Chapter 2
Oral hygiene instruction

REASON FOR PROCEDURE

Oral hygiene instruction is given to patients to ensure that they are maximising their efforts to remove plaque from their teeth and gingival margins to minimise the damage caused by dental caries and periodontal disease, respectively.

Dietary advice is also given to help patients avoid foods and drinks that are particularly damaging to their teeth - those high in refined sugars or those that are acidic.

When the advice is correctly followed on a regular basis, the patients can enjoy a well-cared-for and pain-free mouth, as well as avoid the expense of reparative dental treatment.

The procedures discussed are:

• Use of disclosing agents
• Toothbrushing instruction
• Interdental cleaning instruction
• Dietary advice to reduce the risk of dental caries

BACKGROUND INFORMATION OF PROCEDURE - DISCLOSING AGENTS

Disclosing agents are harmless vegetable dyes supplied in liquid or tablet form and in various colours, usually red or blue (Figure 2.1). Alternatively, a similar disclosing action can be achieved by swilling the mouth with a solution of food colourant liquid (such as those used to colour cake icing).

The disclosing agents act by staining any plaque on the tooth surface to their colour (Figure 2.2), thus making it far easier to show the presence and location of the plaque to the patient, as plaque is normally a creamy white colour and may be difficult for the patient to see otherwise (Figure 2.3).

Figure 2.1 Examples of disclosing tablets

Figure 2.2 Disclosed teeth showing the presence and extent of plaque build-up

Once stained, suitable oral hygiene instructions can be given to remove the plaque effectively. The dyes stain the plaque present on the teeth and gums, but not the teeth themselves, nor any restorations. However, they will also stain any plaque present on other soft tissues, such as the tongue - an area that few patients would think to brush as a matter of routine. Showing the presence of stained plaque in these areas helps persuade patients to carefully brush them routinely as part of their oral hygiene regime.

Figure 2.3 Appearance of undisclosed gingival plaque

DETAILS OF PROCEDURE - DISCLOSING AGENTS

The agents can initially be used at the practice by the oral health team so that the correct problem areas can be identified and suitable cleaning advice can be given. The patient can then use the agents at home to check their progress on a regular basis. The most common agents used are disclosing tablets, but liquid colourants used for cake icing are equally effective.

TECHNIQUE:

• A protective bib is placed over the patient so that their clothing is not inadvertently marked
• The patient is given one disclosing tablet and asked to chew it for about 1 min
• After this time, they are asked to spit out the chewed tablet and saliva, but are instructed not to rinse their mouth out
• Using a patient mirror, any stained plaque is pointed out by the oral health team, and the worst areas are noted (very often the gingival margins or around uneven teeth)
• Detailed advice is then given on how to improve their toothbrushing and cleaning techniques to eliminate the plaque from these areas
• The patient can follow these instructions immediately so that all the stained plaque is removed while under the supervision of the oral health team
• This enables the patient to learn more thorough and more effective techniques for plaque removal, especially in the identified heavily stained areas
• With the plaque easily visible due to the disclosing agent, the patient is able to see their progress and develop the skill to maintain good oral hygiene

BACKGROUND INFORMATION OF PROCEDURE -TOOTHBRUSHING

Toothbrushing is the most commonly used method by patients to remove plaque from the easily accessible flat surfaces of the teeth, but not from the interdental areas unless a sonic-type electric brush is used (Figure 2.4).

Many toothbrushing techniques have been suggested over the years - especially side-to-side brushing and rotary brushing - but the technique used is immaterial as long as the plaque is removed successfully without causing damage to the tooth surface. Disclosing agents can be used to determine the most successful method for a patient.

When performed thoroughly and to a consistently high standard, manual brushing with a good quality brush should be just as effective as that completed with a good quality electric brush on the flat surfaces of the teeth, but the latter takes the effort out of good brushing for those patients who lack the time and skill to perform manual brushing well.

When toothbrushing is combined with the application of a fluoridated toothpaste, the teeth and gums are cleaned free of plaque, and the teeth are protected from dental caries by the action of fluoride on the tooth enamel.

Figure 2.4 Example of sonic-style electric toothbrush

DETAILS OF PROCEDURE - TOOTHBRUSHING

Good toothbrushing aims to remove plaque from the gingival margins and some stagnation areas of the teeth and to protect the tooth surface from carious attack with a layer of fluoride.

Many toothpastes are available (fluoridated, tartar controlling, desensitising, whitening, etc.; Figure 2.5), and the oral health team will advise on the most suitable to be used in each case - patients who have no gum disease issues; for example, do not need to use toothpaste specifically to treat gum disease, and so on.

Similarly, many toothbrush designs are available - both manual and electric - but as a general rule, the head should be small to allow easier manoeuvrability, and the bristles should be multi-tufted and made of medium nylon. Even so, some patients brush with such force that they actually 'saw' into the necks of their teeth and produce abrasion cavities (Figure 2.6).

Figure 2.5 Examples of various toothpastes

Figure 2.6 Abrasion cavity at the neck of a canine tooth caused by heavy-handed toothbrushing

TECHNIQUE:

• Identify those patients with regular residual plaque after toothbrushing
• Apply a small amount of toothpaste to the patient's brush, then allow them to brush their teeth in their usual way and at their usual speed
• Disclose the residual plaque once they have finished brushing to identify the areas of its continued accumulation
• Develop a more thorough brushing technique with the patient to remove all the plaque, particularly that which has accumulated at the gingival margins (Figure 2.7)
• This may involve a change of brush from manual to electric or vice versa, as well as a change of brushing technique by the patient
• Once an effective technique has been identified, a methodical approach is to be developed so that a routine brushing technique is carried out every day
• This tends to be more effective if the more difficult areas are tackled first, such as the lingual surfaces of the lower teeth
• The patient then systematically brushes all the teeth, starting in the same place and ending in the same place each time
• Advice can then be given on the frequency of brushing - usually twice daily as a minimum, but some patients may continue with a high-sugar diet and need to brush after each meal
• Full dietary advice should also be discussed and ideally adjusted where necessary, especially for those patients identified as having a high sugar or dietary acid intake
• Toothbrushes should be replaced once the bristles start to splay, as they will not remove plaque effectively when worn down (Figure 2.8)

Figure 2.7 Toothbrushing the gingival margins

Figure 2.8 Comparison of new and worn toothbrush

BACKGROUND INFORMATION OF PROCEDURE - INTERDENTAL CLEANING

The surfaces of the teeth that remain untouched by routine toothbrushing are the contact points or interdental areas - the points where the 'front' (mesial surface) of one tooth touches the 'back' (distal surface) of the adjacent tooth in each quadrant of the dentition (Figure 2.9). Plaque accumulates here just as easily as on the flat surfaces of the teeth, and even more so when restorations extend into the interdental areas, as microscopically, the restoration margins provide a greater surface area for plaque to accumulate.

Figure 2.9 Contact points of the teeth (arrowed)

Although toothbrushes are too large to clean interdentally, other oral health products have been designed to do so:

• Tape or floss - ideal for dislodging food debris that is trapped at the contact point itself
• Manual interdental brushes - ideal for physically cleaning the interdental area (the mesial and distal surfaces of the adjacent...