Jan Lindhe. Clinical Periodontology

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MECHANICAL SUPRAGINGIVAL PLAQUE CONTROL • 455

Fig. 21-7. (a) A triangular toothpick is used for interproximal toothcleaning. The toothpick is secured in its position

with "finger res

on the cheek for stabilization of movements. (b) The toothpick is properly inserted in an inter

proximal site in the mandibular front tooth region. (c,d.) By changing the direction of insertion of the toothpick, the

two proximal tooth surfaces are properly cleaned.

and tape – a type of broader dental floss – are most

useful where the interdental papillae completely fill

the embrasure space. When properly used, flossing

effectively removes up to 80% of proximal plaque.

Even subgingival plaque can be removed, since dental

floss can be introduced 2-3.5 mm below the tip of the

papilla (Waerhaug 1981). Several types of floss (

waxed, unwaxed) are available; however no clear

differences in their effectiveness were demonstrated

when comparisons were made. Recently, powered

flossing devices have been introduced. In comparison

with manual flossing no differences have been found

in terms of plaque and gingivitis reduction, although

patients preferred flossing with the automated device

(Gordon et al. 1996).

The most important factor that influences daily

flossing is ease of use. For some individuals it is not

easy to perform, especially in posterior areas, since it

requires manual dexterity, is time-consuming, there is

a risk of frequent shredding when passing through the

contact point and there is risk of tissue damage if

improperly used. On the other hand, although it is

clear that flossing, when properly used, removes

plaque in a very efficient manner, there is no evidence

that flossing in adult patients with preserved inter-

proximal periodontal tissues should be routinely in-

dicated (Burt & Eklund 1999). Finally, when inter-

proximal spaces are open due to previous loss of

attachment, dental plaque is best removed using other

interdental devices.

Toothpicks

Toothpicks are an excellent substitute to dental floss

for interproximal open spaces (Bergenholtz et al.

1980). Toothpicks may also be used in primary preven

tion, since they are easy to use, even in cases of poor

manual dexterity, including posterior areas. Probably

this is the main reason why toothpicks are more used

than dental floss, especially in Scandinavia. However,

when used in healthy dentition, they may depress the

gingival margin by up to 2 mm, and in long-term use

this may cause a permanent loss of the papilla and

opening of the embrasure, which may have important

esthetic implications in the anterior dentition.

Toothpicks are usually made of soft wood and have

a triangular shape, since the rectangular ones do not

fit properly in the interdental space at lingual sites

(

Mandel 1990). These cleaning devices should be

clearly recommended in patients with open interden-

tal spaces as secondary prevention for periodontal

diseases (Fig. 21-7).

Interproximal brushes

Introduced as an alternative to toothpicks, interproxi-

mal brushes are also effective in the removal of plaque

from the proximal tooth surfaces (Bergenholtz &

456 • CHAPTER 21

Fig. 21-8. Interproximal brushes of five different sizes.

Fig. 21-9. An interproximal brush has been inserted in

wide interdental space between teeth 46 and 47. Lin-

gual view.

Fig. 21-10. A small interproximal brush inserted in a

custom-made handle.

Fig. 21-11. A large interproximal brush inserted in the

furcation area of the hemirooted tooth 16.

MECHANICAL SUPRAGINGIVAL PLAQUE CONTROL • 457

Fig. 21-12. (a) A single-tufted toothbrush is used in tooth regions where cleaning by the use of an ordinary

tooth

brush is difficult to master. The lingual surfaces of mandibular molars are cleaned. (b) The palatal and

distal sur

faces of maxillary molars are cleaned by means of a single-tufted toothbrush.

Olsson 1984). Interproximal brushes are manufac-

tured in different sizes and forms (Fig. 21-8) and

should be selected to fit, as closely as possible, to the

individual interdental space (Fig. 21-9). Small inter-

proximal brushes can be inserted into handles (Fig.

21-10), which may facilitate the cleaning of interproxi

mal areas in the posterior parts of the dentition. The

interproximal brush is also the aid of choice when

exposed root surfaces have concavities or grooves. In

"through and through" furcation defects, the inter-

proximal brush is also the most suitable cleaning de-

vice (Fig. 21-11) and can also be used as a carrier of

antimicrobial agents, e.g. chlorhexidine. Like tooth-

picks, interproximal brushes are easy to use, although

they may have some drawbacks, including the fact

that different types may be needed to fit different open

interproximal spaces and when not adequately used,

they may elicit dentin hypersensitivity.

Single-tufted brush

A single-tufted brush can be recommended in regions

of the dentition not easily reached with other oral

hygiene devices, e.g. furcation areas, distal surfaces of

the most posterior molars and oral or lingual tooth

surfaces with an irregular gingival margin (Fig. 21-12).

Adjunctive aids

Dental irrigation devices

Powered dental irrigation devices are designed to

eliminate plaque and soft debris through the mechani

cal action of a jet stream of water. Dental irrigation

with water using a pulsating irrigation device has

been shown to reduce adjunctive gingivitis when used

to supplement mechanical plaque control (Hugoson

1978, Cutler et al. 2000). Irrigation devices may be

used with water or with antimicrobial agents (Lang &

Raber 1982); however, results from many studies show

that the added effect of the antimicrobials is very

limited. Although the use of these devices has shown

a limited effect on plaque, gingivitis and periodontitis

when used as an adjunctive to traditional mechanical

plaque control, some patients report that their use

facilitates the removal of food debris in posterior ar-

eas, especially in cases of fixed bridges or orthodontic

appliances, when the proper use of interdental clean-

ing devices is difficult.

Tongue scrapers

The dorsum of the tongue harbors a great number of

microorganisms. These bacteria may serve as a source

of bacterial dissemination to other parts of the oral

cavity, e.g. the tooth surfaces. Therefore, tongue brush

ing has been advocated as part of daily home oral

hygiene together with toothbrushing and flossing,

since this might reduce a potential reservoir of micro-

organisms contributing to plaque formation (Christen

& Swanson 1978). However, results of studies on

tongue brushing as an adjunct to toothbrushing in

order to reduce plaque formation are inconclusive (

Badersten et al. 1975).

The bacterial accumulations on the dorsum of the

tongue may also be the source of bad breath. In indi-

viduals with healthy periodontal conditions, bacterial

accumulations in the dorsum of the tongue are the

Fig. 21-13. Tongue scrapers facilitate the removal of

bacterial accumulations in the dorsum of the tongue,

which are a major cause of halitosis.

' CHAPTER 21

Fig. 21-14. (a) Soft-tissue damage as a result of extensive toothbrushing. Note gingival recession on the buccal gingi

val surface of tooth 13. (b) Note multiple ulcerations of the buccal gingival margin in the right maxilla. (c,d) Hard

tissue damage (arrows) has resulted after extensive use of interdental brushes.

most important source of the volatile sulfide gases

responsible for malodor (van Steenberghe & Rosen-

berg 1996). Therefore, tongue brushing and the use of

tongue scrapers (Fig. 21-13) should be recommended

in the management of patients suffering from halitosis

(Spielman et al. 1996), often in combination with the

use of mouthwashes containing antibacterial agents

(

Loesche 1999). Tongue brushing has also been advo-

cated as a component of the so called "full mouth

disinfection" approach in the treatment of periodonti-

tis, with the aim of reducing possible reservoirs of

pathogenic bacteria (Quirynen et al. 2000).

Dentifrices

A dentifrice is usually used in combination with tooth

brushing with the purpose of facilitating plaque re-

moval and applying agents to the tooth surfaces for

therapeutic or preventive reasons. The addition of

abrasives facilitates plaque and stain removal without

producing gingival recession/tooth abrasion or alter-

ing the remaining components of the dentifrice (

Wulknitz 1997). Fluoride is usually omnipresent in

commercially available toothpastes. The first success-

fully formulated fluoride containing dentifrice was

reported more than 50 years ago. However, although

the fluoride salt form is beneficial in the prevention of

caries, it has not routinely exhibited efficacy in con-

trolling gingival inflammation. For this reason, denti-

frices have also included in their formulations sub-

stances claiming antibacterial, anticalculus and desen

sitizing properties.

With a few exceptions, chemical agents with an-

tibacterial properties have not been formulated suc-

cessfully in dentifrices. Chorhexidine, although very

effective when used as a mouthrinse, has demon-

strated limited efficacy when formulated in denti-

frices. Due to its highly cationic formulation, deter-

gents and flavoring agents usually inactivate it. Even

when the formulation has shown clinical efficacy, its

side effects limit the use of chlorhexidine to specific

indications and for short periods of time (Sanz et al.

1994). Triclosan is another antibacterial agent that in

terferes with plaque growth (Gaffar et al. 1994). As an

additional property, triclosan has shown anti-inflam-

matory effects on gingival tissues (Gaffar et al. 1995).

Triclosan can be effectively formulated into a denti-

frice, either in combination with a co-polymer or with

zinc citrate (Lindhe et al. 1993, Saxton et al. 1993).

Results from 6-month clinical studies report a benefi-

cial effect on plaque formation and gingivitis when

compared with subjects using a regular fluoridated

dentifrice. However, these differences have generally

been of limited magnitude. Additionally, the daily use

of a triclosan/co-polymer dentifrice may have some

effect on the progression of periodontitis (Rosling et

al. 1997).

Dentifrices with claims of reducing supragingival

calculus formation are also available. The anticalculus

MECHANICAL SUPRAGINGIVAL PLAQUE CONTROL • 459

formulation usually includes pyrophosphates able to

inhibit the nucleation and crystal growth of calcium

phosphate minerals. In this way the mineralization of

plaque is delayed and it becomes more susceptible to

mechanical removal. Calculus reductions from these

specially formulated dentifrices when compared to

control dentifrices vary between 15% and 50%. Anti-

calculus dentifrices do not affect subgingival calculus,

since agents applied supragingivally generally do not

penetrate subgingivally (Lobene 1986, Sanz & Herrera

1998).

Effects and sequelae of the incorrect use of

mechanical plaque removal devices

Since a variety of mechanical and chemical products

are used in the self-control of supragingival plaque,

the possibility exists that some deleterious effects may

appear as a consequence of these oral hygiene prac-

tices (Echeverria 1998).

Toothbrushing can cause damage both to soft and

hard tissues (Fig. 21-14). Trauma to soft tissues results

in gingival erosion and gingival recession. Trauma to

hard tissues leads to cervical abrasion of the tooth

surface. These lesions have been associated with

toothbrush stiffness, the method of brushing and the

brushing frequency.

Cervical tooth abrasion has a multifactorial etiol-

ogy, but in most cases it is the consequence of tooth-

brushing due to an excessive pressure of the brush and

an excessive number of toothbrushing episodes/time.

Both situations are probably linked to personality

traits

(compulsive brushers).

Tooth wear has also been

associated with toothbrush characteristics, especially

related to the finishing and hardness of the bristles

(

Fishman 1997). Abrasives in toothpastes may also

play a minor role in the development of tooth abrasion

(Axelsson et al. 1997).

In many instances,

tooth abrasion is

found in combi-

nation with

gingival recession.

Whereas gingival reces-

sion is associated with different etiologic /risk factors,

e.g. periodontal inflammation, smoking, gingival bio-

type or repeated periodontal instrumentation, inade-

quate toothbrushing is probably the most significant

one (Bjorn et al. 1981). Inadequate toothbrushing that

leads to gingival recession has been related to the

brushing method (e.g. Bass system), the direction,

frequency and magnitude of brushing and also to the

characteristics of the toothbrush, such as the end,

hardness and material of the bristles. When manual

and electric toothbrushes have been compared in

terms of their damaging potential, it seems that the

latter tend to better preserve both the dental and the

gingival tissues (Wilson et al. 1993).

The use of dental floss, interproximal brushes and

toothpicks may also induce soft tissue damage. How-

ever, in most cases this damage is limited to acute

lesions, such as lacerations and gingival erosions (Gil

lette & Van House 1980).

Fig. 21-15. Wafers containing disclosing solutions are

often used to identify plaque.

Some substances in toothpastes may induce local

or systemic side effects. Chlorhexidine in toothpastes

may foster tooth staining (Yates et al. 1993). Pyrophos

phates, flavorings and detergents, specially sodium

lauryl sulfate, which are present in most commercially

available toothpastes, have been implicated as causa-

tive factors in certain oral hypersensitive reactions,

like aphthous ulcers, stomatitis and cheilitis (Sainio &

Kenerva 1995, DeLattre 1999), burning sensation

(

Kowitz et al 1990) and oral mucosal desquamation (

Herlofson & Barkvoll 1996). In these cases, the dental

professional should be ready to identify this condition

and advise the patient to discontinue the use of the

suspected dentifrice.

Importance of instruction and motivation in

mechanical plaque control

Mechanical plaque control demands active participa-

tion of the individual subject, and therefore the establ

ishment of proper oral home-care habits is a process

that to a great extent involves and depends on behav-

ioral changes. When implementing behavioral chan-

ges, dental professionals should try to ensure that the

patient recognizes his/her oral health status and the

role of his/her personal oral hygiene procedures in the

prevention of caries and periodontal diseases and

they should encourage the patient to take responsibil

ity for his/her own oral health.

Oral hygiene programs, therefore, should include

components such as self-assessment, self-examina-

tion, self-monitoring and self-instruction. With this

purpose, several devices and chemical agents have

been used in order to make dental plaque more evi-

dent to the patient.

Disclosing agents: Since dental plaque is white, some

times it cannot easily be identified, particularly if it is

not thick enough and/or the observer is not well

trained. A disclosing agent is a chemical compound

such as erythrosine (Fig. 21-15), fuchsin or a fluo-

rescein-containing dye that stains dental plaque and

460 • CHAPTER 21

Fig.

21-16.

Disclosing agents are used to disclose the

presence of dental plaque. Note remaining dental

plaque on the buccal tooth surfaces after staining.

Fig.

21-18.

After self-performed toothcleaning, remain

ing plaque can be identified by the patient following

rinsing with a disclosing solution (arrow).

Fig.

21-17.

A chart illustrating the teeth and tooth sur

faces in the maxilla and mandible. The distribution of

tooth surfaces with dental plaque (shadowed areas) is

identified. In this case the plaque score is

17%.

thus makes it fully evident to the patient, either with

a regular or ultraviolet light. When applied immedi-

ately before toothbrushing, the patient can identify the

amount of plaque built after the last toothbrushing

episode, thus receiving an immediate feedback about

his/her cleaning performance. This procedure is use-

ful during the early phase of plaque control. Later on,

the disclosing agent should be applied after tooth-

brushing, which allows the patient to identify those

areas needing additional cleaning efforts.

However, knowledge of the role of plaque and the

disclosing of plaque in the patient's mouth is usually

not enough to establish good oral hygiene habits.

Other factors might influence the individual to modify

or determine his or her behavior. These factors may

more or less beyond the control of the dental person-

nel (such as social and personal factors, environ-

mental setting and past dental experiences) or may lie

within the control of dental personnel (such as condi-

tions of treatment, instruction and education of the

patient). However, all of them should be considered in

the design of an individualized oral hygiene pro-gram.

The effect of various oral hygiene instruction

programs, administered individually or in groups,

has

been evaluated in a number of clinical studies. These

studies have evaluated whether instruction

given

during one visit only is similar to step-by-step

instruction provided during several visits, or whether

the use of pamphlets or video-tapes is superior to

self-instruction manuals and to personal instruction

given by a hygienist or a dentist. Different types and

amounts of feedback to the patients using disclosed

plaque scores and phase contract demonstrations

have also been investigated. These studies have usu-

ally reported similar improvements in plaque and

gingivitis scores, irrespective of the mode of instruc-

tion. However, these results should be interpreted

with caution since the subjects participating in these

studies were examined at regular intervals, and there

fore it is difficult to separate the influx of repeated

examinations from the effect of the instructions (Ren-

vert & Glavind 1998).

Rylander and Lindhe (1997) have recommended

that oral hygiene instruction be given during a series

of visits allowing the possibility of giving the patient

immediate feedback and reinforcing the patient in

his/her home care activities. The protocol below is

based on the one used in several clinical trials by

Lindhe

Nyman (1975), Rosling et al. (1976) and

Lindhe et al. (1982), where the role of plaque control

in preventing and arresting periodontal diseases was

clearly proven.

First session

1. Apply a plaque-disclosing solution to the teeth and

with aid of a hand mirror, demonstrate to the pa-

tient all sites with plaque (Fig. 21-16). The plaque

MECHANICAL SUPRAGINGIVAL PLAQUE CONTROL • 4.61

score should be recorded using a plaque control

record (Fig. 21-17).

2. Ask the patient to clean the teeth using his/her

traditional technique. With the aid of a hand mirror,

demonstrate the results of the toothbrushing to the

patient, again identifying all sites with plaque (Fig.

21-18).

Without changing the technique, ask the patient to

clean the surfaces with plaque. Depending on the

plaque remaining after this second toothbrushing,

the dentist /dental hygienist should either improve

the technique or introduce an alternative system of

toothbrushing. In order not to overload the patient

with too much information during the first session,

the use of adjunctive devices for interproximal

brushing can be introduced or improved in the

second session.

Second session

A few days after the previous session, the disclos-

ing solution is again applied. The results, in terms

of plaque deposits, are identified in the mouth,

recorded in the plaque control record, and dis-

cussed with the patient.

The patient is then invited to clean the teeth, ac-

cording to the directions previously given in the

first session, until all staining is removed. In many

cases, toothbrushing instructions will need to be

reinforced. If necessary, the use of interproximal

cleaning aids can now be introduced or improved.

Third and following sessions

1. One or two weeks later the same procedure used in

the second session is repeated. However, the effi-

cacy of self-performed plaque control should be

evaluated and presented to the patient at each ap-

pointment. This repeated instruction, supervision

and evaluation aims to reinforce the necessary be-

havioral changes.

The long-term result of oral hygiene instruction is

dependent on these behavioral changes. Therefore

patients may fail to comply with given instructions for

many reasons, ranging from unwillingness to perform

oral self-care, poor understanding, lack of motivation,

poor dental health beliefs and unfavourable dental

health values, to stressful life events or low socio-eco-

nomic status. Although the use of behavior modifica-

tion techniques may offer an advantage over tradi-

tional instruction techniques, there is limited research

in this area to clarify the relationship between health

beliefs and compliance.

In conclusion

•

Oral hygiene instruction should be tailored to each

individual patient on the bases of his/her personal

needs and other factors

•

The patient should be involved in the instructional

process

•

An individualized maintenance program should

follow the basic oral hygiene instruction.

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CHAPTER 22

The Use of Antiseptics in

Periodontal Therapy

MARTIN ADDY

Chlorhexidine

Clinical uses of chlorhexidine

Evaluation of chemical agents and products

Clinical trial design considerations

The concept of chemical supragingival

plaque control

Vehicles for the delivery of chemical agents

Chemical plaque control agents

THE CONCEPT OF CHEMICAL

SUPRAGINGIVAL PLAQUE

CONTROL

Epidemiological studies revealed a peculiarly high

correlation between supragingival plaque levels and

chronic gingivitis (Ash et al. 1964), and clinical re-

search (Loe et al. 1965) led to the proof that plaque was

the primary etiological factor in gingival inflamma-

tion. Subgingival plaque, derived from supragingival

plaque, is also intimately associated with the advanc-

ing lesions of chronic periodontal diseases. On the

basis that plaque-induced gingivitis always precedes

the occurrence and re-occurrence of periodontitis (

Lindhe 1986, Loe 1986), the mainstay of primary and

secondary prevention of periodontal diseases is the

control of supragingival plaque (for reviews see World

Workshop on Periodontics 1996a, Hancock 1996).

Periodontal diseases appear to occur when a patho-

genic microbial plaque acts on a susceptible host (for

reviews see Haffajee & Socransky 1994, Moore &

Moore 1994, Johnson 1994). What constitutes a patho

genic plaque is much researched and certain microor

ganisms have been identified as true or putative

pathogens, but much remains unknown (for reviews

see Zambon 1996, World Workshop on Periodontics

1996b). Susceptibility to periodontal disease is less

well understood and, at this time, certainly difficult to

predict and quantify although risk factors have been

identified (for reviews see Johnson 1994, Porter &

Scully 1994). The relationship of plaque levels to

pathogenicity and susceptibility are also poorly un-

derstood and therefore, for any one individual, what

constitutes a satisfactory level of oral hygiene cannot

be stated. This aside, there is evidence which demon-

strates that the improving oral hygiene and gingival

health, over several decades, noted in developed

countries (Hugoson et al. 1998a), has been associated

with a decreasing incidence of periodontal disease

(

Hugoson et al. 1998b). Additionally, long-term fol-

low-up of treated periodontal disease patients has

shown that success is dependent on maintaining

plaque levels compatible with gingival health

(

Axelsson & Lindhe 1981a,b). Supragingival plaque

control is thus fundamental to the prevention and

management of periodontal diseases and, with appro

priate advice and instruction from professionals, is

primarily the responsibility of the individual (for re-

view see Axelsson 1994).

It could be argued that the heavy reliance on me-

chanical methods to prevent what are microbially

associated diseases is outdated. Very few hygiene

practices against microorganisms used by humans on

themselves, in the home, at the workplace or in the

environment rely on mechanical methods alone and

some methods are only chemical. The contrary argu-

ment must be that the prevention of periodontitis,

through the control of gingivitis, would require the

discovery of a safe and effective agent. Also, such a

preventive agent would have to be applied from an

early age to a large proportion of all populations,

many of whom would have low or no susceptibility

periodontal disease (Baelum et al. 1986, for review

see Papapanou 1994).

These discussions aside, chemical preventive

agents, aimed at the microbial plaque, have been a