Dr Emma Perry | BDSc, AssocDeg DH, GradCert HPEd Content courtesy of Dr Anna Hughes | BDS, MSC, FDS RCPS, MRACDS (Perio) Mechanical **Supragingival** Biofilm Control  THE UNIVERSITY OF WESTERN AUSTRALIA  Dr Emma Perry | BDSc, AssocDeg DH, GradCert HPEd Content courtesy of Dr Anna Hughes | BDS, MSC, FDS RCPS, MRACDS (Perio) Mechanical **Supragingival** Biofilm Control THE UNIVERSITY OF WESTERN AUSTRALIA Stylized illustration depicting mechanical supragingival biofilm control. A large tooth is being cleaned by a woman holding a giant tube of toothpaste and a man scrubbing the tooth surface with a toothbrush held by a child. Bubbles surround the scene, emphasizing cleaning action. Textbook THE UNIVERSITY OF WESTERN AUSTRALIA LINDHE'S Clinical Periodontology and Implant Dentistry SEVENTH EDITION VOLUME 1 EDITED BY Tord Berglundh, William V. Giannobile, Niklaus P. Lang, and Mariano Sanz WILEY Blackwell **Chapter 28** # Mechanical Supragingival Plaque Control **Fridus van der Weijden and Dagmar Else Slot** Department of Periodontology, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands 2  **Textbook** LINDHE'S Clinical Periodontology and Implant Dentistry SEVENTH EDITION VOLUME 1 EDITED BY Tord Berglundh, William V. Giannobile, Niklaus P. Lang, and Mariano Sanz WILEY Blackwell **Chapter 28** Mechanical Supragingival Plaque Control **Fridus van der Weijden and Dagmar Else Slot** Department of Periodontology, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands Photo of the textbook 'Lindhe's Clinical Periodontology and Implant Dentistry', Seventh Edition, Volume 1. The cover is dark purple with white text listing editors Tord Berglundh, William V. Giannobile, Niklaus P. Lang, and Mariano Sanz. Two histological micrographs are displayed on the front cover: one showing a healthy periodontal ligament and bone interface (left) and another showing pathological changes such as bone loss or inflammation (right). The publisher logo 'WILEY Blackwell' is at the bottom right. **Learning Outcomes** * Define Mechanical Supragingival Biofilm Control (MSBC). * Explain the rationale for MSBC. * Describe the role of MSBC in periodontal treatment. * Develop an evidence-based, individualised MSBC regime for a patient. * Instruct a patient in MSBC. The University of Western Australia **Learning Outcomes** - Define Mechanical Supragingival Biofilm Control (MSBC). - Explain the rationale for MSBC. - Describe the role of MSBC in periodontal treatment. - Develop an evidence-based, individualised MSBC regime for a patient. - Instruct a patient in MSBC. University logo for The University of Western Australia. **Lecture outline** **Define Mechanical Supragingival Biofilm Control (MSBC).** **Explain the rationale for MSBC.** * **Patient** * **Dentist** * Gum disease * Caries **Describe the role of MSBC in periodontal treatment.** * **Professional** * **Patient-performed** **Develop an evidence-based, individualised MSBC regime for a patient.** * Brush * Technique * Interdental * Other devices * Dentifrices **Instruct a patient in MSBC.**  **Lecture outline** **Define Mechanical Supragingival Biofilm Control (MSBC).** **Explain the rationale for MSBC.** - **Patient** - **Dentist** - Gum disease - Caries **Describe the role of MSBC in periodontal treatment.** - **Professional** - **Patient-performed** **Develop an evidence-based, individualised MSBC regime for a patient.** - Brush - Technique - Interdental - Other devices - Dentifrices **Instruct a patient in MSBC.** A cartoon illustration of a molar tooth with an angry facial expression. The tooth is depicted as being covered in yellow plaque or biofilm, visually representing the subject of Mechanical Supragingival Biofilm Control (MSBC) mentioned in the text. Definition **The removal of microbial plaque and food debris from dental hard surfaces through abrasion using physical means such as brushes, floss and other devices. ** The University of Western Australia 5   **Definition** The removal of microbial plaque and food debris from dental hard surfaces through abrasion using physical means such as brushes, floss and other devices. Illustration showing two anthropomorphic teeth covered in white plaque. A blue toothbrush is actively scrubbing the left tooth, which has an unhappy expression. The right tooth looks distressed as it sits next to the plaque-covered surface. Illustration showing two clean, sparkling white anthropomorphic teeth smiling happily. This visual contrasts with the previous panel to demonstrate the result of removing microbial plaque and food debris. **# Rationale: A patient's perspective** * **To achieve oral wellbeing** * **To feel clean and fresh** * **To have a nice smile** * **To reduce bad breath** THE UNIVERSITY OF WESTERN AUSTRALIA SEEK WISDOM 6  **Rationale: A patient's perspective** - To achieve oral wellbeing - To feel clean and fresh - To have a nice smile - To reduce bad breath A stock photograph of a woman smiling broadly while forming a heart shape over her eyes with her hands against a yellow background. This visual supports the patient perspective on achieving oral wellbeing, having a nice smile, and feeling clean and fresh. In a dentist's perspective: - Gum disease (gingivitis and periodontitis) - Caries - Systemic effects \[Figure 7\] <img>Dental image demonstrating gum disease, caries, and systemic effects<p>**Rationale:** A dentist's perspective\] - **Figure 7** - **Text:** Gum disease (gingivitis and periodontitis) - **Text:** Caries - **Text:** Systemic effects  **Rationale: A dentist's perspective** - Gum disease (gingivitis and periodontitis) - Caries - Systemic effects Clinical photograph of a patient's mouth demonstrating severe periodontal disease. The image includes specific annotations pointing to: 'Root caries' on the upper anterior teeth; 'Gingival recession' exposing root surfaces on the lower left; 'Spacing between teeth' in the lower arch; and 'Calculus' (tartar) accumulation on the lower incisors. # Rationale: Systemic effects  **Rationale: Systemic effects** An anatomical diagram illustrating the systemic effects of various diseases on human organs. The central visual is a silhouette of the human torso containing labeled internal organs: brain, lungs, heart, kidneys, spine, and pelvic anatomy. Arrows point from specific disease labels to corresponding organs. On the left side, 'Alzheimer's Syndrome' points to the brain, 'Pulmonary Disease' points to the lungs, 'Diabetes' points to the kidneys, and 'Preterm Pregnancy Issues' points to the pelvic region. On the right side, 'Stroke' points to the brain, 'Cardiovascular Disease' points to the heart, 'Chronic Kidney Disease' points to the kidneys, 'Colon Cancer' points to the colon, and 'Prostate Cancer / Erectile Dysfunction' points to the prostate. - Natural self-cleansing mechanisms have limited effect on plaque build-up. - Biofilm adherence to teeth is tenacious and cannot be removed by rinsing alone or chemical dissolution. - Triple Action reduces tartar buildup, cleans teeth, freshens breath. - Triple Action reduces tartar buildup, cleans teeth, freshens breath. Pedigree DENTASTIX® Original Beef Flavor Fresh Triple Action Reduces Tartar Buildup Cleans Teeth, Freshens Breath 62 Treats (4 packs) TOTAL NET WT 3.34 lb (1.51 kg) large The University of Western Australia 9   - Natural self-cleansing mechanisms have limited effect on plaque build-up. - Biofilm adherence to teeth is tenacious and cannot be removed by rinsing alone or chemical dissolution. - Triple Action reduces tartar buildup, cleans teeth, freshens breath. Pedigree DENTASTIX® Original Beef Flavor Fresh Triple Action Reduces Tartar Buildup Cleans Teeth, Freshens Breath 62 Treats (4 packs) TOTAL NET WT 3.34 lb (1.51 kg) large Product packaging for Pedigree DENTASTIX®. The box features a golden retriever on the front with the text 'Triple Action: Reduces Tartar Buildup, Cleans Teeth, Freshens Breath'. It shows three flavor options (Original, Beef Flavor, Fresh) and indicates it contains 62 Treats. A close-up graphic of the product's logo. It displays the words 'TRIPLE ACTION' in red and blue lettering over a stylized white tooth icon against a blue background. Below the main title, smaller text reads 'REDUCES TARTAR BUILDUP', 'CLEANS TEETH', and 'FRESHENS BREATH'. # **Rationale: Gum disease** * Regular personal plaque removal measures must be undertaken to achieve and maintain periodontal health. * **Biofilm removal and control is fundamental to prevention and control of periodontal diseases** *Chapple et al 2015* * **Supragingival plaque control can modify the quantity and composition of sub gingival plaque, but by itself cannot treat moderate and severe periodontitis** *Lindhe et al 1989* **Rationale: Gum disease** - Regular personal plaque removal measures must be undertaken to achieve and maintain periodontal health. - **Biofilm removal and control is fundamental to prevention and control of periodontal diseases** *Chapple et al 2015* - **Supragingival plaque control can modify the quantity and composition of sub gingival plaque, but by itself cannot treat moderate and severe periodontitis** *Lindhe et al 1989* # Rationale: Caries * The evidence for toothbrushing itself to reduce caries is weak and inconsistent [Addy 1986](Addy%201986) > More important than brushing (when considering caries), the toothbrush is an effective vehicle for fluoride toothpaste. * National surveys in Finland [Mattila et al 2010](Mattila%20et%20al%202010) and Germany [Jordan et al 2014](Jordan%20et%20al%202014) have found a strong associated between caries and attachment loss in adults, but no attempts were made to expose to what extent this associated was explained by common risk factors [Jepsen et al 2017](Jepsen%20et%20al%202017). Therefore we cannot conclude poor plaque control caused their carious lesions. 11 **Rationale: Caries** - The evidence for toothbrushing itself to reduce caries is weak and inconsistent [Addy 1986](Addy%201986) > More important than brushing (when considering caries), the toothbrush is an effective vehicle for fluoride toothpaste. - National surveys in Finland [Mattila et al 2010](Mattila%20et%20al%202010) and Germany [Jordan et al 2014](Jordan%20et%20al%202014) have found a strong associated between caries and attachment loss in adults, but no attempts were made to expose to what extent this associated was explained by common risk factors [Jepsen et al 2017](Jepsen%20et%20al%202017). Therefore we cannot conclude poor plaque control caused their carious lesions. University logo for The University of Western Australia featuring a shield with a swan and books. # MSBC in Periodontal Treatment - **Professional** - Part of preventive or active treatment - Prophy - Traditional cup/brush and paste - Air/powder/water jets - **Patient-performed** - OHI - **Professional** - Part of preventive or active treatment - Prophy - Traditional cup/brush and paste - Air/powder/water jets - **Patient-performed** - OHI The logo of The University of Western Australia. MSBC in Periodontal Treatment You’ve got the POWER KaVo PROPHYflex 4: The Power of Power PROPHYflex 4 KAVO 13  MSBC in Periodontal Treatment You’ve got the POWER KaVo PROPHYflex 4: The Power of Power PROPHYflex 4 KAVO 13 Product photo: Three KaVo PROPHYflex 4 dental handpieces (pink, blue, and yellow) arranged diagonally against a white background. Each instrument features a curved metal tip and the brand name 'KAVO' on the body. # Phases of Periodontal Treatment **Corbet & Smales 2012** “...sustainable improvements in plaque control form the cornerstone of **all** phases of periodontal therapy...” - Emergency care - Risk management - Fundamental - Corrective - Supportive Phases of Periodontal Treatment **Corbet & Smales 2012** “...sustainable improvements in plaque control form the cornerstone of **all** phases of periodontal therapy...” - Emergency care - Risk management - Fundamental - Corrective - Supportive **Steps of Periodontal Treatment** **BSP** British Society of Periodontology and Implant Dentistry The University of Western Australia 15 **Steps of Periodontal Treatment** **BSP** British Society of Periodontology and Implant Dentistry The University of Western Australia 15 Logo for the British Society of Periodontology and Implant Dentistry (BSP). It features a green square icon with a stylized white smiley face on the left, followed by the acronym 'BSP' in large grey letters. Below this, the full name is written in smaller text. Logo for The University of Western Australia, located in the top right corner of the slide. **The University of Western Australia** Supported by **gsk** **BSP UK CLINICAL PRACTICE GUIDELINES** **FOR THE TREATMENT OF PERIODONTAL DISEASES** | **ORAL HEALTH AND RISK ASSESSMENT, DIAGNOSIS & CARE PLAN** | | :--- | | **Diagnosis** | **Periodontal Health** <-> **Gingivitis** -> **Periodontitis** | | | Extract teeth with hopeless prognosis or unsavable teeth – eg grade III mobile | **STEP 1** **Building foundations for optimal treatment outcomes** I: Explain disease, risk factors & treatment alternatives, risks & benefits including no treatment II: Explain importance of Oral Hygiene (OH), encourage and support behaviour change for OH improvement III: Reduce risk factors including removal of plaque retentive features, smoking cessation and diabetes control interventions IV: Provide individually tailored OH advice including interdental cleaning, + / - adjunctive efficacious toothpaste & mouthwash, + /- Professional Mechanical Plaque Removal (PMPR) including supra and subgingival scaling of the clinical crown V: Select recall period following published guidance and considering risk factors such as smoking and diabetes VI: Oral Health Educator (I, II), Hygienist, Therapist (I – IV), Dentist, Practitioner accredited for Level 2 and 3 care (I – V) 16 **The University of Western Australia** Supported by **gsk** **BSP UK CLINICAL PRACTICE GUIDELINES** **FOR THE TREATMENT OF PERIODONTAL DISEASES** | **ORAL HEALTH AND RISK ASSESSMENT, DIAGNOSIS & CARE PLAN** | | :--- | | **Diagnosis** | **Periodontal Health** <-> **Gingivitis** -> **Periodontitis** | | | Extract teeth with hopeless prognosis or unsavable teeth – eg grade III mobile | **STEP 1** **Building foundations for optimal treatment outcomes** I: Explain disease, risk factors & treatment alternatives, risks & benefits including no treatment II: Explain importance of Oral Hygiene (OH), encourage and support behaviour change for OH improvement III: Reduce risk factors including removal of plaque retentive features, smoking cessation and diabetes control interventions IV: Provide individually tailored OH advice including interdental cleaning, + / - adjunctive efficacious toothpaste & mouthwash, + /- Professional Mechanical Plaque Removal (PMPR) including supra and subgingival scaling of the clinical crown V: Select recall period following published guidance and considering risk factors such as smoking and diabetes VI: Oral Health Educator (I, II), Hygienist, Therapist (I – IV), Dentist, Practitioner accredited for Level 2 and 3 care (I – V) 16 The University of Western Australia logo and text. The 'gsk' (GlaxoSmithKline) logo. **Steps of Periodontal Treatment** **Periodontitis (continued)** Pre-Dental Hygiene Education STEP 2 Subgingival Instrumentation (root surface debridement / PMPR on root) Reinforce OH, risk factor control, behaviour change Subgingival instrumentation, hand or powered (sonic / ultrasonic), either alone or in combination Use of adjunctive systemic antimicrobials determined by Practitioner accredited for Level 2 and 3 care **Re-e-evaluate afger 3 monthis** Unstable **Step 3** Managing non-responding sites: Reinforce OH, risk factor control, behaviour change Moderate (4–5mm) residual pockets – re-perform subgingival instrumentation Deep residual pocketing (≥6mm). Consider alternative causes Consider referral for pocket management or regenerative surgery If referral not possible, re-perform subgingival instrumentation (If all sites stable after **step 3**, proceed to **step 4**) **Step 4** Maintenance Supportive periodontal care strongly encouraged Reinforce OH, risk factor control, behaviour change Regular targeted PMPR as required to limit tooth loss Consider evidence based adjunctive efficacious toothpaste and / or mouthwash to control gingival inflammation **Maintenance recall (step 4) – individuals tailored intervals from 3-12 months**  **Steps of Periodontal Treatment** **Periodontitis (continued)** Pre-Dental Hygiene Education STEP 2 Subgingival Instrumentation (root surface debridement / PMPR on root) Reinforce OH, risk factor control, behaviour change Subgingival instrumentation, hand or powered (sonic / ultrasonic), either alone or in combination Use of adjunctive systemic antimicrobials determined by Practitioner accredited for Level 2 and 3 care **Re-e-evaluate afger 3 monthis** Unstable **Step 3** Managing non-responding sites: Reinforce OH, risk factor control, behaviour change Moderate (4–5mm) residual pockets – re-perform subgingival instrumentation Deep residual pocketing (≥6mm). Consider alternative causes Consider referral for pocket management or regenerative surgery If referral not possible, re-perform subgingival instrumentation (If all sites stable after **step 3**, proceed to **step 4**) **Step 4** Maintenance Supportive periodontal care strongly encouraged Reinforce OH, risk factor control, behaviour change Regular targeted PMPR as required to limit tooth loss Consider evidence based adjunctive efficacious toothpaste and / or mouthwash to control gingival inflammation **Maintenance recall (step 4) – individuals tailored intervals from 3-12 months** A flowchart titled 'Steps of Periodontal Treatment' illustrating a clinical protocol. The diagram is organized into four main steps: STEP 2 (Subgingival Instrumentation), STEP 3 (Managing non-responding sites), and STEP 4 (Maintenance). It features decision nodes labeled 'Unstable' and 'Stable' with arrows directing the workflow to re-evaluation or progression to maintenance. Logos for the British Society of Periodontology (BSP), The University of Western Australia, and GSK are present. # Steps of Periodontal Treatment I: Patients should be made aware that regular effective self-performed plaque removal offers the largest treatment benefit – engage the patient in a verbal contract to perform daily plaque control II: Toothbrushing should be supplemented by the use of interdental brushes (where anatomically possible) III: Individual patient’s abilities, needs, preferences and manual dexterity should be considered when selecting toothbrush & interdental brush IV: Refer to BSP website for further clarification and glossary of terms Defining **engaging** & **non-engaging** patients (this is a guide) | Engaging Patients | Non-engaging Patients | | --- | --- | | I. Favourable improvement in OH – indicated by ≥50% improvement in plaque and marginal bleeding scores OR | I. Insufficient improvement in OH – indicated by <50% improvement in plaque and marginal bleeding scores OR | | II. Plaque levels ≤20% & bleeding levels ≤30% OR | II. Plaque levels >20% & bleeding levels >30% OR | | III. Patient has met targets outlined in their personal self-care plan as determined by their healthcare practitioner | III. Patient states preference to a palliative approach to periodontal care |   Steps of Periodontal Treatment I: Patients should be made aware that regular effective self-performed plaque removal offers the largest treatment benefit – engage the patient in a verbal contract to perform daily plaque control II: Toothbrushing should be supplemented by the use of interdental brushes (where anatomically possible) III: Individual patient’s abilities, needs, preferences and manual dexterity should be considered when selecting toothbrush & interdental brush IV: Refer to BSP website for further clarification and glossary of terms Defining **engaging** & **non-engaging** patients (this is a guide) | Engaging Patients | Non-engaging Patients | | --- | --- | | I. Favourable improvement in OH – indicated by ≥50% improvement in plaque and marginal bleeding scores OR | I. Insufficient improvement in OH – indicated by <50% improvement in plaque and marginal bleeding scores OR | | II. Plaque levels ≤20% & bleeding levels ≤30% OR | II. Plaque levels >20% & bleeding levels >30% OR | | III. Patient has met targets outlined in their personal self-care plan as determined by their healthcare practitioner | III. Patient states preference to a palliative approach to periodontal care | A grey box containing a numbered list of four procedural steps labeled 'I' through 'IV', detailing patient engagement and tool selection guidelines. Regions I, II, and III are highlighted with pink borders. A two-column comparison table split into green ('Engaging Patients') and orange ('Non-engaging Patients') sections. It lists three criteria (I, II, III) comparing improvement percentages in plaque and bleeding scores to classify patient engagement levels. **Efficient Periodontal Treatment** **PATIENT LEVEL/SUBJECT BASED RISK FACTORS** **MOUTH LEVEL RISK** **TOOTH LEVEL RISK FACTORS** **SITE LEVEL RISK FACTORS** **Number of diseased sites** **Initial Presentation** — **Education phase - Post-OHI** — **PMPR: scaling of teeth crowns, correct plaque retention factors** — **Reinforce step-1 & subgingival PMPR (Root Surface Tx/RSD)** — **Recall: DPC, OHI & re-Tx non-responding sites** — **Recall: Step-3 & enter maintenance** **Step 1 therapy** **Step 2** **Step 3** **Step 4** **Increasing Cost & Decreasing Effectiveness** **Figure 1 – Risk-driven prevention delivers the greatest periodontal health improvement in Step-1 of care, with deceasing return on investment (time & money) towards Step-2 and 3.**  **Efficient Periodontal Treatment** **PATIENT LEVEL/SUBJECT BASED RISK FACTORS** **MOUTH LEVEL RISK** **TOOTH LEVEL RISK FACTORS** **SITE LEVEL RISK FACTORS** **Number of diseased sites** **Initial Presentation** — **Education phase - Post-OHI** — **PMPR: scaling of teeth crowns, correct plaque retention factors** — **Reinforce step-1 & subgingival PMPR (Root Surface Tx/RSD)** — **Recall: DPC, OHI & re-Tx non-responding sites** — **Recall: Step-3 & enter maintenance** **Step 1 therapy** **Step 2** **Step 3** **Step 4** **Increasing Cost & Decreasing Effectiveness** **Figure 1 – Risk-driven prevention delivers the greatest periodontal health improvement in Step-1 of care, with deceasing return on investment (time & money) towards Step-2 and 3.** Labelled diagram illustrating an 'Efficient Periodontal Treatment' protocol. The diagram features a Y-axis labeled 'Number of diseased sites' and a sequence of steps at the bottom labeled 'Step 1 therapy', 'Step 2', 'Step 3', and 'Step 4'. A downward-sloping line graph connects these steps, showing a decrease in the number of diseased sites from 'Initial Presentation' through to maintenance. Above the graph are horizontal bars representing risk factors: 'PATIENT LEVEL/SUBJECT BASED RISK FACTORS', 'MOUTH LEVEL RISK', 'TOOTH LEVEL RISK FACTORS', and 'SITE LEVEL RISK FACTORS'. A large purple arrow points downwards near Step 4. A red arrow at the bottom indicates 'Increasing Cost & Decreasing Effectiveness' as one moves right along the treatment timeline. # Toothbrush <br> • Miswak<br> • Arak-salvadora persica<br> tree<br> • Widely used in Asia,<br> Middle East, Africa.<br> • Can be as effective as<br> a manual toothbrush if<br> used 3-5 x daily.<br> Adam et al 2021 <br> <br> 20    - Miswak - Arak-salvadora persica tree - Widely used in Asia, Middle East, Africa. - Can be as effective as a manual toothbrush if used 3-5 x daily. Adam et al 2021 A close-up photo showing the frayed, brush-like end of a wooden stick (Miswak) used as a toothbrush. Photos demonstrating the use of Miswak: a woman brushing her teeth with a stick on the left, and a man using a smaller piece of the stick to brush his teeth on the right. A hand holding a whole branch of the Arak-salvadora persica tree, showing its texture and form. Toothbrush - Most common method of mechanical plaque control. - Handles usually made of plastic +/- rubber. - Bristles usually made of nylon or polyester +/- rubber. - Head design - Bristles - Handle design - Electric or manual  - Most common method of mechanical plaque control. - Handles usually made of plastic +/- rubber. - Bristles usually made of nylon or polyester +/- rubber. - Head design - Bristles - Handle design - Electric or manual Photo of a man in a red t-shirt shouting with his fists clenched. This image is juxtaposed with text about toothbrushes and plaque control, likely illustrating the frustration associated with poor oral hygiene or the intensity of brushing. # Toothbrush: Head design <table> <thead> <tr> <th colspan="4">Table I: Manual Toothbrushes Utilized In Study and Features</th> </tr> <tr> <th>MTB Heads</th> <th>Manufacturer</th> <th>Type</th> <th>Features</th> </tr> </thead> <tbody> <tr> <td></td> <td>Biotene Supersoft (BIO) (GlaxoSmithKline, USA)</td> <td>Adult</td> <td></td> </tr> <tr> <td></td> <td>Butler Gum Tec (GBTE)</td> <td>Manual</td> <td></td> </tr> <tr> <td></td> <td>Butler Gum Summit</td> <td>Oral-B Advantage</td> <td></td> </tr> <tr> <td></td> <td>Butler Gum (B)</td> <td>Oral-B Advantage (OBA)</td> <td></td> </tr> <tr> <td></td> <td>Butler Gum Crayon</td> <td>Oral-B CrossAction</td> <td></td> </tr> <tr> <td></td> <td>Butler Gum Kids</td> <td>Oral-B Indicator</td> <td></td> </tr> <tr> <td></td> <td>Colgate Wave (Colgate-Palmolive Company, New York)</td> <td>Oral-B Indicator</td> <td></td> </tr> <tr> <td></td> <td>Crest Dual Action (CRDA)</td> <td>Oral-B Pro-Health Action (OBPH)</td> <td></td> </tr> <tr> <td></td> <td>Crest Complete</td> <td>Oral-B Ortho</td> <td></td> </tr> <tr> <td></td> <td>Oral-B Advantage (OBAA)</td> <td>Oral-B Stages 4-24 months (OBS1)</td> <td></td> </tr> <tr> <td></td> <td>Oral-B Advantage (OBAG)</td> <td>Oral-B Stages 2-4 (OBS2)</td> <td></td> </tr> <tr> <td></td> <td>Oral-B Advantage (OBAP)</td> <td>Oral-B Stages 5-7 (OBS3)</td> <td></td> </tr> <tr> <td></td> <td>Oral-B Indicator Designs (OBID)</td> <td>Oral-B Stages 8+ (OBS4)</td> <td>Child</td> </tr> </tbody> </table> <table> <thead> <tr> <th colspan="4">Table II: Power Toothbrushes utilized in study and features (continued)</th> </tr> <tr> <th>PTB Head</th> <th>Manufacturer</th> <th>Type</th> <th>Features</th> </tr> </thead> <tbody> <tr> <td></td> <td>Oral-B Pulsonic (PULSE)</td> <td>Rechargeable</td> <td>Prosoft bristles; pivots and pulses</td> </tr> <tr> <td></td> <td>Oral-B Kids 3+ (OBKP)*</td> <td>Battery</td> <td>Extras Soft bristles; raised row of bristles, blue indicator bristles, round head; oscillating rotation motion</td> </tr> <tr> <td></td> <td>Sonicare Elite Compact (SECP)</td> <td>Rechargeable</td> <td>Soft Bristles; Slim, angled neck and contour-fit bristles; rippled bristles; compact head</td> </tr> <tr> <td></td> <td>Sonicare Elite Standard (SESP)</td> <td>Rechargeable</td> <td>Soft Bristles; Slim, angled neck and contour-fit bristles; rippled bristles</td> </tr> <tr> <td></td> <td>Sonicare Flexcare Compact (SFCP)</td> <td>Rechargeable</td> <td>Soft rippled bristles; indicator bristles; compact head</td> </tr> <tr> <td></td> <td>Sonicare Flexcare Standard (SSFB)</td> <td>Rechargeable</td> <td>Soft rippled bristles; indicator bristles</td> </tr> <tr> <td></td> <td>Sonicare Kid Age 4+ (SKID1)*</td> <td>Rechargeable</td> <td>Extrasoft bristles; compact head; rippled</td> </tr> <tr> <td></td> <td>Sonicare Kid Age 7+ (SKID2)*</td> <td>Rechargeable</td> <td>Extrasoft bristles; rippled</td> </tr> <tr> <td></td> <td>Waterpik Large (WATP1) (Fort Collins, CO)</td> <td>Rechargeable</td> <td>Extrasoft bristles; standard head</td> </tr> <tr> <td></td> <td>Waterpik Small (WATP2)</td> <td>Rechargeable</td> <td>Extrasoft bristles; compact head</td> </tr> </tbody> </table> \*Children PTBs   **Table I: Manual Toothbrushes Utilized In Study and Features** | MTB Heads | Manufacturer | Type | Features | | --- | --- | --- | --- | | | Biotene Supersoft (BIO) (GlaxoSmithKline, USA) | Adult | | | | Butler Gum Tec (GBTE) | Manual | | | | Butler Gum Summit | Oral-B Advantage | | | | Butler Gum (B) | Oral-B Advantage (OBA) | | | | Butler Gum Crayon | Oral-B CrossAction | | | | Butler Gum Kids | Oral-B Indicator | | | | Colgate Wave (Colgate-Palmolive Company, New York) | Oral-B Indicator | | | | Crest Dual Action (CRDA) | Oral-B Pro-Health Action (OBPH) | | | | Crest Complete | Oral-B Ortho | | | | Oral-B Advantage (OBAA) | Oral-B Stages 4-24 months (OBS1) | | | | Oral-B Advantage (OBAG) | Oral-B Stages 2-4 (OBS2) | | | | Oral-B Advantage (OBAP) | Oral-B Stages 5-7 (OBS3) | | | | Oral-B Indicator Designs (OBID) | Oral-B Stages 8+ (OBS4) | Child | **Table II: Power Toothbrushes utilized in study and features (continued)** | PTB Head | Manufacturer | Type | Features | | --- | --- | --- | --- | | | Oral-B Pulsonic (PULSE) | Rechargeable | Prosoft bristles; pivots and pulses | | | Oral-B Kids 3+ (OBKP)* | Battery | Extras Soft bristles; raised row of bristles, blue indicator bristles, round head; oscillating rotation motion | | | Sonicare Elite Compact (SECP) | Rechargeable | Soft Bristles; Slim, angled neck and contour-fit bristles; rippled bristles; compact head | | | Sonicare Elite Standard (SESP) | Rechargeable | Soft Bristles; Slim, angled neck and contour-fit bristles; rippled bristles | | | Sonicare Flexcare Compact (SFCP) | Rechargeable | Soft rippled bristles; indicator bristles; compact head | | | Sonicare Flexcare Standard (SSFB) | Rechargeable | Soft rippled bristles; indicator bristles | | | Sonicare Kid Age 4+ (SKID1)* | Rechargeable | Extrasoft bristles; compact head; rippled | | | Sonicare Kid Age 7+ (SKID2)* | Rechargeable | Extrasoft bristles; rippled | | | Waterpik Large (WATP1) (Fort Collins, CO) | Rechargeable | Extrasoft bristles; standard head | | | Waterpik Small (WATP2) | Rechargeable | Extrasoft bristles; compact head | *Children PTBs A table listing manual toothbrush head types used in a study. Columns include 'MTB Heads', 'Manufacturer', 'Type', and 'Features'. Rows detail various brands such as Biotene Supersoft, Butler Gum Tec, Oral-B Advantage, Crest Dual Action, and others, with corresponding product codes and target demographics like Adult or Child. A continuation of a table listing power toothbrush heads used in the study. Columns include 'PTB Head', 'Manufacturer', 'Type', and 'Features'. Rows cover products from Arm & Hammer Spinbrush, Oral-B (Pulsonic, Kids, Sonic), and Sonicare (Elite, Flexcare, Kid series). It includes details on bristle types, neck design, and motion technology. # Toothbrush: Professional range https://www.colgateprofessional.com.au/products/toothbrush 23   https://www.colgateprofessional.com.au/products/toothbrush Product photo of a Colgate Professional toothbrush in packaging. The package is labeled 'ULTRA COMPACT HEAD' at the top and 'ultra soft' vertically on the left side. It shows a blue-handled toothbrush with a compact head featuring green bristles. A zoomed-in visual callout showing the text 'ULTRA COMPACT HEAD' highlighted in red to emphasize the product feature indicated by an arrow from the main product image. Toothbrush: Bristles Soft - **0.2mm** diameter – less traumatic Medium - **0.3mm** diameter – better cleaning Hard - **0.4mm** diameter - more damaging Filament ends important - cut vs end-rounded vs tapered Number of filaments per tuft Length and shape of filaments **24** - Soft - **0.2mm** diameter – less traumatic - Medium - **0.3mm** diameter – better cleaning - Hard - **0.4mm** diameter - more damaging - Filament ends important - cut vs end-rounded vs tapered - Number of filaments per tuft - Length and shape of filaments The University of Western Australia logo. <table> <tr> <th colspan="2">PTBs</th> <th colspan="2">MTBs</th> </tr> <tr> <td></td> <td></td> <td></td> <td></td> </tr> <tr> <td colspan="2"><b>Arm & Hammer Sonic (PTB) Bilevel, separated tufts/rectangle</b></td> <td colspan="2"><b>Biotene (MTB) Flat</b></td> </tr> <tr> <td></td> <td></td> <td></td> <td></td> </tr> <tr> <td colspan="2"><b>Oral-B Pulsar (PTB) Multilevel</b></td> <td colspan="2"><b>Oral-B Stages mixed dentition (MTB) Angled</b></td> </tr> <tr> <td></td> <td></td> <td></td> <td></td> </tr> <tr> <td colspan="2"><b>Sonicare Elite Standard (PTB) Rippled</b></td> <td colspan="2"><b>Oral-B Advantage Plus (MTB) Multilevel</b></td> </tr> <tr> <td></td> <td></td> <td></td> <td></td> </tr> <tr> <td colspan="2"><b>Oral-B Power Stages 3+ (PTB) Bilevel, round angled</b></td> <td colspan="2"><b>Butler Gum (MTB) Rippled</b></td> </tr> <tr> <td></td> <td></td> <td></td> <td></td> </tr> </table>  | PTBs | | MTBs | | | --- | --- | --- | --- | | | | | | | **Arm & Hammer Sonic (PTB) Bilevel, separated tufts/rectangle** | | **Biotene (MTB) Flat** | | | | | | | | **Oral-B Pulsar (PTB) Multilevel** | | **Oral-B Stages mixed dentition (MTB) Angled** | | | | | | | | **Sonicare Elite Standard (PTB) Rippled** | | **Oral-B Advantage Plus (MTB) Multilevel** | | | | | | | | **Oral-B Power Stages 3+ (PTB) Bilevel, round angled** | | **Butler Gum (MTB) Rippled** | | Table comparing toothbrush bristle configurations. The table is divided into two main columns: 'PTBs' (Power Toothbrushes) on the left and 'MTBs' (Manual Toothbrushes) on the right. Each column contains five rows of images showing different brush head designs with corresponding text labels describing features such as tuft separation, shape (rectangle, angled), or bristle pattern (multilevel, rippled). Toothbrush: **Professional** range %SOFT 360° %SOFT CT LA https://**www.colgateprofessional.com.au/products/toothbrush**  %SOFT 360° %SOFT CT LA https://www.colgateprofessional.com.au/products/toothbrush A photograph showing a single toothbrush in its packaging on the right and a larger group of packaged toothbrushes on the left. A blue arrow points from the single toothbrush to the group, indicating that the single unit is part of the larger set. Visible text includes 'SOFT' and '360°' on the packaging. "THE UNIVERSITY OF WESTERN AUSTRALIA" "360°" "Twister Fresh" "Medium"      "360°" "Twister Fresh" "Medium" Photo of a blister pack containing two toothbrushes (pink and green) with 'MEDIUM' printed on the packaging. Photo of a blue blister pack containing two toothbrushes (purple and pink) labeled 'MEDIUM'. Photo of a multi-pack blister pack containing four toothbrushes (yellow, orange, silver, and white) with 'MEDIUM' text visible at the top. Photo of a single toothbrush package featuring a 'Twister Fresh' model with 'MEDIUM' bristles. Photo of a blister pack containing two toothbrushes (light purple and dark blue) labeled '360°' and 'MEDIUM'. **The UNIVERSITY OF** **WESTERN** **AUSTRALIA** **SEEK WISDOM** Toothbrush: Ergonomics “designed to fit their lifestyle through comfort of use” •Handle design •Grip design •Angulation of head •Design of head •Size •Shape •Tuft length and angle 28   #### Ergonomics "designed to fit their lifestyle through comfort of use" - Handle design - Grip design - Angulation of head - Design of head - Size - Shape - Tuft length and angle Photograph showing three different toothbrushes arranged vertically against a black background. The top brush is green and white with a textured grip. The middle brush is also green and white but has a different head design. The bottom brush is labeled 'Colgate 360°' and features a blue grip area. Schematic diagram illustrating four distinct toothbrush handle configurations. Each design is labeled: STRAIGHT (horizontal alignment), ANGLED (head angled downward), OFFSET (handle offset from head axis), and ANGGLED OFFSET (combination of angle and offset). The diagrams show the relative positioning of the bristle head to the handle for each type. **Toothbrush: Evidence** ●Manual toothbrushing reduced plaque levels by 42%, while powered toothbrushing reduced plaque levels by around 46% Van der Weijden & Slot 2015 **More than 50% of plaque left** ●Angled bristle tuft design scored higher in manual brushes Slot et al 2012 ●Oscillating-rotating brushes appear to reduce plaque and gingivitis more than side to side electric brushes in the short term and also to be safer to the hard and soft tissues compared to manual brushes Van der Weijden & Slot 2015 ●Dexterity, brushing time and technique, type of brush used, frequency important. ●Crowding/spacing/gingival phenotype and the gingival changes after periodontal treatment influence choice of aids The University of Western Australia 29 - Manual toothbrushing reduced plaque levels by 42%, while powered toothbrushing reduced plaque levels by around 46% Van der Weijden & Slot 2015 **More than 50% of plaque left** - Angled bristle tuft design scored higher in manual brushes Slot et al 2012 - Oscillating-rotating brushes appear to reduce plaque and gingivitis more than side to side electric brushes in the short term and also to be safer to the hard and soft tissues compared to manual brushes Van der Weijden & Slot 2015 - Dexterity, brushing time and technique, type of brush used, frequency important. - Crowding/spacing/gingival phenotype and the gingival changes after periodontal treatment influence choice of aids University of Western Australia logo featuring a shield with a swan and books. Heading: **Toothbrush: Technique** The University of Western Australia •Sulcular •Bass/Modified Bass •Can reach up to 1mm subgingival Waerhaug 1981 •Most recommended [Image shows labelled "45°" angle and toothbrush bristles angled against gum line]  - Sulcular - Bass/Modified Bass - Can reach up to 1mm subgingival Waerhaug 1981 - Most recommended Diagram showing toothbrush technique: bristles angled at 45° against gum line to clean subgingival area. Labels include '45°' angle indicator and visual representation of Bass/Modified Bass brushing method. | Vibratory | ---|--- Stillman | | Charters | | Circular | Fones | | Vertical | Leonard | Horizontal | **Chapter 28** **Pages 665-673** **To University of** Western Australia LINDHE'S Clinical Periodontology and Implant Dentistry Edited by Tord Berglundh, William V. Giannobile, Niklaus P. Lang, and Mariano Sanz **SEVENTH EDITION** VOLUME 1 WILEY Blackwell  | Vibratory | | --- | | Stillman | | Charters | | Circular | | Fones | | Vertical | | Leonard | | Horizontal | **Chapter 28** **Pages 665-673** LINDHE'S Clinical Periodontology and Implant Dentistry Edited by Tord Berglundh, William V. Giannobile, Niklaus P. Lang, and Mariano Sanz **SEVENTH EDITION** VOLUME 1 WILEY Blackwell Photograph of the book 'Lindhe's Clinical Periodontology and Implant Dentistry', Seventh Edition, Volume 1. The cover displays two histological micrographs: one showing normal periodontal tissue structure and another showing pathology or disease state. # Toothbrush: Abrasion ## TOO MUCH? **Fig. 28-9** (a) Soft tissue damage as a result of extensive toothbrushing. Note the gingival recession on the buccal gingival surface of tooth 13. (b) Note the 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. 32      #### Too Much? **Fig. 28-9** (a) Soft tissue damage as a result of extensive toothbrushing. Note the gingival recession on the buccal gingival surface of tooth 13. (b) Note the 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. Clinical photo showing the upper left anterior teeth and gums. The image demonstrates soft tissue damage characterized by significant gingival recession (gum pulling back from the teeth), exposing the root surfaces. Clinical photo of the upper right anterior teeth. It shows multiple ulcerations (open sores or erosions) along the gum line (buccal gingival margin). Clinical photo of the lower posterior teeth showing severe hard tissue damage. There is extensive abrasion and discoloration (greenish/brown staining) on the chewing surfaces of the molars, likely caused by aggressive brushing or improper use of interdental brushes. Clinical photo of the lower central incisors with arrows pointing to distinct notches or depressions at the gumline. This represents cervical abrasion/hard tissue damage resulting from excessive friction during brushing. Close-up clinical photo of two upper front teeth showing severe enamel wear and thinning near the gumline. # Electric Toothbrushes *(Source: The University of Western Australia)* ## Features of Oscillating-rotating brushes: - Braun Oral B - 3D movements - High frequency vibrations - Pressure monitoring It appears that oscillating-rotating brushes reduce plaque and gingivitis more than side to side electric brushes in the short term and are also safer to the hard and soft tissues compared to manual brushes. Source: Van der Weijden & Slot 2015 Reference: Slide 33  #### Features of Oscillating-rotating brushes: - Braun Oral B - 3D movements - High frequency vibrations - Pressure monitoring It appears that oscillating-rotating brushes reduce plaque and gingivitis more than side to side electric brushes in the short term and are also safer to the hard and soft tissues compared to manual brushes. Source: Van der Weijden & Slot 2015 Photo showing three Braun Oral B electric toothbrushes standing vertically on white charging bases. The brushes are white, pink, and purple respectively, with visible heads and handles. # Electric Toothbrushes * Sonic * High frequency filament movement creating a turbulent flow * Phillips Sonicare, HiSmile * Not as effective as oscillating-rotating [van der Sluijs et al 2020](https://example.com) 34   - Sonic - High frequency filament movement creating a turbulent flow - Phillips Sonicare, HiSmile - Not as effective as oscillating-rotating [van der Sluijs et al 2020] Photo of a white electric toothbrush (Phillips Sonicare) standing upright on its charging base, with the detachable travel case positioned next to it. Photo of a pink and purple gradient electric toothbrush (HiSmile brand) displayed alongside its packaging box against a purple background. # Toothbrush: When to replace? - 3-monthly - Or when it looks like this: | Wear scores | Description | | :--- | :--- | | **0 – No wear** | No visible signs of wear, inner and outer tufts are intact | | **1 – Light wear** | Outer tufts begin to splay, inner tufts are still intact | | **2 – Medium wear** | Outer tufts are splayed beyond the base of the toothbrush, inner tufts begin to splay | | **3 – Heavy wear** | Outer and inner tufts are splayed | | **4 – Extreme wear** | Outer and inner tufts are splayed whereby no distinction can be made | **THE UNIVERSITY OF WESTERN AUSTRALIA** 35   #### When to replace? - 3-monthly - Or when it looks like this: | Wear scores | Description | | :--- | :--- | | **0 – No wear** | No visible signs of wear, inner and outer tufts are intact | | **1 – Light wear** | Outer tufts begin to splay, inner tufts are still intact | | **2 – Medium wear** | Outer tufts are splayed beyond the base of the toothbrush, inner tufts begin to splay | | **3 – Heavy wear** | Outer and inner tufts are splayed | | **4 – Extreme wear** | Outer and inner tufts are splayed whereby no distinction can be made | A humorous photo of a dog with matted fur, used as a visual analogy for a toothbrush in 'extreme wear'. A composite figure illustrating the progression of toothbrush bristle wear. It includes a table defining five levels (Score 0 to Score 4) from 'No wear' to 'Extreme wear', and corresponding photographs showing the physical appearance of bristles at each stage. # Toothbrush: General conclusions - **No 1 superior technique** **Hansen & Gjermo 1971** - Average time spent on toothbrushing between 30-60s, only 10% of that on lingual surfaces - **Bosman and Powell 1977** and **Lang et al 1973** showed once daily or every other day thorough cleaning can reverse gingivitis in dental students - **Quality of cleaning more important than frequency** **Bjerctness 1991** - Brush twice daily, for at least 2 minutes with a fluoride toothpaste is the current recommendation - Professional instruction is important - **No toothbrush can clean interproximally** 36 - **No 1 superior technique** **Hansen & Gjermo 1971** - Average time spent on toothbrushing between 30-60s, only 10% of that on lingual surfaces - **Bosman and Powell 1977** and **Lang et al 1973** showed once daily or every other day thorough cleaning can reverse gingivitis in dental students - **Quality of cleaning more important than frequency** **Bjerctness 1991** - Brush twice daily, for at least 2 minutes with a fluoride toothpaste is the current recommendation - Professional instruction is important - **No toothbrush can clean interproximally** The University of Western Australia logo featuring a shield with a swan and the text 'SEEK WISDOM' and 'THE UNIVERSITY OF WESTERN AUSTRALIA'. # Interdental cleaning **THE UNIVERSITY OF WESTERN AUSTRALIA** ● Toothbrushes **do not** reach interproximally. ● Residual plaque remains on the interproximal surfaces of premolars and molars after toothbrushing. ● Gingivitis, periodontitis and dental caries occur more frequently in the interdental region than on oral and facial surfaces. ● Choice of method should be personalised to each patient and each interdental space, and needs to be reviewed and possibly modified. 37  - Toothbrushes **do not** reach interproximally. - Residual plaque remains on the interproximal surfaces of premolars and molars after toothbrushing. - Gingivitis, periodontitis and dental caries occur more frequently in the interdental region than on oral and facial surfaces. - Choice of method should be personalised to each patient and each interdental space, and needs to be reviewed and possibly modified. Clinical product photo of an electric toothbrush head with multicolored bristles (green, blue, white, yellow). The image is accompanied by the text 'FLOSS ACTION BRISTLES LOOSEN PLAQUE IN BETWEEN TEETH' and a disclaimer '*does not replace flossing', visually demonstrating the specific function of these bristles in interdental cleaning. # Interdental cleaning ## Table 28-1 Interdental cleaning methods recommended for particular situations in the mouth. | **situation** | **Interdental cleaning method** | |---------------|----------------------------------| | Intact interdental papillae; narrow interdental space | Dental floss or small woodstick/rubber/elastomeric interdental cleaning stick | | Moderate papillary recession; slightly open interdental space | Dental floss, woodstick/rubber/elastomeric interdental cleaning stick or small interdental brush | | Complete loss of papillae; wide open interdental space | Interdental brush | | Wide embrasure space; diastema, extraction diastema, furcation or posterior surface of most distal molar, root concavities or grooves | Single-tufted/end-tufted brush or gauze strip |  #### Table 28-1 Interdental cleaning methods recommended for particular situations in the mouth. | Situation | Interdental cleaning method | |-----------|------------------------------| | Intact interdental papillae; narrow interdental space | Dental floss or small woodstick/rubber/elastomeric interdental cleaning stick | | Moderate papillary recession; slightly open interdental space | Dental floss, woodstick/rubber/elastomeric interdental cleaning stick or small interdental brush | | Complete loss of papillae; wide open interdental space | Interdental brush | | Wide embrasure space; diastema, extraction diastema, furcation or posterior surface of most distal molar, root concavities or grooves | Single-tufted/end-tufted brush or gauze strip | A table titled 'Interdental cleaning methods recommended for particular situations in the mouth' with two columns: 'situation' and 'Interdental cleaning method'. It lists four scenarios (intact papillae/narrow space, moderate recession/slightly open space, complete loss/wide open space, wide embrasure/diastema) and their corresponding cleaning tools (floss/sticks, floss/brushes, interdental brush, single-tufted brush/gauze strip). ### Interdental cleaning: Floss **"It’s low risk, low cost,"** he said. **"We know there’s a possibility that it works, so we feel comfortable telling people to go ahead and do it."** National Institutes of Health dentist Tim Iafolla Associated Press, 2021 https://apnews.com/article/f7e66079d9ba4b4985d7af350619a9e3 THE UNIVERSITY OF WESTERN AUSTRALIA 39  "It's low risk, low cost," he said. "We know there's a possibility that it works, so we feel comfortable telling people to go ahead and do it." National Institutes of Health dentist Tim Iafolla Associated Press, 2021 https://apnews.com/article/f7e66079d9ba4b4985d7af350619a9e3 A color photograph of National Institutes of Health dentist Tim Iafolla. He is an older Caucasian male with short brown hair, a goatee beard, and glasses. He is wearing a dark suit jacket over a blue striped dress shirt and a tie. He is smiling slightly while looking off-camera to his left. <html><body><table><tr><td><span>Most frequently recommended method</span><font color="#161723"></font><font color="#161723"></font></td></tr><tr><td><span>Ideal for crowded spaces and when the</span><font color="#161723"></font></td></tr><tr><td><span>papillae fill the embrasure spaces.</span><font color="#161723"></font><font color="#161723"></font></td></tr><tr><td><span>When properly used can remove up to 80% of</span><font color="#161723"></font></td></tr><tr><td><span>proximal plaque and can reach 2-3.5mm</span></td></tr><tr><td><span>subgingivally. Carnio 2009</span></td></tr><tr><td><span>Waxed (tight contacts)</span></td></tr><tr><td><span>Unwaxed (solid contacts, thinnest and</span></td></tr><tr><td><span>separates during use to cover a wider</span></td></tr><tr><td><span>surface area)</span></td></tr></table></body></html>  - Most frequently recommended method - Ideal for crowded spaces and when the papillae fill the embrasure spaces. - When properly used can remove up to 80% of proximal plaque and can reach 2-3.5mm subgingivally. Carnio 2009 - Waxed (tight contacts) - Unwaxed (solid contacts, thinnest and separates during use to cover a wider surface area) A clinical photograph demonstrating dental floss being used for interdental cleaning. It shows a close-up of upper front teeth with pink gums, where a white strand of floss is positioned between two teeth near the gumline, illustrating the technique described in the slide text. 41 Interdental cleaning: Floss   Product photo of 'MANFLOSS' floss container. The jar is dark with a silver lid and black label featuring the brand name. Text above reads 'SERIOUSLY GOOD FLOSS', 'Made Black', and 'To show white plaque being removed'. This visual demonstrates a specific product variant for interdental cleaning. Product photo of 'QUEEN OF CLEAN DENTAL TAPE' container. The jar is clear glass with a rose-gold lid and white label featuring the brand name in gold lettering. A speech bubble graphic points to it containing the text 'Is White' and 'For the Squeaky Clean amongst us who prefer not to know...'. This visual demonstrates another product variant for interdental cleaning. Interdental cleaning: Floss - Avoid using floss around exposed rough surfaces of dental implants **Montevecchi et al 2016**, **Van Velzen et al 2016** - Difficult to master, special holders available - Time consuming - Several systematic reviews and a meta-review have shown no benefit from flossing **Sälzer et al 2015** - Flossing was only shown to be effective in reducing interproximal caries (by 40%) when applied professionally although this benefit was not seen in self performed flossing and when fluoridated toothpaste was used. **Hujoel et al 2006** - Again, despite the weak evidence of benefit, self or parental-performed flossing should be a routine part of oral biofilm control if no other interdental cleaning devices can be used. - Avoid using floss around exposed rough surfaces of dental implants **Montevecchi et al 2016**, **Van Velzen et al 2016** - Difficult to master, special holders available - Time consuming - Several systematic reviews and a meta-review have shown no benefit from flossing **Sälzer et al 2015** - Flossing was only shown to be effective in reducing interproximal caries (by 40%) when applied professionally although this benefit was not seen in self performed flossing and when fluoridated toothpaste was used. **Hujoel et al 2006** - Again, despite the weak evidence of benefit, self or parental-performed flossing should be a routine part of oral biofilm control if no other interdental cleaning devices can be used. The logo of The University of Western Australia, featuring a shield with the university's motto and name. # Flossing technique 43  Procedure image demonstrating the flossing technique. A close-up clinical photograph shows a person's mouth with lips parted to expose the lower teeth and gums. Two fingers are holding dental floss between them, threading it into the interproximal space of two adjacent lower incisors. The background is blurred, focusing attention on the oral cavity and the specific action of cleaning between teeth. **The University of Western Australia** # Interdental cleaning: Brushes * Highly effective plaque removal especially where root concavities, grooves and for Gr III furcation defects * Most effective interdental cleaning method **Sälzer et al 2015** * Easy to use * More effective than floss in plaque removal and pocket reduction * Can clean 2-2.5mm subgingivally * Caution - overuse/incorrect use can cause soft and hard tissue damage * Wire can cause damage to implant surfaces 44      - Highly effective plaque removal especially where root concavities, grooves and for Gr III furcation defects - Most effective interdental cleaning method **Sälzer et al 2015** - Easy to use - More effective than floss in plaque removal and pocket reduction - Can clean 2-2.5mm subgingivally - Caution - overuse/incorrect use can cause soft and hard tissue damage - Wire can cause damage to implant surfaces A product shot showing a row of colorful interdental brushes (pink, orange, red, blue, yellow, green) with bristles facing up. A package containing multiple interdental brushes in various colors (pink, orange, red, blue, yellow, green). A fanned-out display of several different types of interdental brushes and picks in various colors (blue, pink, purple, silver, yellow, red, light blue, green). A close-up clinical photo demonstrating the use of an interdental brush between teeth to clean the contact area. A close-up clinical photo demonstrating the placement of an interdental brush into the space between two teeth. **Interdental cleaning: Sticks** +img - xylitol mines - Dentle - m - Double - ended - Barman's - Dental Woodsticks - m - Barman's - Anatomically shaped dental sticks - Contoured to fit the interdental space - Approx. 100 pcs - Wooden sticks - one of humanities oldest interdental cleaners - Toothpicks - circular, for food debris - Wooden sticks - triangular, soft wood, easy to use, useful if there is enough space interproximally, can clean subgingival plaque but can traumatisé papillae if incorrectly used      - Wooden sticks - one of humanities oldest interdental cleaners - Toothpicks - circular, for food debris - Wooden sticks - triangular, soft wood, easy to use, useful if there is enough space interproximally, can clean subgingival plaque but can traumatise papillae if incorrectly used Photo of a bundle of loose wooden dental sticks. Product packaging for Dr. Barman's Dental Woodsticks featuring text 'Anatomically shaped dental sticks', 'Contoured to fit the interdental space', and 'Approx. 100 pcs'. Clinical photo demonstrating the use of a circular toothpick for food debris removal between teeth. Clinical photo demonstrating the use of a triangular wooden stick for cleaning subgingival plaque. Clinical photo demonstrating the insertion of a wooden stick into an interproximal space. # Interdental cleaning: **Wood sticks** The University of Western Australia 46  Clinical photo showing a close-up view of upper anterior teeth with visible plaque accumulation. A wooden interdental stick is being inserted between two central incisors to demonstrate the technique for interproximal cleaning. # Interdental cleaning: Rubber sticks * Elastomeric cleaning sticks * Massages gum, dislodges food * Few studies to date, mostly showing no reduction in plaque and gingivitis score * Safe and popular with patients **Figure 3.** Clinical application of CPP-ACP paste using an appropriately sized interdental applicator (courtesy of Louis Mackenzie) 47  - Elastomeric cleaning sticks - Massages gum, dislodges food - Few studies to date, mostly showing no reduction in plaque and gingivitis score - Safe and popular with patients Clinical photograph showing the use of a white interdental applicator with blue bristles to apply paste between teeth and along the gumline. Tongue cleaning The dorsum of the tongue harbours a great number of microorganisms which can disseminate to other parts of the mouth. Tongue microbes can contribute to bad breath Hence tongue brushing has been advocated as part of daily home care However, conflicting evidence on tongue brushing and new plaque formation-insufficient evidence to recommend frequency, duration or delivery **Kuo et al 2013** The dorsum of the tongue harbours a great number of microorganisms which can disseminate to other parts of the mouth. Tongue microbes can contribute to bad breath. Hence tongue brushing has been advocated as part of daily home care. However, conflicting evidence on tongue brushing and new plaque formation — insufficient evidence to recommend frequency, duration or delivery (Kuo et al 2013). **Tongue cleaning** THE UNIVERSITY OF WESTERN AUSTRALIA 49     THE UNIVERSITY OF WESTERN AUSTRALIA Photo of a blue plastic tongue scraper with the brand name 'CURAPROX' visible on the handle. Photo of a lime green plastic tongue scraper next to the blue one. Diagram showing an open mouth with a green Y-shaped tongue scraper positioned on the tongue for cleaning. The illustration demonstrates the placement and usage of the tool relative to the teeth and tongue anatomy. Photo of two metal tongue scrapers lying on a neutral background. These appear to be different types or brands compared to the plastic ones shown on the left. # Water flossers * Uses water jet * Conflicting evidence to show adjunctive benefit * Removes food, debris, loose plaque. * Can be used to deliver antiseptic 3mm subgingivally * Potential bacteraemia? * Can be painful * Useful around implants * Messy  - Uses water jet - Conflicting evidence to show adjunctive benefit - Removes food, debris, loose plaque - Can be used to deliver antiseptic 3mm subgingivally - Potential bacteraemia? - Can be painful - Useful around implants - Messy Photo of a white water flosser device with a nozzle attached to the top and control buttons on the side. # High tech * Full arch sonic toothbrushes **World's Only ADA-Accepted U-Shape Toothbrush** 4.7/5.0 (16,860 Reviews) Get up to 5.1X better clean in 30 seconds— up to 82% more plaque removal, up to 45% less gingivitis. Trusted by families, backed by experts [SHOP 30% OFF] ADA Accepted® American Dental Association 51 #### Full arch sonic toothbrushes **World's Only ADA-Accepted U-Shape Toothbrush** 4.7/5.0 (16,860 Reviews) Get up to 5.1X better clean in 30 seconds — up to 82% more plaque removal, up to 45% less gingivitis. Trusted by families, backed by experts. [SHOP 30% OFF] ADA Accepted® American Dental Association University of Western Australia logo with the university's coat of arms and text. ADA Accepted logo from the American Dental Association. # Low tech Used in hospital settings when toothbrushing cannot be performed adequately * Foam brushes/swabs * Gauze * Finger brushes   Used in hospital settings when toothbrushing cannot be performed adequately. - Foam brushes/swabs - Gauze - Finger brushes Clinical photo showing low-tech oral hygiene tools: a foam brush/swab on the top left and a finger brush (transparent plastic with bristles) below it. Clinical photo of gauze being held by fingers, demonstrating its use as an alternative to toothbrushing in hospital settings when adequate brushing cannot be performed. **# Dentifrices** University of Western Australia QR Code (image) containing a QR Code with "Western Australia" logo embedded. **"a powder, paste, or liquid for cleaning the teeth"** * Plaque removal is dependent on mechanical contact of brush to teeth , rather than the abrasive nature of the toothpaste and more plaque can be removed without the use of toothpaste **Paraskevas et al 2007** **Jayakumar et al 2010** * Compliance to toothbrushing is much lower without toothpaste **Dudding et al 1960**  "a powder, paste, or liquid for cleaning the teeth" - Plaque removal is dependent on mechanical contact of brush to teeth, rather than the abrasive nature of the toothpaste and more plaque can be removed without the use of toothpaste **Paraskevas et al 2007** **Jayakumar et al 2010** - Compliance to toothbrushing is much lower without toothpaste **Dudding et al 1960** Illustration of a tube of toothpaste labeled 'TOOTHPASTE FLUORIDE 1500 PPM' squeezing blue paste onto the bristles of a toothbrush. # Toothpaste: Ingredients **THE UNIVERSITY OF WESTERN AUSTRALIA** ### **Active ingredients** * Anticaries * Antimicrobial * *Triclosan* * Desensitizing agents * Anticalculus * Abrasives * *Paraskevas 2006* <!-- Image (640, 51, 963, 281) --> ### **Inactive ingredients** * Flavouring * Colouring * Detergents/surfactants * Humectants * Thickening agents 54 #### Active ingredients - Anticaries - Antimicrobial - *Triclosan* - Desensitizing agents - Anticalculus - Abrasives - *Paraskevas 2006* #### Inactive ingredients - Flavouring - Colouring - Detergents/surfactants - Humectants - Thickening agents The University of Western Australia institutional logo featuring a shield with a swan and text. **Toothpaste: Ingredients** Potential allergens/irritants * Detergent * Sodium Lauryl Sulphate (SLS) * Preservatives * Flavouring * Essential oils * Casein * Gluten * Xanthan gum * H2O2 * CHX  Potential allergens/irritants - Detergent - Sodium Lauryl Sulphate (SLS) - Preservatives - Flavouring - Essential oils - Casein - Gluten - Xanthan gum - H2O2 - CHX Clinical photo showing the interior of a patient's mouth with visible mucosal lesions. The image includes dental instruments (a mirror and probe) retracting the cheek to reveal the buccal mucosa and teeth. Black arrows point to white, patchy areas on the oral lining, consistent with oral candidiasis or similar mucosal pathology. 56 **OHI: Oral Hygiene Instruction** THE UNIVERSITY OF WESTERN AUSTRALIA  **OHI: Oral Hygiene Instruction** A still image from an educational video showing a hand holding a toothbrush. The text 'brush your teeth' is displayed in large blue letters on the left side of the frame. OHI: Plaque disclosing • Be polite and non-judgemental • Educate • Demonstrate • Constant motivation/feedback **Fig. 28-10** (a) Disclosing solution is often used to identify plaque. (b) Note the remaining plaque on the buccal tooth surfaces after staining. (c) After self-performed tooth cleaning, remaining plaque can be identified by the patient following rinsing with a disclosing solution. 57  **OHI: Plaque disclosing** - Be polite and non-judgemental - Educate - Demonstrate - Constant motivation/feedback **Fig. 28-10** (a) Disclosing solution is often used to identify plaque. (b) Note the remaining plaque on the buccal tooth surfaces after staining. (c) After self-performed tooth cleaning, remaining plaque can be identified by the patient following rinsing with a disclosing solution. Clinical figure demonstrating the use of plaque disclosing solution in oral hygiene instruction. The figure is composed of three panels: (a) shows a close-up of a tooth surface being treated with a black disclosing agent using an applicator; (b) displays teeth stained pink/red, indicating the presence of plaque biofilm on the buccal surfaces; and (c) illustrates a frontal view of teeth after self-performed cleaning, showing residual red-stained areas where plaque remains despite brushing. # OHI - Customise - Patient's previous habits - Dexterity - Motivation - Clinical condition - Anatomical limitations - Practise and refine your delivery The University of Western Australia  **OHI** - Customise - Patient's previous habits - Dexterity - Motivation - Clinical condition - Anatomical limitations - Practise and refine your delivery A procedural demonstration image showing a gloved hand holding a toothbrush and demonstrating brushing technique on an open dental model. The context relates to 'OHI' (Oral Hygiene Instruction) and the bullet points about customizing instruction based on patient habits, dexterity, motivation, clinical condition, and anatomical limitations. <th> OHI: A customised regime </th> <br> - **Device** - Brush - Interdental - **Duration** - **Frequency** - **Technique** - **Dentifrice** - **Adverse effects** <center> </center> Page 59 The ideal technique is the one that allows for complete plaque removal. **The best device and product are the ones that get used!**  **OHI: A customised regime** - **Device** - Brush - Interdental - **Duration** - **Frequency** - **Technique** - **Dentifrice** - **Adverse effects** The ideal technique is the one that allows for complete plaque removal. **The best device and product are the ones that get used!** Illustration depicting a group of white stick figures standing together with one yellow figure in the center raising its arms, symbolizing individuality or selection within a population. 60 # Product reviews   **Product reviews** Screenshot of the 'ElectricTeeth' website homepage featuring a hand holding an electric toothbrush and text describing their product review services. Portrait photo of Dr Gemma Wheeler, BDS, identified as an in-house dentist. # **Questions?** emma.perry@uwa.edu.au pradeep.koppolu@uwa.edu.au Images in presentation not otherwise credited are licence-free from https://www.freepik.com/ 61   **Questions?** emma.perry@uwa.edu.au pradeep.koppolu@uwa.edu.au Images in presentation not otherwise credited are licence-free from https://www.freepik.com/ Portrait photo of a woman with short hair and glasses, smiling. The background shows an outdoor setting with a blue canopy tent. Portrait photo of a man with dark hair and a beard, wearing a plaid jacket and purple tie, smiling. The background is a neutral studio backdrop. [^1]: Original PDF page 1: [[L6 Mechanical Supragingival Biofilm Control 2025.pdf#page=1|L6 Mechanical Supragingival Biofilm Control 2025, p.1]] [^2]: Original PDF page 2: [[L6 Mechanical Supragingival Biofilm Control 2025.pdf#page=2|L6 Mechanical Supragingival Biofilm Control 2025, p.2]] [^3]: Original PDF page 3: [[L6 Mechanical Supragingival Biofilm Control 2025.pdf#page=3|L6 Mechanical Supragingival Biofilm Control 2025, p.3]] [^4]: Original PDF page 4: [[L6 Mechanical Supragingival Biofilm Control 2025.pdf#page=4|L6 Mechanical Supragingival Biofilm Control 2025, p.4]] [^5]: Original PDF page 5: [[L6 Mechanical Supragingival Biofilm Control 2025.pdf#page=5|L6 Mechanical Supragingival Biofilm Control 2025, p.5]] [^6]: Original PDF page 6: [[L6 Mechanical Supragingival Biofilm Control 2025.pdf#page=6|L6 Mechanical Supragingival Biofilm Control 2025, p.6]] [^7]: Original PDF page 7: [[L6 Mechanical Supragingival Biofilm Control 2025.pdf#page=7|L6 Mechanical Supragingival Biofilm 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