Tooth Brush

TOOTH BRUSHING TECHNIQUES BY:

AYUSHI AGRAWAL III rd yr BDS , INDIA

TOOTH BRUSHES

TOOTH BRUSHES ØToothbrushes are most widely used oral hygiene aids for plaque control ØAcc. to ADA council “ The toothbrush is designed primarily to promote cleanliness of teeth & oral cavity” ØAdult Toothbrush length: 15 to 19 cm ( 6 to 7.5 inch) ØLength of brushing plane: 25.4 to 31.8 mm ØWidth of brushing plane: 7.9 to 9.5 mm ØBristle & filament height: 11mm

ØParts of Toothbrush 2. 3. 4. 5. 6.

HANDLE HEAD TUFTS BRUSHING PLANE SHANK

I. HANDLE : • That part which is grasped in hand during tooth brushing. • Composition is single type of plastic or a combination of polymers. • A handle of larger diameter may be useful for the patient with limited dexterity such as children, aging patient & those of any age with disability. • Straight handles are more common. Handles with contra-angle provide better sense of touch

II. HEAD • • • •

The working end of the toothbrush that holds the bristles or filaments. It should be small enough for max. maneuverability in oral cavity. Length of brush head: 5-12 tufts Width of brush head: 3-4 rows

III. TUFTS • •

Cluster of bristles or filaments secured in head Toothbrush BRISTLES

Hard , soft Medium

Multitufted & space tufted

Natural & synthetic

Comparison of Natural & Synthetic bristles

IV. BRUSHING PLANE • • • • •

The surface formed by the free ends of the bristles or filaments Length: Range from filaments of equal length (flat plane) to those variable length. There are variously shaped filament profile like flat, rippled, dome, multilevel, angled etc. Brushing plane is commonly soft and rounded for safety to oral soft tissues & tooth structure. ADA specification of toothbrush brushing surface:- length: 1-1.2 inch, width: 7.9-9.5

V.SHANK The section that connects head and handle.

ØTypes of Toothbrushes MANUAL

IONIC POWERED SONIC & ULTRASONIC

I. c. d. e. f. g. h.

MANUAL TOOTHBRUSH The ideal characteristics for a manual toothbrush can be listed as follows: Should confirm individual patient requirement in size, shape & texture. Be easily& effectively manipulated Be readily cleaned & aerated. Be impervious to moisture. Durable& inexpensive. Designed for utility efficiency & cleanliness.

II. POWERED TOOTHBRUSH • • •

Also known as Automatic, Mechanical or Electric toothbrush. The powered toothbrush was first designed in 1885 by Fredrick Tonberg & first made in 1939. PRINCIPLE: The head of toothbrush oscillate in a side to side motion or in rotary motion. The frequency of oscillation is around 40 Hz.

• INDICATIONS FOR POWERED TOOTHBRUSH:2. 3. 4. 5.

Young children Handicapped patient Individuals lacking manual dexterity Patient with prosthodontic or endosseus implants. 6. Orthodontic patient. 7. Institutionalized patient including the elderly who are dependent on care providers. 8. Patient on supportive periodontal therapy.

•ADVANTAGES OF POWERED TOOTHBRUSH:2. It increases patient motivation resulting in better patient compliance. 3. Increased accessibility in the interproximal & lingual tooth surface. 4. No specific brushing technique required. 5. Uses less brushing force than manual toothbrush. 6. Brushing timer is incorporated in some brushes to help the patient in brushing for required duration.

III. SONIC AND ULTRASONIC TOOTHBRUSH •

•

•

PRINCIPLE: These types of toothbrushes produce high frequency vibration(1.6MHz) . ADVANTAGE: This phenomenon aids in stain removal as well as disruption of bacteria cell wall. DISADVANTAGE: It leads to cavitation & acoustic

IV. IONIC TOOTHBRUSH • •

They change the charge of a tooth by an influx of positively charged ions. The plaque with similar charge is thus repelled from the tooth surface & is attracted by negatively charged bristles have to be carried out to prove the efficacy of these type of toothbrushes.

TOOTH BRUSHING

OBJECTIVES OF TOOTHBRUSHING 1) To clean teeth & interdental spaces of food remnant debris & stain. 2) To prevent plaque formation. 3) To disturb & remove plaque. 4) To stimulate & massage gingival tissue. 5) To clean tongue.

TOOTH BRUSHING IN CHILD & ADOLESCENT (0 to19 yrs) above)

IN ADULT (19 yrs &

Tooth brushing in Child & Adolescent Various methods of removal of plaque in child & adolescent are :-

4) TOOTHBRUSH • •

Synthetic(nylon) manual toothbrush is the most commonly used. Soft brushes are most preferred in pedodontics due to decreased chances of gingival tissue trauma & increased interproximal cleaning ability.

•Round type of bristles is of choice because it is associated with lower incidence of gingival tissue irritation. •Toothbrush shd also have smaller head & thicker handle to aid access to oral cavity & facilitate better child grip.

4) FLOSS •

Interproximal removal of plaque beyond tooth brushing is necessary which is done by interdental brushes, floss holders & floss & end tuft brushes.

•Nylon & Teflon floss are available. Teflon has advantage that it has lower coefficient of friction than nylon, this floss also does not shred & slides easily between tight contacts. •Unwaxed nylon filament floss has generally been considered as floss of choice as it has an ease of passing b/w the tight junctions ,lack of wax residue, increased surface contact & greater plaque removal. •In pedodontics, flavored wax floss may be most effective. Floss-holder

•For orthodontic patient super floss or floss threader is helpful.

7) DENTRIFRICES • g) h) i) j) k)

Dentifrices are used as:Plaque removing agents abrasives and Stain removing agents surfactants Tartar control properties pyrophosphates Anticaries property Desensitizing property fluoride

•The child dentifrices should contain fluoride, rank low in abrasives & carry ADA seal of acceptance. •The caries preventive efficacy of fluoride toothpastes in children has been good but these fluoride toothpaste has an adverse effect on the child by increasing the total fluoride intake. • The use of much of toothpaste may lead to ingestion of fluoride which is a substantial source of systemic fluoride for children at risk of dental fluorosis.

•To reduce chance of dental fluorosis children: b) Manufacturers shd market low fluoride toothpaste for infants or reduce diameter of tube orifice. c) Shd advice to use a fluoride dentifrice in a child older 36months. d) To use small, pea sized quantity toothpaste. • The manufacture shd state that it shd be non abrasive, non foaming, without fluoride,safe for infants & ideal for babies 4mth -3yr. It contain mild

4) DISCLOSING AGENT •

A disclosing agent is a preparation in liquid, tablet or lozenges form that contains dye or other coloring agent. The bacterial plaque is usually colorless & after the use of disclosing agents it picks up color of the agent where as dye is rinsed off easily from plaque free areas.

•

Use:

•

e) Personalized patient instruction in location of soft deposits and techniques for removal. f) Self evaluation of patient on daily basis.

c) Continuing evaluation of the effectiveness of the instructions for the patient to determine need for revisions of plaque control procedures. d) Preparation of plaque index. e) To gain new information about the incidence & formation of deposits on the teeth. • Method of application: The patient chews the tablet moves it around for 30-60 seconds rinse it completely.

5) CHEMOTHERAPEUTIC PLAQUE CONTROL • c) d) e) f) g) h)

Chemicals interfere at various stages of development of plaque:Micro- org. for plaque formation may be reduced or eliminated in number. The formation of bacterial & salivary products which constitute the intermicrobial substance in plaque is inhibited. Established plaques may be dissolved. Calcification of plaque may be counteracted. Colonization of bacteria on the tooth surface may be inhibited. Pathogenicity of plaque may be reduced by interference with metabolisation of plaque bacteria.

6) TOOTH BRUSHING TECHNIQUE •

There are predominantly 4 main tooth brushing technique that is described by Anaise, for children of 11 to 14 yrs old:

c) ROLL METHOD • • • •

The brush is placed in vestibule, the bristle ends directed apically with the sides of bristles touching the gingival tissue. The patient exerts lateral pressure with sides of bristles & brush is moved occlusally. The brush is placed again high in the vestibule & the rolling motion is repeated. lingual surface same manner with 2 teeth

b) CHARTERS METHOD • • •

The bristles are placed in contact with enamel of teeth & gingiva. The bristles are placed at 45degree angle towards plane of occlusion. A lateral downward pressure is then placed on the brush & the brush is then vibrated gently back and forth a mm or so.

c) MODIFIED STILLMAN METHOD • •

•

This method combines a vibratory action of bristles with stroke movement of brush in long axis of teeth The brush is placed at mucogingival line, with bristles pointed away from the crown, & moved with stroking motion along the gingiva & tooth surface. The handle is rotated toward the crown & vibrated as brush is moved.

d) HORIZONTAL SCRUBBING METHOD • • •

•

The brush is placed horizontally on buccal & lingual surfaces Then brush is moved back & forth with a scrubbing motion. Anaise concluded that horizontal scrubbing method exhibited a more significant plaque removing effect than the roll, charters & modified stillmans. As this method removes more of plaque as compared to other techniques and it is most naturally adopted by children so the HORIZONTAL SCRUBBING TECHNIQUE is the MOST RECOMMENDED brushing technique for CHILDREN.

7) FLOSSING TECHNIQUE

1. A 18-24 inch length of floss is obtained & ends are wrapped around the fingers.

3. Care shd be taken not to snap the floss down thru the interproximal contacts to avoid gingival trauma.

2. Thumb & index fingers are used to guide the floss b/w the 2 teeth to be cleaned.

4. Floss is then manipulated into “c”- shape around each teeth individually & moved cervical-occlusal reciprocating motion until the plaque is removed.

AGE – SPECIFIC INSTRUCTIONS

II. INFANTS (0 TO 1 yr) • •

•

The plaque removal activities should begin on eruption of the first primary tooth. There shd be cleaning & massaging of gums before eruption of teeth to help establishing a healthy oral flora & to aid teething. This shd be done totally by the parent. Tooth brush can also be used if parent feel comfortable. This cleaning and massaging of gums can be done by wrapping a moistened gauze

•While massaging the child can be placed in numerous ways, but ARM- CRADLING POSITION is the simplest & provides the infant more security. In this the child is cradled with one arm while massaging is done with the other. This procedure shd be practiced once daily. •Nonflouridated tooth & gum cleanser may be used. •The child's first visit to dentist shd be during this period. •Dentifrice is not advised to be used becoz the foaming action of the paste is objectionable.

II. TODDLERS(1 TO 3 yr old) • • •

Introduction of moistened, soft–bristled, child or infant sized TOOTH BRUSH into plaque removing procedure. Only a non-fluoridated dentifrice shd be used. Positioning of child and parent is again important in this case. several positions can be used by the parent but LAP TO LAP POSITION is most common & allows one adult to control child's movements while the other adult

III. PRESCHOOLERS (3 TO 6 yrs old) • • • •

The parents shd continue to brush the teeth for the child. A fluoride dentifrice can be introduced at 3 yrs of age. Only pea sized amount of toothpaste shd be used. Flossing is also started in this age. In the primary dentition , posterior contacts are the only areas where flossing is needed. In this age the position can be such that the parent stands behind the child and both face the same direction. The child rests his or her head back in parents non- dominant arm. With the hand of this arm the cheeks can be retracted& the other hand is used for brushing . This position is also appropriate

IV. SCHOOL-AGED CHILDREN(612yr) • •

• • •

Most of children can provide their basic oral hygiene i.e. brushing & flossing under active supervision by parents. Parents can check the cleanliness of child’s teeth by use of disclosing agent. after the child has brushed, flossed & used disclosing agent, the parent can easily visualize the remaining plaque & assist the child to remove it. Use of fluoridated dentifrices is essential & fluoridated gels & rinses used in children at risk for caries. Early T/t of malocclusion in this age group. This age is at high risk of caries & periodontal

V. ADOLESCENT(12-19yr old) • • •

•

At this age the patient has developed adequate skills for oral hygiene procedures but compliance is major problem at this age. Motivating an adolescent to assume responsibility for personal oral hygiene may lead to rebellious rxns. These patients are at a risk for caries & gingival inflammation bcoz of poor dietary habits, pubertal hormonal changes & poor plaque control habits due to increase in self-esteem. Increasing adolescents knowledge regarding plaque control & oral diseases, as well as appealing to their appearance, may also help in motivating these patients.

Tooth Brushing In Adults

I. TOOTHBRUSHES B. TOOTH BRUSHING TECHNIQUES 3. 4. 5. 6. 7. 8. 9.

The Bass method or Sulcus cleaning method Modified bass method Modified Stillman’s method Charter’s method Scrub brush method The Roll technique Fones method or Circular scrub method

I. BASS/SULCUS CLEANING METHOD Most widely accepted & most effective method for dental plaque removal, adjacent & directly beneath the gingival margin. INDICATIONS: d. e. f.

For all patients for dental plaque removal adjacent to & directly beneath gingival margin. Particularly adaptable for open interproximal areas, cervical areas beneath the height of contour of enamel& exposed surfaces For routine patients with or without

1. Place the brush at a 45 angle against the tooth, making certain that the bristles are at gingival margin. Gently brush the surface of each tooth using a short, gentle vibratory back & forth motion.

2. Brush the outer surfaces of each tooth, upper & lower , keeping the bristles against the gingival margin . Repeat the same method on the inner surface of the teeth as well.

3. To clean the inside surfaces of the front teeth , tilt the brush vertically & make several gentle up and down strokes using the front half of brush.

4. Scrub the chewing surfaces of the teeth using a short back & forth movement. Brushing the tongue will remove bacteria & freshen your breath.

ADVANTAGES: b. Effective method for subgingival cleansing. c. Provides good gingival stimulation. d. Easy to learn. e. Recommended for routine patients with or without periodontal involvement. DISADVANTAGE: h. Time consuming i. Dexterity requirement is too high in some patients.

II. MODIFIED BASS TECHNIQUE INDICATIONS: c. d.

As a routine oral hygiene measure. Intrasulcular cleaning.

TECHNIQUE: g. h. i.

The toothbrush is held such that the bristles are at a 45- degree angle at gingiva. Bristles are gently vibrated back & forth motion i.e. vibratory horizontal motion. In a single motion, the bristles are then swept vertically over the sides of teeth towards their occlusal surfaces.

ADVANTAGES: c. Excellent sulcus cleaning. d. Good interproximal & supragingival cleaning. e. Good gingival stimulation. DISADVANTAGES: h. Moderate dexterity of wrist is required.

III. MODIFIED STILLMANS TECHNIQUE c.

d. e.

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

TECHNIQUE: b. Place the toothbrush at 45 degree angle partly on gingiva & partly on cervix of teeth. c. The bristles are gently moved with a vibratory pulsating motion& gently swept occlusally over sides of teeth. ADVANTAGE: e. Helps in supragingival cleaning. DISADVANTAGE: g. Time consuming. h. Improper brushing can damage the epithelial attachment.

IV. CHARTERS METHOD INDICATIONS: d. g. h. i. j.

Indications having open inter dental spaces with missing papilla & exposed root surfaces. Those wearing FPD or orthodontic appliances. For patients who have had periodontal surgery. Patients with moderate gingival recession particularly interproximally. Massage & stimulation for marginal & interdental gingiva.

IV. TECHNIQUE: b. c.

The bristles are placed at a 90 degree angle to the tooth. The bristles are then moved in a circular vibratory motion.

ADVANTAGE: e. f.

Gingival stimulation. Interproximal cleansing.

DISADVANTAGE: h. i.

j.

Brushing ends do not engage the gingival sulcus to remove subgingival bacterial accumulation. In some areas the correct brush placement is limited or impossible, therefore modifications become necessary which add to the complexity of the procedure. Requirements in digital dexterity are high.

V. SCRUB BRUSH METHOD c. d. f. h. i. j.

TECHNIQUE: The brush is kept in 90 degree angle to the tooth. The bristles are moved in horizontal strokes. ADVANTAGE: Supragingival cleansing. DISADVANTAGE : Ineffective at plaque removal. Tooth abrasion & gingival recession. Detrimental to general oral health.

VI. THE ROLL TECHNIQUE Ø

In patients with anatomically normal gingiva

Indications: d. e. f. g. h.

Children & adult patients with limited dexterity. Patients required gingival massage & stimulation. Cleaning gingiva & removal of plaque, material alba & food debris from the teeth without emphasis on gingival sulcus. For general cleaning in conjunction with the use of vibratory technique. Used as a preparatory instruction for modified stillmans technique.

TECHNIQUE: b. c.

Bristles are placed at a 45 degree angle to tooth surface. Bristles are lightly rolled across the tooth surface towards the occlusal surfaces.

DISADVANTAGE: e. f. g.

Brushing too high during initial placement can lacerate the alveolar mucosa. Tendency to use quick, sweeping strokes resulting in no brushing for the cervical third of tooth & the interproximal area. Replacing the brush with filament tips directed into the gingiva may produce punctuate lesions.

VII. FONES METHOD INDICATION:

Ø e. f.

Indicated for young patients who want to do brushing, but do not have the muscle development for techniques which requires more co-ordinations. TECHNIQUE: The child is used to make big circles in air which are then reduced in diameter very small circles are made in front of mouth The brush is placed in 90 degree angle to the tooth & then bristles are moved in horizontal direction.

ADVANTAGES: b. c. d. e. f. g.

This technique has equal or better potential than bass technique for plaque removal & prevention of gingivitis. It is easy to learn. Shorter time Physically or emotionally, handicapped individuals. Patients who lack dexterity for a more technical brushing method. Gingiva is provided with good stimulation.

DISADVANTAGE: j. k. l.

Possible trauma to gingiva. Interdental areas are not properly cleaned. This technique may cause harm to adults especially who use the brush vigorously.

TOOTH BRUSHING METHODS

CONTINUED…….

B. EFFECTS OF IMPROPER TOOTH BRUSHING II. Toothbrush trauma: gingival alterations Acute alteration

Chronic alteration

f.

ACUTE ALTERATION(LACERATIONS)

7.

Scuffled epithelial border with denuded underlying connective tissue. Punctate lesions that occur as red pinpoint spot. Diffuse redness && denuded attached gingiva.

8. 9.

PRECIPITATING FACTORS: 11.

Horizontal or vertical scrubbing tooth brushing method with pressure (either manual or powered)

2. Over vigorous placement & application of toothbrush. 3. Penetration of gingiva by filament ends. 4. Use of toothbrush with frayed , broken bristles or filaments. 5. Application of filaments beyond attached gingiva.

g. CHRONIC ULCERATIONS 7. Usually appear on the facial gingiva becoz of the vigor with which toothbrush is used. 8. Areas most commonly involved are around canines or teeth in labio- or bucco- version. • RECESSION 11. Appearance: margin of the gingiva has receded towards the apex & cementum is exposed. 12. Predisposing anatomic factors xiii. Malposition of teeth. xiv. Narrow band of attached gingiva cannot withstand pressures of brushing

• CHANGES IN GINGIVAL CONTOUR 2. Rolled, bulbous, hard firm marginal gingiva in ‘piled up’ or festoon shape. 3. Gingival cleft.

PRECIPITATING FACTORS

5. Repeated use of vigorous rotary, vertical or horizontal tooth brushing techniques over a long period of time. 6. Use of long, brisk strokes with excessive pressure over a long period of time. 7. Habitual prolonged brushing in one area. 8. Excessive pressure applied with worn out non-resilient brush. Suggested corrective measures • Use of softer toothbrush. • Demonstration of proper brushing technique.

II.

Abrasion of teeth

DEF: Abrasion is loss of tooth substance produced by mechanical wear other than by mastication, or it may be defined as pathologic wearing away of tooth substance through some abnormal mechanical process. v. vi. vii. viii. ix. xii. xiii.

CONTRIBUTING FACTORS Hard toothbrush. Horizontal brushing Excessive pressure during brushing. Abrasive agent in the dentifrice. Prominence of tooth surface labially or bucally. LOCATION OF ABRADED AREAS Facial surfaces of canine, premolars & first molars or any tooth in bucco- or labio version. Most abraded area cervical areas of exposed root surface.

APPEARANCE Saucer shaped or wedge shaped indentations with smooth shiny surfaces CORRECTIVE MEASURES v. Advise a specific brush with soft textured bristles or filaments. vi. Change the tooth brushing technique. vii. Recommend a less abrasive dentifrice. viii. Use a smaller amount of dentifrice.

L. MAINTAINENCE OF TOOTHBRUSH • • • •

As toothbrushes are vehicle in breeding & transmitting various organisms so advised cleaning with antiseptic mouthwash. Store in dry areas as wet areas may allow bacterial proliferation. Toothbrush shd be kept in open air with head in upright position with no contact with other brushes. Toothbrush has an avg. lifespan of 3 to 6 months.

II. INTERDENTAL CLEANING AIDS •

The toothbrush is not adequate for interproximal cleaning.

C. DENTAL FLOSS • • • • x. xi. xii.

Dental floss is available in forms: Multifilament – twisted / non twisted Bonded / non bonded Thick / thin Waxed / non waxed Unwaxed dental floss is better than waxed bcoz: Small diameter & pass easily thru tight interproximal contact. Under tension it flattens on tooth surface. Unwaxed floss makes a squeaking noise & this can be used to monitor performance.

•Interproximal / Interdental brushes •Powered interdental brushes

CLASSIFICATION OF FLOSS ON BASIS OF GINGIVAL EMBRASURES

III. TONGUE SCRAPING • •

The process of removing debris from surface of tongue with some form of scraper designed for this purpose. Most tongue scrapers are made of soft flexible plastic.

TECHNIQUES: 5. f. g. 9. i.

BRUSHING Place sides of the brush on the dorsum of the tongue with the tip directed towards the throat. Apply light pressure & move the brush forward & out, repeat to cover the entire surface. TONGUE CLEANING DEVICES Device is placed towards the back of tongue on the dorsal surface, the pulled forward with light pressure.

IV. IRRIGATION DEVICES • • •

Valuable in removing the unattached plaque & debris. Mainly composed of a pump & a reservoir These devices are used to deliver antimicrobial agents eg:chlorhexidine.

X. CHEMICAL PLAQUE CONTROL •

Ideal adjunct to mechanical plaque control specially in individuals with a defective host defence mechanism, mentally or physically handicapped & in patients who have undergone surgical procedures postoperatively.

REFRENCES:2. 3. 4. 5. 6.

SOBEN PETER JOSEPH JOHN CARRENZA Textbook of periodontology- WILKINS Textbook of child & adolescentMCDONALD.

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