These are the most common toothbrushing techniques recommended by dental hygienists and dentists that will help you maintain a good oral hygiene

Bass (Sulcular)

Method - Bristles are directed apically at 45◦ to long axis of tooth, gentle force applied into sulcus

Use gentle but firm vibratory strokes without removing bristle ends from sulcus

Indications – Sulcular cleansing, Perio health, Perio disease, Perio maintenance

Stillman’s

Method – Bristles are directed apically and angles same as bass

Bristles are placed partly over cervical part of tooth and partly on adj. gingiva

Short back and forth strokes are used and brush head is moved occlusally with light pressure

Indications – Progressive Perio recession, Gingival stimulation

Charter’s

Method – Bristles are directed toward crown of the tooth. Bristles are placed @ the gingival margin and 45◦ to long axis of tooth; short back and forth strokes

Indications – Ortho, temp cleaning of surgical wounds, fixed prosthetic appliances, gingival stimulation, cleaning of entire facial and lingual surfaces

Modified Bass, Stillman’s and Charter’s

Method - Add a rollto any of  the three maor methods (Charter’s, Stillman’s or Bass);  roll tufts occlusally after cervical area is cleaned by prescribed method

Indication – Rolling motion avoids damaging the base of the gingival sulcus.

Horizontal Scrub

Method – Bristles are activated in gentle, horizontal scrubbing motion

Fone’s (circular)

Method – Bristles are activated in circular motion

Indications – Its mostly indicated for children but it can also be applied to adults. It is a simpler technique but it has shown to be less effective then the three first methods.

Leonard Vertical strokes are used with teeth in an edge to edge position. (Not Recommended)

Roll Stroke

Method – Bristles are pointed apical and rolled occlusally

Indications – Used in conjunction with Bass, Stillman’s and Charter’s

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1)      Disease prevention

2)      Disease treatment

3)      Health promotion

In order to successfully complete our task as dental practitioners we need to understand what client counseling, principles of learning, client motivation and human needs are

-Patient  Counseling

• For most dental patients major attention is focused on control of caries and periodontal infections with emphasis on microbial plaque control, tobacco cessation, nutrition
• Periodontal infections and dental carries can be prevented or controlled
• Teeth can be preserved throughout the patient’s lifetime
• Consider a client who increases oral health knowledge, attitude, & values. Then instills this in respective family, then the community
• Knowledge and beliefs are not enough…
• Knowledge must be put into action, learning occurs when beneficial changes are incorporated into everyday living

-Principles of learning

• More effective when client is ready to learn
• Individual differences must be considered
• Motivation is essential
• What a client learns in a given situation depends on what is recognized & understood
• Recognition between similarities & differences of past & present situation
• Clients learn what is actually used
• Increased when client feels satisfied
• Evaluating results of instruction is essential to determine if learning is taking place

-Motivation

• Individuals are motivated to practice behavior that leads to achievement of goals that are valued (must consider oral health as a valuable asset)
• Motivation stems from a physiologic or social need (peer group approval, fear of rejection)

-Human Needs Model

(The human needs model is used as a framework for dental hygiene care)

• In the human needs model of dental hygiene the client is seen as a biologic, psychological, spiritual, social, cultural and intellectual human being who is

motivated by the fulfillment of his/her human needs.

• The environment affects the client and the DH and both are capable of influencing the environment.
• The higher the level of human need fulfillment, the higher the state of wellness for the individual.

• Dental Hygiene actions are defined as those interventions aimed at assisting clients in meeting their human needs related to optimal oral wellness and quality of life through out the life cycle.

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1. Assessing: Gathering information regarding clients health
2. Diagnosing: Identifying clients oral problems and deviations from normal
3. Planning: Settlement of goals for the patient
4. Implementing: The process that involves meeting of the clients needs designed by Dental Hygienist during planning.
5. Evaluation: Involves measuring of the clients achievements specified during plan care

Dental Hygienists should be able of decision making as well as responsible in identifying and resolving clients problems within the scope of Dental Hygiene profession.

Three are Dental Hygienists responsibilities

Preventive: To prevent oral disease by any methods that they are professionally trained.

(Applying professional fluoride or dental hygiene education sessions)

1. Therapeutic: Arresting oral disease that can compromise clients health in the future by controlled acts. ( dental scaling, root planning, gingival curettage etc)
2. Educational: Involves methods of explaining and educating clients about oral health management, aiding tools and their techniques, learning reinforcements, (E.g. tooth brushing and flossing techniques)

A Dental Hygienist in United States and Canada works in association with a dentist or as an independent oral health clinician.

Carrier opportunities as a Dental Hygienist

1. Clinical practices (independent or in association with a dentist).
2. Manager of oral care programs in hospitals.
3. Research projects.
4. Public health programs.
5. School/daycare health programs.
6. Faculty in dental and dental hygiene schools.
7. Developer in government or private health care agencies.
8. Private dental companies.
9. Army.
10. Educational institutions.

Dental hygienists play an enormous role in helping clients maintain a healthy oral environment. .  They are without a doubt the key success in healthy white teeth and happy bright smiles.

Dental hygiene as a profession continues to change depending on the society demands.

Researches show that 1 in 3 people seek dental hygiene care at least twice a year in North America. This is one of the reasons why the prevalence of dental caries in this population continues to decrease.

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The proper way to brush your teeth should start with setting a sequence that would be easy to remember.  For example  you can divide your mouth in 4 quadrants 1, 2, 3 and 4. If you are left handed the quadrant 1 will be the maxillary left quadrant ( or upper left quadrant), quadrant number 2 would be upper right quadrant, quadrant number 3 right lower quadrant and quadrant number 4 would be the left lower quadrant. The brushing should start from the last posterior tooth of the first quadrant brushing just one surface of the tooth. For ex. the buccal surface ( the surface that is in contact with the checks), then brushing is continued until the last molar of quadrant 2. The next steep will envolve the lingual side of the maxillary teeth. To do so once the after the client finishes brushing the last tooth of the second quadrant immediately follows brushing the lingual side of the last molar in the 2 quadrant continuing until the last molar of the 1 quadrant. Once booth surfaces ( lingual and buccal) are brushed the only surface left is the occlusal surface or the surface of the tooth that contains groves (presend only on posterior teeth “premolars and molars”). The same sequence is applied for the lower mandibular teeth.

Using a sequence helps the you  brush thoroughly avoiding any missing areas during brushing. Sequencing methods are numerous depending on what logical sequence works better for the you.

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Plaque is considered a bacterial biofilm that is organized in colonies creating an independent surviving system that makes it impossible for the immune system to fight and destroy. Plaque consists of different types of microbial flora that interact with each other to create what is called biofilm. Plaque maturation is associated with poor oral hygiene, compromised immune system, and lack of capability to perform oral self care among other things.

Quantity of plaque is the number one factor to determine the aggressiveness of periodontal disease development. There are two different types of microorganisms that populate plaque biofilm: gram negative and gram positive. Gram negative bacteria are significantly found in large numbers at periodontal disease sites. They live in anaerobic ( not needing oxygen ) environment and are proven to be an important factor in periodontitis development. The quantity of gram negative bacteria depends largely on what stage of plaque formation and the location where plaque is accumulated.

Many of you would ask how micro bacterial mouth rinse products can effect reduction of plaque biofilm and how they exactly work? Mouth rinses contain chemical products like phenolic compounds that interfere with bacteria by destroying their membrane layer preventing their metabolic system to develop. Phenolic compounds include oils from plants (eucalyptol menthol) that contain antiseptic properties. These oils are found in almost every mouth rinse product.

Many surveys not only in USA but Europe as well indicate that there are a considerable large number of people that do not use the appropriate oral self care aids to mechanically control plaque leading them to gingivitis or periodontitis, therefore the need for micro bacterial mouth rinses is absolutely necessary to prevent the advancement of periodontal disease. We have to understand that it is not enough to mechanically remove plaque from the tooth surfaces through daily brushing or flossing, but the oral mucosa (especially tongue) as well. Mouth rinses have numerous advantages in maintaining good control of the plaque biofilm. For example some areas that might be missed during regular brushing are not visible, so using a mouthwash rinse will help decrease the possibility of any acid attack that could be caused but the remains of food debris.

Conclusion
Despite these benefits we as dental professionals should keep in mind that clinically speaking there is no existing proves to show that any antimicrobial mouthrinse product is efficient in destroying subgingival bacteria (especially gram negative). This is due to incapability of the rinse to penetrate subgingivally. In conclusion I would like to stress the point made by the Canadian Dental Hygiene Association that we as Dental Hygienists must focus our attention on the information provided with every mouth rinse product and keep ourselves up to date with the information provided by many researches worldwide in order to provide good quality care for the patients.

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Toothbrush History

The first electric toothbrush was created in Switzerland by Berdmann. In United States this toothbrush was introduced in 1960 and was patented by “Broxodent”. Later on the rechargeable version was introduced to the market by “General Electric” company. All these early primitive power toothbrushes were manufactured in small numbers and contained a small motor covered with a plastic case and all toothbrush heads were detachable. At the time there were no consistent proves that indicated any significant efficacy in removing more plaque then the manual brushes, but since 1980’s technology advanced and may companies improved the electric toothbrushes offering the population a variety of models better quality and lower costs.

A variety of studies made since 1980’s until today show that powered toothbrushes are significantly more effective in removing bacterial plaque compared to manual toothbrushes. Except the superiority in removing more dental plaque which is the primary purpose of dental brushes, powered toothbrushes offer a higher rate of acceptance from patients of all group ages. These toothbrushes increase patient’s motivation and compliance by using the 2 minutes timing system incorporated with most of power toothbrushes. This timing system helps clients calculate the necessary time required for brushing.  Recession related to aggressive brushing methods has always been a concern for dental clinicians and still is. Researches show that even though the approved brushing techniques recommended by dental clinicians are specifically recommended to the patient to avoid recession and gingival trauma, patients in most of the cases don’t follow the proper oral care instructions given by the dentist or dental hygienist. Despite the time and effort of th clinicians in stressing the importance of proper tooth brushing most of the clients will continue brushing the same way (horizontally or vertically). This because the old habit of brushing the wrong way takes time to be modified, and that’s why dental clinicians should always include oral care instructions in their planning. In patients with multiple recession areas a clinician might want to reduce the abrasive effect of mechanical brushing by recommending a powered toothbrush. Powered toothbrushes has proven to use (80-190 g/f) less force then manual toothbrushes (over250 g/f). another advantage of electrical toothbrushes is that it helps people that suffer from systemic or non-systemic diseases that cause dexterity problems required to use a manual toothbrush and adapt the proper oral self care methods in removing dental plaque. Caregivers prefer using a powered toothbrush with no toothpaste for people that can not swallow or find it hard to control their reflexes.

-Here’s a summary of the indications for use of a power toothbrush:

1. People with fixed orthodontic appliances (braces)
2. Children with multiple signs of decalcifications.
3. Clients with periodontal problems ( make sure client understands the OSC instructions).
4. Inplant patients are primary candidates for power toothbrush usage.
5. Older adults.
6. Patients with lack of dexterity
7. Clients with gingival recession induced aggressive toothbrushing.

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Mechanical removal of dental plaque through the use of manual toothbrushes and other physiotherapy aids, is the most widely accepted mechanism for plaque control. There are different brushes and different technique that patients can use in maintaining a good oral hygiene.

These toothbrushes are the most common toothbrushes used devices for removing plaque. It can remove plaque from all 5 surfaces of the tooth. Chinese were the first to develop the manual brush in 16^th century and then later it was introduced to the western world where it was developed and improved even more. Today we have a variety of manual toothbrushes and yet there’s not scientific evidence that suggests that one type of manual toothbrush works better then the other. All we hear on TV therefore is just based on commercial purposes. Even ADA ( American Dental Association) states that the proper toothbrush depends on 1- the method of toothbrushing used 2- the position of the teeth and the manipulation skills of the individual. However some characteristics that a toothbrush should meet differs from person to person: size, shape, texture, impervious to moisture, readily cleaned, durable and inexpensive.

The toothbrush bristles are made of nylon filaments which offer most of desired characteristics for a toothbrush. Today most of the toothbrushes are 5-10 tufts long and 2-3 tufts across. Multitufted toothbrushes have 10-12 tufts in 3-4 rows. The multitufted designs allow better delivery of the dentifrice in achieving better results in cleansing. All dental professionals today recommend soft nylon filament toothbrushes because they are less abrasive and less traumatic to the gingival tissue. Soft filament brushes are recommended for sulcular cleaning since researches have shown that they are more flexible and can penetrate better between teeth ( interproximal spaces ). The end of the toothbrush filaments are preferred to be blunt or rounded since to avoid gingival abrasion. Several other factors, besides quality of the bristles can affect the trauma caused by toothbrushing. Hard and worn bristles due to overuse overpressure applied from the user, improper brushing, and the type of the toothpaste used ( can be abrasive and damage the gingival tissue causing recession).

Its best to replace the toothbrush before the bristles become worn or frayed. The average life of a manual toothbrush is 2-3 months. However some dentists suggest that people should change their toothbrush anywhere between 2 weeks to a month because they are sources of pathogens, especially after an oral infection.

Dental clinicians as educators should be influential in helping consumers select the right toothbrush that is best for them. For most clients a soft multitufted toothbrush with rounded-end filaments, wide long handle for a better grasp, and a small enough head to adapt to all areas is the most desirable. If a client perceives benefits from a specific toothbrush then he should stick with it as long as it doesn’t have considerable disadvantages.

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Multiple sclerosis could partially or totally paralyze patients face making it difficult for the dentist or hygienist to work intraorally. One of the most Common oral symptoms in MS patients are teeth, checks, jaw or lips numbness. So you might need to be aware that these signs and symptoms indicate multiple sclerosis not only to identify the early detection of the disease but knowing that the patient has oral symptoms will help you identify the proper treatment planning and proper human needs of the patient. Some MS patients can experience difficulties swallowing, decreased amount of saliva or difficulties of proper use of the tongue. In these conditions its harder for the patient to maintain a good oral hygiene therefore the patients will be at high risk for tooth decay and periodontal disease.

Brushing and flossing

The primary concern that arises in multiple sclerosis patients is the loss of muscle control. This condition can limit the ability to brush and floss using appropriately oral self care tools. In cases where the patient can at least manage to brush easy certain areas of teeth but have difficulties brushing for example posterior teeth, modified brushes or stick floss helpers might be considered ( this depends on the actual muscles that are effected). Every little effort from patients side should be encouraged no matter how little they are. Sometimes patients with severe MS symptoms can require other people assistance to manage oral hygiene care due to lack of adequate muscle control. In this case the caregiver should be motivated to work with the patient, see possible ways that can help the patient become independent and discuss them with the dental hygienist or dentist to find the best possible methods that will help patient maintain a good oral hygiene independently or with less possible help from the caregiver. It is important to emphasize that the most common problems that dental professionals might have to deal with when treating MS patients with severe MS symptoms are: halitosis periodontal disease ( typical problems that are usually associated with poor oral hygiene).

Helping devices during dental treatment

It could be hard for the patient to open his mouth for extended periods of time. Controlling patients tongue movements and swallowing could also be a problem. You may use a rubber bite block or a mouth prop in to keep patients mouth open during treatment to avoid any possible tissue trauma. Your can also use a tongue retractor to keep patients tongue steady. A thin piece of rubber or a rubber dam could be so that the patient won’t inhale foreign substances while being treated.

Sedatives

If we use sedative methods like LA , the client may have worse control of the muscles. Make sure you reveal the proper information regarding the medication that the patient is taking so it wont interfere with the sedative injection. You might want to consider patients physician for more information.

Dentures

With time multiple sclerosis might get worse and effect that category of MS patients that wear different types of dental prosthetic aids like full or partial dentures. Muscle spasticity makes it almost impossible the wearing of dentures and the more severe these episodes are the more likely is the patient to hurt him self or even worse swallow them due to lack of muscle control. In fact people that are known to suffer from MS shouldn’t be prescribed or recommended for removable dentures. There are many other possible solutions to avoid all these problems by installing mandibulary or maxillary implants that can support the denture and decrease the accidental risks of dislodging the denture while MS symptoms occur.

Appointment time

You should keep the length of your dental visits at a comfortable length of time because you must avoid as much stress and fatigue as possible for the patient. In general MS clients have a hard time sitting in the dental chair during lengthy appointment and its advised that the dental professional needs to allow multiple brakes of 5 to 10 minutes every half our treatment. When we deal with paralyzed patients that are not able to move upper or lower limbs the situation becomes more complicated. Try to change their position during the appointment to minimize stress. The treatment will require more time due to possible lack of dexterity that affects clients oral hygiene directly and possible muscle soreness since the client is immobile during the appointment time. To reduce patients discomfort its recommended to set up the dental chair with pads. In this way pads will avoid pressure sores and will make the patient feel more comfortable during the appointment. Remember that for these category of patients its best to schedule the appointments early in the morning because it is less stressful for the patient. Also use extra caution in accommodating the patient in the dental. Use specific procedures designed to transfer patients that are on wheel chair. If heavy require the help of a second clinician.

You might want to discuss these issues with the patient.

1. Possible ways that will help the patient maintain a normal oral function and and an acceptable oral hygiene.
2. Possible ways that will make patient increase oral hygiene care (OSC) and be independent in performing them.
3. How to improve self appearance that will maintain a high level of self-esteem and will make him feel “included” in the society

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OH Lesson Plan
Audience : Grade 3-5 students
Time : 40 min
Goal : To make students understand the importance of brushing and flossing, as well as basic education about teeth function and healthy food choices.
Objective :
Upon completing this session students will better understand:

1-The function of teeth and how many sets of teeth people have.
2-Why is it important to have healthy teeth.
3-What plaque and cavity are.
4-How to brush and floss properly
5-Why eating nutritious food is important.

Content
The importance of teeth as a part of our life
The difference between baby and permanent teeth
The dental plaque process
How to take care of our teeth
Nutrition as an important factor in maintaining good O-Hygiene

Visual aids
Tooth brushing and flossing (animated).
What is dental plaque (animated).
Dental floss and brushes.

Supporting materials
Sir flossmore’s hygiene quiz.
Sir flossmore’s hygiene certificate.
How to brush (charts )
Old and new toothbrushes.

Introduction
Hello, my name is Angela . I am a dental hygienist student.
Today we are going to talk about a very important art of our bodies- our teeth.
-First I would like to know if any of you knows why do we need teeth? (discuss children’s suggestions which may include talking eating smiling etc)

Eating
-Ok, so we need teeth to eat, very well. We need our teeth to chew our food in little pieces. This keeps us choking or getting a stomach ache.
Eating is easier and more fun. Can you imagine settling down to watch your favorite T. V. show with a big bowl of popcorn and not having teeth to chew with? Or having a big, juicy, red apple but no teeth?

Talking
-How about talking?
Is it easy to talk without using our teeth?? Lets try it. Say : “thirty three” without letting your tongue touching your teeth. That was very hard wasn’t it? So our teeth help us chew the food, and also help us talking to each other properly. What else ?

-Smiling!?
We have a nicer smile if we have our teeth .You make other people happy and feel happy yourself when you can give them a big bright smile. (Ask children to smile at each other.)
Think about not having your teeth. ( take one kid and paint some of his teeth with a black eatable pencil.) (Children will laugh).
So now we know that our teeth are very important because, they help us talk properly chew our food and give us beautiful smiles.

Explain teeth
-Lets talk about our teeth. Who knows how to describe our teeth? Are they hard or soft? Are they rounded or sharp? Are they strong or they brake easy?? (Discuss the answers)
So our teeth are white, hard, sharp and strong to help us chew the food smile, and talk.

Teeth # Permanent vs baby teeth
Now i have a hard question. How many teeth babies have? Let’s see the picture and count together.
So when we are babies we have 20 teeth. Will you have these teeth forever? [NO]
What happens to your teeth when you get to be 5-6 years old? Yes your other teeth start to come out.  These teeth are bigger in size (show the difference of primary and permanent dentition with pictures) and they are called permanent teeth because they stay for life in our mouth.
By the age of 18 everyone of you will have 32 permanent teeth. It is very important to understand that this teeth are the only teeth we have and if we brake  one of these permanent teeth, we cant have a beautiful smile anymore, we cant talk and we cant eat properly.

How to take Care of teeth (Demo)

-That’s why we need to take care of our teeth. (Ask the class)  How do we take care of our teeth?
[Brushing and flossing]. Before I show you what are the proper ways to floss and brush I will play a video for you so you can understand what happens in your mouth after we eat a meal.
-Plaque is bad for your teeth because it contains germs that are very harmful for our teeth.
The plaque can hurt our teeth making little holes that are called cavity.
What do you thing happens if we take a strong tooth and put a hole in it. It wont be stronger anymore right? Plaque and cavities make our teeth weaker.
Now we know how important is to keep our teeth cleaned, we should brush and floss twice a day.
Another way to avoid plaque and bacteria to damage our teeth is eating healthy foods.

Tooth brushing and flossing
Now im gone show you another video (Play a video from Youtube)

-So brushing and flossing helps us fight the bacteria that is caused by the food that we eat.
How many of you brush your teeth? Great. How many times a day should we brush our teeth? [twice].
How long should we brush our teeth for? [3 min]
-What do you put on your brush before you start brushing? [toothpaste]. Why do we need to use toothpaste? [cleans better then just water, gets the food off your teeth, makes your teeth stronger, makes your mouth smell good].
-Does any of you know how much toothpaste we should use? [listen to a few suggestions] you might be surprised but you only need a little bit of toothpaste- about the size of a little green pea. [Demonstrate how putting toothpaste on the brush and show it to everyone].
-When you are brushing your teeth with toothpaste we shouldn’t swallow because we are just cleaning our teeth not our stomach.

Nutrition
Like vegetables and fruits for breakfast lunch and dinner. For example if you are hungry and you feel like eating a snack, choose fruits or yogurt and cheese, if you are thirsty choose water or milk. Because all these foods help protecting you teeth. Don’t  eat to much sugary foods like candies o sodas. If you want to eat some sweets try to eat them with your meals.
In the end give them a quiz and a certificate from Sir Flossingmore
Or play more videos about brushing and flossing .

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