DH102 Clinic II OHI & Products

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1 DH102 Clinic II OHI & Products
Lisa Mayo, RDH, BSDH Concorde Career College

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3 Goals for Today Discuss dentifrice Discuss toothrbushing and technique
Discuss interdental care Present advantages to tongue cleaning Discuss oral irrigators Present mouthrinse options Discuss fluoride

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5 #1: Dentifrice

6 Dentifrices Prevention of dental caries: Remineralization
Reduction of biofilm Triclosan: reduces gingival inflammation Colgate has the patent on triclosan ↑ substantivity of fluoride Zinc citrate Stannous fluoride

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8 Review Which of the following is the primary agent that has shown efficacy in reducing gingival inflammation? A) Xylitol B) Triclosan C) Zinc citrate D) Stannous fluoride

9 Answer B) Triclosan is the correct answer. Triclosan is the primary agent for reducing gingival inflammation. Xylitol is a flavoring agent in some dentifrices that has been shown to provide anticaries benefits. Zinc citrate and stannous fluoride are agents used to reduce biofilm formation.

10 Specialty Dentifrices
Caries Prevention Neutral sodium fluoride Na-monofluorophosphate Stannous fluoride APF Xylitol Halitosis Essential oils, chlorine dioxide, triclosan/copolymer, stannous fluoride, sodium hexametaphosphate

11 Specialty toothpaste Whitening Hydrogen peroxide Carbamide peroxide
Tooth sensitivity: occlude dentinal tubules Potassium nitrate/citrate/chloride Gingivitis reduction Stannous Fluoride Triclosan Zinc citrate Sodium Monofluorophosphate

12 Specialty toothpaste Calculus reduction Tetrapotassium pyrophosphate
Tetrasodium hexametaphosphate (ex: Crest Pro Health) Zinc chloride Zinc citrate Triclosan (ex: Colgate)

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14 NBQ Which of the following ingredient in a dentifrice would a dental hygienist recommend to a client struggling to minimize supragingival calculus formation? Potassium nitrate Pyrophosphate Hydrogen peroxide Triclosan

15 NBQ Which of the following ingredient in a dentifrice would a dental hygienist recommend to a client struggling to minimize supragingival calculus formation? Potassium nitrate dentinal hypersensitivity Pyrophosphate calcium phosphate bond in calculus matrix Hydrogen peroxide staining Triclosan antigingivitis

16 #2: Toothbrushing

17 Bristles and Filaments
Most tb today are Nylon Natural bristles: unsanitary Factors influencing stiffness Depends on diameter and length of the filament Diameter: thinner = softer and more resilient Length: shorter are stiffer and less flexible Angle of filaments: more angled = more flexible and less stiff End-rounding : each nylon filament is sealed and rounded by heat treatment

18 Power Toothbrushes: Description
Motion Entire brush head moves as a unit in one type of motion Groups of tufts on the same brush head may move differently Entire brush head moves as a unit, but in different, yet simultaneous motions Different-shaped brush heads move separately, and in different, yet simultaneous motions Speeds: low to high Battery: slower Rechargeable: 3,800-40,000 movements per min

19 Power Toothbrushes: Description
Brush head design Adult: Small and round, conical, or like traditional manual heads Child: Designed for smaller mouth, slower movement Interdental: Designed to fit a standard power brush handle and are similar in shape to manual interdental brushes Filaments: soft, end-rounded nylon Diameter nm Either flat, bi-level or multi-level trims

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22 Power Toothbrushes: Description
Handles larger than manual Several have ADA seal of approval for reduction biofilm and gingivitis Motion of brush varies High frequency pulsating combo with oscillating or rotating movement Sonic vibratory from low-frequency acoustic energy

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24 NBQ Which toothbrushing method should be recommended for a client with plaque biofilm control problems around the cervical areas of the teeth? Stillman’s method Charter method Bass method Leonard method

25 NBQ Which toothbrushing method should be recommended for a client with plaque biofilm control problems around the cervical areas of the teeth? Stillman’s method gingival stimulation Charter method Bass method sulcular Leonard method

26 NBQ Power toothbrushing should be recommended to clients with all of the following EXCEPT one. Which one is the EXCEPTION? Meticulous oral hygiene Gingivitis Orthodontic appliances Abrasion

27 NBQ Power toothbrushing should be recommended to clients with all of the following EXCEPT one. Which one is the EXCEPTION? Meticulous oral hygiene Gingivitis Orthodontic appliances Abrasion

28 Dental Abrasion Definition: abrasion is the wearing away of tooth structure that results from a repetitive mechanical habit Incorrect toothbrushing, especially with an abrasive dentifrice, is the most common cause Appearance: wedge-shaped indentations with smooth, shiny surfaces

29 Dental Abrasion Location Facial surfaces Canines Premolars
Sometimes first molars Cervical areas

30 Dental Abrasion Contributing factors
Brushing with abrasive agent in the dentifrice Horizontal brushing with excessive pressure Prominence of the tooth surface labially or buccally

31 Dental Abrasion Corrective measures Explain the problem to the patient
Use end-rounded filaments Change toothbrushing method Recommend less abrasive dentifrice Use a smaller amount of dentifrice

32 Bacteremia Toothbrushing and scaling actions can produce
Magnitude higher in patients with periodontitis & gingivitis No evidence on the risks of using manual or electric tb in pt’s predisposed to infective endocarditis Imperative to maintain oral health

33 #3: Interdental Care

34 Supplemental Aids Disclosing agents Floss and tape Floss threader
Tufted floss, yarn, gauze: embrasures, pontics, ortho, implants End Tuft Interproximal: embrasures, pontics, FPD, ortho, perio splints, proximal cavities, class V furcation’s, delivering chemotherapeutics Wooden/plastic/triangular wedges/sticks: embrasures Toothpicks, perio aid, rubber tip: embrasures, concavities, furcation's, ortho, apply chemotherapeutics, biofilm removal at/below gum line Tongue cleaners Power brush Oral Irrigation

35 The Interdental Area Anatomy of Posterior teeth
Between adjacent posterior teeth are two papillae, one facial and one lingual/palatal Papillae are connected by a col, a depressed concave area that follows the shape of the apical border of the contact area

36 The Interdental Area Anatomy of Anterior teeth
Between anterior teeth in contact is a single papilla with a pyramidal shape Tip of the papilla may form a small col under the contact area

37 The Interdental Area Proximal tooth surfaces
Interdental papillae are reduced in height Bacterial infection Loss of attachment Dental biofilm can accumulate Easy access for removal of bacterial deposits by the individual is prevented Root surface morphology: concavities, depressions, grooves are predisposed to bacterial accumulations

38 Floss Holder Indications
People who are physically / dexterity challenged to use dental floss with fingers Those with large hands Gag reflex

39 Floss holder/pickers

40 NBQ Floss holders should be recommended for clients with which one of the following? Manual dexterity problems Excellent home oral care Dentinal hypersensitivity Inadequate exposure to fluoride

41 NBQ Floss holders should be recommended for clients with which one of the following? Manual dexterity problems Excellent home oral care Dentinal hypersensitivity Inadequate exposure to fluoride

42 Floss Threader Indications
Fixed bridges Ortho Use in conjunction w/dental floss

43 Floss Threader

44 Floss Threader

45 Tufted Floss Indications
Also called a floss/yarn combination Regular dental floss is alternated with a thickened tufted portion Indications for use Wide embrasures where interdental papillae have been lost Flossing abutments and under pontic of a bridge Implant posts Two products available commercially: Single, precut lengths: Super Floss (2ft length) Roll: NUfloss is available in a roll that is similar to that of regular floss and has a cutting device to allow selection of a preferred length

46 Super Floss

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48 Tufted dental floss. The floss/yarn combination may be Super Floss (A) in a precut length with a tufted portion and a 3-inch stiffened end for insertion under a fixed prosthesis, or NUFloss (B) with tufted portions alternated with plain floss. A preferred length of NUFloss is obtained from the container. (C) NUFloss applied to the proximal surface of a molar. It may be used in an up-and-down and a shoe-shine stroke.

49 Knitting Yarn Indications for use Wide proximal spaces
Areas where regular floss too narrow to remove biofilm efficiently Abutments and under pontics Diastema Distal surfaces of most posterior teeth

50 Interdental Brushes Brush with plastic handle
Soft nylon filaments are twisted into a fine stainless steel wire Tapered or cylindrical brush heads Very short, soft filaments form a narrow brush

51 Interdental Brushes Indications for use
Sufficient space available for the insertion of an interdental brush without excess force Removal of dental biofilm and debris Embrasures Orthodontic appliances Fixed prostheses Dental implants Periodontal splints Space maintainers Concave proximal surfaces where dental floss and other interdental aids cannot reach

52 Interdental Brushes Procedure Select brush of appropriate diameter
Moisten the brush and insert at an angle in keeping with gingival form Brush in and out

53 NBQ An interdental brush can be used to effectively remove plaque biofilm in all of the following situations EXCEPT one. Which one is the EXCEPTION? Teeth with large diastemas Teeth with enamel erosion Type II embrasure space Fixed orthodontic appliances

54 NBQ An interdental brush can be used to effectively remove plaque biofilm in all of the following situations EXCEPT one. Which one is the EXCEPTION? Teeth with large diastemas Teeth with enamel erosion Type II embrasure space Fixed orthodontic appliances

55 End Tuft or Single-Tufted
Design: flat or tapered Uses Remove plaque and biofilm from surface not accessible with larger brushes Crowding Furcations Embrasures Distal to last molar Dental prosthesis

56 Rubber Tip Stimulators
Flexible rubber tip attached to the end of the handle Adapted into interdental area & below the gingival margin without causing damage to the epithelial lining Indications Cleaning debris from the interdental area Removal of biofilm by rubbing the exposed tooth surfaces Biofilm removal at & just below gingival margin

57 Rubber Tip Stimulators
Procedure Trace along the gingival margin with the tip positioned just beneath the margin Rub the tip against the teeth as it is moved in & out of an embrasure and under a contact area Do not flatten the interdental tissue Rinse the tip as indicated during use to remove debris, and wash thoroughly at the finish

58 Rubber tip Stimulators

59 Toothpick Indications
Stim-U-Dents Accessible furcation areas Shallow pockets Normal sulcus depths Patient who already uses toothpicks Ortho Perio: proximal concavities Gum stimulation

60 #4: Tongue Cleaning

61 Tongue Cleaning Microorganisms of the tongue constantly changing
Effects of cleaning the tongue Reduce # microorg. Reduce halitosis Anatomic features of tongue are conductive to debris retention Surface papillae Fissures

62 Tongue Cleaning Brushing procedure
Hold the brush handle at a right angle to the midline of the tongue With the tongue extruded, the sides of the filaments are placed on the posterior part of the tongue With light pressure, draw the brush forward and over the tip of the tongue Do not scrub the papillae Do not use electric tb when it is on

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64 Tongue Cleaning Tongue cleaner may be made of plastic, rubber, stainless steel Single or double handle Procedure Place the cleaner toward the most posterior area of the dorsal surface Press with a light but firm stroke, and pull forward Repeat several times, covering the entire surface of the tongue Wash the tongue cleaner under running water

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66 Tongue cleaners

67 #5: Oral Irrigators

68 Oral Irrigation Effective method of delivery for chemotherapeutic agents Disrupts loosely adherent microbial colonization Point tip perpendicular to long axis of tooth: 90 degree angle to long axis of the tooth

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70 Oral Irrigator Indications
Delivery of liquid antimicrobial agent Presence of gingival inflammation & bleeding Disruption of loosely adherent plaque Ortho Least effective method of removing plaque when compared to other oral physiotherapy aids

71 Oral Irrigator Benefits
Subgingival access Standard jet tip placed supragingivally can penetrate below the gingival margin 44% to 71% of the pocket depth Specialized tips used for marginal or subgingival delivery have shown penetration between 41% and 90%

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74 NBQ All of the following are true regarding the use of the oral irrigator EXCEPT one. Which one is the EXCEPTION? Used with cannula to irrigate to the base of the pocket Can be used as an adjunct to mechanical root debridement Delivers the antimicrobial mouthrinse subgingivally Eliminates the need for controlled release drug therapy

75 NBQ All of the following are true regarding the use of the oral irrigator EXCEPT one. Which one is the EXCEPTION? Used with cannula to irrigate to the base of the pocket Can be used as an adjunct to mechanical root debridement Delivers the antimicrobial mouthrinse subgingivally Eliminates the need for controlled release drug therapy

76 NBQ All of the following are true regarding oral irrig­ation devices EXCEPT one. Which one is this EXCEPTION? Recommended for clients with fixed prosthetics Can be effectively used to treat periodontitis Helps reduce gingivitis Used for the delivery of antimicrobial agents subgingivally

77 NBQ All of the following are true regarding oral irrig­ation devices EXCEPT one. Which one is this EXCEPTION? Recommended for clients with fixed prosthetics Can be effectively used to treat periodontitis Helps reduce gingivitis Used for the delivery of antimicrobial agents subgingivally

78 NBQ What is the MOST commonly used product to control plaque biofilm?
Antimicrobial mouthrinses Dental floss Power toothbrush Toothbrush

79 NBQ What is the MOST commonly used product to control plaque biofilm?
Antimicrobial mouthrinses Dental floss Power toothbrush Toothbrush

80 OHI Basics Disclose Show pt in mirror
Review how to remove areas that stained: TB, floss, interdental aids, etc….

81 Clinical Assessment of Oral Biofilm
Disclosing agents are used to make oral biofilm clinically visible FLUORESCEIN DYE (FD&C Yellow No.8) Visible under UV light More expensive but will leave no visible stain behind Two-tone dyes (FD&C Red No.3 & Green No.3) Combo solution Can differentiate old from new biofilm Discloses plaque but not gingival tissues

82 Disclosing Solution Will stain decalcified and pitted tooth surfaces
Use Vaseline on lips and restorations Avoid using prior to sealant application

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85 #6: Mouthrinse

86 Mouthrinses Treatment of disease by means of chemical substances or pharmaceutical agents Purposes In-Office 1. Pretx rinse to reduce org. 2. Pretx rinse to reduce aerosol contamination 3. Facilitate impressions 4. Rinse and fresh breathe 5. Fluoride rinse as part of caries prevention pgrm

87 Mouthrinses Purposes At Home Vigorous rinsing to aid in oral cleansing
Saline rinse after nonsurgical perio therapy Caries prevention

88 Mouthrinses Ingredients (combo of any of the following):
Water: largest amt of volume Alcohol: ↑ stability essential oils, ↓ surface tension Flavoring agents: essential oils, eucalyptus oil, oil of wintergreen Aromatic waters: peppermint, spearmint, wintergreen Sweetening agents Astringents: zinc chloride, citric acid Anodynes (pain relief) Buffering agents Oxygenating agents: H2O2 Fluoride: decrease caries Deodorizing: sodium bicarbonate, chlorine dioxide. Neutralize odors and volatile sulfur compounds Whitening: H2O2

89 Mouthrinse Types Antimicrobial agents Quaternary Ammonium Compounds
Phenolic-Related Essential Oils

90 Chemotherapeutics Antimicrobial Agents
Reduce oral microbial count Inhibit bacterial activity Agents contain any of the following: Chlorahexidine Phenolic compounds Cetylpyridinum chloride Sanguinarine Triclosan

91 Antimicrobial CHX RX: Peridex, PerioGard, ProDentx, PerioRx
Effective plaque & gingivitis reducer Broad spectrum bacterio-static/cidal Kills gram (+)/(-) microbes US: only 0.12% Mode of action: binds to hydroxyapatite and glycoPRO thus ↓ pellicle formation Absorbs into bacterial cell surface & interferes with cell attachment Inactivated by SLS detergents 8-12 active hours Alcohol or alcohol-free Recommended for short-term use

92 Antimicrobial CHX Side Effects Temp loss of taste
Bitter or metallic taste Burning sensation of mucosa Dryness Epithelia desquamation Discoloration of teeth, tongue, restorations Slight increase supragingival calculus formation (related to dead bacteria that remin. as a result of bactericidal action)

93 Antimicrobial Uses Tobacco User Cancer Pt Acute Perio Disease
Advise to use non-alcohol Alcohol + tobacco = synergistic effect, increase risk of cancer Cancer Pt Rinse baking soda/saline followed by H2O/CHX, avoid alcohol mouthrinses Acute Perio Disease Warm water or weak saline solution, CHX Alcohol Condition Avoid alcohol rinses, if being treated with DISULFIRAM can have medical emergency

94 Mouthrinse Types Antimicrobial agents Quaternary Ammonium Compounds
Phenolic-Related Essential Oils

95 Quaternary Ammonium Compounds
Mechanism of action Cationic agents that bind to oral tissues Rupture the cell wall and alter the cytoplasm Low substantively Most commonly used agent is cetylpyridinium chloride (CPC)

96 Quaternary Ammonium Compounds
Reduce biofilm accumulation Reduction in gingivitis has not been demonstrated in studies like antimicrobials Considerations: Staining of teeth Increased supragingival calculus formation A burning sensation and occasional desquamation

97 Mouthrinse Types Antimicrobial agents Quaternary Ammonium Compounds
Phenolic-Related Essential Oils

98 Phenolic-Related Essential Oils
Listerine® Non-RX Mechanism of action Phenolics disrupt cell walls Low substantively Composition Combination of thymol, eucalyptol, menthol, methylsalicylate in a hydroalcohol solution pH = 5.0

99 Phenolic-Related Essential Oils
Recommended uses Gingivitis, hyperplasia Ortho Pre-procedural rinse Immunosuppression Efficacy Significant reduction in the levels of biofilm and gingivitis (ADA seal of approval) Reduce S.mutans Inhibits calculus formation (contains zinc chloride)(ADA seal of approval)

100 Phenolic-Related Essential Oils
Considerations Burning sensation Bitter taste Alcohol free for recovering alcoholics

101 NBQ All of the following may contribute to oral malodor EXCEPT one. Which one is the EXCEPTION? Active periodontal disease Aphthous ulcer Use of tobacco products Lack of tongue brushing

102 NBQ All of the following may contribute to oral malodor EXCEPT one. Which one is the EXCEPTION? Active periodontal disease Aphthous ulcer Use of tobacco products Lack of tongue brushing

103 NBQ Which one of the following antimicrobial mouthrinses is available only as a prescription in the United States? 0.12% chlorhexidine gluconate mouthrinse 0.0 5% sodium fluoride mouthrinse Essential oils mouthrinse Cetylpyridinium chloride mouthrinse

104 NBQ Which one of the following antimicrobial mouthrinses is available only as a prescription in the United States? 0.12% chlorhexidine gluconate mouthrinse 0.0 5% sodium fluoride mouthrinse Essential oils mouthrinse Cetylpyridinium chloride mouthrinse

105 #7: Fluoride

106 Fluoride Strong affinity for calcified tissues – 99% located in mineralized tissues Stored in crystal lattice of teeth and bones Highest level is on the tooth surface Pre-Eruptive Stage Deposited during formation of enamel starting at DEJ Incorporated in crystals during mineralization New crystals = fluoroapatite = less soluble then hydroxyapatite Results = shallower grooves, less fissures

107 Fluoride Post-Eruptive Stage F benefits from topical application only
Uptake most rapid on enamel surface during 1st 2yrs after eruption Topical = fluorhydroxyapatite (Free F ion moves into crystal & forms) Mature enamel reacts with fluoride to primarily form CaF Demin: Calcium Fluoride dissolves 1st, then hydroxyapatite, then fluorhydroxyapatite (NEED TO KNOW THIS ORDER!)

108 Fluoride: Role in Caries Process
Reacts with hydroxyapatite to form FLUORAPATITE Interferes with bacterial metabolism High concentrations: bactericidal Low concentrations: bacteriostatic Has substantivity: ability to be bound to pellicle and tooth surface and be released over a period of time with retention of potency

109 Fluoride Therapy Methods Systemic: water, supplements, food
Most efficient from 6mo-14yrs Topical: toothpaste, rinse, in-office

110 Fluoride Therapy Professional Application
APF: Acidulated Phosphate Fluoride 1.23% foam, gel, thixotropic gels 4min application Low pH = 3.5 Not for tooth colored restorations: acid will etch glass components - pits and roughens material NaF: Neutral Sodium Fluoride 2% foam or gel with 4min application 5% varnish SnF: Stannous Fluoride (8%) Unpleasant taste, Stains teeth, Gingival sloughing, discolors restorations Typically not used for caries alone, antigingivits/antisensitivity MFP: monofluorophosphate

111 Fluoride Therapy: Topical
Varnish Procedure Dry teeth Gauze for areas of recession or sensitivity A/W syringe Rsrch shows some saliva contamination does NOT affect effectiveness of varnish Apply varnish to teeth with applicator Use small amounts – do not glop on teeth to the point where you can see excess amt of varnish Need just enough the coat the teeth A little goes a long way Use saliva ejector to suction patient as you apply

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114 Fluoride Therapy NaF APF SnF2 Concentration 2% 1.23% 8% ppm fluoride
9,050 12,300 19,360 Efficacy 29% 28% 32% pH 9.2 Adverse Rxns None May etch restorative materials Brown staining, gingiva rxn

115 Fluoride Therapy Indications for topical fluoride in DH Care Plan (Mosby’s/ADA) Children/adults with high to mod risk for caries (CAMBRA) Fl varnish or gel at RC appts No community water fluoridation Fair or poor OH Decalcification, demin, active caries Dentinal exposure Irregular RC appts Xerosotmia Ortho or Pros appliances

116 At-Home Fluoride Mosby’s
Application: tray, rinse, toothbrush Promote remin (bacteriostatic effect) RINSES Daily use of self-applied fluorides: low potency, high frequency 0.044% APF rinse 0.05% NaF 0.1% SnF2 rinse Weekly use of self applied fluorides: high potency, low frequency 0.2% NaF

117 At-Home Fluoride Mosby’s
GELS OTC & Rx 1.1% NaF (brush on, tray or paste) 0.05% APF (tray) 0.4% SnF2 (brush on or tray) Some studies show antiplaque, antihypersensitivity, anticaries effects

118 Dietary Fluoride Supplements
Recommended for kids who live in areas with inadequate water fluoridation Fluoride in foods: tea/fish contain large amounts Includes tablets, lozenges, drops, liquids Tablets intended to be chewed, swished and swallowed Drops are used on infants NOT recommended for pregnant women Not recommended on infants who are breastfed (breast milk contains ppm) School-based fluoride supplement programs yield 30%↓ caries

119 NBQ All of the following are true statements about 5% fluoride varnish EXCEPT one. Which one is the EXCEPTION? Approved for caries control Can be applied to both children and adults’ teeth Recommended for clients with high caries risk Available over the counter for caries prevention

120 NBQ All of the following are true statements about 5% fluoride varnish EXCEPT one. Which one is the EXCEPTION? Approved for caries control Can be applied to both children and adults’ teeth Recommended for clients with high caries risk Available over the counter for caries prevention

121 NBQ Which of the following professional fluoride agents is known for both its efficacy in caries prevention and control of dentinal hypersensitivity because of its high concentration of fluoride? Acidulated phosphate fluoride gel Stannous fluoride Sodium fluoride varnish Neutral sodium fluoride foam

122 NBQ Which of the following professional fluoride agents is known for both its efficacy in caries prevention and control of dentinal hypersensitivity because of its high concentration of fluoride? Acidulated phosphate fluoride gel Stannous fluoride Sodium fluoride varnish Neutral sodium fluoride foam

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