz et al 1972)
Extramural procedures
 Because most periodontal patients are adults, and adults have beliefs that are
often difficult to change, the profession should concentrate on informing
patients when they are children.
 Extramurally this could be done by the dental profession through a more
active participation in the health program at the elementary school level.
 It could be accomplished by supplying attractive audiovisual materials to the
school, by participating in school functions, and by cultivating and educating
the teachers, who are very powerful opinion makers in the child's life.
 Parents may be approached by other dentally educated opinion makers
such as physicians and nurses.
SUGGESTIONS FOR MOTIVATING
PATIENTS
46
Intramural procedures
 Once the patient makes an appointment with the dentist, he has evidenced
a certain amount of need, or the appointment would never have been
made.
 After he arrives, stronger motivation is evidenced.
 Even though the patient has not come to the office for relief of pain, you
may assume that he has come for the relief of some other anxiety (disquiet
of mind).
SUGGESTIONS FOR MOTIVATING
PATIENTS
47
 Kegeles (1963) has suggested a procedure for dealing with such a patient.
 He indicates that the following format is a useful framework in which to
educate the patient relative to dental disease.
 For a patient to make a dental visit and to undergo treatment that is
oriented toward prevention he must believe the following:
1. That he is susceptible to periodontal disease
2. That periodontal disease is personally serious
3. That there is something he can do to treat or correct the condition
4. To a lesser degree that the condition occurred due to natural causes
SUGGESTIONS FOR MOTIVATING
PATIENTS
48
 A patient must first believe that he is susceptible to periodontal disease
before he can possibly consider the personal seriousness of it.
 Likewise he must accept his susceptibility and its seriousness before he
can be required to consider whether any action that he may take will be
beneficial in treating the problem.
 If the patient accepts the fact that periodontal disease is serious for him,
but does not accept the fact that he is susceptible to it., he will never take
any beneficial action.
 Similarly, if he believes that he is susceptible, but that it is of no
consequence, he will never agree to treatment.
 In like manner he may accept his susceptibility and its seriousness for him
and yet not believe that periodontal therapy and oral hygiene will help him.
 He still will not take beneficial action.
SUGGESTIONS FOR MOTIVATING
PATIENTS
49
 Therefore Kegeles outlines must be followed.
 The dentist must develop a suitable presentation that will convince the
patient that he has every right to expect that, as a member of the human
race, he is susceptible to periodontal disease
 If the dentist is aware of some of the motives that compel men to action,
he may similarly present the patient with factual information on the
seriousness of tooth loss from the financial, hygienic, functional, esthetic,
or psychological aspects.
 The choice of approach depends on the patient's values in relation to his
teeth.
SUGGESTIONS FOR MOTIVATING
PATIENTS
50
 Once the patient has truly accepted both his susceptibility and the serious
nature of periodontal disease he will probably ask the dentist what he can
do about treating the condition.
 At this point a personal disease control program is outlined.
 The individual dentist and his complete office staff should have their dental
disease under control and should enthusiastically teach such a program to all
patients (Kutz et al 1972).
 Kegeles' last point states that the patient must believe that periodontal disease
has occurred in his mouth due to natural causes.
 This means that the patient should accept his condition as a natural biologic
sequence of events and not as a punishment evoked by God for some past
sins.
 Occasionally, successful patient motivation is blocked by such a belief.
SUGGESTIONS FOR MOTIVATING
PATIENTS
51
ORAL HYGIENE
INSTRUCTIONS
 Patients can reduce the incidence of plaque and gingivitis with repeated
instruction and encouragement much more effectively than with self-
acquired oral hygiene habits
Gravelle et al 1967, Suomi et al 1969
 However, instruction in how to clean teeth must be more than a cursory
chair side demonstration on the use of a tooth brush.
 It is a painstaking procedure that requires patient participation, careful
supervision with correction of mistakes, and reinforcement during return
visits, until the patient demonstrates that he or she has developed the
necessary proficiency
Anderson JC 1972, Less W 1972
ORAL HYGIENE INSTRUCTIONS
53
 Any strategy for introducing plaque control to the periodontal patient
includes several elements.
 At the first instruction visit, the patient should be given a new toothbrush,
an interdental cleaner, and a disclosing agent.
 The patient’s plaque should be disclosed because dental plaque otherwise is
difficult for the patient to see
Newman et al 2006
ORAL HYGIENE INSTRUCTIONS
54
A - Because bacterial plaque is relatively invisible and many tooth surfaces are
not easily accessed, teaching patients the skills necessary for disease control
can be difficult.
B -Agents that make supragingival plaque visible can enhance the teaching-
learning process by
i) Demonstrating a relationship between the presence of supragingival
plaque and the clinical signs of disease.
ii) Guiding skill development when applied before plaque removal.
iii) Allowing evaluation of skill effectiveness when applied after plaque
removal.
BACTERIAL PLAQUE DETECTION
M L DARBY 1998
55
C - Presence of subgingival plaque cannot be demonstrated by the use of
disclosing agents.
D - Plan for disease control education should include establishing the
association between the presence of plaque and clinical signs of
disease, such as bleeding.
E - Subgingival plaque detection by the client is best managed when there is
an understanding of the gingival sulcus and/or pocket and the
clinical changes that will occur when bacterial plaque removal is not
effective
BACTERIAL PLAQUE DETECTION
56
I. Purposes
 A disclosing agent clearly demarcates soft deposits that might otherwise
be invisible and therefore facilitates the following:
a. Personalized patient instruction in the location of soft deposits
and the techniques for removal.
b. Self assessment by the patient on a daily basis during initial
instruction and periodic checks thereafter.
c. Continuing evaluation of the effectiveness of the instruction for
the patient.
i) Determining the need for revision of the biofilm control procedures.
ii) Studying the long term effects over successive maintenance
appointments.
DISCLOSING AGENTS
E M WILKINS 2005
57
d. Preparation of biofilm indices.
e. Conducting research studies to gain new information about the
incidence and formation of deposits on the teeth, the effectiveness
of the specific diseases for dental biofilm control, and anti biofilm
agents and to evaluate clinical and instructional group health
programs.
DISCLOSING AGENTS
58
II. Properties of an acceptable disclosing agent
A. Intensity of Color : A distinct staining should be evident, color should
contrast with normal colors of oral cavity.
B. Duration of Intensity: should not rinse off immediately with ordinary
rinsing methods, neither should it be removable by the saliva for the
period of time required to complete the instruction or clinical service.
C. Taste: The patient should not be made uncomfortable by an unpleasant or
highly flavored substance
D. Irritation to the mucous membrane: The patient should be questioned
concerning the possibility of an idiosyncrasy to an ingredient.
DISCLOSING AGENTS
59
E. Diffusibility: A solution should be thin enough so it can be applied readily
to the exposed surfaces of the teeth, yet thick enough to impart an
intense color to dental biofilm.
F. Astringent and Antiseptic Properties : These properties may be highly
desirable in that the disclosing agent may contribute other factors to
the treatment procedures
DISCLOSING AGENTS
60
III. Formulae
 A variety of disclosing agents has been used.
 Skinner’s iodine solution was formerly the most classic and widely used.
 In general, iodine solutions are less desirable because of their unpleasant
flavor.
 Aniline dyes have been shown to have carcinogenic potential.
 Therefore, the use of basic fuchsine and beta rose (flavored basic
fuchsine) has been discouraged.
 Other well-known agents are Buckley’s Berwic’s, Talbot’s iodo-glycerol, and
Metaphen solutions.
DISCLOSING AGENTS
61
62
1V Methods for application
A. Solution for Direct Application
(Painting)
1. Have patient rinse to remove food particles and heavy saliva.
2. Apply water-based lubricant generously to prevent staining of the lips.
3. Dry the teeth with compressed air, retracting cheek or tongue
4. Use swab or small cotton pellet to carry the solution to the teeth
5. Apply solution generously to the crowns of the teeth only.
6. Direct the patient to spread the agent over all surfaces of the teeth with the
tongue
7. Examine the distribution of the agent and request the patient to rinse if
indicated.
DISCLOSING AGENTS
63
B. Rinsing
 A few drops of a concentrated preparation are placed in a paper cup and
water is added for the appropriate dilution.
 Instruct the patient to rinse and swish the solution over all tooth surfaces.
C. Tablet or Wafer
 The patient chews the wafer (one half may be sufficient for some patients),
swishes it around for 30 to 60 seconds, and rinses.
DISCLOSING AGENTS
64
V. Interpretation
A. Clean tooth surfaces do not absorb the coloring agent; when pellicle and
dental biofilm are present, they absorb the agent and are disclosed
B. Pellicle stains as a thin, relatively clear covering whereas dental biofilm
appears darker, thicker, ' and more opaque.
C. Two-Tone
1. Red Biofilm. Newly formed, thin, usually supragingival.
2. Blue Biofilm. Thicker, older, more tenacious; usually it is seen at
and just below gingival margin, especially on proximal surfaces and
where brush or floss is not easily applied; may be associated with
calculus deposits.
DISCLOSING AGENTS
65
DISCLOSING AGENTS
66
67
VI. Patient instruction
A. Explain Dental Plaque
B. Show Location and Distribution of Plaque
C. Demonstrate Methods for Daily Plaque Removal
DISCLOSING AGENTS
68
A. Iodine solutions
- Skinner’s solution, Diluted Tincture of Iodine
B. Mercurochrome preparation
- Mercurochrome Solution (5%), Flavored Mercurochrome Disclosing Solution
C. Bismarck brown (Easlick’s Disclosing Solution)
D. Merbromin
E. Erythrosin
- Concentrate for Application by rinsing , For Direct Topical Application , Tablet
F. Fast Green
G. Fluorescein (Lang et al 1972)
H. Two-Tone (Block et al 1972)
DISCLOSING AGENTS
69
 The bristle toothbrush appeared about the year 1600 in China, was first
patented in America in 1857.
 Generally tooth brushes vary in size and design, as well as length,
hardness, and arrangement of the bristles. Silverstone LM , Featherstone MJ
1988
 The American Dental Association has described the range of dimensions
of acceptable brushes:
- Length : 1 to 1.25 inches
- Width : 5/16 to 3/8 inches
- Surface area : 2.54 to 3.2 cm
- No. of rows : 2 to 4 rows of brushes
- No. of tufts : 5 to 12 per row
- No. of bristles : 80 to 85 per tuft
TOOTH BRUSHES
Newman et al
70
 Never advice hard toothbrush  gingival laceration, recession, tooth
abrasion
 Bristles of children's toothbrush  always soft (0.1-0.15mm)
Fransden 1972
 Adult brush head : 2.5 cm, children 1.5cm
 Bristle  even length
 Bristle should penetrate gingival crevice without causing damage
 Brush  easy to clean
 Toothbrush handle should rest comfortably in hand
 Non-toxic, hygienic
TOOTH BRUSHES
71
A. Sequence
1. A methodical, systematic approach will enhance effectiveness
2. Suggested sequence: begin systematic overlapping strokes at the facial
aspect of the maxillary right or left terminal tooth and continue around the
arch to the terminal tooth on the opposite side; switch to the lingual aspect
and begin working back toward the starting side; use the same pattern for the
mandible, then brush the occlusal surfaces.
FACTORS IN TOOTHBRUSHING EFFECTIVENESS
M L DARBY 1998
72
B. Duration
1. Each time the brush is moved, the time spent in an area should be
monitored by counting strokes or seconds
2. Total manual brushing time of 3 to 5 minutes has been suggested; powered
brushes may be used for 2 minutes
FACTORS IN TOOTHBRUSHING
EFFECTIVENESS
73
C. Frequency
1. Thorough bacterial plaque removal once a day is the minimum requirement
for maintaining periodontal health; it may not, however, be the
optimum regimen for some individuals
2. Frequency should be increased when gingival or periodontal conditions
warrant it or when caries risk or activity is high
3. Brushing removes residual food debris as well as bacterial plaque and is one
method for self application of topical fluoride
FACTORS IN TOOTHBRUSHING
EFFECTIVENESS
74
D. Skill level
1. Careful attention should be given to evaluating skill development in all
components of brush manipulation, including grasp, placement,
activation, wrist movement, and amount of pressure applied
2. Control of brush placement and motion is essential for effectiveness
FACTORS IN TOOTHBRUSHING
EFFECTIVENESS
75
Roll: Roll method or modified Stillman technique
Vibratory: Stillman, Charters, and Bass techniques
Circular: Fones technique
Vertical: Leonard technique
Horizontal: Scrub technique
 Scrub technique: probably the simplest and most common method of
brushing.
 Patients with periodontal disease are most frequently taught a sulcular
brushing technique using a vibratory motion to improve access in the
gingival areas.
 The method most often recommended is the Bass technique because it
emphasizes sulcular placement of bristles.
TOOTHBRUSHING METHODS
76
 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.
 Place the bristles at the gingival margin, pointing at a 45-degree angle to the
long axis of the teeth.
 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 as well as
partly into the interproximal embrasures.
 The pressure should be firm enough to blanch the gingiva
 Complete several strokes in the same position.
 Lift the brush, move it to the adjacent teeth, and repeat the process for the
next three or four teeth.
BASS TECHNIQUE
BASS CC 1954
77
BASS TECHNIQUE
• Place the toothbrush so
that the bristles are
angled approximately 45
degrees from the tooth
surfaces.
• Start at the most distal
tooth in the arch, and use
a vibrating, back-and
forth motion to brush.
78
A. Proper position of the brush in the mouth aims the bristle tips toward the
gingival margin.
B. Diagram shows the ideal placement, which permits slight subgingival
penetration of the bristle tips.
BASS TECHNIQUE
79
MODIFIED BASS TECHNIQUE
80
 Brush is placed with bristles resting partly on cervical portion of tooth and
partly on adjacent gingiva, pointing in an apical direction at an oblique
angle to long axis of tooth
 Pressure is applied laterally towards gingival margin to produce blanching
 Brush is activated with 20 short back and froth strokes and is
simultaneously moved in coronal direction along attached gingiva, gingival
margin and tooth surface.
 Recommended in patients with progressing gingival recession and root
exposure to prevent abrasive tissue destruction
STILLMAN METHOD
STILLMAN PR 1932
81
 Brush is placed with bristles pointed towards the crown at 45 degree angle
to long axis of the teeth
 Sides of the bristles are flexed against the gingiva, and the back and froth
vibratory motion is used to massage the gingiva
 Bristle tips should not move across the gingiva
 Suitable for gentle plaque removal and gingival massage
 Indicated in healing wounds after periodontal surgery
CHARTERS METHOD
CHARTERS WJ 1932
82
Method Bristle placement Motion Advantage/
disadvantage
Scrub Horizontal on gingival margin Scrub in anterior position direction
keeping brush horizontal
Easy to learn & best suited fro
children
BASS Apical towards gingival into sulcus at 450 to
tooth surface
Short back and forth vibratory motion
while bristles remain in sulcus.
Cervical plaque removal
Easily learned
Good gingival stimulation
Charter's Coronally 45o, sides of bristles half on teeth
and half of gingiva
Small circular motions with apical
movements towards gingival margin
Hard to learn and position
brush
Clears inter proximal
Gingival stimulation
Fones Perpendicular to the tooth With teeth in occlusions, move brush in
rotary motion over both arches and
gingival margin
Easy to learn
Inter proximal areas not cleaned
May cause trauma
Roll Apically, parallel to tooth and then over
tooth surface
On buccal and lingual inward pressure,
then rolling of head to sweep bristle over
gingiva & tooth
Doesn't clean sulcus area
Easy to learn
good gingival stimulation
Stillman's On buccal and lingual, apically at an oblique
angle to long axis of tooth. Ends rest on
gingiva and cervical part.
On buccal and lingual slight rotary
motions with bristle ends stationary
Excellent gingival stimulation
Moderate dexterity required
Moderate cleaning of
interproximal area
Modified
stillman's
Pointing apically at and angle of 45o to
tooth surface
Apply pressure as in stillmans's method
but vibrate brush and also move occlusally
Easy to master
Gingival stimulation83
 Each of these methods can be modified to add a roll stroke.
 The brush is positioned similarly to the Bass/Stillman technique.
 After activation of the brush head in a back-and-forth direction, the head
of the brush is rolled over the gingiva and tooth in the occlusal direction,
making it possible for some of the filaments to reach interdentally.
MODIFIED BASS/STILLMAN
TECHNIQUE
84
A. Brushes should be rinsed clean after each use, allowed to air-dry in an
upright position
B. Rotating use of more than one brush during 24 prolongs brush life
C. Brushes should be replaced when bristles splay resiliency, generally no
longer than 3 to 4 months.
D. Some brushes have color indicator bristles to monitor replacement time
E. Brushes should be replaced after an illness such or flu or disinfected with a
household bleaches
TOOTHBRUSH MAINTENANCE
85
 In 1939 powered tooth brush invented to make plaque control easier.
 Its mainly recommended for
(a) Individual lacking motor skills
(b) Hospitalized patients whose teeth are cleaned by the caregivers.
(c) Special needs patient ( physical and mental disability)
(d) Patient with orthodontic applied
(e) Whosoever wants to use
ELECTRIC TOOTHBRUSH
( POWERED)
86
 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.
Forgas-Brockmann LB et al 1998
POWERED TOOTHBRUSHES
87
 No evidence of a statistically
significant difference between
powered and manual brushes.
However, rotation oscillation
powered brushes significantly
reduce plaque and gingivitis in
both the short and long-term
C. Deery et al 2003
 Electric toothbrush have not
been shown to provide benefits
routinely for patients with RA,
children who are well-motivated
brushers , or patients with
chronic periodontitis.
Heasman, 1999
88
Definition
Substance used with a tooth brushes are accessible tooth surfaces; available in
gel, paste or powder form.
Purposes
1. Cosmetic – Tooth surfaces are cleaned and polished, breath is freshened.
2. Therapeutic – Certain non drug substances augment the efficiency of the
brush in removal of plaque debris and stain; Vehicle for transporting
biologically active ingredients to the tooth and its environment;
fluoride dentifrices inhibit tooth demineralization
DENTIFRICES
89
A. Products selected should carry the American dental Association (ADA)
seal
B. All ADA accepted dentifrices have safe levels of abrasiveness
C. Dentifrices containing fluoride are granted acceptance based on their
caries-reduction properties
GUIDELINES FOR
DENTIFRICE SELECTION
90
D. Dentifrices that carry the ADA seal have gained acceptance for the
proven efficacy of the fluoride mechanism
E. Desensitizing dentifrices that carry the ADA seal have gained acceptance
for proven efficacy in the control of dentinal hypersensitivity
F. Dentifrices that claim therapeutic benefits other than dental caries
reduction (from fluoride) or control of hypersensitivity have not been
awarded the ADA seal for such claimed benefit
GUIDELINES FOR
DENTIFRICE SELECTION
91
A. Daily use of fluoride dentifrice should be recommended for all individuals,
regardless of caries risk, because these products promote tooth
remineralization
B. Young children (under age 6) should be supervised when using fluoride
dentifrice
C. Use of a small pea-sized amount of toothpaste gel containing no more
than 1100 ppm fluoride is recommended swallowing should be avoided
dental fluorosis has been associated with use of more than a pea sized
amount of toothpaste by young children living in fluoridated
communities
Pendrys DG 1995
GUIDELINES FOR DENTIFRICE USE
ADA 1995
92
 Any toothbrush, regardless of the brushing method used does not
completely remove interdental plaque
 This is true for all brushers even periodontal patients with wide open ,
embrasures. Gejermo et al1970, Schmidet al 1976
 Daily interdental plaque removal is crucial to augment the effects of tooth
brushing because most dental and periodontal diseases originate in
interproximal areas Addy et al 1998
 Tissue destruction associated with periodontal disease often leaves large,
open spaces between teeth and long, exposed root surfaces with anatomic
concavities and furcation's.
 These areas are both difficult for patients to clean and poorly accessible to
the toothbrush Kinane 1998
INTERDENTAL CLEANING AIDS
93
 Many tools are available for interproximal cleaning.
 They should be recommended based on the patient's interdental
architecture (e.g., size of interdental spaces), Presence of furcation's, tooth
alignment, and presence, of orthodontic appliances or fixed prostheses.
 Also, 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.
INTERDENTAL CLEANING
AIDS
94
Type I  The gingival papilla fills up the embrasure space completely
 floss
Type II  The gingival papilla partially fills the embrasure space due to
papillary recession
tufted dental floss/super floss , interdental brushes/proxy-brushes
Type III  The embrasure space is not filled. The gingival papilla has receded
extensively or it is completely lost
 interdental brush/proxy-brushes, single tufted brushes
Norland , Tarnow 1998
CLASSIFICATION OF
EMBRASURE
95
 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 do not fray.
 Clinical research has demonstrated no significant differences in the ability
of the various types of floss to remove dental plaque 
they all work equally well. Grossman 1979, Keller 1969
 Waxed dental floss was thought to leave a waxy film on proximal surfaces,
thus contributing to plaque accumulation and gingivitis.
Robert H. Beaumont 1990
DENTAL FLOSS
96
Dental floss should be held
securely in the fingers or tied
in a loop. (12-18 “)
Dental floss technique.
The floss is slipped between the
contact area of the teeth, is
wrapped around the proximal
surface, and removes plaque by
using several up-and-down
strokes. 97
DENTAL FLOSS
98
INTERDENTAL BRUSH
(PROXY BRUSH)
 Interdental brush are conical shape brushes made of bristles mounted on
a handle / single tufted brushes.
 Suitable for cleaning large, irregular, or concave tooth surfaces adjacent to
wide interdental spaces.
 Inserted inter-proximally and are activated with short back and forth
strokes in between the teeth.
99
100
 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 tooth brushing and flossing, since this might reduce
a potential reservoir of microorganisms contributing to plaque formation
Christen & Swanson 1978
 The bacterial accumulations on the dorsum of the tongue may also be the
source of bad breath.
TONGUE CLEANER
101
 Massaging the gingiva with a toothbrush or an interdental cleaning devices
produces epithelial thickening. increased keratinization, and increased
mitotic activity .
Canter et al1965, Castenfelt 1952, Glickman et al 1965
 The increased keratinization occurs only on the oral gingiva and not the
areas more vulnerable to microbial attack  the sulcular epithelium and
the interdental areas where the gingival col is present.
 Improved gingival health associated with interdental stimulation is much
more likely the result of plaque removal than gingival massage.
GINGIVAL MASSAGE
102
 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.
CHEMICAL PLAQUE CONTROL WITH ORAL RINSES
NEWMAN ET AL
103
1st generation agents
 Decrease plaque by 20-50% Good antimicrobial activity but poor substantivity
 Antibiotics: Penicillin , Erythromycin, Metronidazole
 Quaternary ammonium compounds: Cetylpyridium chloride , Benzylchonium
chloride
 Phenolic compounds: Phenol, thymol
 Essential oils: Eucalyptol, benzoic acid
 Herbal extracts: Sanguinarine
 Oxygenating agents: Peroxides
CLASSIFICATION OF CHEMICAL
PLAQUE CONTROL AGENTS
Lindhe et al
105
2nd Generation Agents
 Decrease plaque by 60-90% Good antimicrobial activity and excellent
substantivity
 Bisbiguanides: Alexidine , Chlorhexidine
 Bispyridines: Octenidine
3rd Generation Agents
 They prevent plaque formation by inhibiting the pellicle attachment.
 Amine alcohol: Delmopinol
CLASSIFICATION
106
 To replace mechanical tooth brushing when this is not possible in the
following situation:
- After oral or periodontal surgery and during the healing period
- After inter-maxillary fixation used to treat jaw fractures or following
cosmetic surgery.
- With acute oral mucosal or gingival infections when pain and
soreness prevents mechanical oral hygiene.
- For mentally or physically handicapped patients who are unable to
brush their teeth themselves.
ID Mandel 1972
USES OF ANTI-PLAQUE
MOUTHWASH
107
 As an adjunct - to normal mechanical oral hygiene in situations where this
may be compromised by discomfort or inadequacies.
 Following sub gingival scaling and root planning when the gingival may be
sore for days.
 Following scaling when there is cervical hypersensitivity due to exposed
root surface. Its use needs to be combined with measures to treat the
hypersensitivity.
 Following scaling in situations when the patients oral hygiene remains
inadequate.
SG Ciancio 1986
USES OF ANTI-PLAQUE
MOUTHWASH
108
 Dispense the prescribed amount of mouthwash
 Pour it into the mouth.
 Close your mouth to create a seal
 Do not swallow the mouthwash
 Swish it through your teeth for 30 seconds
to a minute and then spit
HOW TO PRESCRIBE A
MOUTHRINSE
109
HOW TO PRESCRIBE A
MOUTHRINSE
110
 Colgate  Colgate Plax Peppermint Mouthwash (Rs 85 – Rs 99 /250ml)
 Colgate Plax Complete Care Mouthwash (Rs 100 – Rs 112/250ml)
 Colgate Plax Sensitive Mouthwash (Rs 105 – Rs 112 / 250ml)
 Colgate Plax Fresh Tea (Rs 105 – Rs 112 /250ml)
MOUTHWASHES AVAILABLE
IN INDIA
113
 Listerine  Listerine Fresh Burst Mouthwash (Rs 95 – Rs 100 /250ml)
 Listerine Original Mouthwash (Rs 98 – Rs 100 /250ml)
 Listerine Cool Mint Mouthwash (Rs 100 – Rs 102 /250ml)
MOUTHWASHES AVAILABLE IN
INDIA
114
• Colgate® PerioGard® Rinse
• Acclean® Chlorhexidine
gluconate 0.12% oral rinse
• Rexidine mouth wash
115
CHLORHEXIDINE
MOUTHWASHES AVAILABLE IN
INDIA
 Pepsodent  Pepsodent Germi Check Fresh Mint Mouthwash (Rs 115 – Rs 122
/300ml)
 Pepsodent Germi Check Herbal Fresh Mouthwash (Rs 115 – Rs
122 / 300ml)
MOUTHWASHES AVAILABLE IN
INDIA
116
 Oral-B  Oral B Mouthwash Alcohol Free Multi-Protection (Rs 150 – Rs
165 for 500ml)
 Crest  Crest Pro-Health Complete Fresh Mint Fluoride Mouthwash
(Rs 425 – Rs 525 for 1Litre)
 Crest Pro Health Clinical Deep Clean Mint (Rs 375 – Rs 450 for
975ml)
MOUTHWASHES AVAILABLE IN
INDIA
117
 Himalaya  Himalaya HiOra-K Mouthwash
(Rs 75 – Rs 80 for 215ml)
 Aquafresh  Aqua Fresh Tingling Mint Mouthwash
(Rs 280 – Rs 305 for 500ml)
MOUTHWASHES AVAILABLE IN
INDIA
118
 Oral irrigators for daily home use by patients 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 non-adherent bacteria and debris from the oral cavity
more effectively than toothbrushes and mouth rinses.
 Irrigators are particularly helpful for removing debris from inaccessible
areas around orthodontic appliances and fixed prostheses.
 When used as adjuncts to tooth brushing, these devices can have a
beneficial effect on periodontal health
 Both supra and sub-gingival irrigators are available
ORAL IRRIGATORS
119
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 the
tongue
C, Soft rubber tip is used for daily subgingival irrigation by the patient at home.
120
Coarse fibrous foods
 As part of the plaque control program patients should be advised to include
hard fibrous foods in their diet, particularly at the end of meals.
 Although some investigators disagree (Lindhe et al 1969) it is the consensus that
hard fibrous foods reduce plaque accumulation and gingivitis on tooth surfaces
exposed to their mechanical cleansing action during mastication
Bear et al 1961, Stewart et al 1960
 Coarse fibrous foods  functional stimulation to the periodontal ligament and
alveolar bone.
 Soft diets  increased plaque accumulation and calculus formation, gingivitis
and periodontal disease Plezer et al 1940
 Animals fed soft diets enriched with vitamins and minerals develop severe
periodontal disease with loosening of the teeth, which does not occur when
the diet includes lengths of bone and adherent meat which require
vigorous chewing King et al 1945
DIET
GLICKMAN 1972
121
Limiting sucrose-containing foods
 The fact that the ingestion of sucrose increases plaque formation is of
great clinical importance.
 The polysaccharide dextran is a major component of the plaque matrix.
 It is a sticky substance which envelops the plaque bacteria and attaches the
plaque to the tooth surface.
 The bacteria form the dextran from carbohydrates, particularly sucrose.
 Limiting the intake of sugar and sugar-sweetened foods assists in reducing
plaque formation (Carlson et al 1965) and patients should be instructed
accordingly.
DIET
122
 No therapeutic intervention is without adverse effects, including oral
hygiene practices.
 Tooth abrasion and gingival recession are both alleged to be caused by
traumatic brushing.
Tooth Abrasion
 Evidence implicating the toothbrush in cases of abrasion comes primarily
from in vitro studies, case reports, and cross-sectional studies.
 Some studies have implicated a horizontal scrubbing stroke as a more
important risk factor for tooth abrasion than bristle stiffness.
 Other studies have indicated that abrasive toothpastes are the primary
cause of tooth abrasion.
Vander et al 1996
ADVERSE EFFECTS OF ORAL
HYGIENE AIDS
123
Gingival Recession
 Gingival recession is the result of an interaction between precipitating
factors, such as trauma to the gingival tissues, and predisposing factors,,
such as a thin tissue complex.
 Gingival recession, particularly that occurring on the buccal surface, is
often presumed to be the result of toothbrush trauma.
 It seems logical to assume that the thin gingival biotype might be more
easily traumatized.
 There is evidence suggesting that thin tissue is more prone to recession
Olsson1993
ADVERSE EFFECTS OF ORAL HYGIENE
AIDS
124
Possible Adverse Effects of Home Irrigation
 A number of investigators have examined the effect of pulsating water jet
devices on gingiva and mucosa and most have concluded there is little risk
for tissue damage when such devices are used according to manufacturer's
instructions Rethman et al 1994
 In one investigation, the use of an irrigator at 60 psi in untreated
periodontal pockets created no more tissue damage than was found in the
"no irrigation" control group Cobb et al 1988
 Some investigators have reported no bacteremia after irrigation, whereas
others have reported that this does occur. Because this could have
implications for individuals at risk for endocarditis, some authorities have
recommended that the devices not be used by individuals at risk.
Page et al 1997
ADVERSE EFFECTS OF ORAL HYGIENE
AIDS
125
 Thorough plaque removal may enhance the results of regenerative surgical
therapy and may help provide stability to the gains in clinical attachment
achieved Tonetti et al 1996
 In the immediate postoperative period plaque control is accomplished by
means of chemotherapeutic agents such as chlorhexidine gluconate rinses,
and mechanical plaque removal is generally avoided.
 Some tissue maturation should occur before resumption of normal oral
hygiene
 Critical to the regenerative outcome is wound stability and the preservation
of the delicate fibrin forms on the root surface.
 The presence of this fibrin clot may prevent the down growth of the
epithelium, there by permitting regeneration of the attachment apparatus
ORAL HYGIENE AFTER
REGENERATIVE PROCEDURES
126
 It is often recommended that professional subgingival debridement and
probing be avoided for 6 months after regenerative surgery, but little is said
about the resumption of oral hygiene measures
Slots et al 1999
 Do not brush or floss the surgical area for the first 7-10 days
Bruce B. Wiland
ORAL HYGIENE AFTER
REGENERATIVE PROCEDURES
127
 The foundation of a preventive health-oriented dental practice is an
effective hygiene department.
 We are responsible for delivering not only quality restorations with which
patients can prevent dental disease, but also a structured program to aid
them in taking care of their health and investment.
 It is the quality of the dentist's restorations and the effectiveness of his or
her hygiene program that determine whether he or she is practicing true
preventive dentistry or simply functioning in a reparative manner-always
"putting out fires."
CONCLUSION
128
1. Carranza’s clinical periodontology - 10th edition
2. Clinical practice of the dental hygienist - Esther M Wilkins
3. Dental maintenance for patients with periodontal disease – Thomas G
Wilson
4. Periodontics – BM Eley , JD Manson
5. A handbook for the dental hygienist – W Collins, TF Walsh
6. Arnim, S.S.: Use of Disclosing Agents for Measuring Tooth Cleanliness, J.
Periodontol., 34, 227, May, 1963
7. Glickman I, Petralis R, Marks R: The effect of powered toothbrushing
plus interdental stimulation upon the severity of gingivitis, J Periodontol
35:519, 1964
REFERENCES
129
8. Glickman I, Petralis R, Marks R: The effect of powered toothbrushing
and interdental stimulation upon microscopic inflammation and surface
keratinization of the interedental gingiva, J Periodontol 3:108, 1965.
9. Lindhe, J., and Wicen, P.O.: The Effects on the Gingivae of Chewing
Fibrous Foods. J. Periodont. Res., 4:193, 1969.
10. Loe H, Anerud A, Boysen H: The natural history of periodontal disease
in man: prevalence, severity, and extent of gingival recession, J
Periodontol 63:489-495, 1992.
130
131

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  • 1. 1
  • 2. PRESENTED BY : SHILPA SHIVANAND II MDS PATIENT EDUCATION, MOTIVATION AND ORAL HYGIENE INSTRUCTIONS
  • 3.  Patient education  Methods of patient education  Motivation  Theories of motivation  Oral hygiene instructions  Disclosing agents  Toothbrushes and brushing techniques  Dentifrices  Interdental aids  Oral hygiene after regenerative procedures  Conclusion CONTENTS 3
  • 4. The background to oral health education  The term Dental Health Education (DHE) has been gradually superseded in recent years by Oral Health Education (OHE), reflecting a wider concern than health only of the teeth. Problems with oral health education  Previous inadequacies in OHE delivery have been attributed to two main faults.  The message which has been contained within the dental health advice has not always been correct and has at times been totally misleading. PATIENT EDUCATION 4
  • 5. Domains of learning  In education it is accepted that there are three domains of learning 1. Cognitive domain: this relates to the acquisition of knowledge. 2. Skills domain: this is the learning of practical skills. 3. Affective domain: this involves the creation of attitudes and motivation. THE LEARNING PROCESS 5
  • 6.  The prevention and control of the two major dental diseases  inflammatory periodontal disease and dental caries, depend to a large extent on a change in the behavior of the patient. Changing behavior  The following are the steps which must be followed to establish behavioral changes Factual education. Practical demonstration. Motivation. Reinforcement. BEHAVIORAL CHANGE 6
  • 7.  Information is a necessary but not on its own sufficient condition for changing behavior.  The information supplied should be accurate and comprehensible to lay- people.  Part of this information should include realistic goals that the patient can achieve.  For example, with some patients it would be preferable to concentrate solely on the improvements achievable by brushing before progressing to interdental cleansing. FACTUAL EDUCATION 7
  • 8.  The teaching of the physical skills involved in dental health includes disclosing, brushing, interdental cleansing and the cleaning of dentures and appliances.  Educator should use  'tell-show-do' approach.  The action should first be explained, then demonstrated to the patient, possibly at first on models, then in the mouth.  Finally, the patient should carry out the procedure with the instructor supervising, correcting and giving encouragement.  Do not overload the patient.  It is better to teach a little at a time. PRACTICAL TRAINING 8
  • 9.  Refers to 'that which induces a person to act'.  In dentistry, the phrase 'patient motivation' is often misused, implying that one can cause a third person to co-operate, comply or perform in some desired manner.  This would be a very useful ability, but unfortunately not possible.  Motivation must come from within an individual. MOTIVATION 9
  • 10.  In order to become motivated to alter a behavioral pattern an individual must be able to identify the following: 1. A problem exists which affects the individual personally for example the existence of periodontal disease in the mouth. 2. The problem will have an unwanted personal outcome such as the premature loss of teeth. 3. There is a practical solution such as adequate plaque control. 4. The problem is serious enough to justify the inconvenience of the solution. THE ESSENTIALS FOR MOTIVATION 10
  • 11.  In relation to dental health education, people may be divided into three broad groups: - those who are already motivated, - those with latent motivation, - those lacking the necessary motivation to change their behavior  Motivated  have their own drive and simply require guidance and reinforcement from time to time.  Latent motivation is possessed by a majority of patients.  This is indicated by studies which show that approximately 60% of patients attend a dentist at least every second year, usually for a preventive check-up.  This latent motivation requires a trigger to activate or release it. THE ESSENTIALS FOR MOTIVATION 11
  • 12.  Patients without the desired motivation are intractable problem.  Various forms of threat or sanction may produce an improved short-term behavioral change, but no long-term alteration.  However, even these patients may not be lost for ever, as research suggests that the priority of motives may change with time and circumstances, even in adults, and this will give rise to behavioral changes. THE ESSENTIALS FOR MOTIVATION 12
  • 13.  The process of encouraging or establishing a belief or pattern of behavior.  Once the progression of the disease has been controlled, then most patients require a regular (possibly 3 monthly) maintenance programme of visits.  This can be coupled with reinforcement of the oral hygiene regimen.  The frequency of reinforcement will vary from person to person and will depend to a large extent on their attitudes and the type of problem present. REINFORCEMENT 13
  • 14. A. Learning is more effective when an individual is physiologically and psychologically ready to learn. B. Individual differences must be considered if effective learning is to take place. C. Motivation is essential for learning. D. What an individual learns in a given situation depends on what is recognized and understood. E. Transfer of learning is facilitated by recognition of similarities and dissimilarities between past experiences and the present situation. F An individual learns what is actually used. G. Learning takes place more effectively in situations from which the individual derives feelings of satisfaction. H. Evaluation of the results of instruction is essential to determine whether learning is taking place. PRINCIPLES OF LEARNING E M WILKINS 2005 14
  • 15.  The learning ladder illustrates the six steps from learner unawareness to habit formation.  When beginning to help a patient learn about oral health and what the individual's needs are, one must determine where the patient stands on the ladder and start from there. THE LEARNING LADDER 15
  • 16. A. Unawareness Many patients have little concept of the new information about dental and periodontal infections and how they are prevented or controlled. B. Awareness Patients may have a good knowledge of the scientific facts, but they do not apply the facts to personal action. C. Self-interest Realization of the application of facts/knowledge to the well-being of the individual is an initial motivation. THE LEARNING LADDER 16
  • 17. D. Involvement With awareness and application to self, the response to action is forthcoming when attitude is influenced. E. Action Testing new knowledge and beginning of change in behavior may lead to an increased awareness that a real health goal is possible to attain. F. Habit Self-satisfaction in the comfort and value of sound teeth and healthy periodontal tissue helps to make certain practices become part of daily routine Ultimate motivation is finally reached. THE LEARNING LADDER 17
  • 18.  Periodontal health is important  teeth are worth keeping for life.  The patients must believe this; otherwise any change in habit as an immediate response will be short-lived.  Several arguments may be employed and the experienced practitioner can tailor these to the patient's perceived needs.  Adolescents and adults may respond to different arguments CHANGE IN ATTITUDE TO DENTAL HEALTH DM ELEY, JD MANSON 2OO4 18
  • 19. Impaired function  No appliance can function as efficiently as the natural and healthy dentition  Full dentures may be an extremely poor substitute for the patient's own teeth. ATTITUDE TO DENTAL HEALTH 19
  • 20. Personal hygiene.  These days most people are concerned about personal cleanliness and yet there may be a marked contrast between the patient's general appearance and the state of his mouth.  This usually represents a lack of awareness of oral hygiene and when the true state of affairs is demonstrated the individual who is truly concerned about personal hygiene will be ready to change his habits.  The patient is given a hand-mirror to witness the examination of the mouth, and deposits of plaque and calculus can be pointed out.  The use of a disclosing agent is valuable. ATTITUDE TO DENTAL HEALTH 20
  • 21. Social handicap  Periodontal disease produces halitosis, inflamed gingiva and eventually tooth loss due to mobility  The idea of possessing offensive breath or an ugly smile is often sufficient incentive for patients to improve their home care. General health  The fact that periodontal disease can have an adverse effect on general health should be explained to the patient. ATTITUDE TO DENTAL HEALTH 21
  • 22.  Based on the concept that one's beliefs direct behavior; model is used to explain and predict health behaviors and acceptance of health recommendations; emphasis is placed on perceived world of individual, which may differ from objective reality Components 1. Susceptibility-individuals must believe that they are susceptible to a particular disease or condition 2. Severity-individuals must believe that if they get the particular disease or condition, the consequences will be serious 3. Asymptomatic nature of disease-individuals must believe that the disease may be present without their full awareness 4. Behavior change will be beneficial-individuals must believe that there are effective means of preventing or controlling the potential or existing problem and that action on their part will produce positive results HEALTH BELIEF MODEL M L DARBY 1998 22
  • 23.  Theory regarding human nature that is used to explain the motivational process  Maslow suggested that inner forces, or needs, drive a person to action  He classified needs in a pyramid according to their importance to the individual, his or her ability to motivate, and the importance placed on their satisfaction  Only when an individual's lower needs are met, will the individual become concerned about higher level needs  Once needs are met, they no longer function as motivators "MASLOW'S HIERARCHY OF NEEDS 23
  • 24. HIERARCHY OF NEEDS 24 self-realization  needs that drive the individual to reach the very top of his or her field components necessary for body homeostasis, such as food, water, oxygen, temperature regulation etc Social needs
  • 25.  The first task of the practitioner is to establish rapport with the patient, which then makes possible further development of communication, learning, and motivation.  Despite their importance, history taking, clinical examination, and diagnosis must all wait because, according to Meares 1957, while they may all occur concurrently with rapport, rapport must come first. ESTABLISHMENT OF COMMUNICATION : RAPPORT H E GOLDMAN 1980 25
  • 26.  Rapport is an emotional state in which logical, intellectual, or verbal factors may play only a small role.  Expressions, gestures, and other nonverbal communication, however small, may assume symbolic value to the patient as the initial meeting with the doctor takes place.  On the surface the patient may be reciting his symptoms and concerns, but underneath this veneer he is assessing the competence and trustworthiness of the doctor.  Meanwhile the doctor should be establishing the emotional relationship with the patient that we know as rapport. RAPPORT…. 26
  • 27.  In considering obstacles to rapport the dentist should note the difference between sympathy and empathy.  Empathy, a great gift for a professional to possess, means that although we do not share the emotional feelings with the patients as in sympathy, we do appreciate how he is feeling.  Empathy is a blend of interest and objectivity.  Many times the more sensitive the individual happens to be, the more apt he is to possess a capacity for empathy.  Lack of this qualification by professional is an obstacle to formation of rapport with his patients or clients. SYMPATHY / EMPATHY 27
  • 28.  Cinotti and Grieder advocate methods that may prove to be effective and more efficient.  These are conditioning and insight learning. Conditioning  The dental patient is conditioned by past experiences to expect pain and discomfort before he visits the dental office.  In our society, the dentist is often portrayed in cartoon and lay articles as a threatening mutilator of the mouth who is to be feared.  It has been stated by many that the most feared figure in our society is the psychiatrist and that the dentist is possibly a close second Friedman METHODS OF PATIENT EDUCATION 28
  • 29.  In attempting to reeducate such patients many practitioners perform no treatment per se on the first visit but use it to establish rapport and com- munication and to commence the unlearning of old ideas and fears and the learning of old ideas and fears and the learning of new values.  If several visits elapse without pain the former traumatic association is weakened, and the patient is conditioned to become less fearful in the dental situation.  The dentist may then proceed with the full treatment that is needed. METHODS OF PATIENT EDUCATION 29
  • 30. Insight learning.  If every patient came to the dentist with no previous dental experience or knowledge, patient education would be not only easy but almost effortless because no previous erroneous concepts would have to be unlearned.  There would be no negative conditioning or avoidance reactions already established.  Treatment could be started immediately, and insight learning could be instituted as treatment proceeded.  Insight occurs when there is an instantaneous association between formerly unknown or poorly understood events and present happenings.  In the process the individual avoids trial and error and the long-term building up of associations required in conditioning. METHODS OF PATIENT EDUCATION 30
  • 31.  Education of the patient continues throughout the examination.  A useful list of objectives to be accomplished by the dentist in consultation would include the following: 1. Determine the patient's needs, motives, and desires. 2. Make the patient feel important and accepted . 3. Give the patient some recognition and attention as an active partner in treatment plan. 4. Use visual aids (especially the patient’s own mouth). 5. Be a good listener, especially in the earlier stages of consultation. METHODS OF PATIENT EDUCATION 31
  • 32.  The term "motivation" means conveying to the patient, through a series of words, gestures, and examples, the importance that self-performed oral hygiene has in the health of the oral cavity. A T Botticelli 2002  In order to achieve this goal, dentists must possess: - Technical skill - Communication skill - Psychologic insight  Dentist may have great technical skill, but will not succeed in their profession if they are unable to communicate with their patients in order to motivate them MOTIVATION 32
  • 33.  OUR YOUTH - ORIENTED SOCIETY  OUR DESIRE TO BE PHYSICALLY ATTRACTIVE  SUPERSTITIONS AND FOLKLORE  SELF-DISCIPLINE FACTORS THAT INFLUENCE PATIENT MOTIVATION 33
  • 34.  Our society is a youth oriented one and those things that enable us to prolong our youth and retain our youthful appearance are much sought after and valued.  Teeth are the most important physical facial feature that, if lost almost single handedly give the impression of the onset of old age.  Old age has been portrayed for centuries as a period of toothlessness with a collapse of vertical dimension in the face, subsequent characteristic changes in speech and facial form, and an increase in wrinkling.  Therefore from the aesthetic standpoint teeth are important, not purely for a superficial attractiveness, but also from more deep-seated fear of aging. OUR YOUTH - ORIENTED SOCIETY. 34
  • 35.  Teeth are a major factor in preserving a pleasant facial expression that helps us retain our attractiveness to the opposite sex.  Attractiveness in men and women is aided immeasurably by the presence of teeth —hopefully natural teeth. OUR DESIRE TO BE PHYSICALLY ATTRACTIVE 35
  • 36.  Many times facts regarding teeth and the pathology associated with them are warped slightly incorrect to the extent of preventing patients from receiving proper advice on retaining their teeth and preventing dental disease.  Practitioners have repeatedly heard about the "soft" teeth or the familial susceptibility to decay or pyorrhea.  Folklore also contributes its share of distortion to the truth. H E Goldman 1980 SUPERSTITIONS AND FOLKLORE 36
  • 37.  Tonge (1965) indicates that this reputation is no doubt due to the fact that teeth are the most lasting parts of our bodies, as demonstrated by skeletal remains from all parts of the world.  In present-day life some evidence of' our respect for teeth still remains.  We still use eruption of teeth as a measure of maturity in the child. SUPERSTITIONS AND FOLKLORE…. 37
  • 38.  Both caries and periodontal disease are by nature chronic and thereby slowly progressive.  The practice of preventive measures to prevent future disease and discomfort requires considerable self-discipline by the patient.  Age. Another factor that may be a barrier to successful motivation is the fact that most periodontal patients are adults.  Adults are more difficult to change from their habits of neglect because their previously held concepts must be overcome before learning can take place.  On the other hand an adult can learn from another's experience and can accept long-range goals better than a younger patient can. SELF-DISCIPLINE 38
  • 39.  DARBY , WALSH 1995 1.Self-efficacy Theory  Self-efficacy, also known as self-confidence, is the belief in one's ability to perform specific behaviors.  Self-efficacy theory maintains that self-confidence about being able to perform a behavior has a strong influence on the ability to perform that behavior.  Based on self-efficacy theory, motivation to brush and floss should be stronger when clients feel confident that they know how to floss and have the skill to do so.  An important role of the dental hygienist is to help clients acquire this confidence by training them to perform personal oral hygiene skills and by providing them with ongoing support and encouragement. THEORIES OF MOTIVATION 39
  • 40. 2.Attribution Theory  Attributions are the explanations individuals give for their performance.  Attribution theory is a cognitive theory that emphasizes the importance of content of thoughts.  What people attribute to their success or failure determines their feelings about themselves, their predictions of success at accomplishing the task, and the probability that they will try harder or not as hard at a task in the future.  For example, when people attribute their failure to low ability, they feel depressed, predict that they will fail again, and use less effort in the future. therefore attributions affect expectations of success, emotional (affective) reactions, and persistence at future tasks. THEORIES OF MOTIVATION 40
  • 41.  Some clients may blame someone or something else for their poor performance in maintaining oral health.  Those people believe that external aspects or their environment have control over their failure (or their successes)  The counterpart to these individuals is those who believe they hold their fates in their own hands and are responsible for their own actions.  They are focused on the internal aspects of themselves and how they can influence their environment.  Psychologists categorize such internal and external personality dispositions under the construct locus of control. LOCUS OF CONTROL 41
  • 42.  He developed a 23-item internal-external locus of control scale for classification of individuals.  Three examples of items on Rotter's scale allow the respondent to read each statement and select the statement he or she most agrees with.  1a. Many times I feel that I have little influence over things that happen to me. (external)  1b. It is impossible for me to believe that chance or luck plays an important role in my life (internal)  2a. Getting a good job depends mainly on being in the right place at the right time (external)  2b. Becoming a success is a matter of hard work; luck has little or nothing to do with it. (internal)  3a. Without the right breaks one cannot be an effective leader (external)  3b. Capable people who fail to become leaders have not taken advantage of their opportunities (internal) SOCIAL LEARNING THEORY OF ROTTER 42
  • 43. 43
  • 44. SOURCES OF INFORMATION ON PERIODONTAL THERAPY. (H E GOLDMAN 1980)  Dentist is not the sole source of information about dental disease and its treatment.  Before a Patient makes a dental visit oriented toward prevention, he must have already been informed to some degree about the dangers of neglecting his dental health.  He might have been informed by any one of great number of sources , some of which are listed as follows: 1. Family or friends 2. Mass media-television, radio, magazines 3. Past experiences —personal and family 4. Fear of future pain and discomfort 5. Other authorities —physicians, school teachers, nurses 6. Social and cultural background44
  • 45.  At this point he may not be aware of the status of his periodontal health but be concerned only about the problems associated with dental caries.  The major source of information about periodontal disease should be the private practitioner of dentistry.  We must assume that the patient has come to a dental office for some definite reason.  The dental practitioner may then take steps to inform him through a suitable means of communication to arouse in him a need for the required periodontal therapy. SOURCES OF INFORMATION ON PERIODONTAL THERAPY. 45
  • 46.  Actions that dentists and the dental profession may take to improve the milieu in which the patient will motivate himself can be considered as either extramural or intramural procedures (Katz et al 1972) Extramural procedures  Because most periodontal patients are adults, and adults have beliefs that are often difficult to change, the profession should concentrate on informing patients when they are children.  Extramurally this could be done by the dental profession through a more active participation in the health program at the elementary school level.  It could be accomplished by supplying attractive audiovisual materials to the school, by participating in school functions, and by cultivating and educating the teachers, who are very powerful opinion makers in the child's life.  Parents may be approached by other dentally educated opinion makers such as physicians and nurses. SUGGESTIONS FOR MOTIVATING PATIENTS 46
  • 47. Intramural procedures  Once the patient makes an appointment with the dentist, he has evidenced a certain amount of need, or the appointment would never have been made.  After he arrives, stronger motivation is evidenced.  Even though the patient has not come to the office for relief of pain, you may assume that he has come for the relief of some other anxiety (disquiet of mind). SUGGESTIONS FOR MOTIVATING PATIENTS 47
  • 48.  Kegeles (1963) has suggested a procedure for dealing with such a patient.  He indicates that the following format is a useful framework in which to educate the patient relative to dental disease.  For a patient to make a dental visit and to undergo treatment that is oriented toward prevention he must believe the following: 1. That he is susceptible to periodontal disease 2. That periodontal disease is personally serious 3. That there is something he can do to treat or correct the condition 4. To a lesser degree that the condition occurred due to natural causes SUGGESTIONS FOR MOTIVATING PATIENTS 48
  • 49.  A patient must first believe that he is susceptible to periodontal disease before he can possibly consider the personal seriousness of it.  Likewise he must accept his susceptibility and its seriousness before he can be required to consider whether any action that he may take will be beneficial in treating the problem.  If the patient accepts the fact that periodontal disease is serious for him, but does not accept the fact that he is susceptible to it., he will never take any beneficial action.  Similarly, if he believes that he is susceptible, but that it is of no consequence, he will never agree to treatment.  In like manner he may accept his susceptibility and its seriousness for him and yet not believe that periodontal therapy and oral hygiene will help him.  He still will not take beneficial action. SUGGESTIONS FOR MOTIVATING PATIENTS 49
  • 50.  Therefore Kegeles outlines must be followed.  The dentist must develop a suitable presentation that will convince the patient that he has every right to expect that, as a member of the human race, he is susceptible to periodontal disease  If the dentist is aware of some of the motives that compel men to action, he may similarly present the patient with factual information on the seriousness of tooth loss from the financial, hygienic, functional, esthetic, or psychological aspects.  The choice of approach depends on the patient's values in relation to his teeth. SUGGESTIONS FOR MOTIVATING PATIENTS 50
  • 51.  Once the patient has truly accepted both his susceptibility and the serious nature of periodontal disease he will probably ask the dentist what he can do about treating the condition.  At this point a personal disease control program is outlined.  The individual dentist and his complete office staff should have their dental disease under control and should enthusiastically teach such a program to all patients (Kutz et al 1972).  Kegeles' last point states that the patient must believe that periodontal disease has occurred in his mouth due to natural causes.  This means that the patient should accept his condition as a natural biologic sequence of events and not as a punishment evoked by God for some past sins.  Occasionally, successful patient motivation is blocked by such a belief. SUGGESTIONS FOR MOTIVATING PATIENTS 51
  • 53.  Patients can reduce the incidence of plaque and gingivitis with repeated instruction and encouragement much more effectively than with self- acquired oral hygiene habits Gravelle et al 1967, Suomi et al 1969  However, instruction in how to clean teeth must be more than a cursory chair side demonstration on the use of a tooth brush.  It is a painstaking procedure that requires patient participation, careful supervision with correction of mistakes, and reinforcement during return visits, until the patient demonstrates that he or she has developed the necessary proficiency Anderson JC 1972, Less W 1972 ORAL HYGIENE INSTRUCTIONS 53
  • 54.  Any strategy for introducing plaque control to the periodontal patient includes several elements.  At the first instruction visit, the patient should be given a new toothbrush, an interdental cleaner, and a disclosing agent.  The patient’s plaque should be disclosed because dental plaque otherwise is difficult for the patient to see Newman et al 2006 ORAL HYGIENE INSTRUCTIONS 54
  • 55. A - Because bacterial plaque is relatively invisible and many tooth surfaces are not easily accessed, teaching patients the skills necessary for disease control can be difficult. B -Agents that make supragingival plaque visible can enhance the teaching- learning process by i) Demonstrating a relationship between the presence of supragingival plaque and the clinical signs of disease. ii) Guiding skill development when applied before plaque removal. iii) Allowing evaluation of skill effectiveness when applied after plaque removal. BACTERIAL PLAQUE DETECTION M L DARBY 1998 55
  • 56. C - Presence of subgingival plaque cannot be demonstrated by the use of disclosing agents. D - Plan for disease control education should include establishing the association between the presence of plaque and clinical signs of disease, such as bleeding. E - Subgingival plaque detection by the client is best managed when there is an understanding of the gingival sulcus and/or pocket and the clinical changes that will occur when bacterial plaque removal is not effective BACTERIAL PLAQUE DETECTION 56
  • 57. I. Purposes  A disclosing agent clearly demarcates soft deposits that might otherwise be invisible and therefore facilitates the following: a. Personalized patient instruction in the location of soft deposits and the techniques for removal. b. Self assessment by the patient on a daily basis during initial instruction and periodic checks thereafter. c. Continuing evaluation of the effectiveness of the instruction for the patient. i) Determining the need for revision of the biofilm control procedures. ii) Studying the long term effects over successive maintenance appointments. DISCLOSING AGENTS E M WILKINS 2005 57
  • 58. d. Preparation of biofilm indices. e. Conducting research studies to gain new information about the incidence and formation of deposits on the teeth, the effectiveness of the specific diseases for dental biofilm control, and anti biofilm agents and to evaluate clinical and instructional group health programs. DISCLOSING AGENTS 58
  • 59. II. Properties of an acceptable disclosing agent A. Intensity of Color : A distinct staining should be evident, color should contrast with normal colors of oral cavity. B. Duration of Intensity: should not rinse off immediately with ordinary rinsing methods, neither should it be removable by the saliva for the period of time required to complete the instruction or clinical service. C. Taste: The patient should not be made uncomfortable by an unpleasant or highly flavored substance D. Irritation to the mucous membrane: The patient should be questioned concerning the possibility of an idiosyncrasy to an ingredient. DISCLOSING AGENTS 59
  • 60. E. Diffusibility: A solution should be thin enough so it can be applied readily to the exposed surfaces of the teeth, yet thick enough to impart an intense color to dental biofilm. F. Astringent and Antiseptic Properties : These properties may be highly desirable in that the disclosing agent may contribute other factors to the treatment procedures DISCLOSING AGENTS 60
  • 61. III. Formulae  A variety of disclosing agents has been used.  Skinner’s iodine solution was formerly the most classic and widely used.  In general, iodine solutions are less desirable because of their unpleasant flavor.  Aniline dyes have been shown to have carcinogenic potential.  Therefore, the use of basic fuchsine and beta rose (flavored basic fuchsine) has been discouraged.  Other well-known agents are Buckley’s Berwic’s, Talbot’s iodo-glycerol, and Metaphen solutions. DISCLOSING AGENTS 61
  • 62. 62
  • 63. 1V Methods for application A. Solution for Direct Application (Painting) 1. Have patient rinse to remove food particles and heavy saliva. 2. Apply water-based lubricant generously to prevent staining of the lips. 3. Dry the teeth with compressed air, retracting cheek or tongue 4. Use swab or small cotton pellet to carry the solution to the teeth 5. Apply solution generously to the crowns of the teeth only. 6. Direct the patient to spread the agent over all surfaces of the teeth with the tongue 7. Examine the distribution of the agent and request the patient to rinse if indicated. DISCLOSING AGENTS 63
  • 64. B. Rinsing  A few drops of a concentrated preparation are placed in a paper cup and water is added for the appropriate dilution.  Instruct the patient to rinse and swish the solution over all tooth surfaces. C. Tablet or Wafer  The patient chews the wafer (one half may be sufficient for some patients), swishes it around for 30 to 60 seconds, and rinses. DISCLOSING AGENTS 64
  • 65. V. Interpretation A. Clean tooth surfaces do not absorb the coloring agent; when pellicle and dental biofilm are present, they absorb the agent and are disclosed B. Pellicle stains as a thin, relatively clear covering whereas dental biofilm appears darker, thicker, ' and more opaque. C. Two-Tone 1. Red Biofilm. Newly formed, thin, usually supragingival. 2. Blue Biofilm. Thicker, older, more tenacious; usually it is seen at and just below gingival margin, especially on proximal surfaces and where brush or floss is not easily applied; may be associated with calculus deposits. DISCLOSING AGENTS 65
  • 67. 67
  • 68. VI. Patient instruction A. Explain Dental Plaque B. Show Location and Distribution of Plaque C. Demonstrate Methods for Daily Plaque Removal DISCLOSING AGENTS 68
  • 69. A. Iodine solutions - Skinner’s solution, Diluted Tincture of Iodine B. Mercurochrome preparation - Mercurochrome Solution (5%), Flavored Mercurochrome Disclosing Solution C. Bismarck brown (Easlick’s Disclosing Solution) D. Merbromin E. Erythrosin - Concentrate for Application by rinsing , For Direct Topical Application , Tablet F. Fast Green G. Fluorescein (Lang et al 1972) H. Two-Tone (Block et al 1972) DISCLOSING AGENTS 69
  • 70.  The bristle toothbrush appeared about the year 1600 in China, was first patented in America in 1857.  Generally tooth brushes vary in size and design, as well as length, hardness, and arrangement of the bristles. Silverstone LM , Featherstone MJ 1988  The American Dental Association has described the range of dimensions of acceptable brushes: - Length : 1 to 1.25 inches - Width : 5/16 to 3/8 inches - Surface area : 2.54 to 3.2 cm - No. of rows : 2 to 4 rows of brushes - No. of tufts : 5 to 12 per row - No. of bristles : 80 to 85 per tuft TOOTH BRUSHES Newman et al 70
  • 71.  Never advice hard toothbrush  gingival laceration, recession, tooth abrasion  Bristles of children's toothbrush  always soft (0.1-0.15mm) Fransden 1972  Adult brush head : 2.5 cm, children 1.5cm  Bristle  even length  Bristle should penetrate gingival crevice without causing damage  Brush  easy to clean  Toothbrush handle should rest comfortably in hand  Non-toxic, hygienic TOOTH BRUSHES 71
  • 72. A. Sequence 1. A methodical, systematic approach will enhance effectiveness 2. Suggested sequence: begin systematic overlapping strokes at the facial aspect of the maxillary right or left terminal tooth and continue around the arch to the terminal tooth on the opposite side; switch to the lingual aspect and begin working back toward the starting side; use the same pattern for the mandible, then brush the occlusal surfaces. FACTORS IN TOOTHBRUSHING EFFECTIVENESS M L DARBY 1998 72
  • 73. B. Duration 1. Each time the brush is moved, the time spent in an area should be monitored by counting strokes or seconds 2. Total manual brushing time of 3 to 5 minutes has been suggested; powered brushes may be used for 2 minutes FACTORS IN TOOTHBRUSHING EFFECTIVENESS 73
  • 74. C. Frequency 1. Thorough bacterial plaque removal once a day is the minimum requirement for maintaining periodontal health; it may not, however, be the optimum regimen for some individuals 2. Frequency should be increased when gingival or periodontal conditions warrant it or when caries risk or activity is high 3. Brushing removes residual food debris as well as bacterial plaque and is one method for self application of topical fluoride FACTORS IN TOOTHBRUSHING EFFECTIVENESS 74
  • 75. D. Skill level 1. Careful attention should be given to evaluating skill development in all components of brush manipulation, including grasp, placement, activation, wrist movement, and amount of pressure applied 2. Control of brush placement and motion is essential for effectiveness FACTORS IN TOOTHBRUSHING EFFECTIVENESS 75
  • 76. Roll: Roll method or modified Stillman technique Vibratory: Stillman, Charters, and Bass techniques Circular: Fones technique Vertical: Leonard technique Horizontal: Scrub technique  Scrub technique: probably the simplest and most common method of brushing.  Patients with periodontal disease are most frequently taught a sulcular brushing technique using a vibratory motion to improve access in the gingival areas.  The method most often recommended is the Bass technique because it emphasizes sulcular placement of bristles. TOOTHBRUSHING METHODS 76
  • 77.  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.  Place the bristles at the gingival margin, pointing at a 45-degree angle to the long axis of the teeth.  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 as well as partly into the interproximal embrasures.  The pressure should be firm enough to blanch the gingiva  Complete several strokes in the same position.  Lift the brush, move it to the adjacent teeth, and repeat the process for the next three or four teeth. BASS TECHNIQUE BASS CC 1954 77
  • 78. BASS TECHNIQUE • Place the toothbrush so that the bristles are angled approximately 45 degrees from the tooth surfaces. • Start at the most distal tooth in the arch, and use a vibrating, back-and forth motion to brush. 78
  • 79. A. Proper position of the brush in the mouth aims the bristle tips toward the gingival margin. B. Diagram shows the ideal placement, which permits slight subgingival penetration of the bristle tips. BASS TECHNIQUE 79
  • 81.  Brush is placed with bristles resting partly on cervical portion of tooth and partly on adjacent gingiva, pointing in an apical direction at an oblique angle to long axis of tooth  Pressure is applied laterally towards gingival margin to produce blanching  Brush is activated with 20 short back and froth strokes and is simultaneously moved in coronal direction along attached gingiva, gingival margin and tooth surface.  Recommended in patients with progressing gingival recession and root exposure to prevent abrasive tissue destruction STILLMAN METHOD STILLMAN PR 1932 81
  • 82.  Brush is placed with bristles pointed towards the crown at 45 degree angle to long axis of the teeth  Sides of the bristles are flexed against the gingiva, and the back and froth vibratory motion is used to massage the gingiva  Bristle tips should not move across the gingiva  Suitable for gentle plaque removal and gingival massage  Indicated in healing wounds after periodontal surgery CHARTERS METHOD CHARTERS WJ 1932 82
  • 83. Method Bristle placement Motion Advantage/ disadvantage Scrub Horizontal on gingival margin Scrub in anterior position direction keeping brush horizontal Easy to learn & best suited fro children BASS Apical towards gingival into sulcus at 450 to tooth surface Short back and forth vibratory motion while bristles remain in sulcus. Cervical plaque removal Easily learned Good gingival stimulation Charter's Coronally 45o, sides of bristles half on teeth and half of gingiva Small circular motions with apical movements towards gingival margin Hard to learn and position brush Clears inter proximal Gingival stimulation Fones Perpendicular to the tooth With teeth in occlusions, move brush in rotary motion over both arches and gingival margin Easy to learn Inter proximal areas not cleaned May cause trauma Roll Apically, parallel to tooth and then over tooth surface On buccal and lingual inward pressure, then rolling of head to sweep bristle over gingiva & tooth Doesn't clean sulcus area Easy to learn good gingival stimulation Stillman's On buccal and lingual, apically at an oblique angle to long axis of tooth. Ends rest on gingiva and cervical part. On buccal and lingual slight rotary motions with bristle ends stationary Excellent gingival stimulation Moderate dexterity required Moderate cleaning of interproximal area Modified stillman's Pointing apically at and angle of 45o to tooth surface Apply pressure as in stillmans's method but vibrate brush and also move occlusally Easy to master Gingival stimulation83
  • 84.  Each of these methods can be modified to add a roll stroke.  The brush is positioned similarly to the Bass/Stillman technique.  After activation of the brush head in a back-and-forth direction, the head of the brush is rolled over the gingiva and tooth in the occlusal direction, making it possible for some of the filaments to reach interdentally. MODIFIED BASS/STILLMAN TECHNIQUE 84
  • 85. A. Brushes should be rinsed clean after each use, allowed to air-dry in an upright position B. Rotating use of more than one brush during 24 prolongs brush life C. Brushes should be replaced when bristles splay resiliency, generally no longer than 3 to 4 months. D. Some brushes have color indicator bristles to monitor replacement time E. Brushes should be replaced after an illness such or flu or disinfected with a household bleaches TOOTHBRUSH MAINTENANCE 85
  • 86.  In 1939 powered tooth brush invented to make plaque control easier.  Its mainly recommended for (a) Individual lacking motor skills (b) Hospitalized patients whose teeth are cleaned by the caregivers. (c) Special needs patient ( physical and mental disability) (d) Patient with orthodontic applied (e) Whosoever wants to use ELECTRIC TOOTHBRUSH ( POWERED) 86
  • 87.  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. Forgas-Brockmann LB et al 1998 POWERED TOOTHBRUSHES 87
  • 88.  No evidence of a statistically significant difference between powered and manual brushes. However, rotation oscillation powered brushes significantly reduce plaque and gingivitis in both the short and long-term C. Deery et al 2003  Electric toothbrush have not been shown to provide benefits routinely for patients with RA, children who are well-motivated brushers , or patients with chronic periodontitis. Heasman, 1999 88
  • 89. Definition Substance used with a tooth brushes are accessible tooth surfaces; available in gel, paste or powder form. Purposes 1. Cosmetic – Tooth surfaces are cleaned and polished, breath is freshened. 2. Therapeutic – Certain non drug substances augment the efficiency of the brush in removal of plaque debris and stain; Vehicle for transporting biologically active ingredients to the tooth and its environment; fluoride dentifrices inhibit tooth demineralization DENTIFRICES 89
  • 90. A. Products selected should carry the American dental Association (ADA) seal B. All ADA accepted dentifrices have safe levels of abrasiveness C. Dentifrices containing fluoride are granted acceptance based on their caries-reduction properties GUIDELINES FOR DENTIFRICE SELECTION 90
  • 91. D. Dentifrices that carry the ADA seal have gained acceptance for the proven efficacy of the fluoride mechanism E. Desensitizing dentifrices that carry the ADA seal have gained acceptance for proven efficacy in the control of dentinal hypersensitivity F. Dentifrices that claim therapeutic benefits other than dental caries reduction (from fluoride) or control of hypersensitivity have not been awarded the ADA seal for such claimed benefit GUIDELINES FOR DENTIFRICE SELECTION 91
  • 92. A. Daily use of fluoride dentifrice should be recommended for all individuals, regardless of caries risk, because these products promote tooth remineralization B. Young children (under age 6) should be supervised when using fluoride dentifrice C. Use of a small pea-sized amount of toothpaste gel containing no more than 1100 ppm fluoride is recommended swallowing should be avoided dental fluorosis has been associated with use of more than a pea sized amount of toothpaste by young children living in fluoridated communities Pendrys DG 1995 GUIDELINES FOR DENTIFRICE USE ADA 1995 92
  • 93.  Any toothbrush, regardless of the brushing method used does not completely remove interdental plaque  This is true for all brushers even periodontal patients with wide open , embrasures. Gejermo et al1970, Schmidet al 1976  Daily interdental plaque removal is crucial to augment the effects of tooth brushing because most dental and periodontal diseases originate in interproximal areas Addy et al 1998  Tissue destruction associated with periodontal disease often leaves large, open spaces between teeth and long, exposed root surfaces with anatomic concavities and furcation's.  These areas are both difficult for patients to clean and poorly accessible to the toothbrush Kinane 1998 INTERDENTAL CLEANING AIDS 93
  • 94.  Many tools are available for interproximal cleaning.  They should be recommended based on the patient's interdental architecture (e.g., size of interdental spaces), Presence of furcation's, tooth alignment, and presence, of orthodontic appliances or fixed prostheses.  Also, 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. INTERDENTAL CLEANING AIDS 94
  • 95. Type I  The gingival papilla fills up the embrasure space completely  floss Type II  The gingival papilla partially fills the embrasure space due to papillary recession tufted dental floss/super floss , interdental brushes/proxy-brushes Type III  The embrasure space is not filled. The gingival papilla has receded extensively or it is completely lost  interdental brush/proxy-brushes, single tufted brushes Norland , Tarnow 1998 CLASSIFICATION OF EMBRASURE 95
  • 96.  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 do not fray.  Clinical research has demonstrated no significant differences in the ability of the various types of floss to remove dental plaque  they all work equally well. Grossman 1979, Keller 1969  Waxed dental floss was thought to leave a waxy film on proximal surfaces, thus contributing to plaque accumulation and gingivitis. Robert H. Beaumont 1990 DENTAL FLOSS 96
  • 97. Dental floss should be held securely in the fingers or tied in a loop. (12-18 “) Dental floss technique. The floss is slipped between the contact area of the teeth, is wrapped around the proximal surface, and removes plaque by using several up-and-down strokes. 97
  • 99. INTERDENTAL BRUSH (PROXY BRUSH)  Interdental brush are conical shape brushes made of bristles mounted on a handle / single tufted brushes.  Suitable for cleaning large, irregular, or concave tooth surfaces adjacent to wide interdental spaces.  Inserted inter-proximally and are activated with short back and forth strokes in between the teeth. 99
  • 100. 100
  • 101.  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 tooth brushing and flossing, since this might reduce a potential reservoir of microorganisms contributing to plaque formation Christen & Swanson 1978  The bacterial accumulations on the dorsum of the tongue may also be the source of bad breath. TONGUE CLEANER 101
  • 102.  Massaging the gingiva with a toothbrush or an interdental cleaning devices produces epithelial thickening. increased keratinization, and increased mitotic activity . Canter et al1965, Castenfelt 1952, Glickman et al 1965  The increased keratinization occurs only on the oral gingiva and not the areas more vulnerable to microbial attack  the sulcular epithelium and the interdental areas where the gingival col is present.  Improved gingival health associated with interdental stimulation is much more likely the result of plaque removal than gingival massage. GINGIVAL MASSAGE 102
  • 103.  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. CHEMICAL PLAQUE CONTROL WITH ORAL RINSES NEWMAN ET AL 103
  • 104. 1st generation agents  Decrease plaque by 20-50% Good antimicrobial activity but poor substantivity  Antibiotics: Penicillin , Erythromycin, Metronidazole  Quaternary ammonium compounds: Cetylpyridium chloride , Benzylchonium chloride  Phenolic compounds: Phenol, thymol  Essential oils: Eucalyptol, benzoic acid  Herbal extracts: Sanguinarine  Oxygenating agents: Peroxides CLASSIFICATION OF CHEMICAL PLAQUE CONTROL AGENTS Lindhe et al 105
  • 105. 2nd Generation Agents  Decrease plaque by 60-90% Good antimicrobial activity and excellent substantivity  Bisbiguanides: Alexidine , Chlorhexidine  Bispyridines: Octenidine 3rd Generation Agents  They prevent plaque formation by inhibiting the pellicle attachment.  Amine alcohol: Delmopinol CLASSIFICATION 106
  • 106.  To replace mechanical tooth brushing when this is not possible in the following situation: - After oral or periodontal surgery and during the healing period - After inter-maxillary fixation used to treat jaw fractures or following cosmetic surgery. - With acute oral mucosal or gingival infections when pain and soreness prevents mechanical oral hygiene. - For mentally or physically handicapped patients who are unable to brush their teeth themselves. ID Mandel 1972 USES OF ANTI-PLAQUE MOUTHWASH 107
  • 107.  As an adjunct - to normal mechanical oral hygiene in situations where this may be compromised by discomfort or inadequacies.  Following sub gingival scaling and root planning when the gingival may be sore for days.  Following scaling when there is cervical hypersensitivity due to exposed root surface. Its use needs to be combined with measures to treat the hypersensitivity.  Following scaling in situations when the patients oral hygiene remains inadequate. SG Ciancio 1986 USES OF ANTI-PLAQUE MOUTHWASH 108
  • 108.  Dispense the prescribed amount of mouthwash  Pour it into the mouth.  Close your mouth to create a seal  Do not swallow the mouthwash  Swish it through your teeth for 30 seconds to a minute and then spit HOW TO PRESCRIBE A MOUTHRINSE 109
  • 109. HOW TO PRESCRIBE A MOUTHRINSE 110
  • 110.  Colgate  Colgate Plax Peppermint Mouthwash (Rs 85 – Rs 99 /250ml)  Colgate Plax Complete Care Mouthwash (Rs 100 – Rs 112/250ml)  Colgate Plax Sensitive Mouthwash (Rs 105 – Rs 112 / 250ml)  Colgate Plax Fresh Tea (Rs 105 – Rs 112 /250ml) MOUTHWASHES AVAILABLE IN INDIA 113
  • 111.  Listerine  Listerine Fresh Burst Mouthwash (Rs 95 – Rs 100 /250ml)  Listerine Original Mouthwash (Rs 98 – Rs 100 /250ml)  Listerine Cool Mint Mouthwash (Rs 100 – Rs 102 /250ml) MOUTHWASHES AVAILABLE IN INDIA 114
  • 112. • Colgate® PerioGard® Rinse • Acclean® Chlorhexidine gluconate 0.12% oral rinse • Rexidine mouth wash 115 CHLORHEXIDINE MOUTHWASHES AVAILABLE IN INDIA
  • 113.  Pepsodent  Pepsodent Germi Check Fresh Mint Mouthwash (Rs 115 – Rs 122 /300ml)  Pepsodent Germi Check Herbal Fresh Mouthwash (Rs 115 – Rs 122 / 300ml) MOUTHWASHES AVAILABLE IN INDIA 116
  • 114.  Oral-B  Oral B Mouthwash Alcohol Free Multi-Protection (Rs 150 – Rs 165 for 500ml)  Crest  Crest Pro-Health Complete Fresh Mint Fluoride Mouthwash (Rs 425 – Rs 525 for 1Litre)  Crest Pro Health Clinical Deep Clean Mint (Rs 375 – Rs 450 for 975ml) MOUTHWASHES AVAILABLE IN INDIA 117
  • 115.  Himalaya  Himalaya HiOra-K Mouthwash (Rs 75 – Rs 80 for 215ml)  Aquafresh  Aqua Fresh Tingling Mint Mouthwash (Rs 280 – Rs 305 for 500ml) MOUTHWASHES AVAILABLE IN INDIA 118
  • 116.  Oral irrigators for daily home use by patients 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 non-adherent bacteria and debris from the oral cavity more effectively than toothbrushes and mouth rinses.  Irrigators are particularly helpful for removing debris from inaccessible areas around orthodontic appliances and fixed prostheses.  When used as adjuncts to tooth brushing, these devices can have a beneficial effect on periodontal health  Both supra and sub-gingival irrigators are available ORAL IRRIGATORS 119
  • 117. 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 the tongue C, Soft rubber tip is used for daily subgingival irrigation by the patient at home. 120
  • 118. Coarse fibrous foods  As part of the plaque control program patients should be advised to include hard fibrous foods in their diet, particularly at the end of meals.  Although some investigators disagree (Lindhe et al 1969) it is the consensus that hard fibrous foods reduce plaque accumulation and gingivitis on tooth surfaces exposed to their mechanical cleansing action during mastication Bear et al 1961, Stewart et al 1960  Coarse fibrous foods  functional stimulation to the periodontal ligament and alveolar bone.  Soft diets  increased plaque accumulation and calculus formation, gingivitis and periodontal disease Plezer et al 1940  Animals fed soft diets enriched with vitamins and minerals develop severe periodontal disease with loosening of the teeth, which does not occur when the diet includes lengths of bone and adherent meat which require vigorous chewing King et al 1945 DIET GLICKMAN 1972 121
  • 119. Limiting sucrose-containing foods  The fact that the ingestion of sucrose increases plaque formation is of great clinical importance.  The polysaccharide dextran is a major component of the plaque matrix.  It is a sticky substance which envelops the plaque bacteria and attaches the plaque to the tooth surface.  The bacteria form the dextran from carbohydrates, particularly sucrose.  Limiting the intake of sugar and sugar-sweetened foods assists in reducing plaque formation (Carlson et al 1965) and patients should be instructed accordingly. DIET 122
  • 120.  No therapeutic intervention is without adverse effects, including oral hygiene practices.  Tooth abrasion and gingival recession are both alleged to be caused by traumatic brushing. Tooth Abrasion  Evidence implicating the toothbrush in cases of abrasion comes primarily from in vitro studies, case reports, and cross-sectional studies.  Some studies have implicated a horizontal scrubbing stroke as a more important risk factor for tooth abrasion than bristle stiffness.  Other studies have indicated that abrasive toothpastes are the primary cause of tooth abrasion. Vander et al 1996 ADVERSE EFFECTS OF ORAL HYGIENE AIDS 123
  • 121. Gingival Recession  Gingival recession is the result of an interaction between precipitating factors, such as trauma to the gingival tissues, and predisposing factors,, such as a thin tissue complex.  Gingival recession, particularly that occurring on the buccal surface, is often presumed to be the result of toothbrush trauma.  It seems logical to assume that the thin gingival biotype might be more easily traumatized.  There is evidence suggesting that thin tissue is more prone to recession Olsson1993 ADVERSE EFFECTS OF ORAL HYGIENE AIDS 124
  • 122. Possible Adverse Effects of Home Irrigation  A number of investigators have examined the effect of pulsating water jet devices on gingiva and mucosa and most have concluded there is little risk for tissue damage when such devices are used according to manufacturer's instructions Rethman et al 1994  In one investigation, the use of an irrigator at 60 psi in untreated periodontal pockets created no more tissue damage than was found in the "no irrigation" control group Cobb et al 1988  Some investigators have reported no bacteremia after irrigation, whereas others have reported that this does occur. Because this could have implications for individuals at risk for endocarditis, some authorities have recommended that the devices not be used by individuals at risk. Page et al 1997 ADVERSE EFFECTS OF ORAL HYGIENE AIDS 125
  • 123.  Thorough plaque removal may enhance the results of regenerative surgical therapy and may help provide stability to the gains in clinical attachment achieved Tonetti et al 1996  In the immediate postoperative period plaque control is accomplished by means of chemotherapeutic agents such as chlorhexidine gluconate rinses, and mechanical plaque removal is generally avoided.  Some tissue maturation should occur before resumption of normal oral hygiene  Critical to the regenerative outcome is wound stability and the preservation of the delicate fibrin forms on the root surface.  The presence of this fibrin clot may prevent the down growth of the epithelium, there by permitting regeneration of the attachment apparatus ORAL HYGIENE AFTER REGENERATIVE PROCEDURES 126
  • 124.  It is often recommended that professional subgingival debridement and probing be avoided for 6 months after regenerative surgery, but little is said about the resumption of oral hygiene measures Slots et al 1999  Do not brush or floss the surgical area for the first 7-10 days Bruce B. Wiland ORAL HYGIENE AFTER REGENERATIVE PROCEDURES 127
  • 125.  The foundation of a preventive health-oriented dental practice is an effective hygiene department.  We are responsible for delivering not only quality restorations with which patients can prevent dental disease, but also a structured program to aid them in taking care of their health and investment.  It is the quality of the dentist's restorations and the effectiveness of his or her hygiene program that determine whether he or she is practicing true preventive dentistry or simply functioning in a reparative manner-always "putting out fires." CONCLUSION 128
  • 126. 1. Carranza’s clinical periodontology - 10th edition 2. Clinical practice of the dental hygienist - Esther M Wilkins 3. Dental maintenance for patients with periodontal disease – Thomas G Wilson 4. Periodontics – BM Eley , JD Manson 5. A handbook for the dental hygienist – W Collins, TF Walsh 6. Arnim, S.S.: Use of Disclosing Agents for Measuring Tooth Cleanliness, J. Periodontol., 34, 227, May, 1963 7. Glickman I, Petralis R, Marks R: The effect of powered toothbrushing plus interdental stimulation upon the severity of gingivitis, J Periodontol 35:519, 1964 REFERENCES 129
  • 127. 8. Glickman I, Petralis R, Marks R: The effect of powered toothbrushing and interdental stimulation upon microscopic inflammation and surface keratinization of the interedental gingiva, J Periodontol 3:108, 1965. 9. Lindhe, J., and Wicen, P.O.: The Effects on the Gingivae of Chewing Fibrous Foods. J. Periodont. Res., 4:193, 1969. 10. Loe H, Anerud A, Boysen H: The natural history of periodontal disease in man: prevalence, severity, and extent of gingival recession, J Periodontol 63:489-495, 1992. 130
  • 128. 131

Editor's Notes

  1. Milieu- social environment
  2. Dental plaque is defined as a specific but highly variable sturctural entity, resulting from colonisation and multiplication of microorganisms on tooth surface, restorations and other parts of the oral cavity which consists of salivary components like mucin, desquamated epithelial cells, debris and microorganisms all embedded in a gelatinous extracellular matrix. (WHO 1978) Biofilms: defined as matrix embedded microbial populations, adhering to each other and/or to surfaces or interfaces. (Costerton 1995)
  3. 1. Early colonizers: are either independent or defined complexes. Member of Yellow (Streptococcus spp.) or Purple complexes (Actinomyces odontolyticus). 2. Secondary colonizers:Members of Green complexes (Eikenella corrodens, Actinobacillus actinomycetemcomitans serotype a, and Capnocytophaga species), Orange (Fusobacterium, Provotella and Camphylobacter) and Red complexes
  4. However results of studies on tongue brushing as an adjunct to tooth brushing in order to reduce plaque formation are inconclusive Badersten et al 1975
  5. Epithelial thickening, increased keratinization, and increased blood circulation have not been shown to be beneficial for restoring gingival health Glickman et al 1964
  6. The bacterial cell is characteristically negatively charged. The cationic chlorhexidine molecule is rapidly attracted to the negatively charged bacterial cell surface, with specific and strong adsorption to phosphate-containing compounds. This alters the integrity of the bacterial cell membrane and chlorhexidine is attracted towards the inner cell membrane. Chlorhexidine binds to phospholipids in the inner membrane, leading to increased permeability of the inner membrane and leakage of low-molecular-weight components, such as potassium ions. At this bacteriostatic (sublethal) stage, the effects of chlorhexidine are reversible; removal of excess chlorhexidine by neutralizers allows the bacterial cell to recover (22). This implies that the structural changes to the cytoplasmic membrane caused by low levels of chlorhexidine are minor compared with the gross damage caused by higher concentrations (bactericidal) levels of the agent Increasing the concentration of chlorhexidine causes progressively greater damage to the membrane, reflected in the size of the permeable species lost from the cell (36, 46). As the concentration of chlorhexidine increases, leakage of low-molecularweight cytoplasmic components falls, reflecting the coagulation and precipitation of the cytoplasm by The formation of phosphated complexes such as adenosine triphosphate and nucleic acids (22). Electron micrographs show the cytoplasm of such cells to be chemically precipitated; this bactericidal stage is irreversible (22 great affinity for the cell wall of microorganisms and changes the surface structures. Osmotic equilibrium is lost, and as a consequence,cytoplasmic membrane is extruded, vesicles are formed, and the cytoplasm precipitates (Davies 1973, Brecx & Theilade