Primary Preventive Dentistry 6th Ed. (2004)
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Figure 7-32 Irrigation Devices Implant Maintenance A. Circumferential placement of Postcare braided nylon cord. B. Answers and Explanations Self-evaluation Questions |
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Tongue Cleaners Tongue cleaning has been practiced since antiquity.69 Studies on tongue debridement have renewed interest in this supplemental measure to further reduce bacterial plaque beyond toothbrushing and interproximal cleaning.70,71 The large papillary surface area of the tongue dorsum favors the accumulation of oral microorganisms and oral debris. Anatomically, the shorter fungiform papillae and the longer filiform papillae create elevations and depressions that may entrap debris and harbor microorganisms, making the tongue an ideal location for bacterial growth. Oral debris from these sites may contribute to plaque formation in other areas of the mouth.72 Reduction of this debris by mechanical tongue debridement can affect plaque accumulation, and oral malodor.73 Various designs of tongue cleaners are available (^ ). A soft-bristled toothbrush can also be used after the standard toothbrushing regimen. When using a tongue cleaner, the device is placed on the dorsal surface of the tongue close to the base of the tongue and pulled forward, pressing lightly against the surface of the tongue (Figures 7-33, 7-34). This process is repeated to cover the entire surface area of the tongue. Smokers or those with coated, deeply fissured tongues, or with elongated papillae (hairy tongue) will find that tongue debridement is especially beneficial in reducing oral bacteria. Oral Malodor and the Tongue Oral malodor, another term for bad breath or halitosis, can have a systemic origin or may originate in the oral cavity. A thorough physical examination can rule out a systemic disorder. Usually odors in the oral cavity occur when sulfur-containing proteins and peptides are hydrolyzed by Gram-negative bacteria in an alkaline environment.74 Odiferous sulfur-containing end products created by this process include hydrogen sulfide, methylmercaptans, and dimethyl sulfide. A shift from a predominantly gram positive to a gram negative and anaerobic bacterial population is associated with odor production. Local factors such as reduced salivary flow, and/or a rise in oral pH may affect this shift. Inconsistent or ineffective interproximal plaque removal can provide a niche for gram negative bacteria to degrade sulfur-containing amino acids resulting in malodor.72 The presence of periodontal disease may also be a contributing factor since the inflammatory process creates substrates that stimulate bacterial growth.75 Also, the putrefaction process and its concomitant odor occurs more rapidly when bacterial accumulations on the tongue are high. Active periodontal disease, exhibiting deeper pockets, contributes to malodor. Thus, for some people, management of periodontal disease is an important aspect in the control of malodor. Treatment considerations can include instruction in consistent tongue brushing or scraping since the dorsoposterior surface of the tongue seems to be a common site for production of volatile sulfur compounds. Additionally, the intraoral use of chlorine dioxide rinse, which oxidizes the malodorous sulfides has been shown to effectively reduce malodor.72
Rinsing Vigorous rinsing of the mouth will aid in the removal of food debris and loosely adherent plaque. Although water rinsing does not remove attached plaque, it may help return the mouth to a neutral pH following the acid production that results from ingesting fermentable carbohydrates. Rinsing or use of an irrigator is also helpful for individuals with orthodontic appliances. For maximum effectiveness, a technique should be adopted whereby fluid is forced through the interproximal areas of clenched teeth with as much pressure as possible in order to loosen and clear debris. Use of the lip, tongue, and cheek muscles aids in forcing the fluid back and forth between the teeth prior to expectoration. Rinsing has a limited impact supragingivally and is not efficient in subgingival penetration. It has no impact in reducing clinical parameters associated with gingival inflammation. However, the use of a therapeutic agent enhances the effect of rinsing. Antimicrobial rinsing has been utilized as part of a full mouth disinfection approach to improve oral tissue health.76,77 See Chapter 6 for a detailed discussion of the impact of chemotherapeutics. ^ Irrigation devices are a means of irrigating specific areas of the mouth whereas rinsing is a means of flushing the entire mouth. A home-irrigation device that is used for self-care provides a steady or pulsating stream of fluid, although the pulsating stream is preferable (Figure 7-35). Irrigation can result in the disruption of loosely attached or unattached supra- and subgingival plaque. The action is twofold. Loosely attached microflora are disrupted when the pulsating fluid makes initial contact. There is a secondary flushing action as the irrigant is deflected from the tooth surface. The microflora is disrupted both qualitatively and quantitatively.78 It has been demonstrated that irrigation with water or a nontherapeutic placebo can improve gingivitis or early periodontitis, when combined with toothbrushing.79-83 Supragingival water irrigation alone, without toothbrushing, is not effective and is inferior to toothbrushing.84-87 Home irrigation is not indicated for those who brush effectively and have no gingival inflammation. Individuals with inconsistent or ineffective interproximal cleaning, fixed orthodontic appliances, crowns, fixed partial dentures, and implants however, may benefit from a home irrigation self-care regimen.86,88 Oral irrigation may also be helpful for individuals who have jaws temporarily wired together for stabilization following surgery or head and neck trauma. Irrigation has been shown to reduce proinflammatory cytokines involved in the bone destructive process when periodontal diseases are present.89 The standard tip is designed for supragingival use. The tip is directed perpendicular to the tooth at or near the gingival margin. The cannula-type tip is directed into the gingival sulcus and allows a focused lavage adding to the depth of penetration.90 Rubber-tipped cannulas can be angled into the sulcus about 2 millimeters. Home subgingival irrigation has been used to deliver medicaments further into the gingival sulcus.81,91 Several studies demonstrated additional reductions in gingivitis and bleeding when using an antimicrobial agent in an oral irrigator with a cannula-type tip.82, 92-94 Use of the cannula-type tip should be limited to individuals with adequate skill and dexterity. Antimicrobial agents used as the irrigant have shown clinical and microbiologic improvements in those with gingivitis.83,95,96 The failure to reach the base of the pocket may explain why supragingival irrigation is more effective against gingivitis than periodontitis. Investigations have compared supragingival irrigation with water to rinsing with chlorhexidine. Some studies show no difference97 while others found chlorhexidine rinse more effect-ive in plaque removal than water irrigation alone.82,86 The potential for supragingival irrigation to induce bacteremias has been studied, but does not appear hazardous to healthy patients98 since toothbrushing,99 creates a similar level of bacteremia. Oral irrigators used inappropriately by those with poor oral hygiene have induced bacteremias, but the relationship to bacterial endocarditis is unclear.98 There is less risk of bacterial endocarditis from irrigation of a healthy mouth than when irrigating an inflamed mouth because of differences in microbial load.98, 99
^ Meticulous oral hygiene self-care is essential in maintaining dental implants. Plaque and calculus accumulate more rapidly, in larger amounts and adhere more easily to the implant abutment than to natural teeth.100 The epithel- ial barrier and connective tissue attachment mechanism is not as strong around an implant when compared to a natural tooth. This weaker attachment allows for a more rapid bacterial invasion of the biologic seal which can contribute to the destruction of osseous integration. Effective plaque removal is a critical factor in the maintenance of a healthy biologic seal and to prevent implant failure.101 There is a positive correlation between the amount of plaque and subsequent gingivitis and bone loss around implants.102 The loss of natural teeth resulting in the placement of implants is often caused by a history of poor oral hygiene resulting in dental disease. A commitment to meticulous daily oral hygiene self-care is critical for those with implants. Cleaning the abutment posts, bars, and prosthetic superstructures, presents a challenge that can be even more demanding than cleaning natural teeth. As with natural teeth, a combination of devices is usually needed to remove plaque from all surfaces. The goal of implant maintenance is to regularly remove soft deposits without altering the surface of the implants. Damage to titanium implants can increase corrosion and affect the molecular interaction between the implant surface and host tissue.103 A scratched surface may lead to increased plaque accumulation.104 The subsequent bacterial invasion can progress rapidly to peri-implantitis and potential implant failure. An effective brushing technique should be the first component of an implant oral hygiene self-care regimen. A soft, manual toothbrush can be used. A sonic powered toothbrush has been shown to be better than a manual toothbrush in reducing plaque and bleeding scores around implants.105 Some individuals may prefer a powered rotary brush with a tapered brushhead design. Neither type of powered brush was found to damage the implant surface and both were effective in areas where access is difficult.105,106 Whatever brush is used, a demonstration of the adaptation of the brush to the abutment posts and pontics should be provided. The dentifrice used should meet American Dental Association standards to ensure that it is not abrasive. To aid in plaque removal from abutment posts there are a variety of other devices that can be utilized (Figure 7-36). A tapered or cylindrical shaped interproximal brush or uni-tufted brush can be used with an in-and-out motion to clean the abutment posts. (Figure 7-36 B, 7-36 C) The interproximal brush must have a nylon-coated wire rather than the standard metal wire to prevent scratching the implant with the tip of the interproximal brush. Foam tips are an alternative choice for cleaning the interproximal surface of an implant. To help control bacteria, the foam tip, interproximal brush, or either of the powered brushes may be dipped into an antimicrobial solution such as chlorhexidine gluconate (0.12%). Alternately, a cotton swab can be used to apply the agent. Any type of floss, tape, or yarn can be used for circumferential plaque removal around abutment posts. In some cases, traditional floss with a floss threader, variable thickness floss or gauze can be placed in a 360-degree loop around the abutment post and moved with a shoeshine motion in the direction of the long axis of the tooth. Alternately, floss products designed specifically for use with implants can be used (Figure 7-36 A). Ribbon floss is a wide, woven, sometimes braided, gauze-like version of floss, which provides increased texture to enhance plaque removal. One product has a hook on the end of the floss ribbon to allow for wrapping the floss around an entire post by inserting from the facial aspect, thus eliminating insertion from both facial and lingual surfaces. Yarn and shoelaces can also be used. Placing a small amount of nonabrasive toothpaste on the flossing product can polish the posts. Oral irrigators can be used for cleaning around abutments, however, the water spray should be used on the lowest setting and should not be directed subgingivally. Daily subgingival irrigation with 0.06% chlorhexidine has shown beneficial effects on gingival, plaque, bleeding, and calculus indices while rinsing with 0.12% chlorhexidine affected gingival and bleeding indices only.107 The substantivity effect is not as strong for implants as for natural teeth but would be better facilitated by subgingival irrigation than rinsing. A critical factor in successful implant maintenance as with all oral health self-care is to recommend only the minimal number of cleaning devices needed for effective plaque removal. With proper instruction, the motivated individual can successfully maintain implants.
Denture Maintenance Instructions should be provided for the proper care and cleaning of both the dentures and the underlying tissues. According to one survey, only 40% of dentures worn by the elderly are adequately cleaned.108 Care of the soft tissues on which a denture rests includes removing the denture overnight or for a substantial time each day, cleaning and massaging the tissues under the denture daily,109,110 and performing regular oral self-examinations to observe and report any irritation or chronic changes in appearance of the tissues. Failure to remove the denture may result in oral malodor, excessive alveolar ridge resorption, diseased or irritated oral tissues, or the development of epulis fissuratum. Cleaning and massaging of the soft tissues can be performed simultaneously by brushing with a soft-bristled toothbrush or by massaging with the thumb or forefinger wrapped in a clean facecloth. Deposits that form on dentures include pellicle, plaque, calculus, oral debris (e.g., desquamated epithelial cells), stain and food debris. The microscopic porous surface of a denture attracts dental deposits. Consistent, effective cleaning of dentures not only serves to enhance the sense of oral cleanliness, but also serves to prevent oral malodor, denture stomatitis, and other tissue irritations. Mucosal irritation may impair eating, which can have a negative nutritional impact on a frail, elderly individual. The incidence of denture stomatitis varies from 20 to 40% of the denture population and occurs most commonly in females. Frequently, denture wearers are only aware of the aesthetic benefits to be derived from maintaining cleanliness. It is incumbent upon the oral health professional to stress the numerous health benefits of denture cleaning. Bacterial and fungal organisms can colonize the porous denture surface. For candidial infections the denture should be soaked in a nystatin antifungal suspension while simultaneously treating the oral tissues with the same medication. Daily thorough cleansing of the denture is recommended because dentures harbor the bacteria involved in the creation of the volatile sulfur compounds that contribute to oral malodor.110,111 Commonly practiced cleaning methods include immersion, brushing, or a combination of both. Immersion Cleaners Immersing the denture in a cleaning solution has the advantage of reaching all parts of a denture, while with brushing, areas of the denture may be missed. Consequently a combination may result in a more thoroughly cleaned denture. When selecting an immersion cleaner, the type of denture material must be considered. Alcohol or essential oils found in commercial mouthwashes are not compatible with denture acrylic, which may become dry or lose color from prolonged contact with these substances. Hypochlorite solutions diluted 1:10 with tap water act as antifungal and antibacterial agents.112 Adding a teaspoon of calcium-chelating dishwasher detergent (e.g., Calgonite) may help to control calculus or stains. Care must be taken to not immerse appliances with metallic components in hypochlorite solutions since the metallic surface may corrode.112 It is imperative that individuals be instructed to thoroughly rinse the bleach off before placement on the oral tissues. Acetic acid (vinegar) can be used for immersion, will kill some organisms, and is less caustic to soft tissues if not thoroughly rinsed. Commercial alkaline peroxide powders and tablets are available. These typically contain an alkaline for oxidizing, perborate or carbonate for effervescing, and a chelating agent (EDTA).106 When dissolved in water, these agents decompose and release oxygen bubbles, which mechanically loosen plaque debris on the denture surface. The alkaline substances and detergent enhance the mechanical effect of the bubbles. A 99% bacterial kill has been reported with these commercial products, and their effects are enhanced at 122 F.113 Enzyme proteolytic agents have been used but appear inferior to alkaline peroxides.114 Cleaning the Denture Brushing in conjunction with an abrasive agent or brushing a denture before and after it has soaked in an immersion cleaner, can be utilized to aid in the removal of deposits. Incorrect use of an abrasive agent (poor technique and/or too much pressure) can damage the denture. A brush with medium or soft end-rounded bristles, if used properly, should not abrade denture materials. A denture brush provides access to all surfaces of a denture (Figure 7-37). The dental professional should assess the level of manual dexterity when providing instruction in denture brushing. Nonabrasive agents such as soap or baking soda, or a commercial dentifrice may be safely used in conjunction with a brush. Other agents may be harmful to denture materials. The denture delivery appointment is an excellent time to explain and demonstrate how to care for the new denture. Ultrasonic or sonic devices are available for home denture cleaning. They utilize a cleaning solution in conjunction with agitation produced by ultrasonic (inaudible, high frequency) or sonic (audible) sound waves to remove debris and stains. Studies verify the efficacy of the ultrasonic cleaner; they are more effective than brushing with water.115,116 Use of these devices may be particularly helpful for individuals with limited dexterity or for the personal-care staff at long-term care facilities. Whichever method is used, the denture should be thoroughly rinsed under running, tepid water before reinsertion into the mouth in order to remove any substances that could irritate soft tissue. Instruction in the recommended method of self-care of their denture and of the tissues upon which it rests is critical to successful denture maintenance. It is the responsibility of the dental professional to ensure an understanding of both the "why" and "how" of denture maintenance and the potential consequences of poor denture self-care. Explaining the procedure, demonstrating the correct method, and then requesting a return demonstration are all instructional methods to improve compliance. Written instructions and recommendations should be provided for easy reference and referral.
Question 4 Which of the following statements, if any, are correct? A. Implants accumulate dental plaque and thus can contribute to the development of periodontal disease. B. Plaque removal from an implant can best be accomplished with a pipe cleaner. C. The stream of solution from an irrigating device should be directed apically to clean the sulcus around implants. D. Immersion cleaning of dentures is usually more effective than brushing because immersion ensures the cleaning agent reaches all areas of the denture. E. After providing education on auxiliary methods of oral hygiene, instructions should be given on the use of several methods to solve the patient's problem. Summary In addition to oral conditions, several factors affect the appropriate selection and use of supplemental oral hygiene devices. The dexterity and motivation for performing oral hygiene procedures, and the preferences for specific devices should be assessed when recommending supplemental oral hygiene devices and techniques. When a device is introduced, it is essential that the proper application in all areas of the mouth be demonstrated and that the potential for damage with improper use is understood. Despite adequate dexterity and ability, attainment of optimal oral health requires motivation and daily compliance in performing oral care. To enhance compliance and skill development, the number of recommended oral hygiene devices should be limited. Studies examining compliance and effectiveness indicate that development of proper skills and a willingness to use supplemental oral hygiene devices is facilitated when the number of devices is limited to no more than two.117,118 Personal preferences for particular oral hygiene devices should also be considered. Although a specific device may be favored by the oral health professional, it will be ineffective if not used. If an individual has shown a preference for a specific device, its use should be encouraged. For example, if an individual uses a toothpick but presents with inadequate oral hygiene as evidenced by disclosed plaque and/or tissue inflammation the oral health professional might consider one of the following: Instruction to enhance the effectiveness with the toothpick, Introduction of a toothpick holder to facilitate access and manipulation of the toothpick, Use of the wooden or triangular interdental stick because of its similarity to the toothpick. A wide variety of interproximal plaque removal devices are available. The oral health professional will need to stay informed of the research describing new devices, as it becomes available. Devices with evidenced based significance should be considered. Clinical experience and expertise should not be discounted, however, since these are also important components of evidence-based decision making.119,120 It is incumbent upon the oral health professional to consistently investigate evidence and apply clinical judgment. ^ 1. A and Dcorrect. Bincorrect. Studies show incomplete plaque removal increases rate and growth of new plaque. Cincorrect. Motivational factors are considered during the planning phase. The evaluation phase focus is on patient outcomes and whether the oral hygiene self-care regimen needs to be adjusted. EIncorrect. Only when rigorous interproximal cleaning was performed by an oral hygiene professional was there a reduction in caries incidence; there is very little evidence to support that theory. 2. B and Ecorrect. Aincorrect. Waxed and unwaxed floss have both been shown to be equally effective in removing plaque from the interproximal surface, without leaving a waxy residue. There is no evidence to indicate that one type of floss is better than the other. Cincorrect. The circle (or loop) method is best for children who do not yet have the dexterity needed for the spool method. Dincorrect. There is no study to date that shows one method is more effective than the other. Patient preference on the other hand, favors the use of floss holders. 3. A, B, D, and Ecorrect Cincorrect. It should be slightly larger so as to effectively scrub against the surface disrupting and removing bacterial plaque. 4. A and Dcorrect. Bincorrect. Circumferential plaque removal from an implant is best accomplished with a soft material that can be wrapped around its circumference: floss, tape, or yarn. Metal wire in a pipe cleaner could scratch the implant. CIncorrect. The stream of solution from an irrigating device should be at a right angle to the long axis of the tooth; otherwise bacteria can be forced into the blood supply to the area. EIncorrect. It is best to restrict the recommendation to one or two options, which will enhance compliance potential. ^ 1. The tooth surface least accessible to the toothbrush is the (interproximal) (buccal) (lingual) surface. 2. The (waxed) (unwaxed) floss frays and breaks more frequently on contact with calculus and restoration overhangs. The spool method of flossing requires (more) (less) psychomotor coordination than is required for the circle method. When using floss for the loop method, approximately _________ inches are needed, of which only about _________ inch(es) is/are held between the fingers to insert the floss between the teeth. A new segment of floss (is) (is not) used to clean each interdental space. If floss is forced too deeply into the sulcus, it can cause _________ in the gingiva, whereas if it is whipsawed buccolingually with too much force, it causes _________ of the cementum. If a periodontal condition exists, there is/are usually (one best) (several satisfactory) device(s) for plaque removal from areas with difficult access. 3. Four indications for the use of a dental floss holder in lieu of regular finger flossing are _________, _________, _________, and _________. 4. Three indications for the use of a floss threader are _________, _________, and _________. 5. Research (has) (has not) proved the value of the toothpick in maintaining oral health. 6. Irrigation devices have been used (successfully) (unsuccessfuly) to deliver medicaments further into the gingival sulcus. 7. Scratching the titanium implant while removing plaque can cause a more rapid buildup of _________ and hence pose a greater risk of gingivitis and periodontitis. 8. The wrapping of floss around an implant post for plaque removal is accomplished using a _________ _________ motion. 9. One study indicates that as few as _________% of the dentures worn by the elderly are adequately cleaned. Failure to maintain clean dentures can result in denture _________ _________ (overgrowth of tissue), a condition which is seen in 60 to 70% of denture wearers. 10. Four objectives that may be attained by proper use of dental floss are: _________, _________, _________, and _________. 11. Two auxiliary cleaning aids that can be used to safely and effectively clean under a fixed partial denture are _________ and _________. References 1. Kinane, D. F. (1998). The role of interdental cleaning in effective plaque control: Need for interdental cleaning in primary and secondary prevention. Lang, N. P., Loe, H., & Attstrom, R., Eds. In Proceedings of the European Workshop on Mechanical Plaque Control: Quintessence, Berlin, 156-68. 2. Kiger, R. D., Nylund, K., & Feller, R. P. (1991). A comparison of proximal plaque removal using floss and interdental brushes. J Clin Periodontol, 18:681-84. 3. Loe, H. (2000). Oral hygiene in the prevention of caries and periodontal disease. 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J Amer Geriatr Soc, 45:863-70. 117. Heasman, P. A., Jacobs, D. J., & Chapple, I. L. (1989). An evaluation of the effectiveness and patient compliance with plaque control methods in the prevention of periodontal disease. Clin Prevent Dent, 11:24-28. 118. Johansson, L. A., Oster, B., & Hamp, S. E. (1984). Evaluation of cause-related periodontal therapy and compliance with maintenance care recommendations. J Clin Periodontol, 15:689-99. 119. Jahn, C. A. (2000). Automated oral hygiene self-care devices: Making evidence-based choices to improve client outcomes. J Dent Hygiene, 2:171-86. 120. Abt, E. (1999). Evidence-based dentistry: An overview of a new approach to dental practice. Gen Dent, Jul-Aug, 369-73. 0.375 Copyright © 2004 by Pearson Education, Inc., Pearson Prentice Hall. All rights reserved.  (+/-) Show / Hide Bibliography Working... × Chapter 8. Water Fluoridation - M. Elaine Neenan Mike Easley Michael Ruiz, Research Assistant |
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