This document discusses various methods of plaque control and oral hygiene. It defines plaque control as the regular removal of dental plaque and outlines its objectives such as removing soft deposits and treating and preventing periodontal diseases. It then describes different toothbrushing techniques, toothbrush designs, powered toothbrushes, dentifrices, interdental cleaning aids, and the effects of improper toothbrushing. Finally, it discusses various chemical plaque control agents classified by generation and chemical composition.

2. ● Definition:
It is the regular removal of dental plaque and prevention of its
accumulation on the teeth & adjacent gingival surfaces.
● Objectives of plaque control:
1. Primary role in removal of soft deposits on teeth and gingival
tissue.
2. Effective method of treating as well as preventing periodontal
diseases.
3. Gingival stimulation (gingival massage): by increasing
gingival tone, surface keratinization, gingival vascularity and
gingival circulation.

3. ● The toothbrush:
Toothbrushes vary in size, design, hardness &
arrangement of bristles.
There is no significant differences in gingivitis scores or
bleeding indices.
● Toothbrush design:
The bristles are grouped in tufts & arranged in 3 or 4 rows.
They may be round ended or flat-cut ended.
They may be natural from hogs or artificial from nylon.
They also vary in their hardness.

4. ● Powered toothbrush :
They remove plaque as well as, if not slightly better than,
manual brushes.
Usage:
Children, handicapped pts., old aged pts., hospitalized
pts., pts. have orthodontic or fixed appliances.

5. ● Dentifrices :
They aid in cleaning & polishing tooth surfaces, and are
available in pastes, powders & gels.
The composition:
1- abrasive (silicon oxides & aluminum oxides).
2- flavoring & sweeting agents.
3- water.
4- humectants.
5- soap & detergent.
6- coloring agents.
7- therapeutic agents (fluoride,
pyrophosphates).
8- preservative.
The effect of vigorous tooth brushing with
an abrasive dentifrice.

6. Brushing sequence and timing:
 Regardless of the tooth brushing method selected a sequence of
brushing should be given to the patient.
 Patient is instructed to start with molar region of one arch around
the facial surfaces then continue back around the lingual surfaces
of the same arch starting with the molar region on the opposite
side. Same procedure is followed for other arch.
 Last surfaces to be brush are occlusal.
 Patient is instructed to stroke each area ten time of spend 10
seconds per area then move on to next area.

7. ●Tooth brushing methods :
Are classified according to the pattern of motion:
1- Roll: Roll method or modified Stillman technique.
2- Vibratory: Stillman, Charter, Bass techniques.
3- Circular: Fones technique.
4- Vertical: Leonard technique.
5- Horizontal: Scrub technique.

8. 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, aplically at an
ablique 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 stimulation

9. Bass Method
Indications:
For all patients for dental plaque removal adjacent
to & directly beneath gingival margins.
Recommended for routine patients with or without
periodontal involvement.

10. •Technique:
Place the head of a soft brush parallel with the
occlusal plane, with the brush head covering 3 to 4
teeth, beginning a 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

11. • Exert gentle vibratory pressure, using short back &
forth motions coming without dislodging the tips of
the bristles.
• This motion forces the bristle ends into the gingival
sulcus area as well as partly into the inter-proximal
embrasures. The pressure should be firm enough to
blanch the gingiva

12. Complete several strokes in the same position. The
repetitive motion cleans the tooth surface,
concentrating on the apical third of the clinical
crowns, the gingival sulci & as far onto the proximal
surfaces as the bristles can reach.
Lift the brush, move it to the adjacent teeth & repeat
the process for the next three or four teeth.
Continue around the arch, brushing about three teeth
at a time. Then, use the same method to brush the
palatal surfaces.
After completing the maxillary arch, move the brush to
the mandibular arch & brush in the same organized
way to reach all the teeth.

13. Brush the occlusal surface of 3 to 4 teeth at a time by
pressing the bristles firmly into the pits & fissures &
brushing with several short, back & forth strokes.
Advantages:
Effective method for removing plaque adjacent to &
directly beneath the gingival margin, cervical areas
& sulcus.
Provides good gingival stimulation.
Easy to learn.
Disadvantages:
Overzealous brushing may convert the “very short
strokes” into a scrub brush technique & cause
injury to the gingival margin.
Time consuming.

14. Modified StiIlman’s Method
 Indications:
Recommended for cleaning in areas with progressing
gingival recession & root exposure to prevent
abrasive tissue destruction.
Dental plaque removal from cervical areas below the
height of contour of the enamel & from exposed
proximal surfaces.
General application for cleaning tooth surfaces and
massage of the gingiva.

15. Technique:
The brush be placed with bristle ends resting partly on
the cervical portion of the teeth & partly on the adjacent
gingiva, pointing in an apical direction & at an oblique
angle to the long axis of the teeth.
Apply pressure against the gingival margin to produce
a perceptible blanching.
Then move the brush about 20 short back and forth
strokes while simultaneously moving it coronally
along the attached gingiva, the gingival margin & the
tooth surface.

16. A soft or medium
multi-tufted brush
should be used with
this technique to
minimize trauma to
the gingiva.
With this technique,
the sides rather than
the ends of the
bristles do the work.
The bristles tend not
to penetrate into the
gingival sulcus.

17.  The occlusal surfaces of the molars & premolars are
cleaned with the bristles placed perpendicular to occlusal
plane and penetrating into the grooves & interproximal
embrasures.
Disadvantages:
 Time consuming.
 Improper brushing can damage the epithelium
attachment.

18. Charter’s Method
Indications:
For patients who have had periodontal surgery.
Those wearing prosthetic or orthodontic appliances.
Individual’s having open inter-dental spaces with
missing papilla & exposed interproximal root surfaces.

19. Technique:
Bristles are placed at an angle of
45 degree to gingiva with the
bristle directed coronally.
The bristles are activated by
mild vibratory strokes with
bristles ends lying inter-
proximally.
Disadvantages:
Brush ends don’t engage the
gingival sulcus to remove sub
gingival bacterial
accumulations.
Requirements in digital dexterity
are high.

20. Effects of Improper Tooth Brushing
Gingival alterations:
 Acute alterations:
 Scuffled epithelial surface with denuded underlying C.T.
 Punctate lesions that appear as red pinpoint spots.
Precipitating factors:
 Horizontal or vertical scrubbing tooth brushing method with pressure.
 Over vigorous placement and application of tooth brush.
 Penetration of gingiva by filament ends.
 Use of tooth brush with frayed, broken bristles of filaments
 Chronic alterations:
 Usually appear on the facial gingiva because of the vigor.
 Area most commonly involved are around canines or teeth in labio or bucco version.

21.  Recession:
 The margin of the gingiva has receded towards the apex and the cementum is
exposed.
 Predisposing anatomic factors
Malposition of teeth.
Narrow Band of attached gingiva can’t withstand pressures of
brushing.
Precipitating factors:
 Repeated use of vigorous rotary, vertical or horizontal tooth brushing techniques
over a long period of time.
 Use of long brisk strokes with excessive pressure over a long period of time.
 Habitual prolonged brushing in one area.

22. Abrasion of the teeth:
It is defined as the pathologic wearing away of
tooth substance through some abnormal
mechanical process.
 Contributing factors:
 Hard tooth brush.
Horizontal brushing.
Excessive pressure during brushing.
Abrasive agent in the dentifrice.
 Appearance:
Saucer shaped or wedge shaped indentation
with smooth shiny surfaces.

23. ● Interdental cleaning aids:
Brushing does not completely remove ID plaque even in
wide embrasures.
ID cleaning augment the effects of tooth brushing.
The purpose is to remove ID plaque not dislodge food
wedged between teeth.
● Dental floss:
It is a multifilament nylon yarn which may be:
twisted or non twisted
bonded or non bonded
waxed or unwaxed
thick or thin
There is no difference between these types but the choice
depends on the tightness of tooth contact & roughness of
proximal surfaces.

24. Dental flossing

25. ● Floss holder:
It should be rigid & simple to string with floss.
● Powered flossing devices:
It has a single bristle moving in a circular
motion.

26. ● Interdental cleaning devices:
Dental floss can not clean the concave root surfaces &
furcations present in pts. with significant attachment loss
& recession.
Embrasures vary in size & shape. The larger the space,
the larger the device should be.
A :dental floss is used in embrasure with
no gingival recession.
B:interproximal brush is used in embrasure
of larger spaces.
C:single-tufted brush is used in
interproximal space
with no papilla.

27. A wide variety of ID cleaning devices are
available. (A, B, E, G)

28. ● lnterdental brushes:
They are suitable to clean large, irregular or
concave tooth surface adjacent to wide ID
spaces. (C, D, F)

29. ● Wooden or rubber tips:
They are used with or without a handle.
The base resting on gingiva & sides in contact
with proximal surfaces.

30. They are used around all surfaces.
Wooden toothpick used to clean subgingivally
and along the gingival margins.

31. ●Gingival massage:
Tooth brushing or ID cleaning devices leads to:
epithelial thickening
increase keratinization of oral gingiva
increase mitotic activity of epithelium & C.T.
These effects do not produce gingival health
which is produced by brushing.

32. ● Oral irrigation:
Supragingival irrigation.
Subgingival irrigation.
A:oral irrigator with a built-in pump & reservoir.
B:supragingival irrigator for gingiva & tongue.
C:subgingival irrigator with a soft rubber tip.

33. Chemical Plaque Control
Ideal requirements of antiplaque agents:
It should significantly reduce plaque & gingivitis.
Should prevent growth of pathogenic bacteria.
Should prevent development of resistant
bacteria.
Should be compatible with oral tissues.
Should not stain teeth or alter taste.
Should exhibit good retentive properties.
Should be inexpensive & easy to use.

34. Classification:
Based on substantivity & anti-plaque effect:
1st generation:
 Capable of reducing plaque spores about 20-50%
• Exhibit retention in mouth.
eg. 1. Antibiotics
2. Phenols
3. Quaternary ammonium compounds.
4. Sanguanarine

35. 2nd generation:
• Produce an over all plaque reduction about 70-
90%
• Are better retained by oral tissues & exhibit slow
release properties.
eg. Bis-biguanides
Chlorhexidine
3rd generation:
• Block binding of micro-organism to the tooth.
eg. Delmopinol

36. Antibiotics
Phenols
QAC
Biguanides
Enzymes
Metallic salts
Herbal extracts
Amino alcohols
Other surfactants
Classification based on the chemical
agent:

37. generationst1
Antibiotics:
•Penicillins
•Tetracycline
•Vancomycin
•Kenamycin
•Erythromycin
•Niddamycin
•Spiromycin
•Metronidazole

38. Bactericidal or bacteriostatic action.
Advantages:
Limiting the side effects of systemic drug therapy,
such as:
1- Penicillin hypersensitivity.
2- Bactericidal resistance
Mechanism of Action

39. Phenols & Related essential
oils:
eg.Triclosan
Listerine
25-35% - plaque reduction
Mechanism of action :
Cell wall disruption & inhibiting of bacterial
enzymes.
Listerine compounds:
Thymol + mixed with menthol and methylsalicylate,
benzoic acid and basic acid in 26.9% hydro
alcoholic vehicle.

40. Triclosan:
It has been introduced in toothpaste & mouth rinses
along with zinc citrate & copolymer to enhance its
retention within the oral cavity.
It can delay plaque maturation & also inhibits
formation of prostaglandins & leukotriens.

41. Quaternary ammonium compounds :
eg. Benzathonuim chloride
Benzalkonium chloride
Acetyl pyridinium
They are cationic, antiseptics & surface active agents.
Side effects:
burning sensation of oral mucosa
brownish discoloration of teeth
recurrent ulceration
discoloration of tongue
Mechanism of action:
Molecules have a net positive charge interact with the
negatively charged cell membrane phosphates
resulting in rupture of cell wall structure & increase its
permeability.

42. Sanguanarine:
(Natural products/ Herbal extracts)
It is benzophenanthradine alkaloid found in
commercial mouth rinse paste.
Mechanism of action:
Inhibiting the growth of bacteria.
Its PH is 4.5.
Other herbal extracts:
Miswak, green tea, pomegranate, propolis, carnberry.

43. Metal salts:
Zinc Salts
Tin Salts (Stannous fluoride)
Sodium fluoride
Copper salts
Adverse effects
 Metallic taste
 Dryness of Mouth
 Yellow – brown discoloration of teeth and tongue
Have a plaque inhibitory capacity as they reduce glycolytic activity
in micro-organisms & delayed bacterial growth.

44. 2nd Generation
Bisbiguanides:
eg. Chlorhexidine gluconate – 0.2 %
Alexidine
Cationic Chlorophenyl biguanide
• pH – 3.5
• It is a cationic effective against gram +ve ,gram
-ve, fungi, yeasts & viruses.
Mechanism Action
• It prevents pellicle formation.
• It prevents adsorption of bacterial cell wall on to the tooth surface.
• It prevents binding of mature plaque.

45. Metabolism of Chlorhexidine Glauconate
Bacteriostatic
(Reversible effects )
Cationic Chlorhexidine
molecule is attached towards
negatively charged bacterial
cell surface & it is adsorbed
by phosphate containing
compounds.
The permeability of the inner
membrane will increase &
there will be leakage of low
molecular weight
components.
Bactericidal
(Irreversible effects )
Increase Conc. of
chlorhexidine
Coagulation + precipitation
of the cytoplasm by the
formation of phosphated
complexes, adenosine
phosphate & nucleic acid.

46. Properties:
 Bacteriostatic at low conc.
 Bactericidal at high conc.
 It exhibits antibacterial activity for 5 hrs &
suppresses salivary bacterial count for over 12 hrs.
after a single use.
 Plaque reduction up to 80-90%.
European Formula 0.2%
USA Formula 0.12%

47. Adverse effects of chlorhexidine:
 Brownish staining of teeth & restoration which is
reversible.
 Has a bitter taste.
 Loss of taste sensation which is transient.
 Painful desquamative lesions of the oral mucosa
with burning sensation.
 Rarely, parotid swelling & the condition subside in a
few days by discontinuing the mouth wash.
 Rarely, hypersensitivity.

48. Enzymes:
Used as active agents in antiplaque preparations.
Capable of breaking down the matrix of already
formed plaque were considered for inhibition of
plaque & calculus formation.
eg.: Mucinase
Dextranase
Mutanase

49. 3rd Generation
Delomopinol:
• Inhibits plaque growth – reduce gingivitis
• It interferes with plaque matrix formation & also reduces bacterial
adherence.
• It is indicated as pre- brushing mouth rinse as it weakens binding of plaque
to the tooth surface.

50. Surfactants:
eg. Plax
• Commercial mouth rinse with surfactants properties.
• It is a combination of anionic & ionic surfactants inducing sodium lauryl
sulphate and polysorbate 20.
• Loosen the already formed plaque
• Indicated as pre-brushing mouth- rinse.

51. ● Caries control:
By a fluoride-containing toothpaste to reduce
demineralization & enhance remineralization of
tooth surfaces.
● Disclosing agents:
Used as educational &motivation tools to
improve the efficiency of plaque control
procedures.
● Frequency of plaque removal:
Gingival health can be maintained by thorough
cleaning every 24 – 48 hrs. Improved
periodontal health is associated with brushing
twice daily (not less than 2 min.)