plaquecontrol

	PLAQUE CONTROL is the removal of microbial plaque and the prevention of its accumulation on the teeth and adjacent gingival tissues. Besides, it also deals with the prevention of calculus formation.
	Plaque control includes the usage of mechanical procedures as well as chemical agents which retards plaque formation.
	Mechanical plaque control methods includes tooth brushing and interdental cleaning using oral hygiene aids and professional prophylaxis.
	As of now, mechanical plaque control seems to be the most dependable form of plaque control method.
	Chemical plaque control has been used only as adjunct to mechanical means and not a substitute.
	The various aids used for mechanical plaque control can be listed as follows

Toothbrushes

manual toothbrush

electric toothbrush

Interdental Aids

Dental floss

Triangular tooth picks

handheld triangular toothpicks

proxapic

interdental brushes

proxabrush system

bottle brushes

single-tufted brushes (flat or tapered)

Yarn

superfloss

perio-aid

Aids for Gingival stimulation

rubber tip stimulator

balsa wood edge

Others

gauze strips

pipe cleanser

water irrigation device

Aids for Edentulous or Partially edentulous Patients

denture and partial clasp brushes

cleansing solutions

TOOTHBRUSHES
	Toothbrushes are the most widely used oral hygiene aids.
	It is the principal instrument in general use for accomplishing the goals of plaque control
	A toothbrush has been described as "The most classic and principal method employed in oral hygiene".
	According to ADA's council on Dental therapeutics " The toothbrush is designed primarily to promote cleanliness of teeth and oral cavity".
HISTORY/DEVELOPMENT OF TOOTH BRUSHES

YEAR	PROGRESS
1000 AD	There is evidence that Chinese used ivory brush handles and bristles made from a horses mane as early as 1000 AD.
1498 AD	Most historians trace the development of the first toothbrushes (hog bristles set in oxbone) in 1498 AD in China.
1600 BC	They were first introduced in China as early as 1600 B.C.
1640	It is believed that the tooth brush was introduced into the western world in 1640 and has undergone very little change ever since.
1780	One of the early tooth brushes made in England was produced by William Addis in 1780.
	By early nineteenth century craftsmen in various European countries constructed handles of Gold, Ivory or ebony in which replaceable brush heads could be fitted.
1938	Nylon came into use in toothbrush construction in 1938.
	World War II complications prevented Chinese export of wild boar bristles, and synthetic bristles were substituted for natural bristles.
1960	Powered toothbrushes were developed earlier but not until 1960 were they actively promoted.
TYPES OF TOOTH BRUSHES
	Manual toothbrushes powered toothbrushes Sonic & ultrasonic toothbrushes Ionic toothbrushes
MANUAL TOOTH BRUSHES

	Traditional (top) and novel (bottom) design of manual toothbrushes. The latter shows multiple tufts of bristles angled in different directions.
	This novel design of toothbrush allows bristles to be easily angled in the direction of approximal tooth surfaces. In this particular case, the Stillman method of toothbrushing is being used.

Toothbrushes from the 19th and 20th centuries, one with an ivory handle from about 1890 (left), one with a composition handle from the 1950s (center), and one with a sterling silver handle from the early 20th century (right).
The ivory handled brush belonged to a dental student who used the handle to practice cutting preparations and filling the "preps" with amalgam or gold foil.

variations in brush head and handle design.

At the European Workshop on Mechanical Plaque Control, it was agreed that the features of an ideal manual toothbrush should include

Handle size appropriate to user age and dexterity.

Head size appropriate to the size of the patient's mouth.

Use of end-rounded nylon or polyester filaments not larger than 0.009 inches in diameter.

Use of soft bristle configuration as defined by the acceptable international industry standards (ISO)

Bristle patterns which enhance plaque removal in the approximal spaces and along the gum line.

PARTS OF A TOOTH BRUSHE
1.	Handle :-- The part grasped in the hand during tooyhbrushing.
2.	Head :-- The working end of a toothbrush that holds the bristles or filaments
3.	Tufts :-- Clusters of bristles or filaments secured into head.
4.	Brushing plane :-- The surface formed by the free ends of the bristles or filaments.
5.	Shank :-- The section that connects head and handle.
HEAD - HANDLE - SHANK - DIFFERENT DESIGNS
	The preference of handle characteristics is a matter of individual taste.
	The handle should fit comfortably in the palm of the hand; it may be straight or angled, thick or thin
	Brushes with modest angulation between the head and the handle are available, and some clinical evidence supports the idea that these brush handles improve access for plaque removal under supervised brushing conditions.
	In fact, a recent study described a toothbrush with a double angulation of the neck of the handle and demonstrated significantly more plaque reduction, especially on the buccal and lingual surfaces.
	The clinical significance of these findings has not been determined, but it is reasonable to surmise that modifications improving access may help some patients to brush more effectively.
	However, consideration in choosing a brush should include the appropriate size of the head, which should be small enough for maximum maneuverability in the oral cavity.
	It is best for the head therefore to be no longer than 1.625 inches in adult brushes, 1 inch or less in children and to be no wider than .5 inch in adult and .3125 inches in children brushes
	Straight handles are more common. Handles with contrangle may provide the brushes with a better sense of touch.
	some novel toothbrush designs intended to make difficult-to-reach areas more accessible have been described.
	One brush, designed to brush buccal, lingual and occlusal / incisal surfaces at one time, has curved bristles on both sides of the brush head and shorter bristles running down the center.
	One study even demonstrated a brush's improved plaque removal ability compared with a conventional brush, but as with other tooth brush studies, absolute differences were slight.
	The plaque-removing efficacy of another design featuring a U - shaped head with bristles that would also reach buccal, lingual, and occlusal / incisal surfaces at one time is supported by a small clinical trial, but changes in gingival health were not evaluated.
	The notion of brushing all reachable surfaces of the teeth at one time is attractive, and these inventive brush designs may be useful for some patients to achieve better plaque control.
	There is no reason to discourage use of any particular device, especially if the patient likes it and uses it more or better than a conventional brush.
	There may well be a truly better design in the hands of an individual patient that results in better plaque removal and improved gingival health.
TOOTH BRUSH BRISTLES
	Rounded bristle ends cause fewer sratches on the gingiva than flat-cut bristles with sharp ends

	Force & Time required for Brushing :-- The amount of force used to brush is not critical for effective plaque removal.
	Brushing time ( Cancro & Fischman 1995 ) recommended by professionals is 2 minutes twice per day. Vigorous brushing is not necessary and can lead to gingival recession bacteremia, especially in patients with pronounced gingivitis edge-shaped defects in the cervical area of root surfaces and painful ulceration of the gingiva.


	Hard and soft Natural and synthetic Multitufted & Space tufted
Hard And Soft :--
	The question of the most desirable bristle hardness is not settled.
	Bristle hardness is proportional to the square of the diameter and inversely proportional to the square of bristle length. Number of filaments in a tuft Curvature of filaments
	Diameters of commonly used bristles range from 0.007 inch ( 0.2 mm) for soft brushes 0.012 inch ( 0.3 mm) for medium brushes and 0.014 inch ( 0.4 mm) for hard brushes.
	Length of bristles :-- Siffness of the bristles is inversely proportional to its length. Shorter bristles are stiffer as compared to longer bristles.
	Number of filaments in a tuft :-- Each filament gives support to adjacent filaments and each tuft gives support to adjacent tufts.
	Curvature of filaments :-- Curved filaments may be more flexible and less stiff than straight filaments of equal length and diameter.
	Soft bristle brushes of the type described by Bass have gained wide acceptance.
	Bass recommended a straight handle nylon bristles 0.007 inch ( 0.2 mm) in diameter 0.406 inch ( 10.3 mm) long with rounded ends arranged in three rows of tufts six evenly spaced tufts per row with 80 to 86 bristles per tuft.
	Opinions regarding the merits of hard and soft bristles are based on studies carried out under deffering conditions; these studies are often inconclusive and contradict one another.
	Soft bristles are more flexible, clean beneath the gingival margin when used with a sulcus brushing technique, and reach further onto the proximal tooth surfaces.
	Use of hard bristled tooth brushes is associated with more gingival recession, and frequent brushers who use hard bristles have more recession than those who use soft bristles
	However the manner in which a brush is used and the abrasiveness of the dentifrice affect the action and abrasion to a greater degree than the bristle hardness itself.
	Bristle hardness does not significantly affect wear on enamel surfaces.
Natural And Synthetic :--
	Natural bristles :-- Obtained from the hair of Hog or Wild boar.
	The bristles are tubular in form with drawbacks that They loose their elasticity and soften quickly. more susceptible to fraying and bristles break quickly contamination with microbial debris
	Synthetic bristles :-- Synthetic bristles are made of artificial filaments of nylon. They are uniform in size and elasticity resistant to fracture does not get contaminated repulsion of water and debris
	Patients accustomed to the softness of an older natural bristle brush can easily traumatize the gingiva when using a new brush with comparable vigour.
	Natural as well synthetic - both of these remove plaque, nylon filaments are superior in terms of homogenicity, uniformity of bristle size, elasticity resistance to fracture and repulsion of water and debris.

Multi-tufted And space-tufted :--
	Though the most desirable bristle design is questionable, multitufted brushes show better cleaning ability and rounded ends produce fewer lacerations.
ADA SPECIFICATION OF A TOOTHBRUSH
	The American Dental Association has described the range of dimensions of acceptable brushes A brushing surface 1 to 1.25 inches ( 25.4 to 31.8 mm) long. .3125 to .3750 inches ( 7.9 to 9.5 mm ) wide 2 to 4 rows of bristles 5 to 12 tufts / row
POWERED TOOTHBRUSHES

Electrically powered toothbrushes designed to mimic back-and-forth brushing techniques were invented in 1939.
Subsequent models featured circular or elliptic motions, and some with combinations of motions.
Currently, powered toothbrushes have oscillating and rotating motions and some brushes use low frequency acoustic energy to enhance cleaning ability.

Power toothbrushes rely on mechanical contact between the bristles and the tooth to remove plaque.
The addition of low frequency acoustic energy generates dynamic fluid movement and provides cleaning slightly away from the bristle tips.
The vibrations have also been shown to interfere with bacterial adherence to oral surfaces.
Neither the sonic vibrations nor the mechanical motion of powered toothbrushes has been shown to affect bacterial cell viabiliy.
Hydrodynamic shear forces created by these brushes disrupt plaque a short distance from the bristle tips, providing additional interproximal plaque removal.
Typically, comparison studies of powered toothbrushes, manual toothbrushes, or other powered devices demonstrate slightly improved plaque removal for the device of interest in a short term clinical trial.
A distinct overall advantage for any one particular product has not been demonstrated.

	Patient acceptance of powered toothbrushes is good.
	One study reported that 88.9% of patients introduced to a powered toothbrush would continue to use it.
	However, patients have also been reported to quit using powered toothbrushes after 5 or 6 months, presumably when the novelty is gone
	Powered toothbrushes with features that permit slightly better brushing on proximal surfaces and timers to remind patients to brush longer are useful for some patients.
	Powered toothbrushes with oscillating and rotating motions demonstrated modestly greater reductions in plaque and gingivitis than manual toothbrushes.
	Patients sometimes are reluctant to purchase power toothbrushes because of the relatively high cost compared with manual toothbrushes.
	Less expensive models are now available, however, and have been shown to be as effective as the higher-priced models.
	Indications for Powered Toothbrushes Poorly motivated patients In periodontal patients whose maintenance care shows poor plaque control Young children Handicapped patients Individuals lacking manual dexterity Patients with prosthodontic or endosseous implants orthodontic patients Institutionalized patients including the elderly who are dependant on care providers Patients on supportive periodontal therapy Those having difficulty in mastering a suitable handbrush
	Advantages for Powered Toothbrushes 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 and time than manual toothbrushes. Brushing timer is incorporated in some brushes to help the patient in brushing for the required duration.

SONIC AND ULTRASONIC TOOTHBRUSHES
	These types of toothbrushes produce high frequency vibrations ( 1.6 MHz), which lead to the phenomenon of cavitation and acoustic micro streaming.
	This phenomenon aids in stain removal as well as disruption of the bacterial cell wall ( bactericidal ).
IONIC TOOTHBRUSHES
	Ionic 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 the toothbrush.
	However further studies have to be carried out to prove the efficacy of these type of toothbrushes.
OBJECTIVES OF TOOTHBRUSHING
1.	To clean teeth and interdental spaces of food remnants, debris and stain etc.
2.	To prevent plaque formation
3.	To disturb and remove plaque
4.	To stimulate and message gingival tissue
5.	To clean the tongue.