DENTAL PLAQUE

PLAQUE CONTROL IN PEDIATRIC DENTISTRY

MAKAL MADHAV M.P FINAL YEAR PART II REG NO:100020257

CONTENTSIntroductionDental plaqueDisclosing agentMechanical plaque controlChemical plaque controlPlaque control for disabled childPediatric preventive programme

Dental plaque is a complex metabolically interconnected highly organized bacterial ecosystem.

Steps in plaque formationOrganic Pellicle formationAdherenceMaturation Microbiology of plaque includesStreptococci,actinomyces,veillonellae

Plaque controlRemoval of plaque and prevention of its accumulation on teeth and adjacent gingival surface.Key to prevention and successful treatment of periodontal diseasePlaque control can be professional and patient performedRemoval of plaque leads to resolution of gingival inflammation in early stages and prevent reccurence

DISCLOSING AGENTA preparation in liquid tablet or lozenge, which contains a dye or coloring agent which is used for identification bacterial plaque , which is invisible to naked eyes.

INDICATIONSPatient education,instructions for plaque control,self assessment,evaluation effiectiveness ,assessment of clinician,plaque indices.

PropertiesIntensity of color: distinct staining of depositsDuration of intensity: color should not rinse of fastTaste : comforatable, pleasant and flavoredIrritation :should not cause irritation to oral mucosaDiffusibility :solution should be thin,can be applied readily to teeth,thick to impart color to plaqueAstrigent and antiseptic properties

Agents used for disclosing plaqueIodine preparations skinners iodine solution diluted tincture of iodineMercurochrome preparation mercurochrome solution 5% flavored mercurochrome disclosing solution Bismark brown

ErythrosineTwo tone solutionFD &c blue no:1,FD & c red no:3 Fluoresceen FD & yellowBasic fuchsin

Application Directly applied on tooth surface using cotton pellet or rinsed after proper dilution Tablet or wafers may be chewed or swished for 30 or 60 sec and rinsed

Mechanical plaque control aidsChemical plaque control agentsDentifricesBis-biguanides and related compoundsChlorhexidine Alhexidine Tooth brushQuaternary ammonium compound ce tylpyridiniumDental flossAntibioticsPencillin,tetracycline,vancomycin,metronidazoleOral irrigationFluoride and inorganic ionsStannous fluoride,chlorine dioxide ,hydrogen peroxide,sodium bicarbonate,sodium chlorideInterproximal brushesEnzymesDextranase, glucose amyloglucosidase

Wooden tipsOrganic compoundSaguinarine,menthol/thymol,soluble pyrophosphates

Gauze piece for infantsGingival massageTongue scrapers

DENTIFRICES A substance used with tooth brush to remove bacterial plaque, material alba , debris from gingiva and teeth for cosmetic , sanitary ,prevention and therapeutic purpose.Function Minimize plaque build upAnticarious action Removal of stains Mouth freshner

COMPOSTIONAGENTSMATERIALS USEDFUNCTIONPolishing/Abrasive Calcium carbonate, dicalicum phosphate dehydrate, alumina, silica mild abrasive actionBinding /thickeningWater soluble agentsAlginates ,sodium carboxymethyl celluloseWater insolubleMagnesium aluminum silicate,colloidal silica,sodium magnesium silicateStability and consistencyDetergents/surfactantsSodium lauryl sulfateProduces foam which aids in removal of debrisHumectantsSorbitol, glycerin,polyethylene glycolReducing loss moisture Flavoring Peppermint oil,spearmint oil,oil of wintergreenRender product pleasant to use and fresh tastewaterDistilled waterVehiclepreservativesBenzoic acidPrevent microbial growth

Therapeutic Tetrasodium,zncl,pyrophosphateTherapeutic actionSweeting SaccharinSweetenerAntibacterial Triclosan,delmopinol,metallic ions,zinc citrate trihydrateAnticaries Sodium monoflurophosphateSodium fluoride,stannous fluorideAnticalculusPyrophosphates,zinc citrate,zinc chloride ,gantrez acidInhibits mineralization of plaque

Desensitizing Sodium fluoride,potassium nitrate,strontium chloride

Recent development in dentrifices

Tooth paste for childrenHerbal tooth pasteWhitening tooth paste(highly abrasive)Fluoride tooth pasteSensitivity tooth paste

TOOTH BRUSH

The mechanical cleaning of teeth can be traced back to ancient times.Oral hygiene was practiced by egypitans 5000 years ago.Romans used tooth picks made of bones and metals.It was only in 1728 tooth brush made of horses hair evolved,then came manual tooth brush,and now era of powered tooth brushes

Ancient tooth brushes

ADA Specification

Length : 1 to 1.25 inchesWidth :5/16 to 3/8 inchesSurface area :2.54 to 3.2cmNo rows : 2 to 4 rowsNo of tufts :5 to 12 per rowNo of bristles :80 to 85 per tuftDiameter for Soft brush:0.007inchMedium brush:0.012inchHard brush :0.014inch

Parts of tooth brushHandle :grasped in the hand during toothbrushing.Head : the working part and consist of tufts of bristles or filaments.Shank: the location that connects the head and the handle.

DIFFERENT TYPES OF BRISTLE PATTERNBlockWavy or v shapedMultilevel trim patternCriss -cross patternCross action with gum stimulator

Types of handlesStraight handleContra-angle handleFlexible handleGrip handle

Tooth brushes should be able to reach and effectively clean most area of teeth.Frequency and duration of brushingJenkens suggested that tooth brushing before meals is optimal,he says that saliva is a good remineralizing agent that will neutralize and the buffer the lowered PH of oral fluids caused by acidic foods and fermentable carbohydrate,so teeth brushing done after meals it may remove saliva and decrease remineralizing action.

Powered tooth brush

The level of oral hygiene achieved by an individual is dependent on technique,motivation,dexternity and preservence.Since behavioural practices cant be modified the greatest potiential for improving oral hygiene will come from advancements of brush design that enhance plaque removal.

Powered toothbrush deviced in 1939.They have three motion back and forth,circular,elliplical.Recommended forIndividuals lacking motor skillsHandicapped patientsPatients under fixed orthodontic treatment.

Manual Vs Powered Tooth BrushesCHARACTERISTICMANUALPOWEREDDuration20-40 sec1-3 minTeeth brushed at a timemultipleOne /multipleBrush head motionCross & multipleMinimalBrush head speedZero1000 s/minBrush head strokes40 -100/min10 -40/minBrush head load150-1000gm50 -250 gm

Methods of tooth brushingSCRUB Bristle placement: horizontal on gingival marginMotion :anterior posterior direction keeping brush horizontal directionIndication:childrenAdvantage : easy to learn

BASSBristle placement:apcal towards gingiva into sulcus at 45degree of tooth surfaceMotion :short back & forth vibratory motion while bristles remain in sulcusAdvantageGood gingival stimulationCervical plaque removal

ChartersBristle placement: coronally 45degree sides of bristle half on teeth and half on gingivaMotion: small circular motion with apical movement towards gingival marginAdvantagesClear interproximalDisadvantages Hard to learn

FonesBristle placement: perpendicular to toothMotion :with teeth in occlusion ,move brush in rotatory motionAdvantageEasy to learnDisadvantageTrauma Interproximal not cleaned

RollBristle placement:apically ;parallel to tooth and then over tooth surfaceMotion:on buccal and lingual inward pressureAdvantageGood gingival stimulationDisadvantageDoesnt clean sulcus

StillmansBristle placement :on buccal and lingual apically at an oblique angle to long axis of toothMotion :On buccal and lingual slight rotary motionAdvantagesModerate dexternityGingival stimulation

Modified stillmansBristle placement: pointing apically at an angle of 45 degree to tooth surfaceMotion: apply pressure as in stillmans method but vibrate brush also movie occlussalyAdvantageGood gingival stimulationEasy to master

Dental flossFirst paper on dental floss was published by Parmly in 1819.later in 1882 codman and shurtuff made 1st commercial floss made of silk .Floss constructed with help of individual filament 2 to 3 D thick.TypesTwisted and non twistedBanded and non bandedThin and thickMicrofilament and macrofilament

Type I unbonded dental floss compossed of yarn having no additivesType II bonded dental floss composed of yarn having no additives other than binding agent or agent of cosmetic performanceType III- bonded or unbonded having drug for therapeutic usage

TechniqueString floss method: use 18 inches of floss wrap 2-3 inches of floss around middle finger of left hand and similarly to right hand.

Circle floss method: take floss and tie a double knot to secure it,the size of circle is like an orange position knot to the left side of working area and place middle ,little and ring finger of both hand on the side of circle

ApplicationMaxillary tooth:direct the floss by holding floss over two thumbs or a thumb and an index finger rest a side of finger on teeth of opposite side of the arch to provide balance and fulcrumMandibular teeth:direct the floss down by holding the two index fingers on top of the stand.one index finger holds floss on the lingual aspect other on facial aspect

InsertionHold floss firmly in a diagonal or oblique positionGuide the floss past catch contact are with gentle saving motionControl floss to prevent snnnapping through the contact area onto gingival tissue.

PrecautionCol area is not keratinized and is vulnerable to bacterial innovationDo not use long piece between the fingers when held for insertionSnapping the floss through contact areaCurve the floss around teethUse rest prevent injury

Interproximal brushesCone shaped brushes made of bristles mounted on handle ,single tufted brushes or small conical brushes.Cleaning interdental spacesInserted interproximally and activated in short back and forth strokes in between teeth.

For best cleaning efficiency the diameter of brush should be slightly larger than gingival embressure.Single tufted more effective on lingual surface of mandibular molar and premolar

Wooden tipsThese are used with or without a handleSoft triangular wooden tips such as a stemu dent are placed in interdental spaces.Repeatedly moved in and out of the embrassure removing soft deposit for the teeth and mechanically stimulating gingiva.Use limited to facial surfaces

Gingival massageThe mechanical stimulation of gingivaSimple finger massageIncreased keratinizationIncreased blood flowIncreased flow GCF to sulcusResults in overall improvement in gingival health

Oral irrigation device (water pik)

Mainly beneficial in removal of unattached plaque and debrisThey are helpful removing debris from inaccessible areas around orthodontic appliance and fixed prosthesisPower driven deviceNon power driven device

Power driven device: generate an intermittent or pulsating jet of fluid. An adjustable deal for regulation of pressure is provided along with a end held interchangeable tip that rotate 360 degree.Non power driven device:attached to household water supply,disadvantage uncontrolled water pressure.Contraindicated Advanced periodontitisMedically compromised patients like leukemia etc

procedureDirect jet to interdental area,hold tip at right angle to long axis of tooth

Start at low pressure and increase gradually depending condtion of tissue

Follow a definte pattern across mouth,1st maxillary arch then mandibular apply for 5to 6 sec in each interdental area

Chemical plaque controlADA has accepted two agents as plaque control agentsPrescription chlorhexidine rinseNon prescription essential oil rinse

Chlorhexidine gluconate(0.2%)

Chlorhexidine gluconate is a cationic bisbigunide which is effective against array of microorganism(gram positive,negative, fungi, yeast,virus)Chlorhexidine exhibits both antiplaque and antibacterial property.It is bacteriostatic at low concentration and bacteriocidal at high concentration.

Mechanism of actionThe bacterial cell is negatively charged so cationic chlorhexidine molecule is rapidly attracted to negatively charged bacterial cell surface.

This alters integrity of bacterial cell membrane

Chlorhexidine attracted towards innercell membrane

It binds to phospholipids on inner membrane

Increased permeability of inner membrane

Leakage of low molecular weight component such as potassium

Exhibits antimicrobial action

Prevents pellicle formation by blocking the acidic group on salivary glycoproteins thus reducing the protein adsorption to tooth surfacePrevents adsorption of bacterial cell wall on to tooth surface by binding to the bacteria. Prevents binding of mature plaque precipitating agglutination factor in saliva and displacing calcium from plaque matrix

Adverse effectsBrownish staining of teethLoss taste sensationStenosis of parotid ductOral mucosal erosion

Essential oilThese are the oldest form of mouthwash.Most popular one is listerineIt is combination of phenol related essential oil,thymol and acetyl mixed with menthol and methyl salicylate.It has shown plaque reduction in range 20-34% gingivitis reduction 20 -34%

Mechanism of actionCell wall disruption and inhibition of bacterial enzymesAdverse effectsIntial burning sensation and bitter taste in mouth

Quaternary ammonium compoundsCommonly used are cetylpyridinium chloride at 0.05%.Cationic and binds to oral tissues but not strong as bisbiguanide.When used orally they bind strongly to plaque and tooth surface but are released from binding site rapidlyMechanism of actionAbility to rupture the cell wall and alter cytoplasmic contents.

Adverse effectsYellow brownish discoloration of tongue and gingival margin of toothBurning sensationOccasional desquamation

SanguinarineUsed both mouth wash and tooth pasteIt is alkaloid extract from blood root plant sangunialic cancidenseIt contain the extract at 0.3 and 0.2 zinc chlorideAdverse effect burning sentationHelps in plaque reduction and reduction in gingivitis

EnzymesActive agentsThey can break already formed matrix of plaque and calculusEg mucinax

AntibioticsAntibiotics such as vancomycin,erythromycin,niddamycin and kanamycin has used for plaque control.However due potential problem of bacterial resistance and hypersensitivity reaction use of theses agents have been reduced considerably.

Plaque control for disabled childFor older children who are unwilling or physically unable to cooperate the dentist should teach parent or guardian correct tooth brushing techniqueIf child is institutionalized the staff should be instructed in proper dental care regimen

Tooth brushSoft multi tufted nylon brushes with long handle is prefferedPowered tooth brush will be helpful

ModificationGrasp Velcro strap with a pocket on plam side into which tooth brush is insertedFixed fingers: with griped handle

Limited hand closure or reduced dexterity;use of sponges ,soft rubberballSuper brush

Use of mouthwash especially chlorhexidineFluoride application stannous fluoride gel are more effective anti plaque agentApplication of fluoride gel by tooth brush after normal brushing

Guidelines for home careWheel chair

Bed or sofa

Lying on floorPatient lies on floor with head on pillowCan use your arm to hold person still

Sitting on floorPatient sits on floor, you sits behind person in chairIndividual leans head against your kneesIf patient is uncooperative you can place leg over arms to keep patient still

Pediatric preventive programmePrenatal periodThe counsel parent is to be doneThe importance of oral hygiene maintenance should be stressed at each visit and myths about teething and the initation of brushing in a infant should be cleared to the parent

Infants(0-1)Mechanical plaque removal should be initiated by the parent after the eruption of 1st tooth using moistened soft bristled infant size tooth brush.However the cleaning and massage gum pads using wrapped moistened gauze piece need to be taught to the parentAlso parent should be instructed to feed the child with plain water after milk or rinse mouth

Toddlers (1-3year)This best age to introduce tooth brush,if not done earlierNon fluoridated dentrifice should be usedFlossing can be usedBrushing can be carried out using lap to lap postion of child

Preschoolers(3-6year)Fluoridated dentifrice can be introduced after 3 year of ageOnly pea shaped tooth paste should be dispensedParent should assist child in brushingFluoride gel or rinses can be introduced

School going childrenParents need only supervise brushing this age groupPosses dextertity to brush on his ownUse of fluoride gel and rinses

Adolescents (12-18)Patient compliance is most important area of concern in this age group

conclusionEffective plaque control measures should be takenGuide to use plaque control measures