CHAPTER 22 Mechanical Oral Biofilm Control: Interdental and Supplemental Self-Care Devices

Deborah M. Lyle

Competencies

Discuss the appropriate use and indications for self-care devices designed to remove or reduce interdental and subgingival plaque biofilm.

Recommend the appropriate device for clients based on efficacy, client needs, and preferences.

The recommendation of self-care devices can be challenging. There are numerous devices on the market to help meet client's self-care needs. However, the plethora of products also makes it difficult to decide which is the appropriate device to recommend. Clients depend on the dental hygienist to help them navigate the “oral healthcare aisle.” In many cases several devices will provide the desired outcome for a client. Therefore it is important for dental hygienists to be familiar with the different devices, the research specific to each device, and the expected results from using the device. This knowledge will foster a conversation between the dental hygienist and client that leads to a recommendation that produces the outcomes valued by the client.

SELECTING SELF-CARE DEVICES

Traditionally, self-care recommendations have consisted of brushing and flossing. Toothbrushes, either manual or powered, continue to be the product of choice for cleaning the facial, lingual, and occlusal surfaces of the teeth. Toothbrushing does not reach the proximal surfaces of teeth or the area immediately under the contact point of adjacent teeth (embrasure space). These areas are known as the interproximal or interdental areas. Dental floss is designed to clean the proximal surfaces of the teeth. In a healthy mouth, brushing and flossing performed effectively on a daily basis can be effective in preventing periodontal diseases in low-risk clients. However, clients who have an increased risk for or who have periodontal disease may need other devices to address their special needs.

With the introduction of new technology, several studies have demonstrated that in some individuals alternatives to manual floss such as floss holders, interdental brushes, and power flossers can be as effective at reducing plaque biofilm, gingivitis, and bleeding as string floss.^1,² Recently studies also have demonstrated that a dental water jet or an antimicrobial mouthwash were as effective as manual floss for the reduction of the same clinical parameters, that is, plaque biofilm, bleeding, and gingivitis.^3,⁴

Removal of plaque biofilm from the interdental areas where toothbrushing does not reach is important for the following reasons:

To prevent periodontal diseases, most of which commonly begin in the interdental col area, a depressed concave area of gingival tissue under the contact area of two teeth. The col area connects the lingual and buccal papillae, and because of its saddle-like shape it harbors plaque biofilm (Figure 22-1). The epithelial tissue covering the col area is thin and less resistant to infection. When inflammation is present in this area, the papilla is enlarged and the col becomes deeper (see Chapter 17) as evidenced by increased probe readings.

To prevent malodor (bad breath) caused by interdental and subgingival plaque biofilm.

Figure 22-1 Location of the col, the nonkeratinized epithelial depression connecting the buccal and lingual papillae of teeth, apical to the contact area (in gray).

(From Perry DA, Beemsterboer PL: Periodontology for the dental hygienist, St Louis, 2007, Saunders.)

TYPES OF INTERDENTAL AND SUPPLEMENTAL SELF-CARE DEVICES: NONPOWERED

A wide variety of interdental and supplemental plaque control aids are available. In general, when the interdental gingiva fills the embrasure spaces, plaque biofilm removal from proximal tooth surfaces and shallow pockets can be accomplished with dental floss or tape, provided the client has the dexterity and the inclination to use them. When the interdental gingiva is reduced or missing, however, the embrasures are open (type II and type III) and other methods of interdental cleaning are needed. The dental hygienist evaluates the information gained during the assessment phase of care to select the most appropriate interdental and supplemental aids for the client. To accomplish this, it is important to keep in mind the following client conditions and risk factors:

Contour and consistency of the gingival tissues

Probing depths

Gingival attachment levels

Size of the interproximal embrasures

Tooth position and alignment

Condition and types of restorative work present

Susceptibility of the client to disease (risk assessment)

Level of dexterity and ability to use a device

Client motivation

Cost, safety, and effectiveness of the recommended device

Client preference

Once an assessment is made, the dental hygienist reviews the care plan and goals with the client to determine which self-care device will be most effective. The simplest, least time-consuming procedures that will effectively control bacterial plaque biofilm and maintain oral health are recommended. Also, if one device works, the dental hygienist chooses it over two devices that would accomplish the same goal. Studies demonstrate that both client acceptance and effectiveness of self-care recommendations improve when the number of devices is limited.

If the client's current self-care regimen is effective in maintaining optimal oral health, the dental hygienist reinforces the behavior, documents the products used in the permanent record, and does not introduce anything new to the daily routine. If a client's regimen is not effective, then the dental hygienist reviews assessment data, including risk factors, and presents new recommendations to the client. Table 22-1 summarizes a variety of powered interdental and supplemental self-care devices.

TABLE 22-1 Powered Interdental and Supplemental Self-Care Devices

In addition, Table 22-2 summarizes nonpowered interdental self-care devices and Table 22-3 summarizes nonpowered interdental supplemental self-care devices commercially available to help control plaque biofilm. These devices can enhance the benefits of a toothbrush, reach areas that the toothbrush is not designed to access, or meet special client needs based on assessment. They include:

Dental floss and tape

Floss holders and threaders

Toothpicks and wooden wedges

Rubber tip stimulators

Interdental brushes and tips

End-tuft, single-tuft brushes

Tongue cleaners

TABLE 22-2 Nonpowered Interdental Self-Care Devices

TABLE 22-3 Nonpowered Supplemental Self-Care Devices

Dental Floss and Tape

Dental floss is the most frequently recommended product for cleaning proximal tooth surfaces with normal gingival contour and embrasure spaces. Figures 22-2 and 22-3 illustrate the various embrasure types and devices. Dental floss is recommended only for individuals with type I embrasures. Dental floss is most effective when interdental spaces are covered by the papilla; however, as recession becomes more pronounced, floss becomes progressively less effective.

Figure 22-2 A to C, Interproximal embrasure types.

Figure 22-3 Use of interdental plaque control devices. A, Dental floss. B, Interdental brush. C, End-tuft brush.

Most types of dental floss are made of nylon, and some are impregnated with flavoring, fluoride, or antimicrobial or whitening agents. The following general types of dental floss are available:

Unwaxed, waxed, and dental tape

Braided and tufted

Unwaxed, Waxed, and Dental Tape

The first dental floss was a waxed silk thread that was designed to go between the teeth to remove the irritants that the toothbrush could not reach. Today dental floss is made of nylon waxed or unwaxed multifilaments. A monofilament type also is available and is coated with a material called polytetrafluoroethylene (PTFE). The coated monofilament slides easily between the teeth and does not fray. The multifilament type allows for separation of the fibers and is either thick or thin. Studies have shown no difference in the effectiveness of unwaxed versus waxed dental floss. Recommendations are based on client's ease of use or preference. Waxed floss may be easier to use for those clients who have tight contacts.

Dental tape or ribbon is a waxed floss product that is wider and flatter than conventional dental floss. The flat-sided surface of dental tape is preferred by some, particularly when the surface area to be flossed is large. The choice of which floss to recommend or even if dental floss is the best choice is influenced by:

The tightness of the contact area

The contour of the gingival tissue

The roughness of the interproximal surface

The client's manual dexterity and preference

Braided and Tufted Floss

Tufted dental floss, or variable-diameter dental floss, has been found to be equally as effective as waxed or unwaxed dental floss for removing plaque biofilm. Tufted dental floss is designed to have three continuous segments: a length of waxed or unwaxed dental floss; a shorter segment of cylindric, nylon meshwork; and a relatively rigid nylon needle capable of being threaded beneath the contact or under fixed bridges (Figure 22-4). The dental floss segment is used in areas of normal gingival contour, and the other segments are used as indicated in Table 22-2.

Figure 22-4 Tufted dental floss.

Other types of floss are intended for cleaning dental implants. For example, braided floss is sold on a spool or as a precut piece with a stiff nylon end for threading. The braided nylon resembles a cord, can be washed after use, and is reused after drying. Some floss has a mesh or gauze appearance and is meant for one-time use. More information on both types of floss can be located in Chapter 57 on osseointegrated dental implants.

String Flossing Methods

The two primary methods of dental flossing are the spool method and the loop method. Procedure 22-1 reviews the spool method of flossing, a method used by many teens and adults.

Procedure 22-1 SPOOL FLOSSING METHOD: ADULTS

STEPS

1. Break off a piece of floss 12 to 18 inches long from the spool.

2. Wrap floss around middle fingers; wrap floss around right middle finger two to three times; wrap remaining floss around left middle finger (or vice versa) (Figure 22-5, A).

3. For maxillary insertion, grasp floss firmly with thumb and index finger of each hand, using ½ inch of floss between fingertips (Figure 22-5, B). For mandibular insertion, direct the floss down with the index fingers (Figure 22-5, C).

4. Select area to begin flossing, and establish a pattern to progress throughout the mouth.

5. Set a fulcrum on the cheek or in the mouth.

6. Use gentle seesaw motion to pass through contact area.

7. Wrap tightly in C shape around tooth (Figure 22-6).

8. Move floss up and down on mesial of tooth three to four strokes, then move above papilla (just below contact); wrap in C shape on distal surface of adjacent tooth, moving floss up and down three to four strokes (Figure 22-7).

9. Use a seesaw motion to remove floss through contact.

10. Advance floss to a new area by unwrapping floss from left-hand middle finger and wrapping onto right-hand middle finger (or vice versa; see step 2).

11. Repeat steps 5 to 11 until all teeth have been completed, continuing to grasp the floss with the thumb and index fingers.

12. Dispose of floss in waste receptacle.

Figure 22-5

Figure 22-6 A, Dental floss. B, Dental tape.

(A, from Perry DA, Beemsterboer PL: Periodontology for the dental hygienist, St Louis, 2007, Saunders. B, from Newman MG, Takei HH, Klokkevold PR, Carranza FA: Carranza's clinical periodontology, ed 10, St Louis, 2006, Saunders.)

Figure 22-7 Floss wrapped around dental surface.

(From Hoag PM, Pawlak EA: Essentials of periodontics, ed 4, St Louis, 1990, Mosby.)

The spool method of flossing requires manual dexterity. Children or those who have less manipulative ability with their hands may prefer to use the loop method of flossing as described in Procedure 22-2.

Procedure 22-2 LOOP FLOSSING METHOD: CHILDREN AND CLIENTS WITH LIMITED MANUAL DEXTERITY

STEPS

1. Break off a piece of floss 8 to 10 inches long from the spool.

2. Tie the two ends together in a knot (Figure 22-9).

3-10. Follow steps listed for spool flossing method (see Procedure 22-1).

11. Advance floss to new area by sliding floss away from the knot.

12. Repeat steps 5 to 11 until all teeth have been completed, continuing to grasp the floss with the thumb and index fingers.

13. Dispose of floss in waste receptacle.

Proper flossing technique is not easy to master, and detailed instructions need to be given and demonstrated. If the client does not have the ability to master the technique or does not like to floss, other devices need to be recommended. Disclosing solution and the presence of plaque biofilm, gingival bleeding, and periodontal indices are parameters used to assess the effectiveness of plaque biofilm removal in terms of clinical outcomes. Oral signs of gingival trauma (e.g., floss cuts, gingival clefts, gingival abrasion) are used for the safety evaluation (Figure 22-8). Causes of gingival trauma include:

Using too long a piece of floss between fingers when inserting between teeth

Snapping the floss in the contact area

Failing to wrap the floss around the tooth before moving it subgingivally between the tooth and the papilla

Failing to use a finger rest to prevent undue pressure and to provide control

Figure 22-8 Floss cuts.

(Courtesy Dr. Margaret Walsh, University of California–San Francisco.)

Figure 22-9

Gingival bleeding during flossing can be a result of trauma or an indication of inflammation. When clients with gingival inflammation initiate flossing, the gingiva bleeds as a result of the microulcerations in the sulcular lining that occur during the active disease process. Clients must be aware that bleeding is not a sign to avoid flossing, but rather an indicator of infection that needs to be controlled by improved self-care techniques. In most cases bleeding from gingival inflammation subsides with the regular removal of the plaque biofilm and supportive periodontal therapy.

Floss Holders and Threaders

Clients who have difficulty mastering string floss techniques for interdental cleaning may find it easier to use a floss holder (Figure 22-10). Floss holders are plastic handles that aid in the placement and movement of floss between the teeth. Floss holders are described in Table 22-2, and their method of use in Procedure 22-3. Studies have found that use of floss with proper use of a floss holder reduced plaque biofilm and gingivitis as effectively as use of string floss. In addition, those who used the floss holder preferred using it to traditional flossing techniques.

Figure 22-10 Disposable floss devices are convenient for some clients and may enhance plaque biofilm control.

Figure 22-11 Placement of floss holder in mouth.

(From Perry DA, Beemsterboer PL: Periodontology for the dental hygienist, St Louis, 2007, Saunders.)

Procedure 22-3 USE OF A FLOSS HOLDER

STEPS

1. Tightly string floss on holder following the manufacturer's recommendations (see Figure 22-10).

2. Follow steps 4 to 10 for spool method of flossing.

3. To direct floss in a C shape toward mesial and distal in step 8, use push or pull motion with floss holder (Figure 22-11).

4. To move to a new area of floss (step 11 of the spool method), the holder must be unwrapped, the floss advanced, and the holder rewrapped.

5. Continue until all teeth are completed.

6. Dispose of the floss in waste receptacle.

7. Wash off floss holder with warm water and soap, dry, and store in clean, dry area until next use.

Another device that assists clients in cleaning under bridges and around abutments or orthodontic appliances is the floss threader (see Figure 22-12). As described in Table 22-2, a floss threader assists in introducing floss between an abutment tooth used for support of a fixed bridge and a pontic, the artificial tooth that replaces a missing natural tooth. Procedure 22-4 reviews the use of a floss threader.

Figure 22-12 A, Facial insertion of the threader tip. B, Threader pulled lingually through the interproximal space.

Figure 22-13

Procedure 22-4 USE OF A FLOSS THREADER

STEPS

1. Determine the need to use a floss threader and appropriate areas for use.

2. Break off a piece of floss 4 to 6 inches long from the spool.

3. Thread floss through eye of floss threader, overlapping floss 1 to 2 inches.

4. Grasp threader with thumb and index finger of one hand.

5. Insert tip of threader from the facial surface through an open interproximal area or area between a pontic and an abutment tooth (Figure 22-12, A).

6. Pull floss threader toward the lingual side until threader has passed completely through the interproximal space or under a pontic (only floss is now in the space) (Figure 22-12, B).

7. Slide the floss threader off the floss and remove from mouth.

8. Move floss back and forth several times under the pontic. Then follow steps 8 and 9 of the spool method of flossing (Figure 22-13).

9. Remove floss by letting go with hand that is on the lingual side and pulling floss toward the buccal side.

10. Dispose of floss and threader in waste receptacle.

Benefits of Flossing

The benefit of daily flossing is the reduction or prevention of inflammation caused by the presence of interdental plaque biofilm. Studies show that flossing reduces plaque biofilm, bleeding, and gingivitis. It is commonly accepted that flossing reduces the incidence of interproximal caries. However, in some studies, if fluoride was used there was no additional benefit from flossing.^5,⁶ For more details on caries risk and prevention see Chapter 16.

Toothpicks

Some individuals prefer to use toothpicks for control of interdental plaque biofilm, particularly on concave proximal surfaces and exposed furcation areas. Toothpicks can be either wooden or plastic. Studies have shown that the toothpick is as effective as dental floss in reducing interproximal plaque biofilm and gingival bleeding. To use toothpicks, however, there must be sufficient interdental space available (see Table 22-2 for indications). Toothpicks are often too long and have the potential to damage tissue while working lingually. To prevent damage, use of a toothpick holder is recommended for cleaning lingual surfaces. Toothpick holders (Figure 22-14) are designed to allow use from the facial or lingual aspect and adapt better interproximally and posteriorly when compared with toothpicks alone.

Figure 22-14 Example of toothpick holder.

Figure 22-15 A, Toothpick tip placed at gingival margin. B, Gentle up-and-down motion keeping tip on tooth.

(From Newman MG, Takei HH, Klokkevold PR, Carranza FA: Carranza's clinical periodontology, ed 10, St Louis, 2006, Saunders.)

The main concern with using a toothpick or toothpick holder is avoidance of gingival damage. Clients need to be taught proper toothpick use to remove plaque biofilm effectively without causing damage to the gingiva, especially the epithelial attachment (Procedure 22-5).

Procedure 22-5 USE OF A TOOTHPICK IN A TOOTHPICK HOLDER

STEPS

1. Insert a round tapered toothpick into the end of an angled plastic holder. Twist toothpick securely into holder, and break off longer end of toothpick (see Figure 22-14).

2. Moisten the end of the toothpick with saliva.

3. Place the toothpick tip at the gingival margin with the tip pointing at a 45-degree angle to the long axis of the tooth. Trace the gingival margin around the tooth (Figure 22-15, A).

4. Some clients may be dexterous enough to point the tip at less than a 45-degree angle into the sulcus or pocket and trace around the tooth surfaces and root concavities. The tip should maintain contact with the tooth at all times. Insertion should stop once the toothpick meets a slight resistance in the space without the teeth being forced apart interproximally or the tissue being impinged. Keeping the tip at the tooth, use a gentle up-and-down motion to clean concave proximal surfaces (Figure 22-15, B).

5. For exposed furcation areas, trace the furcation and use an in-and-out motion to clean the furcation. The tip should maintain contact with the tooth at all times.

6. If debris accumulates on toothpick, rinse under running water.

7. Once all areas of the mouth are completed, dispose of toothpick in waste receptacle.

8. Holder may be washed with soap and warm water and stored in a clean, dry place for reuse.

Wooden Wedges

Wooden wedges are designed to remove interproximal plaque biofilm from type II and III embrasures. They are recommended for use only from the facial aspect, where the proximal surfaces are exposed to avoid traumatizing gingival tissue. The use of wooden wedges is reviewed in Procedure 22-6. The key difference between the use of toothpicks and wooden wedges relates to the triangular design of the wedge. Wedges are inserted interdentally, with the base of the triangle resting on the gingival side, the tip pointing occlusally or incisally, and the sides of the triangle against the adjacent tooth surfaces (Figure 22-16). Placing the triangle base against the tissue prevents damage, such as gingival cuts and clefts, to the interdental papilla and gingival margins (see Figure 22-17). The triangular wedge fits the interdental area more snugly, covering a larger surface area, thereby allowing for the removal of more plaque biofilm.

Procedure 22-6 USE OF A WOODEN WEDGE

STEPS

1. Determine the need to use a wooden wedge and appropriate areas for use.

2. If wedge is made of wood, moisten the end of the wedge or toothpick with saliva. Establish a rest by placing the hand on the cheek or chin or by placing a finger on the gingiva convenient to the place where the tip will be applied.

3. Place wedge against the proximal surface of a tooth with the base of the wedge triangle toward gingival border and the tip pointing occlusally or incisally at approximately a 45-degree angle (see Figure 22-16).

4. Use an in-and-out motion interproximally from the facial area only. Apply a burnishing stroke with moderate pressure first to the proximal surface of one tooth and then to the other, about four strokes each. Stop once wedge meets a slight resistance in the space (Figure 22-17).

5. Trace margin of tissue to remove marginal debris, again with tip pointing occlusally (away from tissue).

6. If debris accumulates on wedge, rinse under running water.

7. Once all areas of mouth are completed, dispose of wedge in waste receptacle.

Figure 22-16 Proper placement of the Balsa wooden wedge against the proximal surface of a tooth.

(From Hoag PM, Pawlak EA: Essentials of periodontics, ed 4, St Louis, 1990, Mosby.)

Figure 22-17 Wooden wedge placement. The tip is moved in and out to remove plaque biofilm.

(From Newman MG, Takei HH, Klokkevold PR, Carranza FA: Carranza's clinical periodontology, ed 10, St Louis, 2006, Saunders.)

Rubber Tip Stimulators

Interdental stimulators are devices designed primarily for gingival stimulation. The rubber tip stimulator, attached to the end of a metal or plastic handle (see Figure 22-18), is used to remove plaque biofilm by rubbing it against the exposed tooth surfaces, to stimulate the gingiva, and to recontour gingival papillae after periodontal therapy (see Table 22-3). Research on rubber tip stimulators is limited and inconclusive regarding the efficacy of plaque biofilm removal and reduction of infection. A rubber tip stimulator can cause injury to the gingiva if used improperly (Procedure 22-7).

Figure 22-18 Proper placement of a rubber tip stimulator.

(Courtesy Sunstar Americas, Inc, Chicago, Illinois.)

Procedure 22-7 USE OF A RUBBER TIP STIMULATOR

STEPS

1. Determine the need to use a rubber tip stimulator and appropriate areas for use.

2. Place side of rubber tip interdentally and slightly pointing coronally (45-degree angle) (Figure 22-18).

3. Move in and out with a slow stroke, rubbing the tip against the teeth and under the contact area.

4. Remove from the interproximal space and trace the gingival margin, with the tip positioned just below the margin, following the contour of the gingiva.

5. Once all appropriate areas are completed, rinse stimulator with soap and warm water, then store in a clean, dry place.

6. Replace rubber tip as it becomes worn, cracked, or splayed.

Massaging the gingiva with a rubber tip or other device can lead to improved circulation, increased keratinization, and epithelial thickening. Whether these gingival changes provide any clinical benefits has not been studied. Improved gingival health resulting from oral hygiene practices has been shown to be directly related to plaque biofilm removal and reduction of risk factors.

Interdental Brushes and Tips

Interdental brushes are available in various sizes and shapes. The most common brushes are conical or tapered (like an evergreen tree) and designed to be inserted into a plastic, reusable handle that is angled to facilitate interproximal adaptation (see Figure 22-19). Studies have shown that interproximal brushes are equal to or more effective than floss for plaque biofilm removal and for reducing gingival inflammation in type II embrasures, type III embrasures, and exposed furcations. Further indications for use are discussed in Table 22-2. The brush design selected is related to the size of the gingival embrasure or furcation to be cleaned. The interdental brush needs to be slightly larger than the embrasure space so that it can effectively clean the designated area. Interdental brush use is reviewed in Procedure 22-8 and illustrated in Figure 22-19, B.

Figure 22-19 A, Cleaning of concave or irregular proximal tooth surfaces. Dental floss may be less effective than an interdental brush on long root surfaces with concavities.

B, Proper placement of inderdental brush. (A, from Newman MG, Takei HH, Klokkevold PR, Carranza FA: Carranza's clinical periodontology, ed 10, St Louis, 2006, Saunders. B, from Perry DA, Beemsterboer PL: Periodontology for the dental hygienist, St Louis, 2007, Saunders.)

Procedure 22-8 USE OF AN INTERDENTAL BRUSH

STEPS

1. Determine the need to use an interdental brush and appropriate areas for use.

2. Insert bristles into embrasure at a 90-degree angle to tooth surface (long axis of the tooth) (Figure 22-19, A).

3. Move brush using in-and-out motion from facial and/or lingual surfaces of appropriate areas (Figure 22-19, B).

4. Rinse bristles under running water as necessary to remove debris.

5. On completion of use, rinse entire handle and bristles with soap and warm water.

6. Store in a clean, dry place.

7. Replace bristles as they become worn or splayed.

Other interdental tips (see Table 22-2) are also available in various sizes and material including plastic and foam for plaque biofilm removal in areas similar to interdental brushes. Some interdental tips are designed to fit into smaller areas than a Class II embrasure. The tips made of foam or other absorbent material can facilitate delivery of liquid chemotherapeutic agents, such as antimicrobials or desensitizing agents, to the proximal surface. Research in this area is limited, however. Interdental brushes and tips are available in disposable units designed for travel or use when away from home.

End-Tufted or Single-Tufted Brushes

End-tufted or single-tufted toothbrushes, indicated for type II and III embrasures, for difficult-to-reach areas, or around fixed dental appliances (see Table 22-3), are designed with a smaller brush head that has a small group of tufts (end-tufted) or a single tuft (single-tufted) (Figure 22-20). The bristles are directed into the area to be cleaned and activated with a rotating motion, similar to the vibratory motion of Bass toothbrushing. End-tufted brushes have been shown to be effective adjuncts to toothbrushing in controlling gingivitis in adults.

Figure 22-20 End-tufted brush.

Tongue Cleaners

Bad breath, also known as malodor, is a common client complaint. Tongue cleaning is often overlooked because clients are not aware that the papillae of the tongue harbor bacteria. Bacteria on the tongue are the primary cause of bad breath. Tongue cleaners or scrapers are designed and intended for removal of debris and bacteria from the tongue's dorsal surface (see Figure 22-21). Brushing the tongue with a toothbrush also can remove bacteria and debris. Some clients may find it difficult to reach the tongue's posterior third with a toothbrush, and the bristles may be too soft to remove moderate to heavy debris adequately. Clients may find that a tongue cleaner is easier to use because it does not stimulate the gag reflex as readily as a toothbrush. Tongue cleaners come in many shapes, styles, and colors, from a simple plastic strip to a variety of handled devices. Procedure 22-9 outlines use of a tongue cleaner.

Figure 22-21 Tongue cleaner.

(Courtesy Sunstar Americas, Inc, Chicago, Illinois.)

Procedure 22-9 USE OF A TONGUE CLEANER

STEPS

1. Determine the need to use a tongue cleaner.

2. Hold the handle of the tongue cleaner, or if it is a strip tongue cleaner, wrap in a U shape by holding both ends of the cleaner.

3. Start at the posterior part of the tongue, and drag the tongue cleaner to the tip of the tongue. If gag reflex is triggered, drag from the lateral border of the tongue to the opposite lateral border (Figure 22-21, and see Chapter 21, Figure 21-10).

4. Rinse tongue scraper with water.

5. Repeat step 3 until tongue cleaner is clean on removal, being sure to cover all aspects of the tongue with overlapping strokes.

6. Rinse tongue cleaner with soap and warm water to clean. Store in a clean, dry place.

Procedure 22-10 USE OF A DENTAL WATER JET: JET TIP

STEPS

1. Fill the reservoir with lukewarm water or an antimicrobial agent.

2. Select the appropriate tip and insert into the handle, pressing firmly until it is fully engaged.

3. Adjust the pressure gauge to the lowest setting when using for the first time. Increase as needed or dicated by client comfort.

4. Place the tip in the mouth, then turn the unit on. Lean over the sink and close the lips enough to prevent splashing while still allowing the water to flow from mouth into the sink.

5. Aim the tip at a 90-degree angle to the long axis of the tooth (Figure 22-27). Starting in the posterior, follow the gingival margin, pausing between the teeth for a few seconds before continuing to the next tooth. Be sure to irrigate from the buccal and lingual aspects of all teeth.

6. Read manufacturer's instructions for each model of dental water jet before demonstration.

Additional Devices

Tooth Towelettes

Tooth towelettes are being marketed as a method of plaque biofilm removal when toothbrushing is not possible. The tooth towelettes are gauze squares usually treated with some form of mouthwash to freshen breath. The gauze square is held between the thumb and index finger and wiped on the tooth surface, moving from the cervical margin to the incisal or occlusal edge. Both facial and lingual surfaces are cleaned at the same time. Use of towelettes is not meant to replace a daily toothbrushing.

Clasp and Denture Brush

Specialty brushes such as the clasp brush and denture brush have been designed with firm nylon filaments to clean dentures and the clasps of partial dentures (see Table 22-3 and Figures 22-22 and 22-23). Because these prostheses are removable and cleaned outside of the mouth, the firmer filaments cannot cause gingival tissue destruction (see Chapter 35).

Figure 22-22 Example of denture brushes.

Figure 22-23 Example of a denture clasp brush.

Yarn, Pipe Cleaners, and Gauze

Yarn, pipe cleaners, and gauze were often recommended for interdental cleaning before the introduction of devices that are specifically designed to clean type II and III embrasures. These products are rarely recommended today.

TYPES OF INTERDENTAL AND SUPPLEMENTAL SELF-CARE DEVICES: POWERED

In the past several years, many new powered devices have become available to consumers. The most recognizable is the powered toothbrush (see Chapter 21). Other powered devices include flossers, interdental brushes, dental water jets, and tongue cleaners. Not all products have undergone clinical testing. Table 22-3 describes a variety of powered interdental and supplemental devices.

Flossing Devices

Power flossing devices are available to make interdental cleaning easier. Research has shown that these devices can remove plaque biofilm and reduce bleeding and gingivitis similarly to string floss.7,8 Some designs are similar to a floss holder, with floss pulled taught between a bow-shaped handle (Figure 22-24). Another design uses a single flexible nylon tip that is placed interproximally between the tooth and the papilla and is long enough to reach to the lingual aspect of the tooth (Figure 22-25). these products may increase compliance with some clients.

Figure 22-24 Power flosser with bow type tip, similar to nonpower devices.

(Courtesy Procter & Gamble, Cincinnati, Ohio.)

Figure 22-25 Power flosser with a single filament nylon tip.

(Courtesy Water Pik, Inc, Fort Collins, Colorado.)

Figure 22-26 A, countertop dental water jet. B, cordless dental water jet.

(Courtesy Water Pik, Inc, Fort Collins, Colorado.)

Figure 22-27 Proper placement of a standard jet tip.

(From Daniel SJ, Harfst SA, Wilder RS: Mosby's dental hygiene, ed 2, St Louis, 2008, Mosby.)

Interproximal Brushes and Tips

Some power toothbrushes come with attachments designed to clean the approximal or interproximal area. Attached to the brush handle, they are activated by turning on the brush and using it according to the manufacturers directions. These attachments may be similar to a floss holder, an interdental brush, or a single- or end-tufted brush.

Dental Water Jets

In studies of clients with fixed orthodontics, implants, crown and bridge, and gingivitis and those in a periodontal maintenance program, irrigating the gingival area with a dental water jet that produces pulsating streams of fluid has been reported to reduce plaque biofilm, bleeding, gingivitis, pocket depth, pathogenic microorganisms, and calculus. 8-11 In addition, studies have shown that daily water irrigation can reduce inflammatory mediators that promote or enhance the periodontal disease process. These improvements to the inflammatory response may potentially extend to systemic health, as documented by a study on persons with diabetes in which systemic measures of inflammatory mediators were reduced by the addition of oral irrigation to the self-care routine.^9,¹⁰

On the other hand, dental water jets that produce a steady stream of fluid as seen with such devices that are attached to a shower or faucet have not been tested clinically for efficacy in reducing clinical parameters.

Mechanism of Action

A dental water jet that produces a pulsating stream of fluid (Figure 22-26) works by impacting the gingival margin with the pulsed irrigant (impact zone) and the subsequent flushing of the gingival crevice or pocket (flushing zone). This hydrokinetic activity produces a compression and decompression action that allows the irrigant to reach subgingivally. The majority of studies demonstrating safety and efficacy have been done with devices that deliver 1200 pulsations per minute and pressure settings between medium and high (50 to 90 pounds per square inch). Irrigation pressure can be controlled on most devices. Procedure 22-10 outlines the basic use of a pulsating dental water jet. For additional information on the use of a dental water jet, see Chapter 29.

Depth of Delivery of a Solution

The dental water jet has the ability to reach deeper into the periodontal pocket than a toothbrush, interdental aid, or rinsing. This penetration allows for better subgingival cleaning and deeper delivery of antimicrobial agents. The depth to which the solution can reach is dependent on the tip used. A standard jet tip has been shown to reach 71% in pockets 0 to 3 mm, 44% in pockets 4 to 7 mm, and 68% in pockets greater than 7 mm. Specialty tips designed to be placed slightly below the gingival margin deliver a solution up to 90% in pockets 6 mm deep and 64% in pockets 7 mm or greater (Figure 22-28).

Figure 22-28 A, Irrigation with a specialized subgingival tip. B, Proper placement of a specialized subgingival tip.

(B, From Daniel SJ, Harfst SA, Wilder RS: Mosby's dental hygiene, ed 2, St Louis, 2008, Mosby.)

Tongue Cleaner Attachments

Powered tongue cleaners have been developed to remove plaque and debris from the dorsum of the tongue and to help control or eliminate malodor. Automation provides a means for additional action that may help clients who have difficulty with dexterity. A tongue cleaning attachment is available for dental water jets and provides a water flushing action or the delivery of an antimicrobial. Tongue cleaning attachments are also available for some power toothbrushes. There are no data to demonstrate that these devices are better than a manual tongue cleaner.

CLIENT EDUCATION TIPS

Explain the importance of interdental and subgingival cleaning to the prevention and control of periodontal disease.

Demonstrate proper use of power and nonpower mechanical self-care devices other than a toothbrush.

Explain that breath malodor may be improved by cleaning the tongue and periodontal pocket.

Explain that minor dexterity and visual acuity problems may be compensated through use of power devices.

Explain how certain devices are better for specific embrasure spaces based on product design and function.

Explain the limitations of floss, especially with clients who have deeper pockets, loss of attachment, and type II or III embrasures.

Explain that client-specific self-care is an integral part of achieving and maintaining therapy outcomes.

Question clients to determine which devices they currently use, the reasons they chose the devices, and whether they feel the devices are effective.

Instruct clients based on their unique human needs to promote client acceptance.

LEGAL, ETHICAL, AND SAFETY ISSUES

The legal standard of care requires that dental hygienists educate clients about oral self-care.

The legal records of the client should reveal that the client has been counseled on why and how to perform an effective daily personal self-care program. Specific recommendations of products are noted in the legal records.

The clients' progress and compliance with recommendations are recorded. Alternative methods are recommended and demonstrated if prior instructions are not producing the expected outcomes or if the client is not able or willing to use a recommended device.

Malpractice cases for failure to recognize and treat periodontal disease can be related to failure to teach adequate plaque biofilm techniques to clients. This includes recommending products that do not address client needs or failure to recommend alternatives based on client preferences.

Improper use of devices can cause damage to the hard and soft tissue in the oral cavity. Properly educating and demonstrating the recommended devices to the client are required and noted in the legal records.

KEY CONCEPTS

Interdental and subgingival plaque biofilm control is essential for the prevention of oral disease.

Self-care recommendations are based on client's preferences, values, and needs.

If a client refuses to floss, recommend alternatives that will provide similar benefits.

Flossing is not the device of choice for many clients based on preference and assessment. It is effective when used properly and daily by the clients who have type I embrasures and normal sulcus. It is a good choice for prevention of periodontal disease in clients with a healthy periodontium.

Risk assessment is an important part of determining which self-care device to recommend.

Clients must be involved in the selection of self-care devices. Recommendations should be based on the fewest devices that provide the optimal plaque biofilm control for the client.

CRITICAL THINKING EXERCISES

Scenario: As a result of a recent automobile accident, one of your teenage clients has a broken jaw. To allow healing, her mouth is wired shut, keeping her from moving her jaw. She is seeking advice on how to care for her oral cavity. Several wires are present, and staples appear at the cervical margins of all teeth. She also has several intraoral cuts and abrasions, making any form of cleaning somewhat painful.

1. Discuss devices that could be used, and make recommendations for home care.

2. Identify and discuss the benefits of the different types of floss provided by your instructor in class.

3. Demonstrate proper flossing techniques for spool and loop methods on a typodont. Once mastered on a typodont, demonstrate flossing in your own mouth and then on a partner while using proper infection-control methods.

4. Identify devices that would benefit clients with orthodontics, and demonstrate proper use of the devices on a typodont with fixed orthodontic brackets and wires.

5. With a partner, role-play providing instructions on the use of floss, floss threader and holder, dental water jet, interdental tips, brush and stimulator, wood or plastic sticks, toothpick and holder, and tongue cleaner.

6. Identify the names of different devices provided in class by your instructor. Also describe the areas in which each aid may be used in the mouth based on design and function.

7. On a periodontal typodont, demonstrate use of the various devices designed specifically for periodontal maintenance clients.

8. Divide into groups of two or three, with each group assigned one device or category. Students should deliver oral reports to the class that include features, benefits, expected outcomes based on clinical research, and what types of clients would benefit from using the device. Compare and contrast the assigned device to another category of device that can deliver the same benefits.

ACKNOWLEDGMENT

The authors acknowledge the contributions of Brenda Parton Maddox for her past contributions to this chapter.

Refer to the Procedures Manual where rationales are provided for the steps outlined in the procedures presented in this chapter.

REFERENCES

1. Noorlin I., Watts T.L. A comparison of the efficacy and ease of use of dental floss and interproximal brushes in a randomized split mouth trial incorporating an assessment of subgingival plaque. Oral Health Prev Dent. 2007;5:13.

2. Yost K.G., Mallatt M.E., Liebman J. Interproximal gingivitis and plaque reduction by four interdental products. J Clin Dent. 2006;17:79.

3. Barnes C.M., Russell C.M., Reinhardt R.A., et al. Comparison of irrigation to floss as an adjunct to toothbrushing: effect on bleeding, gingivitis and supragingival plaque. J Clin Dent. 2005;16:71.

4. Zimmer S., Kolbe C., Kaiser G., et al. Clinical efficacy of flossing versus use of antimicrobial rinses. J Periodontol. 2006;77:1380.

5. Hujoel P.P., Cunha-Cruz J., Banting D.W., Loesche W.J. Dental flossing and interproximal caries: a systematic review. J Dent Res. 2006;85:298.

6. Smiech-Slomkowska G., Jablonska-Zrobek J. The effect of oral health education on dental plaque development and the level of caries-related Streptococcus mutans and Lactobacillus spp. Eur J Orthod. 2007;29:157.

7. Shibly O., Ciancio S.G., Shostad S., et al. Clinical evaluation of an automatic flossing device vs. manual flossing. J Clin Dent. 2001;12:63.

8. Cronin M., Dembling W.Z., Cugini M., et al. A 30-day clinical comparison of a novel interdental cleaning device and dental floss in the reduction of plaque and gingivitis. J Clin Dent. 2005;16:33.

9. Al-Mubarak S., Ciancio S., Aljada A., et al. Comparative evaluation of adjunctive oral irrigation in diabetics. J Clin Periodontol. 2002;29:295.

10. Cutler C.W., Stanford T.W., Abraham C., et al. Clinical benefits of oral irrigation for periodontitis are related to reduction of pro-inflammatory cytokine levels and plaque. J Clin Periodontol. 2000;27:134.

11. Sharma N.C., Lyle D.M., Qaqish J.G., et al. The effect of a dental water jet with orthodontic tip on plaque and bleeding in adolescent patents with fixed appliances. Am J Orthod Dentofacial Orthop. 2008;133:565.

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