plaquecontrol

TOOTH BRUSHING TECHNIQUES
	Many methods for brushing the teeth have been described and promoted as being efficient and effective.
	These methods can be categorised primarily according to the pattern of motion when brushing and are primarily of historical interest, as follows
1.	Roll:-- Roll method or modified Stillman technique
2.	Vibratory:-- Stillman, Charters, and Bass technique
3.	Circular:-- Fones technique
4.	Vertical:-- Leonard technique
5.	Horizontal:-- Scrub technique
	Controlled studies evaluating the effectiveness of the most common brushing techniques have demonstrated no clear superiority for any method.
	The scrub technique is probably the simplest and most common method of brushing.
	Patients with periodontal disease are most frequently taught a sulcular brushing technique using a vibratory motion to improve access in the gingival areas.
	The method most often recommended is the Bass technique because it emphasizes sulcular placement of bristles.
	The basic premise is to adapt the bristles tips to the gingival margin in order to reach the supragingival plaque, using controlled movement to avoid trauma and moving the brush systematically around all the teeth.
	Clinicians and patients often modify brushing techniques for their own situations.
1. THE BASS METHOD OR SULCUS CLEANING METHOD ( 1948 )

1. Place the head of a soft brush parallel with the occlusal plane, with the brush head covering 3 to 4 teeth, beginning at the most distal tooth in the arch.

2. Place the bristles at the gingival margin, pointing at a 45-degree angle to the long axis of the teeth.

3. Exert gentle vibratory pressure, using short, back and forth motions without dislodging the tips of the bristles.
This motion forces the bristle ends into the gingival sulcus area, as well as partly into the interproximal embrasures.

The pressure should be firm enough to blanch the gingiva.

4. Complete several strokes in the same position. The repetitive motion cleans the tooth surfaces, concentrating on the apical third of the clinical crowns, the gingival sulci, and as far onto the proximal surfaces as the bristles can reach.

5. Lift the brush, move it to the adjacent teeth, and repeat the process for the next three or four teeth.

6. Continue around the arch, brushing about three teeth at a time. Then use the same method to brush the lingual surfaces.

7. After completing the maxillary arch, move the brush to the mandibular arch, and brush in the same organized way to reach all the teeth.

8. If the brush is too large to reach the lingual surfaces of the anterior teeth, it should be turned vertically to press the end of the brush into the gingival sulcus area.

9. Brush the occlusal surfaces of three or four teeth at a time by pressing the bristles firmly into the pits and fissures and brushing with several short, back-and-forth strokes.

The Bass technique requires patience and placement of the toothbrush in many different positions to cover the full dentition.

Patients need to be instructed to brush in a controlled and systematic sequence.
Other methods of brushing, such as the modified Stillman and Charters, are variations of the Bass technique.

Indications
For all patients for dental plaque removal adjacent to and directly beneath the gingival margins.
Particularly, adaptable for open interproximal areas, cervical areas beneath the height of contour of the enamel and exposed root surfaces.
Recommended for routine patients with or without periodontal involvement

Advantages

Disadvantages

	Effective method for removing plaque adjacent to and directly beneath the gingival margin, cervical areas and sulcus
	Provides good gingival stimulation
	Easy to learn
	Recommended for routine patients with or without periodontal involvement

	Overzealous brushing may convert the " very short strokes " into a scrub brush technique and cause injury to the gingival margin
	Time consuming
	Dexterity requirement is too high for certain patients.

2. MODIFIED BASS TECHNIQUE
It is a combination of Bass and Modified Stillman technique.
In this technique, the brush is positioned similar to Bass technique.
The tooth brush is held such that the bristles are at 45 degree to the gingivae
After applying the small movement in anterior posterior direction the head of the brush is rotated applying a movement in occlusal direction
Indications
As a routine oral hygiene measure
Intrasulcular cleansing
Advantages
Excellent sulcus cleaning
Good interproximal and gingival cleaning
Good gingival stimulation
Disadvantages
Moderate dexterity of wrist is required

3. STILLMAN'S TECHNIQUE
	This is a vibratory technique. In this technique the head of the brush is positioned in an oblique direction toward the apex, with the bristles placed partly in the gingival margin and partly on the tooth surface.
	Light pressure together with a vibratory movement is then applied to the handle, without moving the brush from its original position.
4. MODIFIED STILLMAN'S TECHNIQUE (1932)
	The brush is applied in a similar manner to the Stillman technique i.e., the head of the brush is positioned in an oblique direction toward the apex, with the bristles placed partly in the gingival margin and partly on the tooth surface.
	but after applying a vibratory pressure, the head of the brush rotates progressively in an occlusal direction
	A soft brush is recommended for this technique.
Indications
	Dental plaque removal from cervical areas below the height of contour of the enamel and from exposed proximal surfaces.
	General application for cleaning tooth surfaces and massage of the gingiva.
	Recommended for cleaning in areas with progressing gingival recession and root exposure to prevent abrasive tissue destruction.
Disadvantages
	Time consuming
	Improper brushing can damage the epithelial attachment
5. CHARTER'S METHOD (1928)

In this technique the head of the brush is positioned in an oblique direction to the tooth surface, with the bristles directed towards the occlusal surface
The brush is then moved back and forth with a rotation motion
This method is particularly effective in cases with receded interdental papillae, since with this particular situation the brush brisles can penetrate the interdental space.

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

Disadvantages
	Brush ends don't engage the gingival sulcus to remove subgingival bacterial accumulations.
	In some areas the correct brush placement is limited or impossible, therefore modifications become necessary which add to the complexity of the pcocedure
	Requirements in digital dexterity are high.

6. SCRUB BRUSH METHOD (1928)
	This is a Horizontal brushing technique.
	It is a most widespread technique and despite the efforts of the dental profession to instruct patients to adopt other more convienient brushing techniques, most individuals use such technique because it is the simplest.
	The head of the brush is positioned at 90 degree angle to the tooth surface and then movement is applied horizontally.
	The occlusal, lingual and palatal surfaces of the teeth are brushed with the mouth open and the vestibular surfaces are cleaned with the mouth closed.
	It is a free style of brushing
Disadvantages
	Ineffective at plaque removal
	Tooth abrasion and gingival recession
	Detrimental to general oral health.

7. THE ROLL TECHNIQUE
	This method of brushing is also known as the Rolling Stroke Method ADA Method Sweep Method
	It works fairly well for patients with anatomically normal gingival tissues.
	In this method the bristles are placed at 45 degree angle and lightly rolled across the tooth surface towards the occlusal surfaces.
	This technique requires some flexibility around the wrist.
Indications
	Children and adult patients with limited dexterity.
	Patients requiring gingival massage and stimulation
	Cleaning gingiva and removal of plaque, material alba and food debris from the teeth without emphasis on gingival sulcus.
	For general cleaningin conjunction with the use of vibratory technique ( Charter, Stillman or bass ).
	Useful for prepratory instruction ( first lesson ) for modified stillman's technique. Since the initial brush placement is the same.
Disadvantages
	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 the tooth, since the brush tips pass over rather than into the area and likewise for the interproximal area.
	Replacing the brush with filament tips directed into the gingivae may produce punctuate lesions
8. FONES METHOD OR CIRCULAR SCRUB METHOD (1934)
	The child is asked to stretch his/her arms such that they are parallel to the floor.
	The child is then asked to make big circles using the whole arm to draw circles in the air.
	The circles are reduced in diameter until very small circles are made in front of the mouth.
	The child is now ready to make circles on the teeth with the toothbrush, making sure that the teeth and gums are covered.
Indications
	Indicated for young children who want to do their own brushing, but do not have the muscle development for techniques which requires more co-ordinations.
Advantages
	This technique has equal or better potential than Bass technique for plaque removal and 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.
Disadvantages
	Possible trauma to gingiva
	Interdental areas are not properly cleaned
	Detrimental for adults especially who use the brush vigourously.
9. VERTICAL METHODS - LEONARDS METHOD (1939)
	Leonard advocated a vertical stroke in which maxillary and mandibular teeth are brushed separately.
Technique
	The bristles of toothbrush are placed at 90 degree angle to the facial surface of the teeth.
	The motion is vertical up and down brushing movements on the facial surface of the clenched anterior and posterior teeth.
	With the teeth edge to edge, place the brush with the filaments against the teeth at right angles to the long axes of the teeth.
	Brush vigorously, without great pressure with a stroke that is mostly up and down on the tooth surfaces with just a slight rotation or circular movement after striking the gingival margin with force.
	Enough pressure is used.
	It is not intended that upper and lower teeth shall be brushed in the same series of strokes.
	The teeth are placed edge to edge to keep the brush slipping over the occlusal or incisal
Advantages
	Most convenient and effective for small children with deciduous teeth
Disadvantages
	Interdental spaces of the permanent teeth of the adults are not properly cleaned.
10. PHYSIOLOGIC METHOD - SMITH METHOD (1940)
	The physiologic method was described by Smith and advocated later by bell.
	It was based on the principle that the toothbrush should follow the physiologic pathway that food does when it transverse over the tissues in a "natural" masticatory act.
Technique
	A soft brush with " small tufts " of fine bristles arranged in four parallel rows and trimmed to an even length was used in a brushing stroke.
	Bristles are pointed incisally or occlusally and then along and over the tooth surfaces and gingiva.
	The motion is gentle sweeping from incisal or occlusal surfaces over to facial surfaces and progressing toward and over the gingiva.
	It is almost an attempt to duplicate natures self cleansing and gingival stimulation mechanism during mastication of food.
Advantages
	Natural self cleansing mechanism.
	Supragingival cleaning is good.
Disadvantages
	Interdental spaces and sulcus areas of teeth are not properly cleaned
EFFECTS OF IMPROPER TOOTH BRUSHING

TOOTHBRUSH TRAUMA

Gingival Alterations

Abrasion of the teeth

GINGIVAL ALTERATIONS
ACUTE ALTERATIONS ( LACERATIONS )
1. Scuffled epithelial surface with denuded underlying connective tissue.
2. Punctate lesions that appear as red pinpont spots.
3. Diffuse redness and denuded attached gingiva.
Precipitating factors
1. Horizontal or vertical scrubbing toothbrushing method with pressure (either manual or powered)
2. Over vigorous placement and application of toothbrush.
3. Penetration of gingiva by filament ends.
4. Use of toothbrush with fayed, broken bristles or filaments
5. Application of filaments beyond attached gingiva.

CHRONIC ALTERATIONS

1. Usually appear on the facial gingiva because of the vigour.
2. Areas most commonly involved are around canines or teeth - in labio - or bucco - version
3. It is inversely proportional to the right or left handedness of the patient.

RECESSION
1.	Appearance :-- margin of the gingiva has receded towards the apex and the cementum is exposed.
2.	Predisposing anatomical factors malposition of teeth narrow band of attached gingiva cannot withstand pressures of brushing
Changes in gingival contour
1.	Rolled, bulbous, hard firm marginal gingiva in " piled up " or festoon shape
2.	Gingival cleft
Precipitating factors
1.	Repeated use of vigorous rotary, vertical or horizontal toothbrushing techniques over a long period of time.
2.	Use of long, brisk strokes with excessive pressure over a long period of time
3.	Habitual prolonged brushing in one area.
4.	Excessive pressure applied with worn out non-resilient brush.
Suggested corrective measures
	Use of a softer toothbrush
	Demonstration of proper brushing technique.
ABRASION OF THE TEETH
	Abrasion is the loss of tooth substance produced by mechanical wear other than by mastication, or it may be defined as the pathologic wearing away of tooth substance through some abnormal mechanical process.
contributing factors Hard toothbrush Horizontal brushing Excessive pressure during brushing Prominence of the tooth surface labially or buccally.
Location of abraded areas
	The canines are most susceptible because of their prominence on the curvature of the dental arches, sometimes the premolars and first molars are also involved
	Most abraded areas are on the cervical areas of exposed root surfaces, but occasionally may occur on enamel.
Appearance
	Saucer shaped or wedge shaped indentations with smooth shiny surfaces
Corrective measures
	Explain the problem to the patient to assure full cooperation
	Advise a specific brush with soft textured bristles or filaments.
	Change the tooth brushing technique.
	Recommended a less abrasive dentifrice
	Use a smaller amount of dentifrices.

MAINTENANCE OF TOOTH BRUSHES
	Most investigators have observed that , the toothbrush may act as a vehicle in breeding and transmitting various organisms in the oral cavity.
	Experts therefore advise cleansing the toothbrush daily in antiseptic mouthwashes such as phenolic derivatives.
	Storing toothbrushes in dry areas is a necessity, as, wet surfaces may allow bacterial proliferation.
	Toothbrushes cshould be kept in open air with the head in an upright position with no contact with other brushes
	Toothbrushes have an average life span of 3-6 months.
	However they should be replaced as soon as there is any evidence of fraying, as frayed toothbrushes do not clean teeth efficiently and may cause wearing of teeth or gingival recessions.

TOOTH BRUSHING TECHNIQUES

1. THE BASS METHOD OR SULCUS CLEANING METHOD ( 1948 )

2. MODIFIED BASS TECHNIQUE

3. STILLMAN'S TECHNIQUE

4. MODIFIED STILLMAN'S TECHNIQUE (1932)

5. CHARTER'S METHOD (1928)

6. SCRUB BRUSH METHOD (1928)

7. THE ROLL TECHNIQUE

8. FONES METHOD OR CIRCULAR SCRUB METHOD (1934)

9. VERTICAL METHODS - LEONARDS METHOD (1939)

10. PHYSIOLOGIC METHOD - SMITH METHOD (1940)

EFFECTS OF IMPROPER TOOTH BRUSHING

CHRONIC ALTERATIONS

RECESSION

Changes in gingival contour

Precipitating factors

Suggested corrective measures

ABRASION OF THE TEETH

contributing factors

Location of abraded areas

Appearance

Corrective measures

MAINTENANCE OF TOOTH BRUSHES