ORAL PHYSIOTHERAPY

Introduction

Terms that have been used to describe those methods used by the patient to remove plaque are Home care, oral hygiene, oral physiotherapy, personal oral hygiene, and personal plaque control

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This presentation deals with various aspects of personal oral hygiene but not professional debridement.

Periodontal disease is largely preventable.

Like many chronic diseases, behavioral or lifestyle choices play a significant role in the pathogenesis of periodontitis

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Risk factors involved in periodontal disease expression the subgingival flora, genetic predisposition, stress, systemic disease and oral hygiene practices

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The relation between oral hygiene and periodontal disease is more complex than might be thought.

One of the foundations of periodontal health and therapy is Adequate home care.

BIOLOGIC RATIONALE FOR PERSONAL PLAQUECONTROL

Oral hygiene, as used in this chapter, refers largely to efforts to remove the supragingival plaque.

Supragingival plaque is the etiologic agent of gingivitis

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As the plaque matures and becomes thicker, the composition of the flora shifts from gram-positive facultative organisms to an increasingly gram-negative anaerobic flora.

This shift is aided by a slight swelling of the gingival margin that renders the subgingival environment more anaerobic and more hospitable to obligate anaerobes.

The subsequent inflammation results in a protein-rich exudate that is required by many of these asaccharolytic organisms as carbon and energy sources

accumulation of supragingival plaque may affect the composition of the subgingival microbiota, particularly in pockets probing less than 6 mm.

Plaque forms more quickly in sites of gingival inflammation.

Good plaque control is effective in preventing periodontal disease and halting its progress when combined with professional therapy.

HOME CARE TECHNIQUES

The goal of oral hygiene is the physical and chemical disruption of the biofilm on a frequent basis.

Devices and techniques have been used Toothbrush Home irrigation systems Electromechanical devices

TOOTH BRUSHING

Manual toothbrushes Brush should have bristles with rounded tips that are

soft enough to prevent damage to the teeth and gingiva

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Toothbrush handles are as variable as head designs.Brushes generally differ with regard to head size, bristle characteristics, and handle design

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diameter of the bristles is often stated to be around 0.007 inch There is some evidence that rounded bristles are less damaging

than those with cut ends. Similarly, hard or stiff bristles are more damaging than softer

bristles brushes should be discarded at the first signs of matting. Some commercially available brushes have bristles that change

color after a certain amount of use, which serves as a reminder to the patient that it is time to replace the brush

Manual brushing techniques

If a patient can do a good job removing plaque without damage to the teeth and gingival tissues, then there is no reason to suggest a change

Toothbrushing techniques can be grouped by the type of stroke used.

1. Bass and horizontal scrub techniques

2. Charters technique

3. Roll technique

Bass and horizontal scrub techniques

This method emphasizes sulcular brushing and, for this reason, has long been popular among periodontists.

the bristles are angled toward the gingival margin at a 45-degree angle and gently introduced into the sulcus

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The brush is then moved in a short vibratory stroke

It has sulcular penetration of approximately 1 mm Using a horizontal scrub motion may be viewed as a

modification of the Bass technique. The bristles are positioned in a similar 45-degree relation to the sulcus, but the brush is moved back and forth in a scrubbing motion rather than in short, circular vibratory strokes.

Charters technique

The bristles are perpendicular to the long axis of the teeth

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The bristles are then gently forced into the interproximal embrasures, which causes some deflection of the bristles toward the occlusal surfaces of the teeth.

The side of the bristles eventually rests on the surface of the gingiva, unlike the Bass method in which the bristle tip enters the sulcus

Charters method was supposedly good for gingival massage and was alleged to be indicated in cases of advanced periodontitis when the interdental embrasures are relatively open.

It can be argued, however, that one of the various interdental brushes might be more effective in this application.

The Charters method also has been recommended for use in the postsurgical healing phase, to prevent damage to the immature attachment apparatus.

roll technique

The bristles are angled into the sulcus at a 45-degree angle and overlap onto the facial gingiva. The head of the brush is then "rolled" so that the bristles move occlusally

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The modified Stillman technique is similar to the roll technique, except that the bristle ends are placed both into the sulcus and onto the marginal gingiva before the rolling motion is started

This brushing stroke is sometimes suggested for use after periodontal plastic surgery to treat gingival recession. The rolling motion is used to "guide" the healing tissues coronally.

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three concepts must be stressed regardless of the technique used

1. adequate time must be set aside for brushing

2. must be systematic

3. no method of manual brushing is sufficient to remove interdental plaque so that use of interdental aids is required.

Electromechanical toothbrushes

brushes that use a powered brush head more effective in removal of interproximal plaque advantage for patients who do not floss regularly

Interdental Cleaning Aids

The interdental embrasure offers a protected sanctuary for plaque to accumulate undisturbed

Manual toothbrushing does not generally have much of an effect on interdental plaque and gingivitis

The choice of aids depends largely on the size and shape of the interdental embrasure and the degree to which soft tissue fills the space.

1. Dental floss

The most common one Dental floss is available in a variety of different sizes

and configurations. Originally, the choice was limited to waxed and

unwaxed floss. The purpose of the wax was ostensibly to make flossing between tight contacts easier.

Waxed and unwaxed floss are equally effective in removing plaque

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For some patients the use of "floss aids" may allow easier management of the floss. These are used as an option to wrapping of the floss around the fingers. Although these devices do not appear to improve effectiveness of plaque removal, some patients may prefer them to using their fingers

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A piece of floss about 12 to 15 inches in length should be wrapped around the fingers

The floss is introduced into an interproximal space by gently moving it buccolingually in a "sawing" motion

It should be in C-configuration with care to not damage the papilla

The floss is guided into each interproximal space and then curved in a Cshape around each tooth surface. The floss is moved in multiple apicocoronal strokes to remove tooth-adherent plaque.

In the case of fixed partial dentures, floss cannot be passed through the interdental contact, because this is closed. Instead, a device known as a floss threader

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The end of the floss threader is passed into the embrasure space between the retainer and the pontic

The floss is inserted through the "eye" loop and the threader is passed through to the lingual.

The floss is grasped on the facial and lingual and is passed along the intaglio surface of the pontic.

The floss is moved apicocoronally along the interproximal surfaces of the abutment teeth

Floss holders

assist patients who have difficulty flossing.

Floss holders have a rigid handle with a "yoke" at the end, over which dental floss is stretched. The patient holds the handle and passes the floss into each interproximal space

The floss is worked gently past the contact point. The handle can then be moved mesially and distally to bring the floss into contact with the interproximal tooth surfaces.

Automated interdental cleaners

This device removes interproximal plaque by means of rotating monofilaments

Toothpicks and woodsticks

group of interproximal aids includes conventional round or flat toothpicks, in addition to triangular toothpicks designed for interdental cleaning,

these aids are better for situations in which there is a slightly receded interdental papilla

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Interdental brushes

consist of two components: a handle and a small,replaceable brush head. The brush heads are conical or cylindrical in shape. These brushes are best used in open embrasures with low papillary height

where the brush can fit easily in the available space without causing trauma to the papilla.

These devices are probably the instrument of choice for cleaning open embrasures

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As the interdental brush is passed buccolingually into and out of theinterdental space, the bristles clean the tooth surfaces

FREQUENCY OF PLAQUE REMOVAL

The ADA recommends brushing twice a day and cleaning between teeth with floss (or another interdental cleaner) once a day.

Some patients prefer to floss in the evening before bedtime so that the mouth is clean while sleeping.

CHEMICAL PLAQUE CONTROL

The provision of antiplaque benefits to dentifrices assists patients in improving hygiene and reducing susceptibility to gingivitis and caries.

Chemical plaque control involves different mechanisms and is mostly associated with antibacterial effects, but also includes effects on pellicle surface chemistry to improve cleansing or discourage renewed plaque formation.

Basic ingredients include water, alcohol, cleansing agents, flavoring ingredients and coloring agents. Active ingredients vary depending on the type of mouthrinse, but they can be placed into four general groups:

Antimicrobial agents act directly on oral bacteria to help reduce plaque, decrease the severity of gingivitis and control bad breath.

Fluoride helps reduce tiny lesions (tooth decay) on tooth enamel and make teeth more resistant to decay.

Astringent salts can serve as temporary deodorizers that mask bad breath.

Odor neutralizers act by chemically inactivating odor causing compounds.

Schematic presentation of the different mechanisms of action of active ingredients in dentifrice formulations for chemical plaque control

AGENTS FOR HYPERSENSITIVITY AND ROOT CARIES

Root Caries Dentin and cementum are demineralized more easily than

enamel; the pH required for dissolution is 6.0 to 6.5, which is less acidic than that required for coronal caries

Major risk factors for root caries include suboptimal fluoride exposure, recently exposed root surfaces, xerostomia, cariogenic microflora (e.g., lactobacilli and mutans streptococci), frequent consumption of fermentable carbohydrates, and poor plaque control

Root caries can be arrested by meticulous home care and frequent application of fluoride

Dietary analysis and reduction of fermentable carbohydrates is of significant value

Dentinal Hypersensitivity It may be caused by toothbrush abrasion and recession caused by

traumatic brushing, resective periodontal surgery, and repeated professional instrumentation.

A number of agents have been used, primarily in toothpastes, to reduce sensitivity.

Many of these are thought to act by occluding the open orifices of the dentinal tubules.

Agents that have been used include strontium chloride, potassium nitrate, potassium citrate, formaldehyde, and various fluoride preparations. Although some patients undoubtedly derive great benefit from desensitizing agents,

ORAL HYGIENE INSTRUCTION AND HEALTHPROMOTION

ADVERSE EFFECTS OF ORAL HYGIENE AIDS

Tooth Abrasion and Gingival Recession