Initial Treatment 1—


Initial Treatment 1—

• Oral Hygiene by the Patient

The patient’s oral hygiene (plaque control) remains today the primary supportive pillar of periodontal prophylaxis. It also supports treatment, and has great significance for maintenance of the treatment results.

Without continuous compliance by the patient, periodontal treatment by the dentist and the dental hygienist will be less successful and the success will be of shorter duration. Oral hygiene by the patient means, above all, reduction of the amount of plaque and pathogenic microorganisms in the oral cavity. Gingival massage with the toothbrush is of secondary importance, with perhaps some “psychological” effect.

In special indications, mechanical plaque control can be enhanced or supported for a limited period of time by topical medicaments (disinfection agents such as chlorhexidine).

This chapter will describe:

  • Plaque disclosing agents, revealing the plaque

  • Manual toothbrushes

  • Toothbrushing techniques, systems

  • Electric toothbrushes

  • Interdental hygiene—interdental hygiene aids

  • Dentifrices

  • Chemical plaque control—CHX, additional products

  • Irrigators—of value?

  • Halitosis, bad breath—oral hygiene

  • Possibilities, successes and limitations of oral hygiene

Toothbrushes of all kinds are important aids for mechanical plaque removal. They reach, however, only the facial, oral and occlusal tooth surfaces.

The initial lesions of gingivitis and periodontitis, as well as dental caries, usually occur in the interdental region. Therefore, the toothbrush must be enhanced by additional hygiene aids that can ensure cleansing of the interdental area.

There is no single oral hygiene method that is right for every patient. The type and severity of the periodontal disease, the morphological situation (crowding, spacing, gingival phenotype etc.) as well as the patient’s own manual dexterity determine the required hygiene aids and the cleaning techniques. During the course of periodontitis therapy, the techniques may have to be changed or adapted to the new morphological situation (longer teeth, open interdental spaces, exposed dentin).

The patient must be informed about his/her daily oral hygiene, its frequency, time spent and amount of force to be applied. In most cases, once per day is sufficient for a thorough and systematic plaque removal (disruption of the developing biofilm; Lang et al. 1973).

In the final analysis, though, it is not the hygiene aids, the technique or the time spent that is the determining factor, rather the result: Freedom from plaque. This parameter as well as the health of the of the gingiva (BOP) must be checked at regular intervals.

Motivation—Gingival Bleeding

Since 1980, the clinical symptom “bleeding on probing” has assumed the foreground in patient motivation, replacing plaque disclosure. The profession realized that it is not the amount or expanse of plaque or its depiction in a microscope that was most meaningful to patients, rather it was the reaction of the patient’s own tissues to the microbial irritation that held the highest motivational value.

Each person exhibits very different individual reactions to the biofilm, its constituents and especially the microbial metabolites. Thus, even with identical amounts of plaque, quite different levels of pathogenic danger may be present.

Using the PBI (Saxer & Mühlemann 1975, Mühlemann 1978) or BOP (Ainamo & Bay 1975, p. 69) the severity of gingival inflammation can be numerically portrayed. If the gingival bleeding index decreases during initial treatment (1), as depicted by repeated clinical recording of the index, this provides visible evidence of success while simultaneously giving further motivation to the patient.

Bleeding on Probing as a Motivating Factor

475 Initial Condition: Moderate Periodontitis The patient can clearly see the severe hemorrhage as the hygienist performs the bleeding index (PBI or BOP). Right: As a second step, disclosing the plaque reveals the cause of the disease. The next steps include initial oral hygiene instruction and professional, supragingival prophylaxis.
476 Clinical Situation: Two Weeks Later Following professional prophylaxis and repeated OHI, the patient can readily see the return to health as indicated by the minimal bleeding during recording of the PBI data. The patient is motivated by this success to further intensive cooperation and compliance.
477 Clinical View at 4 Weeks The virtual absence of bleeding (inflammation) and the dramatic plaque reduction convinces the patient definitively of the logic of this treatment. Right: The minimum plaque accumulations demonstrate the correlation: Less plaque = less gingivitis. Additional oral hygiene instruction is now targeted toward those sites that are not completely plaque-free, e.g., interdental areas.

Plaque Disclosing Agents

Frequently during the case presentation, when motivation is being emphasized using the bleeding index, the patient will pose questions concerning the cause of periodontal disease. Now—right now!—is the prime time for demonstration of microbial plaque, the most important etiologic factor in gingivitis and periodontitis.

Using non-toxic food coloring agents, the adherent plaque on tooth surfaces and gingiva can be selectively stained. The patient watches in a mirror as the clearly visible plaque is revealed and then scraped off using a probe.

Patients are further impressed to hear that only 0.001 grams of plaque contain ca. 300,000,000 bacteria. The necessity and possibility for plaque removal via oral hygiene measures becomes visible to the patient, and the initial tooth-brushing instruction session falls on fertile soil.

One disadvantage of plaque disclosing agents that remain in the mouth for some time can be avoided by using the Plaklite system (Fig. 480). A solution that is virtually invisible in daylight clearly reveals accumulated plaque bacteria when illuminated with blue or UV light.

478 Red and Violet Disclosing Agents Left: Classic red staining by erythrosin. This procedure is still permitted by the FDA. Middle: Plaque disclosing agents for the patient (tablets) and for the clinician (solutions, pellets). Right: Differential disclosing agents that stain “fresh” plaque light violet, and old, “mature,” plaque a darker violet color.
479 Details of Four Plaque Disclosing Agents (adapted from Roulet & Zimmer 2003) Older, deeply-staining agents such as basic fuschsin, malachite green and other “histologic stains,” which are depicted in some illustrations in this Atlas, are no longer used in clinical practice because of their potentially injurious side effects or toxicity.
480 Fluorescent Disclosing Agents, Blue or UV Light In normal room lighting, plaque disclosed with 0.75% Na-fluorescein solution appears light yellow (left), but glows intensively yellow-green under blue light (right). The disclosing products are available from Vivadent, Lactona, Clairol and International Pharmaceutical Co. (IPC) and others. A disadvantage of this technique is the requirement of a special light source or a filter mirror.


For centuries, the toothbrush has served to remove food debris and plaque from all facial, oral and occlusal tooth surfaces. Today the toothbrush remains indispensable, but it does not provide adequate interdental hygiene. In addition, when used with excessive force it has the potential to injure even healthy gingiva.

There is no ideal toothbrush (shape, size, handle) but in periodontics more and more brushes with softer, flexible bristles have found acceptance. Rounded bristle tips are the standard today.

Worthy of consideration also is the fact that toothbrushes are always used with toothpastes (p. 234). It seems only reasonable that these two components should be “synchronized” for each individual patient (König 2002) and this must be accomplished by the dental hygienist. This should replace the often wildly extravagant commercial claims with facts, and permit targeted recommendations for each individual patient.

481 “The Best Brush” Patients always ask: “What’s the best toothbrush”? Who wins gold, silver or nothing? Fact: There is no “best” brush! For the hygienist it is important to know the commercially available brushes, but more important to know the needs of the individual patient, in order to properly advise
482 ADA Type and New Trends New brushes and their efficacy are standardized according to ADA guidelines after in vitro testing. Clinical tests with human subjects are more costly and provide limited data. The ADA “norm” (left) is a four-row brush, multi-tufted. At right today’s trend, the Oral-B “Cross Action.” Right: Rounded bristle tips are today’s standard.
483 Toothpaste and Toothbrush: One Goal The role of the toothbrush is generally overvalued! Only in combination with a dentifrice is it effective; the toothbrush is really only a carrier. Its positive effects (gingival massage?) are insignificant. Its negative effects, especially with hard bristles, can be grave: Damage or injury to gingiva and mucosa can lead to gingival recession or aphthous ulcers.

Oral hygiene devices have become a huge worldwide market. The industry has done and will continue to do everything in its power to persuade consumers of the efficacy of its product, using brilliant colors and bizarre shapes! Using the latest generation of high-tech machines, it has been possible to create exceptional types of bristle arrangements—parallel or crossed, variously colored bristles, flat plane or irregular, straight or round brush heads etc.

The question that remains, however, is whether any of this is actually useful for patients!

It is up to dental hygienists and dentists not to react but rather to act! Guidelines for good toothbrushes need to be defined, for example, for periodontitis patients with thin gingiva, recession, large interdental spaces etc. Worthy of thought: A motivated patient brushes daily for 60, 70 or 80 years! Long-term freedom from injury is more important than momentary efficiency.

It seems that a start has been made: Superfine bristles—they clean just as well as hard bristles—and unconventional 3- headed brushes are being widely discussed.

484 Modern Toothbrushes—Frontal View How is one to evaluate the enormous differences in shape, bristle array, handle etc.? The best that a toothbrush can offer is its ability to effectively clean the teeth, while preventing damage or injury to gingiva or teeth, and help reduce bad breath.
485 Modern Toothbrushes—Lateral View This figure corresponds to Fig. 484. From left to right… Elmex Supersoft Paro Future Elmex Inter X medium Trisa FlexHead soft Dr. Best X-aktiv Flex Oral-B Cross Action Colgate Navigator medium Mentadent Insider soft-medium Superbrush Junior
486 Meridol and Superbrush—New Developments; Progress? Left: The Meridol brush has superfine, flexible bristles, designed to absorb excessive force. Right: The three brush heads simultaneously clean vestibular, occlusal and oral tooth surfaces. Using a light vibratory movement, teeth are cleaned one-by-one. This design was superior to other brushes in clinical trials (middle: head of the Nais electric toothbrush. cf. p. 230).

Toothbrushing Technique

Innumerable toothbrush movements have been recommended over time, and then abandoned: Rolling, vibrating, circular, vertical and horizontal (Jepsen 1998). More important than the technique is the efficiency of cleaning, a systematic procedure and that no damage is caused.

Dental hygienists have recognized again and again that most patients, despite instruction, seem to be satisfied with an apparently “genetically determined” horizontal scrubbing technique.

The most frequently recommended “modified Bass technique” (Bass 1954) is depicted below.

487 Systematic Toothbrushing The sequence depicted has been shown to be effective (start: right, posterior*) 1 Oral Surfaces mandible/maxilla, and all distal surfaces at the end of each arch. 2 Facial Surfaces mandible/maxilla 3 Occlusal Surfaces mandible/maxilla 4 Interdental Spaces, using special hygiene aids

Modified Bass Technique

488 Placement of the Toothbrush Toothbrush bristles positioned perpendicular to the tooth long axis will not effectively clean the interdental spaces. Right: Instead of the “original” Bass technique, which used a two-row brush, today the “sulcus cleansing technique” is performed with the more common three-or four-row brushes. This combination should provide improved cleaning.
489 45° Angle of the Bristles—Occlusal View When the brush is applied at a 45° angle to the teeth and then rotated toward the occlusal plane, the bristles slip easily into the interdental areas and gingiva sulci without excessive force. With the brush in this position, small rotatory or vibratory movements will effectively remove plaque. Problem zone: Angular arch form in the canine regions.
490 45 Degree Angle—Distal Surfaces Viewed from the distal, the position of the bristles in the Bass technique becomes obvious. Right: Distal surfaces will not be effectively cleaned by hard bristle brushes; extremely flexible toothbrush bristles may provide effective distal cleaning. Dental floss is not recommended for such surfaces, which often exhibit concavities and/or furcations. Single-tuft brushes are more effective (right).
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Jul 2, 2020 | Posted by in Dental Hygiene | Comments Off on Initial Treatment 1—
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