1

DEPARTMENT OF PEDEODONTICS AND PREVENTIVE DENTISTRY

SANTOSH DENTAL COLLEGE AND HOSPITAL , GHAZIABAD

ASSIGNMENT ON PLAQUE CONTROL

GUIDED BY: Dr. BINITA SRIVASTAVA Dr. ARCHANA AGGARWAL Dr. H.P BHATIA Dr. ASHISH KUMAR SINGH Dr. AARTI PURI

PRESENTED BY RISHABH SARAN GUPTA B.D.S (FINAL YEAR) BATCH-2005-2006

SL NO.
1
2

TOPIC INTRODUCTION PLAQUE

2.1 2.2 2.3 2.4 DEFINATION STRUCTURE AND COMPOSITION OF PLAQUE INORGANIC CONSTITUENT OF PLAQUE PATHOGENIC CONSTITUENT OF PLAQUE

PAGE NO.
4

5 5,6 6 6

3 4

PLAQUE INDEX PLAQUE CONTROL

4.1 4.2 DEFINATION OBJECTIVE

7 8 8

MECHANICAL PLAQUE CONTROL

5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8
6

DEFINATION MECHNICAL PLAQUE CONTROL AID TOOTH BRUSH POWERED TOOTH BRUSH DENTAL FLOSS TOOTH PICKS INTERPROXIMAL BRUSHES INTERDENTAL STICKS ORAL IRRIGATORS TOUNGE SCRAPPER DENTIFRICERS 24 26 27

ADJUNTIVE AID
6.1 6.2 6.3

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7

CHEMICAL PLAQUE CONTROL AGENT

7.1 7.2 7.3 7.4 7.5 7.6 7.7 7.8 7.9 7.10 7.11 CLASSIFICATION BISBIGUANIDES QUATERNARY AMMONIUM TRICLOSAN ESSENTIAL OILS OXYGENATING AGENTS HALOGEN ENZYME SANGUARINE METAL IONS VEHICLE OF DELIVERY OF CHEMICAL AGENTS

34 34,35 36 37 37,38 38 38 39 39,40 40 41

8 9

CONCLUSION BIBILLOGRAPHY

41,42 43

1. INTRODUCTION

The oral microbiology includes many types of organisms that accumulate on the surface of the teeth and at the gum line. These bacteria and their products form the sticky residue known as plaque.1,2 As the organisms grow, the colonies branch out to involve virtually all surfaces of the teeth, extending below the gum line. When allowed to grow unchecked, plaque causes two conditions: caries and gingivitis. It is also thought to be the major cause of halitosis.3

The specific plaque organism that induces caries is currently thought to be Streptococcus mutans because it is an efficient producer of the acids that dissolve tooth enamel, resulting in the typical caries lesion.1,4-6 This organism also is able to synthesize polysaccharides from dietary sucrose and may be the primary etiologic agent behind gingivitis.

Proper control of plaque can help prevent cavities and gingivitis. Clinical observations and epidemiological investigations have demonstrated that plaque removal after an experimental period of 3 weeks will lead to cure gingivitis. The dentist and dental hygienist can remove plaque during a regular professional appointment. In between visits oral hygiene practices can remove plaque.

2. PLAQUE
2.1 DEFINITIONSACCORDING TO WEI- plaque is complex mixture of dense microbial elements enmeshed within a gel like matrix of bacterial polysaccharide, salivary proteins and cellular and components of the oral mucosa. ACCORDING TO STURDEVANT- plaque is a soft translucent and tenaciously adherent material accumulating on the surface of teeth ACCORDING TO LOE plaque is a soft, non mineralized, bacterial deposits which forms on teeth and dental prosthesis that are not adequately cleaned. ACCORDING TO GLICKMAN plaque is a soft deposit that form the biofilm adhering to the tooth surface or other hard surfaces in the oral cavity, including removable and fixed restoration.
{1 page, no. 167,168}

2.2STRUCTURE AND COMPOSITION

SUPRAGINGIVAL PLAQUE : It is found at or above the gingival margin. When in Supragingival plaque is made of 4 layers: Plaque tooth interface Condensed microbial layer Body of the plaque Plaque surface SUBGINGIVAL PLAQUE : In children subgingival plaque may appear as either: Loose arrangement of mostly cocci Condensed arrangement of cooci and rods or Dense arrangement of cocci covered by a layer of filamentous organisms

COMPOSITION : plaque is composed of organic and inorganic constituents with some pathogenic constituents. ORGANIC CONSTITUENTS OF PLAQUE : Polysaccharides Proteins Glycoproteins Lipid material

2.3INORGANIC CONSTITUENTS OF PLAQUE:

Calcium and phosphorous form the main inorganic constituents. Trace amounts of other Calcium and phosphorous form the main inorganic constituents. Trace amounts of other minerals such as sodium, potassium and fluoride are also present. Source of inorganic constituents of supragingival plaque is primarily saliva and that of subgingival plaque is crevicular fluid .

2.4PATHOGENIC CONSTITUENTS OF PLAQUE:

Substances producing/ inducing direct tissue damage, e.g. organic acids, ammonia, hydrogen sulfide, protease, collagenase, hyaluronidase, neuraminidase, etc. Inflammation inducing substance, e.g. chemotactic substances like polypeptide, activators of complement cascade, histamine, etc. Substances inducing indirect issue damage by host immunological response. e.g. endotoxin, peptidoglycan, polysaccharide, bacterial antigen, etc.
{1,pageno.167,168}

Dental Plaque

3.PLAQUE INDEX (SILNESS AND LOE, 1964)

Rather than examine the whole, dentition, a few Index teeth are selected Permanent Dentition - 16,12,24,36,32,44 Primary Dentition - 55,52,64,75,72,84 In cases of mixed dentition sometimes depending on the teeth present, the index teeth may be as : 16,12,24,36,32,44 or such combination where the deciduous counterpart, if present is considered. Should both the primary and permanent teeth be present, the permanent one is to be considered. Should both be absent , the tooth distal to them may be considered or only 5 teeth are considered. Each tooth is divided into 4 parts. SCORING CRITERIA: 0 No plaque in the gingival area 1- A film of plaque adhering to the free gingival margin and adjacent area of the teeth. Only running a probe across the teeth surface may recognize the plaque.3 2 Moderate accumulation of soft deposits within the gingival margin and / or adjacent tooth surface that can be seen with naked eye.

3 Abundance of soft matter within the gingival pocket and / or on the gingival margin and adjacent tooth surface. CALCULATION: Plaque index for a tooth = Add sores from 4 areas of tooth/ 4 Plaque index for a individual = Add scores for each tooth/ no. of teeth examined INTERPRETATION SCALE: 0.0 Excellent 0.1-0.9 Good 1.0-1.9 Fair 2.0-3.0 Poor

{5, page no. 91,93}

4.PLAQUE CONTROL
4.1 DEFINITION Plaque control is the removal of plaque prevention of its accumulation of the teeth and adjacent gingival surfaces. Plaque control is the key to precaution and successful treatment of periodontal disease. {7,pageno.241} Plaque control is the removal of microbial plaque and the prevention of its accumulation on the teeth and gingival tissue .besides, it also deals with the prevention of calculus formation. Plaque control includes the usage of mechanical procedures as well as chemical agents which retard plaque formation. {5.page 432}

4.2 OBJECTIVES OF PLAQUE CONTROL1. The objective of oral hygiene is to reduce the number of microorganism on the teeth. all accessible dental plaque and debris shold be removed from gingival margins,proximal tooth surface and where possible gingival sulci.

2. One of the cause of halitosis may be removed. 3. Gingival stimulation may play a role in increasing gingival tone, surface keratinization, gingival vascularity and gingival circulation

5.MECHANICAL PLAQUE CONTROL

5.1 DEFINATIONMechanical plaque control include tooth brushing and interdental cleaning using oral hygiene aids and professional prophylaxis. Mechanical plaque control seems to be most dependable form of plaque control method. {5.page 432} Mechanical methods of plaque control are the most widely accepted techniques for plaque removal. tooth brushing and flossing are the essential elements of these mechanical methods, adjuncts include Disclosing agent, oral irrigators ,and Tongue scrappers {7.page239}

5.2Mechanical plaque control aids1. Toothbrush a. Manual toothbrush b. Electrical toothbrush 2. a. b. c. d. e. f.

Interdental aids Dental floss Triangular tooth picks Interdental brushes Yarn Yuper floss Perio-aid

3. Aids for gingival stimulation a. Rubber tip stimulator b. Balsa wood edge

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4. a. b. c.

Others Gauze strips Pipe cleansers Water irrigation device

5. Aids for edentulous or partially edentulous patient a. Denture and partial clasp brushes b. Cleansing solutions.

6. Adjuvant a. Disclosing agent b. Tongue scrappers

{5.page 433}

5.3TOOTHBRUSH:
Tooth brush has been described as the most classic and principal method employed in oral hygiene Acc to ADAS council on dental therapeutics the tooth brush is designed primarily to promote cleanliness of teeth and oral cavity
{5.page433}.

Type of tooth brush1.Manual toothbrushes 2.Powered tooth brushes 3.Sonic & ultrasonic toothbrushes 4.Ionic tooth brushes
{5.page433}

There is no clear cut evidence that one particular type of toothbrush is superior to others however soft filament brushes are better in view of the damage the hard filaments. {4.page224}

Ideal characteristics for a tooth brush1. Handle size appropriate to user age and dexterity 2. Head size appropriate to size of patients mouth

11 3. Use of end-rounded nylon or polyester filaments not larger than

0.009inches in diameter 4. Use of soft bristles configuration as defined by the acceptable ISO 5. Bristles patterns which enhance plaque removal in the approx. spaces and along the gum lines.
{6.page450}

Ideal pedodontic brush1. Diameter of each nylon filament-0.007-0.008 2. Tufts 24-33 3. Long handle 4. Small head size.
{1,page.244}

COMPONENT OF A TOOTH BRUSHA Tooth brush consist of head and a handle connected by a neck. The head portion contains bristles, made of nylon. HEADCorrect head size of a brush should be selected for attaining maximum manuverity in oral cavity. BristlesTexture of the bristles are characterized by1. Diameter of the filament. 2. Length of the exposed bristle 3. Size of the hole into which the filament comprising a tuft are inserted 4. Number of bristle filament in each tufts
{1.page 247}

ADA Specifications 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 if brushes No. of tufts - 5 to 12 per row
{5.page434}

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For children, brush is smaller , with nylon bristles 0.005inch(0.1)diameter and 0.344 inch(8.7mm) length. For maintaining effectiveness of cleaning ,toothbrushes must be replaced periodically .toothbrush with wear reminders are also available in which the dye fades with use and act as reminder to replace the tooth brush. {9.page237}

FREQUENCY AND DURATION OF BRUSHING: Jenkins suggested that tooth brushing before meal is optimal. He says that saliva is a good remineralizing agent that it will neutralize and buffer the lowered ph of Fluids caused by acidic food and fermentable carbohydrates. So if tooth brushing is done after meals it may remove saliva and decrease the remineralizing action.
{6.page452}

POWERED TOOTHBRUSH:
The powered toothbrushes were introduced in 1939.they are also known as automatic, mechanical or electric toothbrushes.
{5.page435}

The rationale for using powered brushes is that many patient remove plaque poorly because they lack adequate manual dexterity in manipulating the brush, the powered brushes should decrease the need for dexterity by automatically including some movement of brush head. Mostly recommended for Individual lacking motor skill Handicapped patients Patients who have orthodontic appliances Patients with prosthodontic or endoosseous implants Patient on supportive periodontal therapy.
{5.page.435}

Three types of movements may be present.

13 1. rotation in an arc of about 60 degree, so that the

bristles sweep the tooth similar to roll method 2. Back and forth horizontal action as in horizontal scrub 3. An elliptic movement combining oscillating with back and forth movements.
{1.page247}

Advantages of an electric tooth brush It increases patient motivation resulting in better patient compliance Increased accessibility in interproximal and lingual tooth surfaces. No specific brushing technique required Uses less brushing force than normal manual brushes Brushing timer is incorporated in some brush to help patient in brushing required duration.
{2.page237}

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MANUAL TOOTH BRUSH

POWERED TOOTHBRUSH

15

SONIC AND ULTRA SONIC TOOTHBRUSH These type of tooth brushes produce high frequency vibrations (1.67 MHz) , which lead to phenomenon of cavitations and acoustic micro steaming. This phenomenon aids in stain removal as well as disruption of the bacterial cell wall.

IONIC TOOTHBRUSHESIonic tooth brushes change the surface charge of a tooth by an influx of positively charged ions. The plaque with a similar charge is thus repelled from the tooth surface and is attracted by the negatively charged bristles of tooth brush

16

{5.page435}

TOOTHBRUSH WITH SILVER COATINGTo prevent the contamination of the brush with micro organism, tooth brush with silver coated head has been introduced. When the tooth brush comes in contact with water, pure silver that covers the head of a toothbrush displays an antibacterial action and reduces the bacterial contamination of toothbrush.
{2.page 237}

TOOTHBRUSH WEAR AND REPLACEMENTThe life of a toothbrush is variable and can depend on: - length of use - forcefulness of the toothbrush stroke - amount of pressure exerted on the bristles as they are flexed - bristle quality and design; Worn bristles are less effective thus this is when a toothbrush should be replaced. some brushes comes with a indicator. when blue band fades to halfway down the bristles, it is time to replace the brush.
{6.page 433}

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5.4TECHNIQUE OF TOOTH BRUSHING

As with toothbrush design, several different types of tooth brushing techniques for children have been advocated over the years. Roll Method : The brush is placed in the vestibule, the bristle ends directed epically, with sides of the bristles touching the gingival tissue. The patient exert lateral pressure with the same manner, with two teeth brushed simultaneously. Charters Method: the ends of the bristles are placed in contact with the enamel of the teeth and the gingival, with the bristles pointed at about a 45 degree angle towards the plane of occlusion. A lateral and downward pressure is them placed o the brush , and on brush, and the brush is vibrated gently back and forth a milliner for or so. Horizontal Stillman Method : The brush is placed horizontally on buccal and lingual surfaces and moved back and forth with a scrubbing motion Modified Stillman Method: Combines a vibratory action of the bristles with a stroke movement of the brush in the long axis of the teeth. The brush is placed at the mucogingival line, with the bristles pointed away from the crown, and moved with a stroking motion along the gingival and the tooth surface. The3 handle is rotated toward the crown and vibrated as the brush is moved. Anaise concluded that the horizontal scrubbing method exhibited a more significant plaque-removing effect than the roll, charters, and modified stillman methods.
{7,page no. 245}

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Recommended Brushing techniques for children -most children find horizontal scrub technique easier to perform -scrub or circular scrub are the best for young children with little manual dexterity and is more effective than roll technique -incisal and occlusal areas and facial and lingual two thirds are frequently not brushed so these areas should be double checked by patient. -time taken is at least 2-3 min. to cover entire surface -parents brush their childrens teeth until the later have achieved manual dexterity i.e.5-6 yrs of age. {1.page250,251}

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5.5DENTAL FLOSS
Dental floss or tape is usually the device of choice for removal of interproximal plaque, which is in accessible to tooth brushing.
{4.page227}

Clinical studies clearly show that, when toothbrushing is used together with flossing, more plaque is removed from proximal surfaces than by toothbrush alone.
{7.page455}

Types of floss

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unwaxed - thinner, for tighter contacts, but frays easily if subgingival calculus/overhanging restorations waxed - easier to use Polytetrafluoroethylene (PTFE) floss are stronger, shred resistant and easier to use if tight contacts or rough proximal surfaces tape is wider and easier to use especially those who find floss difficult and have wider embrasures superfloss - used if have large diastemas, under bridgework - floss holders can be used to assist with flossing, .
{5.page440}

According to American national standard committee, floss can be of 3 types: Type1-unbonded dental floss comprised of yarn having no other additives, Type2-bonded dental floss comprised of yarn having no additives other than binding agents Type3-bonded or un bounded containing a drug additive intended to give a therapeutic prophylactic such as fluorides.
{1.page.254}

TECHNIQUE

1. STRING FLOSS METHOD: Use 18 inches of floss. Wrap 2-3 inches of floss around middle finger of left hand and similarly to the hand. 2. CIRCLE OF FLOSS METHOD Take floss and tie a double learnt to secure it. The size of the circle is lie an ORANGE . Position the knot to the left side of working area and place middle, little and ring fingers of both hand on the inside of circle to keep it taut. Rotate counterclockwise for fresh segments. METHOD Hold floss firmly in a diagonal or oblique position.

21

Guide the floss past contact area with a gentle motion. Control floss to prevent snapping through the contact area onto the gingival tissue Pass the floss between the gingival margin, Curve to adapt the floss around the tooth, press And side up and down over the tooth surface.
{7page.245}

FLOSSING FOR CHILDREN Not all children can floss effectively and parent might find it difficult to floss her childs teeth. This can be made easier by the use of floss holders which are available in different shapes that enable younger children or parents to floss

22

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5.6Toothpicks Toothpicks are excellent substitute to dental floss for interproximal open spaces. Toothpicks may also be used in primary prevention, since they are easy to use, even in poor manual dexterity, including posterior areas.
{6.page455}

Toothpicks come in various shapes:flat,round and triangular in cross section. They have been made from soft and hard wood, metal and plastics. Tooth picks should not be used where a normal interdental papilla fills the interdental space, because it may cause ression in that area.
{4page.229}

5.7Interproximal brushesDeveloped as an alt. to toothpicks. Interdental brush are manufactured in different sizes and forms and should be selected to fit, as closely as possible, to the individual interdental space.

24

5.8Interdental sticks
- eg Interdens, Stimudent; - soft wood, triangular shape - limited usefulness - used to remove food particles esp if wide embrasures - potentially dangerous, can break and lodge in tissues
{6.page 457}

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6.ADJUNCTIVE AIDS
6.1Oral irrigation
Imitation is the targeted application of a pulsated of steady. Stream of water other irrigation for a cleansing and therapeutic purpose. Oral irrigation can be done by the patient or the clinician. Oral irrigation cleans adherent bacteria and debris from the oral cavity more effectively then do toothbrushes and mouth rinse. They are particularly helpful for removing debris from inaccessible areas around orthodontic appliance and fixed prosthesis. When used as adjuncts to tooth brushing, these devised can have

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a beneficial effect on periodontal health by retarding the accumulation of plaque and calculus and by reducing gingival inflammation.
Delivery Methods:

The target of the oral irrigation in the loosely attached sub gingival bacterial plaque. When the pulsated irritant is directed perpendicular to the long axis of the tooth, hydrokinetic activity is started. Some tip that are used to deliver the oral irritants are: 1. According to composition of tip- metal, rubber 2. According to angulations- straight, angulated 3. According to use- standard specialized.
PROCEDURE Direct the jet tip towards the interdentally area almost touching the tooth surfaces; hold tip at a right angle to the long axis of the tooth.

Start on the low pressure setting and increase Gradually depending on the condition of the Gingival tissue comfort. Follow a definite pattern across the mouth Maxillary arch first the mandibular arch Applying for 5 to 6 sec at each interdentally area.
{4,page no. 230,231}

6.2Tongue scrapping-

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It is relatively new phenomen defined as the process of removing debris from the surface of tongue with form of scrapper designed for this purpose. Recent studies have shown a correlation between tongue scrapping and a reduction in halitosis , gingival disease and tooth decay Most tounge scrappers are made of soft flexible plastic.

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6.3Dentifrices-(dens = tooth ; fricare = to rub)

Acc. To ADA A dentifrice is a substance used with a toothbrush for purpose of cleaning the accessible surface of teeth

Components of ToothpastesAbrasive 20-40% - to remove stains and plaque; - chalk and calcium salts eg: calcium carbonate, calcium phosphates, original abrasives; interfered with F - baking soda (sodium bicarbonate) original abrasive also (used to be in a powder form too). Fell out of use BUT have made a re-appearance in toothpastes Currently - silica compounds (hydrated silica is approved by AmDA as an effective abrasive b/c its compatible with F) - aluminium oxides - calcium pyrophosphates Abrasives they do dull the tooth so they add polishing agents to compensate eg: these are finer small sized particles eg: Al, Ca, Tin, Magnesium, zirconium compounds NB: chalk and silica both have an abrasive and polishing effect Humectant 20-40% - to prevent it from hardening in the tube or when exposed to the air - glycerol, sorbitol, mannitol, propylene glycol

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- are non toxic but can cause bacteria to grow and thus need to add a preservative such as sodium benzoate - at higher concentrations >40%, humectants can act as preservatives Water 20-40%

Binder/Thickening agent 1-2% - to prevent liquid/solid components of the toothpaste settling out during storage; - initially gums (gum tragacanth). Seaweed derivatives eg sodium alginates, carrageenan but now most common - synthetic binders eg: cellulose - In higher concentrations cellulose can act as a thickening agent for the gel types of toothpastes. Gel type toothpastes have a higher amt of thickeners cf pastes Detergent 1-2% - enhances cleaning ability; loosening soft deposits and aid in their removal - foaming action sodium lauryl sulphate (SLS) also found in shampoos, dishwashing detergents, soaps, body soaps - SLS stable, antibacterial properties, lowers surface tension & helps toothpaste flow over the teeth; active at neutral pH - some people find SLS to irritate their mucosal tissues (apthous ulcers, mucosal ulceration) and especially those with dry mouths Flavour 1-2% - essential oils, spearmint, anniseed, peppermint, wintergreen, cinnamon people have different taste preferences thus there is not one universal toothpaste Sweeteners 1-2% Eg: saccharin, cyclamate, sorbitol, mannitol (also a humectant), glycerine (also a humectant) New one = xylitol which also has an anticaries effect also Colourants and Opacifiers <1% - to enhance the attractiveness of the toothpaste without staining the teeth or oral soft tissues Preservative less than 1 %

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- sodium benzoate Therapeutic up to 5% - fluoride: usually Na2FP03, NaF, SnF2 F level of active F must be adequate and must be maintained over the shelf life - others triclosan , pyrophosphate ( in gingivitis, plaque and tartar control toothpastes)
{5.page448}

Functions of dentifrices- release F topically to tooth surface and important role in preventing caries remineralisation - removal of plaque - cleaning superficial stains - freshen breath - bacterial inhibition caries and plaque Form in which the dentifrices comes - pastes, gels (sparkles, striped paste & gel, clear gels, colored gels, colored pastes, white pastes) - of these forms they all are just as effective as each other and no difference other than personal choice
{6.page 458}

Wide Range of dentifrices on the market. tartar control whitening protects exposed and sensitive dentine plus fresh breath refreshing clean feeling extra clean mouth feel deep cleaning formula helps shield your teeth long after youve brushed gently polishes to help get teeth the whitest they can be fight plaque, fight decay long lasting protection effect cleaners for shiny white teeth long lasting freshness

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leaves your whole mouth feeling extra clean great bubblegum flavors; helps strengthen growing teeth

{6.page 459}

Fluoride toothpastes most common - active ingredients: sodium fluoride (NaF) ; sodium monofluorophosphate (Na2FP03), stannous fluoride (SnF2) - effectiveness: proven anticaries effect Eg: Active Ingredient Colgate Fluoriguard Na2FP03 (paste) or NaF (gel) Macleans Triple Stripe Na2FP03 + NaF + calcium glycerphosphate AIM original and freshmint Na2FP03 Floran SnF2 Ipana Na2FP03 Anti-plaque/Anti-tartar/Anti-gingivitis toothpastes -- Aim to reduce plaque build up, calculus (tartar) build up and gingivitis Active ingredients: -triclosan is an antibacterial agent, shown to be effective to a certain degree against plaque regrowth and the quality of the existing plaque In US ADA has given Colgate Total its seal of approval triclosan with copolymer 2% polyvinylmethylether (this enhances retention of the triclosan on the surface of the tooth). Triclosan thus can help to can help in inhibit plaque and reduce gingivitis and calculus build up -pyrophosphate Introduction of soluble pyrophosphate in toothpastes provides a chemical means of reducing supragingival calculus formation. Calcium and phosphorus from saliva are prevented from incorporating into the plaque matrix to form calculus. Pyrophosphates act as crystal growth inhibitors and help delay the mineralisation of plaque and make it more susceptible to mechanical removal. Pyrophosphates also kill and inhibits some bacterial growth. The addition of copolymer (methoxyethylene and maleic acid) to pyrophosphate toothpastes can help to enhance the anticalculus

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effect. Other active ingredients -Stannous ion, -zinc citrate, -sanguinaria. Eg: Colgate Total toothpaste and pump +PVM/copolymer (& NaF) Colgate Fresh Confidence gel PVM/copolymer (& NaF) Colgate tartar control toothpaste Macleans Complete Care Freshmint + calcium glycophosphate)

Active Ingredient triclosan triclosan +

pyrophosphate (& NaF) triclosan (Na2FP03 + NaF

Sensitive teeth toothpastes Aim to reduce dentine hypersensitivity - Active ingredients: potassium nitrate, strontium chloride, stannous fluoride - These aim to sclerose over the dentinal tubules and thus prevent fluid flow and pain transmission Important not to be too abrasive. May not be effective in all cases seek professional dental advise especially in terms of diagnosis of cause of the sensitivity. Eg: Active Ingredient Sensodyne original Strontium chloride only Sensodyne with F paste (Na2FP03)/gel (NaF) KNO3 Sensodyne with baking soda KNO3, NaF , sodium bicarbonate Floran STP+ SnF2, KNO3 Macleans sensitive teeth toothpaste Strontium acetate (NaF) Whitening toothpastes - new ones on the market due to aesthetic/cosmetic demands. Include toothpastes which remove stains and bleach teeth. - includes gels or pastes Aim: Remove superficial stains only; have no effect on intrinsic stains and variable effectiveness in changing shade of the tooth very limited or no effect in altering yellow shade of teeth due to ageing effects. Give teeth and mouth clean sensation. Peroxide containing types have mild bleaching effect or whitening effect.

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Active ingredients: peroxides (carbamide peroxide, hydrogen peroxide) titanium dioxides peroxide free abrasives = calcium carbonate, sodium bicarbonate (baking soda) Carbamide peroxide breaks down to urea and hydrogen peroxide. Hydrogen peroxide forms free radicals containing oxygen which is the active bleaching molecule. Eg: Colgate Sensation with baking soda and peroxide = 0.76% Na2FP03 , sodium bicarbonate, calcium peroxide, titanium dioxide Colgate sensation whitening plus tartar control = 0.76% Na2FP03, sodium bicarbonate, titanium dioxide, aluminium dioxide, PVA/MA copolymer Macleans whitening = 0.22NaF; titanium dioxide, Triclene - Cedel Soft polish calcium carbonate, titanium dioxide

Effectiveness of whitening: ineffective on altering intrinsic stains due to tetracycline, moderate-severe fluorosis or age changing effects, limited effectiveness on surface staining depending on severity and active ingredient. Relapse does occur ie., if patient keeps smoking or drinking coffee, tea, wine then surface stains reappear. If used inappropriately loss of enamel abrasion and exposure of dentine sensitivity Long term side effects of peroxides - free radicals on oral tissues is unknown Baking soda (sodium bicarbonate) has been used as a cleansing agent for many yrs. 2 in 1 toothpastes New product - Colgate 2 in 1 Liquid gel. Marketed as an antibacterial liquid gel that combines toothpaste with a mouthwash to freshen breath. Active ingredients: NaF, triclosan, and pyrophosphate Natural/Herbal toothpastes

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Contain no fluoride Use variety of natural flavourings Several have fairly abrasive cleaners in them eg; calcium carbonate; sodium carbonate Eg: Active Ingredients Ultrabite Non F toothpaste dicalcium phosphate, tetrasodium pyrophosphate Tea tree toothpaste fluoride free calcium carbonate, 0.4% tea tree oil Products formulated for xerostomic patients Eg. Biotene dentrifice and mouthwash Contain enzymes -lactoperoxidase, lysozyme, glucose oxidase Enhances the natural protective mechanisms in saliva ie., antibacterial action Eg., it aims to inhibit growth pf plaque bacteria
{3.page 3,4}

Effect and sequale of incorrect use of mechanical plaque control devices Improper toothbrushing can cause damage to both soft and hard tissue. Trauma to soft tissues results in gingival recession. Trauma to hard tissues leads to cervical abrasion of tooth surface. Tooth wear has also been associated with toothbrush. The use of dental floss , interproximal brushes and tooth picks may also induce soft tissue damage But in most cases this damage is limited to acute lesions,such as lacerations and gingival erosion. Some substance in toothpaste may induce local or systemic side effects.
{6.page 459}

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7.CHEMOTHERAPEUTIC PLAQUE CONTROLChemical plaque control agents have proven to be an ideal adjunct to mechanical plaque control procedure especially in individuals with a defective host defense mechanism, mentally or physically handicapped patients or in patients undergone surgical procedure post operatively.
{5.page443}

Mode of action Anti-plaque agents can act directly on plaque bacteria and thus minimize plaque build-up or can disrupt different components of plaque to permit easier and more complete removal during brushing/flossing they are not a total substitute for routine oral hygiene measures used for non specific plaque control or against specific micro-organisms assoc with gingivitis, caries. ie: act against the microflora per se or can interfere with bacterial attachment (attack plaque matrix components / alter the tooth surface).

Ideal characteristics of a plaque control agent specifity only for the pathogenic bacteria substantivity,the ability to attach to and be retained by oral surfaces. Chemical stability during storage Absence of adverse reactions, such as attaining or mucosal interactions Toxicologic safety Ease of use {7page.248}

7.1CLASSIFICATION
First generation antiplaque agents: They are capable of reducing plaque scores by about 20-50%.they exhibit poor retention within mouth. Eg.antibiotics,phenols,quaternary ammonium compound and sanguarine

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Second generation antiplaque agents: They produce an overall plaque reduction around 70-90% and are better retained by oral tissues and exhibit slow release properties Eg.bisbiguanides(chlorhexidine) Third generation anti plaque agent: They block biniding of microorganism to the tooth or to each other. Eg.delmopinol {5page.443} Chemotherapeutic plaque control agents:
ANTISEPTIC AGENT

Positively charged organic molecules: Quaternary ammonium compound-cetypyridinium chloride Pyrimidines hexedine Bis-biguanides-chlorhexidine,alexidine Noncharged phenolic agents:Listerine(thymol ,eucalyptol,menthol and methylsalicylate),tricosolan,phenol Oxygenating agents:peroxidase and perborate Halogens :iodine,iodophors and fluorides Heavy metal salts:silver mercury,zinc,copper ANTIBIOTICS Niddamycin , kanamycin , sulfactate. ENZYMES: Mucinase,pancreatin,fungal enzymes and protease. PLAQUE-MODYFYING AGENTS Urea peroxidase SUGAR SUBSTITUES Xylitol,mannitol PLAQUE ATTACHMENT INTERFRENCE AGENTS Sodium polyvinylphosphonic acid.

38 {7page.248}

7.2Bisbiguanide
- Chlorhexidine gluconate (CHx) 0.2% - mouth rinse in a water base, alcohol, glycerine, flavouring agents. - gel - pH 5.5 Rationale - has anti-plaque (reduces by 55%) and anti-microbial activity ( reduces gingivitis by 45%) which is very effective - suppresses oral microflora, low concentrations - bacteriostatic against many G+ve and G-ve bacteria and S. mutans, - anti-fungal and anti-viral effects - strong affinity to anions eg PO4= on cell walls of oral microflora which colonise tooth surfaces . CHx decreases the ability of these organisms to attach and colonise the tooth. Bind to hydroxyapatite and glycoprotein to prevent pellicle formation and absorbs to bacterial cell surface and interferes with attachment. - CHx adsorbs to plaque, pellicle, the oral mucosa, hydroxyapatite, these surfaces become reservoirs - slowly release active CHx for up to 24 hours - antiplaque effect is due to anti-microbial action and to the retention on oral tissues and its slow release in an active form (substantivity) - adsorption to bacteria is rapid and extensive and anti-microbial effect is long lasting Adverse effects - staining of teeth (yellow-brown), artificial denture teeth, composite resins. Staining depends on concentration and varies between individuals -temporary alteration of taste sensation - burning lips - unpleasant bitter taste - suppresses gut flora and long term side effects remain unclear - mucosal changes: desquamation of oral mucosa - activity is decreased by blood, pus,

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Should not be used at same time as brushing surfactants found in toothpastes can inactivate chlorhexidine and also F ion in toothpaste is a negatively charged ion and chorhexidine is positively charged thus inactivating it. Patient needs to rinse with chlorhexidine at least 30mins before or after brushing their teeth with a toothpaste. Indications - acute gingivitis - acute periodontal disease - after periodontal surgery - compromised patients who cant brush
{4.page444, 7.page 249}

7.3Quaternary Ammonium
- cetylpyridinium chloride eg. Cepacol, Oral B tooth and gum care, Ultrafresh Rationale - cationic - attracted to anionic tooth surface - surface active agents - lower surface tension - increases bacterial cell wall permeability - favours lysis - decreases cell metabolism - decreases bacterial ability to attach to tooth - decreases plaque accumulation Benefits - possibly does reduce plaque - no significant effect on gingivitis Adverse Effects - tooth staining - burning sensation

7.4Triclosan
2,4,4 - trichloro-2-hydroxydiphenyl ether Rationale - Triclosan alone has weak anti-plaque activity and does not have good substantivity by itself - Triclosan alone is non-ionic, has a neutral pH and is compatible with dentrifice ingredients

40

- its a broad spectrum antibacterial agent (used in antibacterial scrubs and soaps) -Triclosan with copolymer of polyvinyl methyl ether maleic acid (PVM/MA = polyvinyl methyl ether maleic acid) has better anti-plaque activity and substantivity. The copolymer increases the retention (substantivity) of triclosan to surfaces and thus to increase its anti-plaque and anti-microbial activity. Clinic trials triclosan and copolymer can reduce supragingival plaque/calculus & gingivitis compared to water placebo, alcohol wash Zinc citrate + triclosan similar effects as triclosan and copolymer -Triclosan with copolymer is available as a mouth rinse eg Colgate Plax or is available in toothpaste eg Colgate Total , Colgate Gum Protection - 0.3% Triclosan with copolymer Gantrez - Triclosan and Triclosan with copolymer had no side effects or an unpleasant taste, it does not stain the teeth - Triclosan has also been added to zinc citrate (ie Mentadent toothpaste) and added to pyrophosphate (Crest Ultra Protection toothpaste). Triclosan combined with zinc citrate is more effective - not as effective as CHx
{6.page 473}

7.5Essential oils
One type = 3 essential oils - thymol, menthol, eucalyptol in methylsalicylate eg Listerine (contains = thymol, menthol, eucalyptol, methyl salicylate, alcohol) Rationale - alteration (disruption) of the bacterial cell wall; also interfere with bacterial enzymes Benefits - Long term clinical trials - reduces plaque and gingivitis by approx. 30% Adverse Effects - burning, bitter
{7.page 251, 6.page 473}

7.6Oxygenating agents
hydrogen peroxide, gaseous oxygen eg: Amosan

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- disinfectants which when acted on by tissue and bacterial derived enzymes release oxygen with an associated effervescence. Hydroxyl radicals are released, these damage cell membranes, inactivate bacterial enzymes and disrupt bacterial chromosomes Rationale - anaerobes +++ in initiating gingivitis - have anti-inflammatory properties Benefits - effect on reducing plaque/gingivitis not well established and thought to be ineffective - none significant Adverse Effects - unsafe; free radicals released may cause tissue damage, ulceration side effects of long term use - ineffective - tissue injury and delay of wound healing, must use in concentrations of less than 3%
{7.page 251}

7.7Halogen
eg Fluorides - sodium fluoride- sodium monofluorophosphate- stannous fluoride Benefits - none known - no statistically significant improvement in GI scores Adverse Effects - tooth staining - fluorosis if swallowed in young children
{7.page 474}

7.8Enzymes
eg amylases, proteases, dextranase, mutanase, amyloglucosidase, glucoseoxidase

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- attempts have been to add these enzymes to mouth rinses and toothpastes but results from studies are not available Biotene mouth rinse and toothpaste - marketed for people with sensitive mouths/dry mouths - have natural enzymes that are found in saliva replenish and also have antibacterial effect eg., Glucose oxidase; Lactoperoxidase; Lysozyme. Lactoferrin
{7.page251}

7.9Herbal extracts Sanguinarine

alkaloid extract from plant Sanguinaria canadensis benzophenathradine alkaloid - mouth rinse or dentifrice eg Vivadent toothpaste, mouth rinse - may alter receptor sites of freshly formed pellicle and decrease ability of bacteria adhering to tooth -inhibit enzyme activity and reduce glycolysis - usually combined with metal salts eg zinc chloride - retained in mouth 2- 4hrs - less effective compared to CHx
{6.page 474}

7.10Metal ions
- Stannous ion (if in stannous pyrophosphate) has shown some anti-plaque effect . Have shown some antibacterial effect. Enters bacterial cell and clogs metabolism. Affects growth and metabolism. - Zinc
{6.page 474}

7.11Vehicle for the delivery of chemical agents MOUTHRINSES most of the chemical plaque control agents have

been formulated in mouthrinse vehicle. Mouthrinse vary in their constituents but are usually considerably less complex than tooth pastes.

43 SPRAY-spray has advantage of focusing delivery on required site.the

dose is clearly reduced and for antiseptics such as chlorohexidene has taste advantages.
IRRIGATORS -irrigators were designed to spray water,around the

teeth.antiseptics and other chemical plaque control agents, such as chlorohexidene,have been added to reservoir of such devices.
CHEWING GUMS-chewing along with other chemical agent serve as

plaque control chemical agents.

VARNISHES -varnishes has also been employed to deliver antiseptics.

8.CONCLUSIONThe goal of oral care is to keep the teeth free of cavities and to care for the gums to prevent loss of teeth. Dental plaque is the cause of both of these problems. Plaque is the sticky substance that you feel on your teeth several hours after a meal when they have not been cleaned. It is mainly growing bacteria. As the bacteria grow, they form dangerous substances which cause harm. The acids the growing bacteria produce eat into tooth enamel, causing the typical cavity. As further acids erode the tooth, it becomes painful. The person who waits until the cavity is painful before seeking dental care may lose the tooth. If the root is affected, a root canal or removal might be necessary. Also, the acids irritate the gums. The gums become swollen, painful and tender, red, and irritated. They may bleed following brushing and flossing. None of these symptoms is normal. Instead, they indicate that the patient may be suffering from a common disease known as gingivitis.

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Gingivitis is reversible if prompt care is sought. However, if it is not treated, the person can suffer from a worse condition known as periodontitis. In this serious medical diagnosis, the teeth become loose and can fall out. Proper control of plaque can help prevent cavities and gingivitis. Mechanical plaque control is important regular brushing and flossing. Technique is more important than what type of toothpaste is used. Chemical plaque control should only be used in situations where mechanical plaque control is difficult eg. physical handicap, acute periodontal disease, medical illness. Effect of chemical antimicrobial agents is transient, at levels which can be used intraorally because plaque formation is rapid and a continuous process. Even if decrease numbers of bacteria, they can still regrow. Chlorhexidine is most effective chemical antimicrobial agent but has problems related to taste and staining of teeth only use in acute periodontitis or compromised patients. .

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BIBLIOGRAPHY-

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Principles and practice of pedodontics Textbook of pediatric dentistry Clinical periodontology Periodontology and periodontics:morden theory and practice Preventive and community dentistr y Clinical periodontology and implant dentistry Dentistry for the child and aldoescent

Arathi Rao S. G. Damle carranzza Ramfjord and Ash Soben Peter Jan Lindhe McDonald and Avery

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3rd edition 4th edition 8th editon

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Clinical pedodontics

Finn

4th edition