Oral Infection Control: Toothbrushing Essentials

Hi, in this chapter we are going to review oral infection control and we're going to focus on toothbrushes and toothbrushing. So the learning objectives for chapter 26 in your Wilkins is to be able to identify the characteristics of an effective toothbrush, to be able to differentiate between the different manual toothbrushing methods, including limitations and benefits of each, to describe the different motions of action for powered toothbrushes, to identify the basis for power toothbrush selection, to describe tongue cleaning and its effects on reducing dental biofilm, and to also identify the negative effects of improper toothbrushing can have on our hard and soft tissue. So first of all, I think it's important to kind of look back at history and find out where this all began. So before we even had toothbrushes, we found evidence of something called chew sticks in the early 3500s, and that was B.C. The chew stick was considered to be a primitive toothbrush. And we know it exists because we see it appearing in Chinese literature around 1600 BC. Care of the mouth during this period was mostly associated with religious trainings and rituals. So not really done by all. And the two sticks were made from various types of wood by crushing the end of a twig or a root and spreading the fibers. to kind of fan them out and be more like a brush. So from there we see that the first toothbrush made was made of hog hair or horse hair and is believed that this came about in about 1000 AD. So after that, for the longest time this hog hair or horse hair was something that was used to take care of teeth. And then we have this man, Pierre Fitchard, who came along in 1728. And he said, no, we're not going to be able to use these toothbrushes made of horse hair or hog hair, because it's just too rough and destructive to the teeth. And so he advised instead of doing that. We really should be using something different. And so he thought using sponges and herb roots would be a better choice. And he developed instruments for scaling and splints. So the first patent on a toothbrush was not actually until the middle of the 19th century. And this is when... toothbrushes started to be constructed of gold, of ivory, and ebony. And so, you know, when you think about that, back at that time, that was very expensive. So not a lot of people got to take advantage of using these toothbrushes. So then we jump forward to 1919. And um, we're getting a little more specifications on what toothbrushes should be and what they should be like. And so that was in 1919 and the AAP started to develop these different specifications for toothbrushes. And then in 1938 introduced was our synthetic materials. So we started using nylon bristles instead of the. bristles that were made from things in nature. So I think that's kind of an interesting little historical background on toothbrushes and how they started. So we're going to talk mainly about the characteristics of an effective manual toothbrush, and then we're going to talk about the different methods that we can recommend to our patients based on their needs. So what kind of characteristics are we looking for in a toothbrush? We are looking for something that conforms to the individual patient requirements in size, shape, and texture. So everyone's going to need a different size of toothbrush depending on the size of their hand, shape of a toothbrush, and then we're looking at the texture of that toothbrush. And then we want to get something that's easily and efficiently manipulated. So easily able to move around and be able to complete the job that needs done. They have to be easily cleaned and impervious to moisture. They've got to be durable and inexpensive. We want them to have soft bristles. We want their end filaments to be rounded. and we want them to be designed for utility, efficiency, and cleanliness. And if you think about a manual toothbrush and you think about what expectations you have for an electric toothbrush, they probably align right there with what you would want to purchase. So here we're looking at a toothbrush. So you probably never thought that you look at and label the parts of a toothbrush. but that is what we are going to do. And then we're going to discuss each part. So we have the head of the toothbrush, which contains the bristles. And then we have the shank of the toothbrush, which connects the head of the toothbrush to the handle. We then have the toe of the toothbrush, which is the very end, farthest away from the handle. And then we have the bottom of the bristles, and that is considered our heel. When we look across the filaments, that is considered our brushing plane. If we look at the toothbrush head on and take kind of a bird's eye view of it, we can see that our bristles are arranged in what we call tufts. Okay. And so each little section of tufts will have our nylon bristles. And depending on the manufacturer and the way they design the toothbrush, usually you'll have about three. rows of bristles, and you'll have about five to 12 maybe lines or columns of these tufts of bristles. So let's talk about the composition of the toothbrush. So most often, a single type is made of a plastic, okay, or it's made of a polymer. And the properties we want it to have is we want it to be. durable. We want to be easy to clean. We want it to look nice, right? If it's sitting in our bathroom, we don't want it to be expensive. This is something we throw away and we want to be able to maneuver it. The shape of the brush, the preferred characteristics are that we want it to be very easy to grasp and we don't want it to slip or rotate when we're trying to use it. We don't want to have any sharp corners or projections coming from the toothbrush and we want it to be fairly... lightweight. Now, when we also look at the handle, we might see different variations depending on the manufacturer. Sometimes we'll see a twist or a curve, or we'll see it offset, or we might see an angle in the shank with or without somewhere to rest our thumbs. And that can actually help patients who have areas that are very difficult to reach. So we might want a handle that has the rubber. back the rubber coating on it. We might want a handle where the shank bends and we have a little bit of an angle because that might help us be able to maneuver it better. A handle of longer diameter may be useful for patients with limited dexterities. So if we have a patient who has a lot of trouble maneuvering a handle, we might want something either wider or longer. But then if we have someone such as a child with a smaller hand will want that handle to probably be shorter. Now then we look at the brush head. So there are different designs of brush heads. Like I said, the length of it may be 5 to 12 tufts long and 3 to 4 rows wide. The size and the shape is going to vary. So there are a lot of different shapes and sizes that are available. The brushing plane also may vary. And we're going to look at some lateral profiles of brushing planes. When we are selecting a toothbrush, we might want something that's black. We might want something that has more of a ripple design. We might want something that has more tapered filaments. We might want something multi-leveled for our patients. We might want something angled with bristles going in each direction. Or we might want something more bi-level. that we would use for an orthodontic patient. So as far as which is the best for patients, research has been pretty inconsistent on saying which actually design removes the most biofilm. But some suggest that angling the tufts make it easier to remove the plaque than a flat trim toothbrush. However, some studies have still failed to show that conclusively. So it really has to do a lot with patient preference when we look at bristles, but also what you're seeing as a result of what they're using at home. So if you're seeing poor oral hygiene with moderate biofilm and our patient is using a flat brush, you might recommend them use something more multi-leveled or tapered or rippled or angled to see if those bristles will benefit them. and their biofilm will reduce. So when we look at the bristles themselves, we know that most bristles have nylon filaments, okay? And many manufacturers of synthetic filaments refer to filaments as bristles, okay? And what we need to be aware is that synthetic filaments are actually the bristles. So, um... When we look at the bristles, the important thing that we want to look at is the stiffness of those bristles. So that stiffness is really going to depend on the diameter of the bristle and the length of the filament. So brushes in the store when we buy them are usually designated as soft, medium, or hard. But know that between you manufacturers, there might be differences just because of the way they construct. their filaments. So it's really important that we look for a softer bristle toothbrush, so that way our patients are avoiding doing any damage to their tissue or to their teeth. And in some cases, we might even recommend the sensitive bristles or extra soft bristles, so that they can clean more interproximally or clean more. into like the receded areas of their, of their mouth. So you typically, we're going to recommend either a soft or a sensitive, which is an extra soft toothbrush. I think I covered everything from that other slide. Yes, I did. Okay. So the next thing we're going to go over is influencing factors. So how do we help, um, select a toothbrush for our patients? Well, there are a lot of influencing factors that we have to keep in mind. First of all, we have to look at our patient. We have to figure out what the ability of the patient is to use the brush and remove the dental biofilm from their tooth without damaging the structure. We've got to look at the manual dexterity of the patient. And we really need to look at the age of the patients and the difference is in their dentition. Because if they only have primary teeth, or they only have mixed dentition or they have all their adult dentition, that's going to definitely make a difference in the type of toothbrush that we're selecting for our patients. Next, we're going to look at the gingiva. So that is the tissue that surrounds their teeth. We want to look at the status of their gingival and periodontal health and the anatomic configurations of their gingiva. So if someone has recession, open embrasure spaces, We are probably going to pick something that has more of those multi-tufted or multi-height in their bristles rather than pick something that's more flat across. Positioning of the teeth. That's another thing that helps us decide what toothbrush. Are our patients'teeth crowded? Do they have open contacts between their teeth? Okay. Do they have, what size is their mouth? Do they have a large mouth? or do they have a small amount? And we have to look at compliance. What does the patient actually prefer? Because that is going to impact a lot of which toothbrush we're going to recommend. If our patient wants to use a particular toothbrush and that's all they'll use, we kind of have to work with that. So the patient might have preferences and they might be resistant to change. Patients sometimes lack motivation. ability, or the willingness to follow a prescribed procedure. So other things we need to look at is patient affordability, especially when we're looking at options such as electric toothbrushes. There are battery-operated electric toothbrushes, which are a little more affordable than the electric toothbrush that we plug in and recharge. But patient affordability is going to be a big factor. Let's look at timer options. So if we're looking at an electric toothbrush, does our patient, would they benefit from a timer? Something on their toothbrush that tells them when to finish each quadrant of their mouth or when to finish brushing. Also, again, our filament or bristle selection and then our brush head selection. So a lot of things with it need to come into place just to pick the actual toothbrush that we want our patients to be brushing with. So the next thing we have to do is talk about the guidelines of manual tooth brushing. Before we even get into. what different types of toothbrushing are. So the guidelines for brushing would be like, how do we teach our patients how to grasp a toothbrush? And has anyone ever told you how to hold a toothbrush? So the ability to be able to brush means to successfully hold that toothbrush and be able to remove biofilm. We need to make sure that the patient has a light but controlled grasp, because if they do, then they are going to be more effective. They're going to be able to position it better and they're going to be able to apply the correct amount of pressure to remove the deposit that's in their mouth. So here's our procedure when we're teaching our patients how to use it to grasp a toothbrush. So they're going to grasp the toothbrush handle in the palm of their hand with the thumb against the shank, okay? So there's no name to this. this grasp, okay, like there is to instrumentation. But we want our patients to have a palm grasp, and we want our patients to use their thumb on the actual shank. That is going, grasping the head, the brush near the head will help them be able to control the head a lot better than if they're grasping that brush down at the end of the handle. But they, of course, don't want to grasp so close to the head. that manipulation of the brush is difficult because the fingers are in the way. And then we want them to be able to position it according to the brushing method we select. We want them to be able to adapt the grasp from various positions of the brush head and the teeth throughout the procedure. So we might need to adjust their arm or their hand or their grasp as we're going into different areas, such as the lingual of the mandibular. um, molars or the mandibular anteriors. We might have to hold it differently and maneuver it differently. And we need to teach them to apply that appropriate pressure for removal of the dental biofilm. We don't want to put so much pressure that the bristles of the brush are bending. And then we're, we're going through a toothbrush every couple of weeks because all of our bristles are distorted. Okay. Once the bristles become distorted. they are no longer effective. So then we need to talk to our patient after we teach them how to hold a toothbrush. We need to talk to them about a brushing sequence. So it's really important that when we're trying to get a brushing sequence established, that our patients tell us or let us know if they're right hand or left hand dominant, because that's going to have a lot to do with where they start brushing. Right-handed brushers are going to start on their upper left side. Most left-handed brushers are going to start on their upper right side. Okay, so we usually start off on the opposite. Now, mind you, when we first start off brushing, it's usually when we are starting the most aggressive. So that is a lot of times where we first see damaging effects of recession and abrasion to teeth when patients start over brushing. So sometimes making alterations in that sequence can really help give that area that's might have been overbrushed a break. But the brushing process should definitely be something that is ritual and that the patient establishes so they do not forget an area to brush. So usually what we'll recommend is divide the mouth into sextants or quadrants. And to start brushing from the molar region of one arch around to the midline of the facial and then the lingual, followed by brushing the occlusal surfaces. And then go ahead and repeat it in the opposite arch. Each brush placement should overlap the previous one to avoid missing spots. All right. So approaches to address areas where patients might be having difficulty. Usually people have difficulty right around the canine area because that's where they kind of change directions from going from the posterior to the anterior. So sometimes that first premolar canine area is an area that's often missed when brushing. So it's really important to give a little extra attention to those areas. The next thing we need to talk to our patients about is the duration of brushing. So how long they're going to be brushing. So there's a lot of different recommendations you can give to your patients so that they brush the adequate amount of time. So two minutes is the recommended brushing time length. Okay. So we can do that by telling our patients to count to 30. for every quadrant they brush, right? And so by the time they're done, they will have hit their two minutes. We can also have them set a timer, set them, set a timer for two minutes, tell them to spend one minute on the maxillary and one minute on the mandibular. Sometimes I have told patients to sing happy birthday, especially when I'm talking to kids. Sometimes I have told them it's as long as a commercial break. If they brush their teeth and like to watch TV. Or I will tell them if they're listening to the radio and brushing their teeth to brush them as long as one song on the radio. So just trying to get them to set some kind of goal so that they're brushing long enough. Because one of the problems we run into is patients usually don't usually spend as much time as they should brushing. The next thing we need to address is the frequency of brushing. How many times a day are they brushing? So we recommend that our patients brush at least two times a day. And there are certain circumstances where we might ask for more, such as patients who have orthodontics. But typically, for most patients, two times a day is sufficient. So we recommend those brushing times happen in the morning and at night, with nighttime being the one I usually put the most emphasis on. So usually everything that we've eaten all day is sitting on our teeth. And we want to get that off before we go to bed at night. When we go to bed at night, we don't have our natural cleansing mechanisms at work. We're not eating. We're not talking. We're not doing anything to get anything moving in our mouth. So bacteria is just sitting there undisturbed and it has a dark, quiet, moist place to grow. So we definitely want to get that nighttime brushing in and then also brush in the morning. And of course, we want to do interdental care, which we'll get into more in Chapter 27. So toothbrushing force and pressure. So again, that's another thing that we have to address with our patients. We don't want them putting too much pressure or force on their teeth because that pressure or force has no benefit and actually can harm the tissue and can harm the teeth. Okay, so we definitely do not need them putting force and pressure onto brushing. The next thing we go over is our general tooth brushing instruction. We really have to make time in our visits to sit down and talk to our patients about what we recommend. So before we do that though, we have to prepare. We have to gather information about what our patient currently does as far as oral hygiene. And we're talking about tooth brushing. So we want to know what kind of tooth brushing are they using? How are they doing it? And then we want to take that information and we want to look at their oral cavity and decide, are they using the right method for them? Or can we take what they're using and make some adaptions so that they can have better results? So Research actually suggests that the most effective teaching strategies for patient education include the use of a computer or the use of a videotape or the use of demonstrations or written material. So I'm asking you, when you do your oral hygiene instructions for your patients, to make sure that you are doing a demonstration for them, maybe on your typodont. with a toothbrush and then having them do it, or that you are giving them something written that says, this is what we talked about today. And this is what I want you to do. or maybe you're playing some kind of a video and you put together some kind of a presentation that you're going to pull up chair side on your computer and you're going to go through what is biofilm? What is calculus? How can we get it off? Why do we want to get it off, right? And then you can give them recommendations. That usually is how the patient really starts. understand our concepts. If we just sit down and talk to them, sometimes they just don't grasp it. So using visuals and making our presentations interactives are going to give us much better results. So verbal instructions alone have only a small effect on our patient outcomes. And we definitely always want our patients to come back in better shape than they left in. So demonstrations had the largest effect on patient outcomes and are an essential component of patient education. So demonstrations are huge. So having them demonstrate and you demonstrate, maybe it's on a model, maybe it's in their mouth, multiple educational strategies. So when you combine things and maybe use the computer and do a demonstration. then you're going to get even better outcomes. So when initially introducing a new self-aid, it is very important to have a demonstration model or to have a video around so that you can show your patient the product and how to use it. One other thing I like to do with my patients, especially if I'm recommending a new product or a new toothbrushing method is, or a new toothbrush, is to show them a picture of the actual toothbrush I'm recommending. Okay. So actually show them the Crest Oral-B toothbrush that I want them to use. Maybe I'll even do some research and find out where you can find it. Okay. You know, I found it on Amazon for $3.50 or I found it at Walmart for $2. Patients really appreciate... You taking and going that extra mile and not only telling them what to use, but giving them actual manufacturer names, showing them what it looks like, and then telling them an approximate cost. Okay. And where they can find it. So a lot of times, you know, we recommend things and then our patients come back and they're like, I was not even ever to be able to find that. What did you recommend again? So they don't even remember. So those kinds of things are really. helpful. Another thing that's really useful during our patient instructions is to utilize the disclosing solution in our patient's mouth. So what we can do with the disclosing solution is paint it on their teeth, have them swish, and then have them look in the mirror and show them the areas. It makes a great visual for where they're missing brushing. Okay. And then have them or show them an area where you're using the correct technique and now the area is clean. So these types of methods and these types of visuals incorporated into our patient education conversations are really helpful and definitely effective. So we're going to talk about several different methods for manual tooth brushing. We have a bass or modified bass. We have a stillman and modified stillman. We have a roll or rolling stroke method. We have a charters method. We have a phones method. We have a Leonard method and we have a scrub method. We're going to talk about all of these in the next few videos. And I actually even, or in the next. few slides and I actually did incorporate a few videos so I could show you the actual technique in the video and you can go back to these and click on these and of course you're always welcome to use them if you design a presentation and want to incorporate something that I have in here so I might have to do a little like clicking back and forth just so that you're seeing everything you need to see on the screen. So the first method we're going to go over is called the BAS or the modified BAS method. I would probably put a star on this one. This is a method that is very often recommended to our patients. So it's pretty popular. It's accepted as a method for dental biofilm removal adjunct to and directly beneath the gingival margin or sulcular area. So we often call this a sulcular. toothbrushing technique. It is considered that sulcular brushing. The areas of the gingival margin and the coal are the most significant areas of gingival infection and periodontal disease, and we get those clean with this method. So what are the purposes and indications of this method? Well, to remove the dental biofilm adjunct to and directly beneath the gingival margin, To clean any open embrasures, which you know are open spaces, around the cervical areas of teeth, beneath the height of the contour of the enamel. And it also does a great job cleaning around our root surfaces. Adaptation to abutment teeth or implants and under the gingival border of a fixed partial denture. So this is a great method, especially for patients who have extensive dental work, right? Have crowns, have bridges, have implants. This is a really great method. method. So what is the procedure? So I'm going to kind of talk you through it, and then I'm going to play the video after I get through the limitations. So you're going to direct the filaments apically. So up for the maxillary and down for the mandibular. And we see that in A here. And then in B, we see the filaments actually sliding underneath the tissue. So we kind of have it at an angle. It's at a 45 degree angle to the tooth. Okay. From that position, we are going to turn the, from this position, we're going to turn it into the tooth. So now we have that 45 degree angle and direct the filament tips into the sulcus. We're then going to press lightly so the filaments enter the gingival sulcus and cover the gingival margin. We don't want to bend the filaments with excess pressure. We are then going to vibrate the brush back and forth with very, very short strokes. without disengaging the tips of the filament. So we're kind of, it's kind of more of a massaging. We count to 10 with those vibrations in each section of the mouth that we do. In the modified bass, so that's the bass method. In the modified bass, the vibratory motions are then followed by a rolling down of the toothbrush over the crown of the tooth to clean the rest of the surface. Then we reposition the brush to the next few teeth. And we're usually focusing on just about two or three teeth at a time. And we're repeating this all the way around the mouth and then going down to the lower. And we're repeating it down on the lower. We're making sure that we do the buccal surfaces and all the lingual surfaces. So the limitations of this brush, the biggest limitation is that someone who is a very aggressive person. Toothbrusher needs to be aware that they're going to have to do very short strokes and eliminate any kind of scrubbing pattern because these bristles are going to be underneath that tissue and they can definitely do a lot of damage. The other thing we have to make sure of is that our patient has pretty good dexterity because making these vibratory strokes is going to be a challenge if our patient is compromised with their dexterity. So I'm going to go ahead and... I think I have to stop sharing and then reshare to get you guys to see the video. So I'm going to go ahead and stop sharing for a second. I am going to pull up my video. All right, it's going to take me longer than I thought. Sorry, guys. Hopefully you can just fast forward towards me. for me doing this. I think when the next time I just won't give in. Oh, this really doesn't want to do it. Yeah, just keeps coming up some other stuff, guys. Okay. I am just going to go find it. I hope I pull up the same video that I put in. Almost there. Sorry guys. Got something. All right. This is not, this is not the right video though. Okay. Maybe if I, okay. I figured it out now. Technology is super fun. It will be better than expert. All right. All right. I should be sharing now. So here we go with our modified bath. and in case you want to go shopping. So when you saw that herp, then brush that, sweep that biofilm away, that's when it becomes modified. So if we stay with just those vibratory motions and we don't add that swipe away, then we just have the bass. Okay. So here we are with the bass and then we make it modified. Since this guy has a flip top head, I really wonder why they can't open his mouth more. But they're not. But I hope this gives you the idea of how that brushing method. And then this is actually occlusal brushing. So this is separate, but they're showing you occlusal brushing right here. So that's just brushing, you know, back and forth that occlusal surface. So they're actually doing a modified bass. They're showing you the bass and they're also showing you that occlusal brushing. So I do want you guys to see the lower, especially the lower anterior. Okay. So hopefully you guys get the idea of that tooth brushing technique. So now I'm going to go back to my presentation. I almost think if I stay in this view, I hope this doesn't mess you guys up, that I might be better off when I go to, when I go to the video for the next one. So I'm going to kind of stay in this view. I hope that's okay. All right, so that is the bass and the modified bass method. So next thing we're going to talk about is the Stillmans and the modified Stillman method. This is another method that is very... very recommended. So we definitely use this a lot. So this is also considered another circular brushing technique along with the modified bass. Um, what are its purposes and indications? Well, this method is for massage and stimulation, as well as cleaning the cervical areas. The modified Stillman method adds a rolling stroke to the vibratory stroke to clean the crowns of the teeth. So dental biofilm removal is effective from the cervical area below the height contour of the crown and from exposed proximal surfaces. The general application for cleaning two surfaces and massaging the gingiva. This is probably one of the most recommended or prescribed toothbrushing methods. This is good for the general public. When they have a lot of dental work, then I will go to the bass or the modified bass. If they don't, you know, I just have some occlusals or maybe some MODs or things like that, composite restorations, then I will stick with this modified Stillman's. And I do always add in the modified. I don't usually just recommend the Stillman without the modified and the same with the modified bass. Okay, so what is the procedure of this tooth brushing method? We're going to place the side of the brush on the attached gingiva. So just kind of flat, exactly like what it's showing here, the facial. And then the filaments are directed apically for the maxillary. That would be up. And then for the mandibular, that's going to be down. And when the plastic portion of the brush head is level with the occlusal plane, generally the brush is at the proper height. Okay. So if you see the occlusal plane here in A, you can see where the plastic is. Okay. And that's how we're going to. place the toothbrush. The strokes. So we take and press to flex the filaments. The sides of the filaments are pressed lightly against the gingiva and blanching of the tissue occurs. So it does blanch slightly. We angle the filaments, turn the handle by rotating the wrist. So the filaments are directed at an angle with approximately 45 degrees. Okay. We activate the brush and use a rotating motion. maintaining light pressure on the tooth surface. We count to 10 slowly and vibrate that and then rotate the handle. So roll and vibrate the brush, turn the wrist and work the vibrating brush slowly down over the gingiva and the tooth. So then we will repeat that as we go on to the next section of teeth. And usually we are just concentrating on about two or three teeth at a time. Now one of the differences between this method and the modified bath is the anterior portion. When we get to the anterior, we will position the brush somewhat vertically using the toe of the brush for the anterior lingual area and then we will press and vibrate and roll and repeat. Okay, so what kind of limitations are there for the Stillman's or modified Stillman method? We have to have careful placement of a brush with the round and rounded filaments to prevent any tissue laceration. We have to make sure that our patient or our patient understands they need to have light pressure because the patient might try to move the brush into the rolling stroke too quickly. And that can be pretty ineffective and it really won't get as much biofilm off as we want them to. So let's see here if I figured it out. If I'm in this view, it won't even let me click it. Okay. But I think what I can do is say link. I do have to stop sharing again and reshare, but I'm there quicker. Stop share. And now share. Here we go. Hi there, my name is Nicole. Today in this oral hygiene instruction video, we will go over two brushing methods. First is the Stillman's brushing method. Stillman's brushing method was designed for massage and stimulation as well as cleaning the cervical areas of the teeth. We will position our toothbrush on the tissues directly and angle the toothbrush filaments slightly apical or going towards the root of the teeth. Now a slight... Circular movement is done several times while applying light pressure, just enough to show the tissues to turn white. So that's the blanching of the tissue that she's referring to. After several movements, the overlap moves to the next area, still doing circular motions using light pressure. The linguals are done the same. We angle the toothbrush, we apply the light pressure, and do the small circular movements. For the anteriors, we angle the toothbrush, do small circular movements, massaging the tissue, and we continue to overlap when we move to the next area. The second technique is the modified stillman method. In this method only a small modification is added which is the roll method. We again place the brush at a 45 degree angle directly on the gingival tissue and make small circular movements. But now we'll roll the toothbrush down to the crown of the tooth. This will be especially helpful for patients with gingival recession to achieve adequate gingival stimulation as well as maximum cleanliness. Don't forget to overlap and clean all surfaces of your mouth. Anteriors, we again use angulation to fit into the area and roll up on the mandible. Maxilla, we angle it to fit and roll up using the heel. The only thing that I would almost tell you about this method that I would kind of change. and that is the linguals of the mandibular anteriors and the maxillary anteriors. You see her using more of the heel, and you see all this bristle across her whole palate. For some patients, they won't be able to handle that because it could stimulate the gag reflex. So you may actually be more here towards the front third of the toothbrush, towards the toe third of the toothbrush, and using that portion. to do your vibrations and then pulling that up in a way. So I just wanted to add that in. Okay so that is it for that one. So I am going to go ahead and stop sharing and go back to screen one. Okay. And now we, no, we're not back to our screen sharing. I don't know what I'm screen sharing now. I'm sorry, guys. Okay, now we're back. Okay, I don't know what it was sharing. Maybe it was just fine, but it looked weird to me. All right, so that is a Stillman and modified Stillman. So hopefully you guys understand. the difference between those. So we're going to go on and talk about a few more. The next one is we're going to talk about is the roll or the rolling stroke method and the purposes and indications for this. This does remove biofilm, material, alba, and food debris from teeth without emphasizing the gingival sulcus. So we're really just focusing more on the teeth. This is usually used in conjunction with the Bass method and the Stillman's method. So if you think about what this is called, the roller rolling stroke method, remember how we had the bass method and then we added in the modified part. So that's the rolling. OK, so now this technique is just the rolling. All right. This can be really helpful when there's a question about the patient's ability to master and practice a more complex method. So if our patients can't do those modified bass or those modified Stillman. methods just because of limited dexterity or other reasons, then this in and of itself can be a toothbrushing method that we would recommend. So how would we do this? Well, we would direct the filaments apically. We would place the side of parallel and against the gingiva. And that, and we would get that plastic height, right? But instead of doing those vibratory strokes into the sulcus, we are just going to roll the brush slowly over the teeth. And as the brush is rolled, the wrist is turned slightly and the filaments remain slightly flexed and follow the contour of the tooth. Then we go on to the next area and we do the same, all right? So the limitations I'm sure you can kind of guess are that we're not going to get much interproximal or insulfate cleaning. The brushing is going is can sometimes the brush will be placed too high and that can hit the alveolar mucosa and the alveolar mucosa you remember that's that movable tissue and that can be easily abraded. Also, patients tend to do this very quickly. And so effective biofilm removal can sometimes be not that effective. So I'm going to go ahead and play our video on the rolling stroke method. Stop sharing. And then I'm going to start sharing. And here we have the rolling method. Okay, so that... is that. So I will stop sharing and then again I will reshare. Okay. All right. So that is our rolling or the roll or the rolling stroke method. So now let's go on to our charters method. So our charters method is um is the method that is going to be helpful in teaching, can be helpful in teaching children proper home care and was used to be something that was recommended in that regard. The purpose is to loosen debris and dental biofilm to stimulate the marginal and interdental gingiva, aid in biofilm removal from proximal surfaces, and remove dental biofilm from abutment teeth and under the gingival border of a fixed partial or denture. So again, it can be helpful also with some dental work. The biggest difference, and I like this picture right here that I put on this page because it shows a comparison of two different toothbrushes. So we talked about the modified bass technique, right? We were We're going at a 45 degree angle to the sulcus. So basically when we look at the Charter's method, it's the opposite. So now we're taking and we're angling down into the tooth instead of up at the tissue. Okay, so we're starting with a different direction of our filaments. All right, so that is going to help you hopefully understand the difference between the Stillman and the Bass, which is more like this. And then of course the, um, the charters being more like this. All right. So the bristles are gently pushed between the teeth, um, being careful not to injure the gingiva with the bristles between the teeth. We use as little pressure as possible and make three or four small rotary movements with the bristles. The side of the bristles should come in contact with the gingiva to massage them. And we remove the bristles from the interproximal area. and then place it into the next. And then we repeat that every two to three teeth. So what are the limitations? Well, I think that one thing you're probably seeing is that we're not directing the filaments underneath the gingival sulcus. So we're not getting a lot of sulcular cleaning done. Okay. In some areas, correct placement of a brush in this manner can be difficult. All right, so let's go ahead and we'll play the charters method. So this is, like I said, something that used to be recommended a lot for children. a huge fan of recommending it for children, but it is something that your textbooks recommend as one of the methods that can be. Stop sharing. I don't think you guys are seeing it. Okay. Now you should be. The Charter Seek Neat is mainly used by ortho patients. It is used to clean around the brackets and to remove plaque under abutment teeth of a fixed bridge. So patients with a bridge can also use this method to reach under the contact of a bridge. Brushing directly over the surface of the teeth will not work for an ortho patient because the bristles will not reach the edges of the bracket, leaving areas unclean. Contraindication for Charter's method is that you can get subgingival cleaning. For the Charter's technique, the bristles are placed at a 45 degree angle toward the occlusal or incisal surface of the tooth. The bristles should touch the surface of the bracket. at the junction of the three gingival margin and tooth. A circular vibration motion or wiggling the toothbrush then activates this method. Brush two to three teeth for about 10 seconds slowly overlapping to the next section. So I'm sure you guys are getting from this video that this is a really great method. for our orthodontic patients. Brackets for maxillary teeth or in this case above the brackets for mandibular teeth. Just brush through those surfaces of the teeth as you normally would and this should reach into the top or under the bracket. For maxillary teeth the same information would apply just making sure that the bristles are facing the incisal edge. Okay, so that is a great video to show the Charter's Method. So you might want to write on your PowerPoint, like this is the one that I would recommend for my patients with braces. All right, so I am going to go ahead and stop sharing again and then go back to reshare. Okay. All right, so moving on to the horizontal method. So the horizontal method, so sometimes we'll see this done by children, but we really don't recommend this tooth brushing technique. It might be effective when the child is young, like six or seven, and they're not putting much pressure, but this is also known as the scrub brush technique and we do not scrub brush technique our patients. So if you recommend someone a horizontal tooth brushing method you are going to have to come up with a pretty good rationale as to why you would recommend that. So how is this toothbrush done? We direct the bristles at right angles to the tooth, replace the brush head, at 90 degree angle to the long axis of the tooth. And we do both the facial and the lingual, and we are just going in horizontal strokes, okay, all the way around. And that is the horizontal method. The limitations of this is that it can remove biofilm or plaque, but it does not reach interproximally. And this is one of the biggest concerns is the cervical abrasion. that can happen if there is excessive pressure along with um you know abrasive toothpaste that's used so not a toothbrushing method that's recommended but um but it's out there so i did not find a video on that because it's people don't make videos on it because it's something we usually tell people to stay away from all right so next we're going to talk about the um phones method so the phones method This to me is our kids method. Okay, so you see I have all the little kids down there in the picture. This is the one that I would recommend to kids when I'm first teaching them how to brush because usually they don't have the dexterity and or the ability to do the vibratory motions and do all of those with the modified bass and stillman's technique. So the Phones method is the way to go. So the Phones method, another name for it, is a circular method of brushing. So indications, purpose is going to be for children. The procedure is going to be to place that toothbrush at a 90 degree angle to the long axis of the tooth on the buccal and the lingual and gently press the bristles against the teeth. The strokes are going to be in. a circular motion and we're going to do those several times and then the brush is moved to a new area. Usually when we're doing the buccal surfaces, we'll have the patient bite their teeth together and we'll do the circles and then go around and we'll do the circles on the lingual. The limitations, the plaque removal is not as much plaque and biofilm is removed. then as is removed on our soft, on our soft filler brushing techniques. So that is definitely a limitation. All right. So we're going to go ahead and play this one. Stephen George Holiday's Door Wait with Michael here to everyone on your list and we're going to see if it's guaranteed at the end of the day. If anyone is looking for fresh heading, they have certain options as well. We're going to look towards the end of the day. When I show you your heading, I want you to try out the long-term care solution. I'm going to give you a chance. Once you get your team, you want to switch sides with them. You can't say no to that. You will be doing the same circular motion, just at a smaller diameter. where you'll get more creature anterior teeth. If you have greased your anterior teeth, you are unable to turn the brush to the left and the right to get the anterior teeth. I'm on this area of the mouth where my anterior teeth are. I'll mention the new year's total in July, which will be released on November 1st. As we develop the facial side of your teeth, you want to switch sides once you've reached the identity of the same person and over the age. Grab that one too, and press it to the maxilla, keeping the same angle, and pressing it to the base of your elbow. Just like the magic 13, you will want to turn your attention to the angle you are using to feel the difference between your knees. Once the section is completed, you will want to move to the side, so do the same movement towards the end of the chain, and press it to the maxilla. Okay, so make sure you have that handle coming up out of the mouth though, because the way she has it is back towards their head and no one can do a toothbrush that way. The toothbrush handle needs to be coming up and out of the mouth, but hopefully you got the idea of the phones method or circular brushing technique. All right. So stop share and reshare. Okay. Okay. So now next we're going to talk about the Leonard's method. The Leonard's method is also considered the vertical method. This also may work well for small children. And in this toothbrushing method, they're going to place the toothbrush at a 90 degree angle to the long axis of the tooth on the buccal and lingual. And they're going to press the bristles gently against the teeth. The teeth are edge to edge. The strokes are going to be in an up. and down motion with light pressure on the two surfaces. And then you're going to move from one area of the mouth to the next. The limitations on this are going to be that this is much like the rolling stroke, except for there is minimal plaque removal from the interproximal and from the sulcular areas. So you're going to get limited removal of that biofilm there, but another good alternative for our kids. All right, so those are the methods of manual toothbrushing that we would recommend. So we don't recommend these methods when we go to our power toothbrush. That's a little different. So before I go on and leave this topic, I want to play you one more video. And it is a video of a... combination, sorry guys, I'm trying to find the video, a combination of all the most recommended toothbrushing methods, which is the modified bass, the charters, the modified Stillman's, and the phones method. Those are the four most prescribed or recommended toothbrushing techniques. So I do want to play this for you just to give you one last look and hopefully you'll be able to see what I'm doing. you are understanding and grasping these different techniques. So stop sharing and then reshare. Oh, there we go. It's exciting, right? Okay, here we go. This is our BAS method. There's no talking in this video, so it's just kind of showing it. BAS method by itself. This is our charters method. Remember, this is a great one for ortho because think about the brackets that are sitting there or could be sitting there. This is our modified Stillman. So now she's going to add in that roll. And this is our phones. So our big circle brushing. Okay. So. Usually a very good thing to go by. I like this here down at the bottom of this video. Bass is good for everyday use. Bass is good for everyday use. Charter is good for bridges, crowns, ortho type of appliances. A modified Stillman's is good for recession, also good for those appliances and phone, or I'm sorry, the VAS is the one that's good for the appliances as well. And then phones is good for our small children with limited dexterity because they can do those big circles. And I will tell you a lot of times students kind of get a little mixed up with the modified Stillman's and the modified VAS because they do look very similar, but really it. the biggest thing is the brush placement at the beginning. Okay. So if you look back at the brush placement at the beginning, when you are with the modified bass, you are going in at that 45 degree angle. When you are at the modified Stillmans or Stillmans, you are more like right next to the tooth with your toothbrush, and then you'll slightly angle in. So that's really where the differences come in. All right. So let's go back to my PowerPoint here. Okay. Here we go. All right. So let's talk about power toothbrushes. We know we have the, we all have the Oral-B Braun electric toothbrush. I think we have the Genius version. We do know that electric toothbrushes are very effective. And there's been a lot of studies that show that it removes quite a bit more biofilm than a regular manual toothbrush. So definitely patients can benefit from a power toothbrush. However, there are things to keep in mind. The patient has got to have a way to power up and recharge these toothbrushes. They've got to be able to afford these toothbrushes, right? And they've got to want to use these toothbrushes. So that is sometimes the issue. or the barrier that we face with power toothbrushes is the cost. Now I will tell you there are toothbrushes out there that are battery operated that are a little cheaper that patients can purchase but please do your research before you recommend one of those because sometimes you're better off to recommend that manual toothbrush. Whatever you recommend to your patients, make sure you've researched what you're recommending to them, because if they have any questions or concerns, they're going to, they're going to come back to you as the expert. So make sure you're researching whatever you're recommending. Okay. Um, so we know effectiveness of power toothbrushes is definitely very good. They're great, um, recommended for patients who brush too hard. They're great recommended. for patients who have periodontal disease. They're great recommended for patients who don't brush enough, right? And who have poor oral hygiene. So it really satisfies a lot of patients'needs. It also works really well for patients with limited dexterity because the toothbrush actually does all the work. So the way we brush with a power tooth brush brush, we don't have a name to the actual method. We recommend the electric tooth brushing technique. Okay, so it doesn't matter which toothbrush you're using. Our techniques are going to be the same, but the design of the heads are a lot of times different. So it's important that you look at the design of the head and recommend something that works for your patients, because sometimes patients would prefer more of a toothbrush type of head. Um, that is more rectangular. And if so, they're going to want something more like a sonic hair type toothbrush. And then there are patients who would, would rather have something smaller and round that mimics our prophy cup. And therefore they would, they would prefer maybe our oral be brown. All right. So when we use the electric toothbrush, we're going to place the bristles at a 45 degree angle to the tooth. So just like we would place it for. that modified bass technique. We are going to move the brush over the bristles. So we're actually just the guide of the toothbrush. So once we place it, so it's half like on the tissue and half on the tooth and that the filaments are directed into the sulcus, then we turn it on and we concentrate on only about two teeth at a time. Okay. And then we are just the guide. We do not brush with it. So getting patients to understand that they should not be brushing with the electric toothbrush, no horizontal back and forth. We're just guiding it to the next spot and then guiding it to the next spot. Okay. And that's how we're going to recommend our patients use the electric toothbrush. There's no modified. Patients don't need to roll that away from their tissue. They just need to hold it there and let it massage and remove the biofilm. Many power toothbrushes actually have. timers build into them. And usually they are for two minutes and they will signal when the patient has met that. A lot of them will also go off every 30 seconds to let you know it's time to switch to a new quadrant. Some people don't like the vibrations of an electric toothbrush. So that's something to keep in mind. The sounds, the vibrations, sometimes people have a lot of sensitivity. with an electric toothbrush. And there are, there are patients who have certain, um, intellectual disabilities, maybe such as autism or, um, those types of, of, um, mental, um, disabilities that sometimes can't handle those vibrations. Okay. And, and they affect them negatively. So you have to make sure that, that your patient is, um, willing and able to use a power toothbrush before that you recommend them. So those are some of the limitations. As far as instruction, when I'm instructing someone on an electric toothbrush, I will, if I have a model in my office, I will usually demonstrate that on a typodont. So I'll take that electric toothbrush and I'll demonstrate it on a typodont and then I'll let them do it. I'll let them play with the buttons, turn it off and on, all of that. And then I will also usually come up with. a, I'll find a video from the manufacturer. So from Sonicare or from Oral-B and I will play the video from that, their website and show them the benefits of that toothbrush. So that can be something that is really effective and something that they can go back and always watch later too. So this next picture I have, or this next slide goes over the different trim files, profiles of tooth. electric toothbrushes. So there are quite a bit of different heads for our toothbrushes. So when we're looking here at these top four, we're looking at electric toothbrushes that are more like that Sonicare type brand, right? Even these two. But when we're looking here, we're looking more at that Oral-B, you know, that round circular motion. Down here, this electric toothbrush was something that was recommended. a while ago. I wouldn't say a long time ago, but it definitely was in my career. It's called the Rotadent. You don't see it as much anymore. You don't see it recommended much. I feel like Sonicare and probably Oral-B have kind of taken over the market there and they're not really out there as much. So I'm not really going to share too much about that. Child toothbrushes profile. So here's it. Here's the different, when we're looking at the oral B bronze, sometimes for pediatric we'll have, because these patients may have mixed dentition, they might have different brush lengths to be able to reach into different areas. And then an adult is more of a flat profile for that oral B. Now, sometimes the middle of those bristles will kind of dip in and kind of hug the tooth, almost like our prophy cup. All right, so next thing we're going to talk about is supplemental brushing. So supplemental brushing, extra brushing, okay? I don't really think of these as extra brushing. I think of these as required brushing, but they're called supplemental, so we'll go with it. So first I'm going to go over occlusal brushing. I'm going to kind of go a little out of order. Occlusal brushing we already saw on the videos, and that is just that back and forth motion on the occlusal brushing. So when we do the modified stillmans or when we do the modified bass or when we do the charters, we always want to also recommend the occlusal brushing. So our patients need to brush that occlusal surface because we have those deep grooves and pits and fissures that we want those our patients to clean so that they can prevent decay. Okay. Next, we want to go over the difficult to reach areas. So sometimes we have to make adaptations for our patients. Um, and, uh, that would be because they might have an area that is either hard to access because of dexterity or because the area is just hard to reach. Maybe it's wisdom teeth, right? So sometimes we will use some disclosing solution and then we will look and find out like, okay, where are our patients hard to reach areas? Especially if we have them brush and then do it, then we can see exactly where those hard to reach areas are. So The distal surfaces of the most posterior teeth is usually one of those spots that has that very hard to reach area. So at best, the brush may only reach the distal line angle. So sometimes we'll recommend something called a single or an N-tufted brush. And so that we will talk about more in Chapter 27. But that type of toothbrush has a very long handle with just a few bristles on it. and sometimes can be used to get back there. Another thing that I will sometimes recommend is a child's toothbrush because the patient can, because the head is smaller on the toothbrush, the only problem is now we don't have a long handle. Teeth that are facially displaced, especially canines and premolars, things like that might sometimes be hard to reach areas. And these areas might be areas that, that might get on the other hand, abraded as the patient brushes, because they stick out a little bit more buckly. So the, the The patient is constantly hitting those as they're going around, creating recession and creating abrasion. So lingually inclined teeth, such as the maxillary anterior teeth, sometimes those can be difficult. Exposed root surfaces can be difficult because they kind of go in, right? That you have the tooth and the enamel, and then the root surface kind of goes in and thins out there. Overlap. black teeth or wide embrasures can sometimes be an issue, which may require the use of vertical brush position and surfaces of teeth next to edentulous areas. So it's just really important to take a look in your patient's mouth to find out, you know, maybe we need to combine a couple methods to brush to make sure that we get all those areas. Maybe we need to recommend some sort of supplemental aid for them to be able to clean around the areas that we need. The next thing I want to talk about is tongue cleaning, because tongue cleaning is a very important part of brushing that patients don't sometimes do. So the dorsum of the tongue is an ideal environment for harboring bacteria, and it's a key component of the overall oral self-care process. Okay, so getting that tongue clean is really just as important as getting our teeth cleaned, both with our toothbrush and with our floss. So we know that the tongue contains papilla, right? We have filiform papilla, we have fungiform papilla, we have circumvallate papilla. So these papilla provide a surface area for the microflora of the mouth to kind of adhere to the tongue. Some people actually even have fissured tongues and they can be several millimeters deep. And in that, they can actually get bacteria caught and they can have bacterial growth. So anaerobic bacteria is involved sometimes in volatile sulfur compounds, which we've talked about. And those compounds are directly related to bad breath or halitosis. And those a lot of times reside on the tongue. Okay. So when patients complain of bad breath or halitosis, it's usually because they need to step up their tongue cleaning. And if that doesn't help, They might have to see a gastrointestinal specialist because it might be stomach related. So periodontal pathogens often are found on the dorsum of the tongue and the microorganisms and the saliva are the same as found on the tongue. So we really need to get that tongue clean because even if we get our teeth clean, if we don't clean our tongue, then that bacteria is now going to go onto the teeth from our tongue. Okay. So the tongue can be, have a coating on it. It can be a whitish or a brownish layer, and that is actually something that should be removed. Okay. That is bacteria, it's food debris, it's blood cells, it's disquamous epithelial cells, and it needs to be removed. The composition of the coating is affected by factors, including periodontal status, salivary flow, age, tobacco use, and oral hygiene. And the tongue coating, as we talked about, is definitely a major cause of halitosis. All right. So we need to reduce that bacterial load. All right. So to do that, what we need to do is we can use a toothbrush or we can use a specific device that is specifically for tongue cleaning. All right. So I'm actually going to play my video on. tongue cleaning. I thought I put it in here. It doesn't matter since I've had to stop them anyways. Okay. Stop sharing. In addition to your other teeth cleaning routines, I want you to start cleaning your tongue. The tongue has dead skin and blood cells, food debris, metabolites, and microorganisms. So what you do is place this two-in-one Toki cleaner toward the most posterior area. So this is a device that is specifically for tongue cleaning. You can find all different types of brands in the grocery store. So definitely do some research on tongue cleaners. These harbor microorganisms that release the oil sulfurtosin. Thank you. Another added bonus is to start cleaning those little red, gray, and brown taste buds called fungiparvapilla. Doing this will help you better perceive taste. So I recommend adding tongue cleaning to your daily regimen. Okay, so that is that. All right, so that's just one, like I said, one of the methods that you could use. They all kind of look that way, kind of have like that round area and you kind of pull it forward. You can also use a toothbrush. Some toothbrushes actually have on the opposite side a rubber tongue scraper so you can hold that horizontally and take it down your tongue. But at least having them even take their toothbrush and bring it down their tongue and to bring down any bacteria. Now, they should definitely be holding it horizontally and not vertically as to bring down as much as they can and going back as far as they can. um, comfortably without gagging. All right. And then I believe my next slide is just occlusal brushing, which we already went over. And then we have, I have some pictures of our tongue cleaning. So this is that toothbrush I was talking about with the rubber on the back that you can use and kind of pull down the tongue. And if for some reason you don't have that rubber and the patient doesn't want to buy a tongue scraper. then they can always turn that toothbrush around and use the bristles to pull down. They might not be able to get as much off as they can with something that's specific for tongue cleaning. This here is the plastic, kind of like you just saw in the video, and that can be used to pull down the tongue. It's just another brand of tongue scraper. So definitely tongue scraping is something we should recommend to all of our patients. So toothbrushing for special concerns. So there are certain times when we have to give special toothbrushing considerations. And that might be to our patient who has some sort of oral inflammation or traumatic lesion. It might be following periodontal surgery, might be following a dental extraction, or it might be on someone who has a blood disorder. Okay, so if we go back to the acute. oral inflammatory traumatic lesion, we want to make sure that we tell our patients to brush all the areas of the mouth that are not affected. And if tolerable, to clean the affected area with an extra soft tissue. Because getting that bacteria out of there and reducing the bacteria in the mouth is definitely going to speed up the healing process. Rinsing with a mild, warm saltwater solution can also be recommended for our patients. And we can always consider having the dentist prescribe an antimicrobial rinse like chlorhexidine to aid in the reduction of the bacterial load. Once the area has been healed, then the patient should definitely resume regular biofilm control measures. Following periodontal surgery, it's going to depend on the type of surgery that the patients undergo. the patient does need to perform oral self-care in the areas not involved in the surgery as usual. They need to follow directions provided by the periodontal office for care of the surgical area. Sometimes it will be to stay away from that area for a few days, sometimes not. Rinsing and brushing the surgical area may not be recommended until at least 24 hours after surgery, at which time care can be taken to avoid the gingival areas when brushing. If a gingival graft was done, no brushing may be allowed until the post-operative follow-up appointment. So it's important to keep that in mind if you're working in a general office and someone comes in who has had periodontal surgery, which they probably won't be because they're getting their cleanings probably at the periodontist for just a little while, at least, to keep them under close observation. But we should always ask them what kind of recommendations were given to them by their periodontist. An antimicrobial rinse like chlorhexidine may have been prescribed to aid with healing. So oral self-care process might be modified, but it is important that they keep the other areas of their mouth clean. Following dental extractions, clean the teeth adjacent to the extraction site the day following the surgery. Brush areas not involved in the surgery as usual, keeping the bacteria count low in the mouth. Beginning 24 hours after surgery, they should start allowing the patient to rinse with warm salt water after meals and at snacks to prevent and remove debris from adhering to the extraction sites. But the actual pre and post surgical instructions will be given to the patient at the time of their surgery. Sometimes even rinsing can be an issue for our patients with dental extractions. because we don't want them to be pulling out or removing the blood clot that was there. So oral self-care of our neutropenic patient or a low white blood cell count patient. This is a patient who they don't have a lot of white blood cells because maybe they've undergone chemotherapy, radiation therapy, maybe they've had a bone marrow transplant. And because of that... They don't have enough white blood cells in their blood to fight off infections. So these patients need to keep the bacteria out of their mouth, but we don't want to do anything to stir up bleeding because then bacteria will, of course, get into the bloodstream and they're not going to be very effective at fighting that off. But there, and there are some oral complications that go along with that. So mucositis. which is an inflammation or an ulceration of the mucous membranes of the mouth and throat, xerostomia, dry mouth, using dysgousia, which is changes in taste, fungal and viral infections, they can be affected by trismus, which is difficulty opening or not being able to open very wide. They may have diffuse pain and they might have an aggravation of existing periodontal disease. So there are a lot of oral care recommendations that we have for these patients. We are going to get into these really in depth when we talk about our patients with these conditions next semester in theory, because we're going to look at many different special needs patients and what we need to do with them as far as self-care and as far as creating a dental hygiene. care plan for patients who need us to make accommodations. So adverse effects of toothbrushing, we can have adverse effects of toothbrushing if patients are not doing it correctly. So we can have gingival abrasion. This is going to result sometimes from the toothbrush, if they're using bristles that are too hard, sometimes it can be from the pressure, okay? And sometimes it can... actually be from the abrasive paste that they're using, but it can create trauma of the gingiva and also recession of the gingiva where we are seeing the root surface of the tooth. On hard tissue lesions, so this is considered dental abrasion. So these lesions result from mechanical abrasion and typically look like this. wedge-shaped indentations in the cervical areas with a smooth and shiny surface. We typically see these on the facial surfaces, especially of the canines and premolars and sometimes the first molars. These teeth can be very sensitive. These teeth can be more susceptible, this area can be more susceptible to decay. So it's important that we educate the patient about the abrasion and advise them to use a soft. bristle toothbrush with a less abrasive dentifrice and then demonstrate the type of toothbrushing that we would recommend. Power toothbrushes are also a great recommendation because many of them do have pressure sensors if the patient starts brushing too hard. The other thing that we have to keep in mind is bacteremia, right? So we know that we have to keep that in mind with things that we do, but keep in mind that even things like toothbrushing and flossing can cause a bacteremia. So that suggests that daily oral activities, including chewing, toothbrushing, flossing, can produce transient bacteria. So something to just keep in mind with our patients that have a lot of health concerns. Even more of a reason for them to keep their mouth as clean as possible to prevent bacteria from being in their mouth so that their tissue is not bleeding and bacteria is not getting into the bloodstream. and causing them further complications. So next thing we need to teach our patients about is the care of their toothbrushes. So when do we replace it? How do we store it? How do we clean it? So supply of toothbrushes, I think it's always great to keep a supply of toothbrushes on hand, and I recommend my patients do that. Because if they are ill, they really should go ahead and switch out toothbrushes, even if it hasn't been two or three months. Usually good to have an extra toothbrush for work or school or for travel. So having a good supply of toothbrushes at home really is beneficial. Brush replacements. So whether it be an electric toothbrush head or an actual toothbrush. Manual toothbrush. Toothbrushes need to be replaced every two to three months, depending on the way those bristles look. If the bristles start to look displaced after two months, we need to throw it away and get a new one. If it looks displaced after three months, we need to get a new one, okay? If for some reason they're frayed and displaced after one month, then they need to get a new one, all right? Um, cleaning toothbrushes. So after each use, our toothbrushes need to be rinsed and they need to be set out so they can dry. Okay. So we don't want them to rinse them off and put them in a drawer because then we can get bacteria and mold and all that kind of stuff that can grow on them. So we definitely want to keep it out and, um, let them air dry. So as far as storage, um, usually being kept in open air with the head. upright is a good position to keep our toothbrush in. We don't want to keep it in contact with any other toothbrushes because yes, we can catch bacteria from another person. So our toothbrushes should not touch. Don't store toothbrushes in closed containers only if you're using it to take on vacation. But then of course, you know, once you get to wherever you're going, you need to take that toothbrush and take it out so that it is so that it has air and it's not wet in a container. All right. So last thing is just documentation. So this is just for you, for your patients. When patients come in, we always document all the recommendations we are making to their patient oral hygiene instructions. We will recommend a certain type of toothbrush. We'll recommend methods. We might recommend supplemental aids. We will write all of that down and we will explain why we recommended those methods. And there are times when we will take plaque scores. So that is when we use the disclosing and we take a score. And then we take a score again at a previous visit or not previous, a next visit, a future visit and see how things have improved, hopefully. So I hope that information makes sense. I hope that helps you in kind of thinking about toothbrushes and which ones to pick and what kind of methods to pick a little bit more than a lot of people ever think goes in, goes behind, you know, picking out that, that special method for our patients.

So before we even had toothbrushes, we found evidence of something called chew sticks in the early 3500s, and that was B.C. The chew stick was considered to be a primitive toothbrush. And we know it exists because we see it appearing in Chinese literature around 1600 BC.

Care of the mouth during this period was mostly associated with religious trainings and rituals. So not really done by all. And the two sticks were made from various types of wood by crushing the end of a twig or a root and spreading the fibers.

to kind of fan them out and be more like a brush. So from there we see that the first toothbrush made was made of hog hair or horse hair and is believed that this came about in about 1000 AD. So after that, for the longest time this hog hair or horse hair was something that was used to take care of teeth.

And then we have this man, Pierre Fitchard, who came along in 1728. And he said, no, we're not going to be able to use these toothbrushes made of horse hair or hog hair, because it's just too rough and destructive to the teeth. And so he advised instead of doing that. We really should be using something different.

And so he thought using sponges and herb roots would be a better choice. And he developed instruments for scaling and splints. So the first patent on a toothbrush was not actually until the middle of the 19th century.

And this is when... toothbrushes started to be constructed of gold, of ivory, and ebony. And so, you know, when you think about that, back at that time, that was very expensive.

So not a lot of people got to take advantage of using these toothbrushes. So then we jump forward to 1919. And um, we're getting a little more specifications on what toothbrushes should be and what they should be like. And so that was in 1919 and the AAP started to develop these different specifications for toothbrushes. And then in 1938 introduced was our synthetic materials.

So we started using nylon bristles instead of the. bristles that were made from things in nature. So I think that's kind of an interesting little historical background on toothbrushes and how they started.

So we're going to talk mainly about the characteristics of an effective manual toothbrush, and then we're going to talk about the different methods that we can recommend to our patients based on their needs. So what kind of characteristics are we looking for in a toothbrush? We are looking for something that conforms to the individual patient requirements in size, shape, and texture. So everyone's going to need a different size of toothbrush depending on the size of their hand, shape of a toothbrush, and then we're looking at the texture of that toothbrush. And then we want to get something that's easily and efficiently manipulated.

So easily able to move around and be able to complete the job that needs done. They have to be easily cleaned and impervious to moisture. They've got to be durable and inexpensive. We want them to have soft bristles.

We want their end filaments to be rounded. and we want them to be designed for utility, efficiency, and cleanliness. And if you think about a manual toothbrush and you think about what expectations you have for an electric toothbrush, they probably align right there with what you would want to purchase.

So here we're looking at a toothbrush. So you probably never thought that you look at and label the parts of a toothbrush. but that is what we are going to do. And then we're going to discuss each part. So we have the head of the toothbrush, which contains the bristles.

And then we have the shank of the toothbrush, which connects the head of the toothbrush to the handle. We then have the toe of the toothbrush, which is the very end, farthest away from the handle. And then we have the bottom of the bristles, and that is considered our heel.

When we look across the filaments, that is considered our brushing plane. If we look at the toothbrush head on and take kind of a bird's eye view of it, we can see that our bristles are arranged in what we call tufts. Okay. And so each little section of tufts will have our nylon bristles. And depending on the manufacturer and the way they design the toothbrush, usually you'll have about three.

rows of bristles, and you'll have about five to 12 maybe lines or columns of these tufts of bristles. So let's talk about the composition of the toothbrush. So most often, a single type is made of a plastic, okay, or it's made of a polymer. And the properties we want it to have is we want it to be. durable.

We want to be easy to clean. We want it to look nice, right? If it's sitting in our bathroom, we don't want it to be expensive. This is something we throw away and we want to be able to maneuver it.

The shape of the brush, the preferred characteristics are that we want it to be very easy to grasp and we don't want it to slip or rotate when we're trying to use it. We don't want to have any sharp corners or projections coming from the toothbrush and we want it to be fairly... lightweight.

Now, when we also look at the handle, we might see different variations depending on the manufacturer. Sometimes we'll see a twist or a curve, or we'll see it offset, or we might see an angle in the shank with or without somewhere to rest our thumbs. And that can actually help patients who have areas that are very difficult to reach. So we might want a handle that has the rubber. back the rubber coating on it.

We might want a handle where the shank bends and we have a little bit of an angle because that might help us be able to maneuver it better. A handle of longer diameter may be useful for patients with limited dexterities. So if we have a patient who has a lot of trouble maneuvering a handle, we might want something either wider or longer.

But then if we have someone such as a child with a smaller hand will want that handle to probably be shorter. Now then we look at the brush head. So there are different designs of brush heads.

Like I said, the length of it may be 5 to 12 tufts long and 3 to 4 rows wide. The size and the shape is going to vary. So there are a lot of different shapes and sizes that are available.

The brushing plane also may vary. And we're going to look at some lateral profiles of brushing planes. When we are selecting a toothbrush, we might want something that's black. We might want something that has more of a ripple design. We might want something that has more tapered filaments.

We might want something multi-leveled for our patients. We might want something angled with bristles going in each direction. Or we might want something more bi-level.

that we would use for an orthodontic patient. So as far as which is the best for patients, research has been pretty inconsistent on saying which actually design removes the most biofilm. But some suggest that angling the tufts make it easier to remove the plaque than a flat trim toothbrush. However, some studies have still failed to show that conclusively. So it really has to do a lot with patient preference when we look at bristles, but also what you're seeing as a result of what they're using at home.

So if you're seeing poor oral hygiene with moderate biofilm and our patient is using a flat brush, you might recommend them use something more multi-leveled or tapered or rippled or angled to see if those bristles will benefit them. and their biofilm will reduce. So when we look at the bristles themselves, we know that most bristles have nylon filaments, okay? And many manufacturers of synthetic filaments refer to filaments as bristles, okay?

And what we need to be aware is that synthetic filaments are actually the bristles. So, um... When we look at the bristles, the important thing that we want to look at is the stiffness of those bristles.

So that stiffness is really going to depend on the diameter of the bristle and the length of the filament. So brushes in the store when we buy them are usually designated as soft, medium, or hard. But know that between you manufacturers, there might be differences just because of the way they construct.

their filaments. So it's really important that we look for a softer bristle toothbrush, so that way our patients are avoiding doing any damage to their tissue or to their teeth. And in some cases, we might even recommend the sensitive bristles or extra soft bristles, so that they can clean more interproximally or clean more. into like the receded areas of their, of their mouth.

So you typically, we're going to recommend either a soft or a sensitive, which is an extra soft toothbrush. I think I covered everything from that other slide. Yes, I did. Okay.

So the next thing we're going to go over is influencing factors. So how do we help, um, select a toothbrush for our patients? Well, there are a lot of influencing factors that we have to keep in mind. First of all, we have to look at our patient.

We have to figure out what the ability of the patient is to use the brush and remove the dental biofilm from their tooth without damaging the structure. We've got to look at the manual dexterity of the patient. And we really need to look at the age of the patients and the difference is in their dentition. Because if they only have primary teeth, or they only have mixed dentition or they have all their adult dentition, that's going to definitely make a difference in the type of toothbrush that we're selecting for our patients. Next, we're going to look at the gingiva.

So that is the tissue that surrounds their teeth. We want to look at the status of their gingival and periodontal health and the anatomic configurations of their gingiva. So if someone has recession, open embrasure spaces, We are probably going to pick something that has more of those multi-tufted or multi-height in their bristles rather than pick something that's more flat across. Positioning of the teeth.

That's another thing that helps us decide what toothbrush. Are our patients'teeth crowded? Do they have open contacts between their teeth? Okay.

Do they have, what size is their mouth? Do they have a large mouth? or do they have a small amount?

And we have to look at compliance. What does the patient actually prefer? Because that is going to impact a lot of which toothbrush we're going to recommend. If our patient wants to use a particular toothbrush and that's all they'll use, we kind of have to work with that.

So the patient might have preferences and they might be resistant to change. Patients sometimes lack motivation. ability, or the willingness to follow a prescribed procedure.

So other things we need to look at is patient affordability, especially when we're looking at options such as electric toothbrushes. There are battery-operated electric toothbrushes, which are a little more affordable than the electric toothbrush that we plug in and recharge. But patient affordability is going to be a big factor.

Let's look at timer options. So if we're looking at an electric toothbrush, does our patient, would they benefit from a timer? Something on their toothbrush that tells them when to finish each quadrant of their mouth or when to finish brushing. Also, again, our filament or bristle selection and then our brush head selection. So a lot of things with it need to come into place just to pick the actual toothbrush that we want our patients to be brushing with.

So the next thing we have to do is talk about the guidelines of manual tooth brushing. Before we even get into. what different types of toothbrushing are.

So the guidelines for brushing would be like, how do we teach our patients how to grasp a toothbrush? And has anyone ever told you how to hold a toothbrush? So the ability to be able to brush means to successfully hold that toothbrush and be able to remove biofilm.

We need to make sure that the patient has a light but controlled grasp, because if they do, then they are going to be more effective. They're going to be able to position it better and they're going to be able to apply the correct amount of pressure to remove the deposit that's in their mouth. So here's our procedure when we're teaching our patients how to use it to grasp a toothbrush. So they're going to grasp the toothbrush handle in the palm of their hand with the thumb against the shank, okay? So there's no name to this.

this grasp, okay, like there is to instrumentation. But we want our patients to have a palm grasp, and we want our patients to use their thumb on the actual shank. That is going, grasping the head, the brush near the head will help them be able to control the head a lot better than if they're grasping that brush down at the end of the handle. But they, of course, don't want to grasp so close to the head.

that manipulation of the brush is difficult because the fingers are in the way. And then we want them to be able to position it according to the brushing method we select. We want them to be able to adapt the grasp from various positions of the brush head and the teeth throughout the procedure.

So we might need to adjust their arm or their hand or their grasp as we're going into different areas, such as the lingual of the mandibular. um, molars or the mandibular anteriors. We might have to hold it differently and maneuver it differently. And we need to teach them to apply that appropriate pressure for removal of the dental biofilm. We don't want to put so much pressure that the bristles of the brush are bending.

And then we're, we're going through a toothbrush every couple of weeks because all of our bristles are distorted. Okay. Once the bristles become distorted.

they are no longer effective. So then we need to talk to our patient after we teach them how to hold a toothbrush. We need to talk to them about a brushing sequence.

So it's really important that when we're trying to get a brushing sequence established, that our patients tell us or let us know if they're right hand or left hand dominant, because that's going to have a lot to do with where they start brushing. Right-handed brushers are going to start on their upper left side. Most left-handed brushers are going to start on their upper right side. Okay, so we usually start off on the opposite.

Now, mind you, when we first start off brushing, it's usually when we are starting the most aggressive. So that is a lot of times where we first see damaging effects of recession and abrasion to teeth when patients start over brushing. So sometimes making alterations in that sequence can really help give that area that's might have been overbrushed a break.

But the brushing process should definitely be something that is ritual and that the patient establishes so they do not forget an area to brush. So usually what we'll recommend is divide the mouth into sextants or quadrants. And to start brushing from the molar region of one arch around to the midline of the facial and then the lingual, followed by brushing the occlusal surfaces.

And then go ahead and repeat it in the opposite arch. Each brush placement should overlap the previous one to avoid missing spots. All right.

So approaches to address areas where patients might be having difficulty. Usually people have difficulty right around the canine area because that's where they kind of change directions from going from the posterior to the anterior. So sometimes that first premolar canine area is an area that's often missed when brushing.

So it's really important to give a little extra attention to those areas. The next thing we need to talk to our patients about is the duration of brushing. So how long they're going to be brushing.

So there's a lot of different recommendations you can give to your patients so that they brush the adequate amount of time. So two minutes is the recommended brushing time length. Okay. So we can do that by telling our patients to count to 30. for every quadrant they brush, right?

And so by the time they're done, they will have hit their two minutes. We can also have them set a timer, set them, set a timer for two minutes, tell them to spend one minute on the maxillary and one minute on the mandibular. Sometimes I have told patients to sing happy birthday, especially when I'm talking to kids. Sometimes I have told them it's as long as a commercial break.

If they brush their teeth and like to watch TV. Or I will tell them if they're listening to the radio and brushing their teeth to brush them as long as one song on the radio. So just trying to get them to set some kind of goal so that they're brushing long enough.

Because one of the problems we run into is patients usually don't usually spend as much time as they should brushing. The next thing we need to address is the frequency of brushing. How many times a day are they brushing?

So we recommend that our patients brush at least two times a day. And there are certain circumstances where we might ask for more, such as patients who have orthodontics. But typically, for most patients, two times a day is sufficient. So we recommend those brushing times happen in the morning and at night, with nighttime being the one I usually put the most emphasis on.

So usually everything that we've eaten all day is sitting on our teeth. And we want to get that off before we go to bed at night. When we go to bed at night, we don't have our natural cleansing mechanisms at work. We're not eating. We're not talking.

We're not doing anything to get anything moving in our mouth. So bacteria is just sitting there undisturbed and it has a dark, quiet, moist place to grow. So we definitely want to get that nighttime brushing in and then also brush in the morning. And of course, we want to do interdental care, which we'll get into more in Chapter 27. So toothbrushing force and pressure.

So again, that's another thing that we have to address with our patients. We don't want them putting too much pressure or force on their teeth because that pressure or force has no benefit and actually can harm the tissue and can harm the teeth. Okay, so we definitely do not need them putting force and pressure onto brushing. The next thing we go over is our general tooth brushing instruction. We really have to make time in our visits to sit down and talk to our patients about what we recommend.

So before we do that though, we have to prepare. We have to gather information about what our patient currently does as far as oral hygiene. And we're talking about tooth brushing.

So we want to know what kind of tooth brushing are they using? How are they doing it? And then we want to take that information and we want to look at their oral cavity and decide, are they using the right method for them? Or can we take what they're using and make some adaptions so that they can have better results? So Research actually suggests that the most effective teaching strategies for patient education include the use of a computer or the use of a videotape or the use of demonstrations or written material.

So I'm asking you, when you do your oral hygiene instructions for your patients, to make sure that you are doing a demonstration for them, maybe on your typodont. with a toothbrush and then having them do it, or that you are giving them something written that says, this is what we talked about today. And this is what I want you to do.

or maybe you're playing some kind of a video and you put together some kind of a presentation that you're going to pull up chair side on your computer and you're going to go through what is biofilm? What is calculus? How can we get it off? Why do we want to get it off, right?

And then you can give them recommendations. That usually is how the patient really starts. understand our concepts. If we just sit down and talk to them, sometimes they just don't grasp it.

So using visuals and making our presentations interactives are going to give us much better results. So verbal instructions alone have only a small effect on our patient outcomes. And we definitely always want our patients to come back in better shape than they left in. So demonstrations had the largest effect on patient outcomes and are an essential component of patient education.

So demonstrations are huge. So having them demonstrate and you demonstrate, maybe it's on a model, maybe it's in their mouth, multiple educational strategies. So when you combine things and maybe use the computer and do a demonstration.

then you're going to get even better outcomes. So when initially introducing a new self-aid, it is very important to have a demonstration model or to have a video around so that you can show your patient the product and how to use it. One other thing I like to do with my patients, especially if I'm recommending a new product or a new toothbrushing method is, or a new toothbrush, is to show them a picture of the actual toothbrush I'm recommending. Okay.

So actually show them the Crest Oral-B toothbrush that I want them to use. Maybe I'll even do some research and find out where you can find it. Okay.

You know, I found it on Amazon for $3.50 or I found it at Walmart for $2. Patients really appreciate... You taking and going that extra mile and not only telling them what to use, but giving them actual manufacturer names, showing them what it looks like, and then telling them an approximate cost.

Okay. And where they can find it. So a lot of times, you know, we recommend things and then our patients come back and they're like, I was not even ever to be able to find that.

What did you recommend again? So they don't even remember. So those kinds of things are really.

helpful. Another thing that's really useful during our patient instructions is to utilize the disclosing solution in our patient's mouth. So what we can do with the disclosing solution is paint it on their teeth, have them swish, and then have them look in the mirror and show them the areas.

It makes a great visual for where they're missing brushing. Okay. And then have them or show them an area where you're using the correct technique and now the area is clean. So these types of methods and these types of visuals incorporated into our patient education conversations are really helpful and definitely effective.

So we're going to talk about several different methods for manual tooth brushing. We have a bass or modified bass. We have a stillman and modified stillman.

We have a roll or rolling stroke method. We have a charters method. We have a phones method. We have a Leonard method and we have a scrub method. We're going to talk about all of these in the next few videos.

And I actually even, or in the next. few slides and I actually did incorporate a few videos so I could show you the actual technique in the video and you can go back to these and click on these and of course you're always welcome to use them if you design a presentation and want to incorporate something that I have in here so I might have to do a little like clicking back and forth just so that you're seeing everything you need to see on the screen. So the first method we're going to go over is called the BAS or the modified BAS method.

I would probably put a star on this one. This is a method that is very often recommended to our patients. So it's pretty popular.

It's accepted as a method for dental biofilm removal adjunct to and directly beneath the gingival margin or sulcular area. So we often call this a sulcular. toothbrushing technique. It is considered that sulcular brushing.

The areas of the gingival margin and the coal are the most significant areas of gingival infection and periodontal disease, and we get those clean with this method. So what are the purposes and indications of this method? Well, to remove the dental biofilm adjunct to and directly beneath the gingival margin, To clean any open embrasures, which you know are open spaces, around the cervical areas of teeth, beneath the height of the contour of the enamel. And it also does a great job cleaning around our root surfaces.

Adaptation to abutment teeth or implants and under the gingival border of a fixed partial denture. So this is a great method, especially for patients who have extensive dental work, right? Have crowns, have bridges, have implants. This is a really great method.

method. So what is the procedure? So I'm going to kind of talk you through it, and then I'm going to play the video after I get through the limitations. So you're going to direct the filaments apically.

So up for the maxillary and down for the mandibular. And we see that in A here. And then in B, we see the filaments actually sliding underneath the tissue.

So we kind of have it at an angle. It's at a 45 degree angle to the tooth. Okay.

From that position, we are going to turn the, from this position, we're going to turn it into the tooth. So now we have that 45 degree angle and direct the filament tips into the sulcus. We're then going to press lightly so the filaments enter the gingival sulcus and cover the gingival margin. We don't want to bend the filaments with excess pressure.

We are then going to vibrate the brush back and forth with very, very short strokes. without disengaging the tips of the filament. So we're kind of, it's kind of more of a massaging. We count to 10 with those vibrations in each section of the mouth that we do. In the modified bass, so that's the bass method.

In the modified bass, the vibratory motions are then followed by a rolling down of the toothbrush over the crown of the tooth to clean the rest of the surface. Then we reposition the brush to the next few teeth. And we're usually focusing on just about two or three teeth at a time.

And we're repeating this all the way around the mouth and then going down to the lower. And we're repeating it down on the lower. We're making sure that we do the buccal surfaces and all the lingual surfaces. So the limitations of this brush, the biggest limitation is that someone who is a very aggressive person.

Toothbrusher needs to be aware that they're going to have to do very short strokes and eliminate any kind of scrubbing pattern because these bristles are going to be underneath that tissue and they can definitely do a lot of damage. The other thing we have to make sure of is that our patient has pretty good dexterity because making these vibratory strokes is going to be a challenge if our patient is compromised with their dexterity. So I'm going to go ahead and...

I think I have to stop sharing and then reshare to get you guys to see the video. So I'm going to go ahead and stop sharing for a second. I am going to pull up my video.

All right, it's going to take me longer than I thought. Sorry, guys. Hopefully you can just fast forward towards me. for me doing this. I think when the next time I just won't give in. Oh, this really doesn't want to do it.

Yeah, just keeps coming up some other stuff, guys. Okay. I am just going to go find it. I hope I pull up the same video that I put in. Almost there.

Sorry guys. Got something. All right. This is not, this is not the right video though.

Okay. Maybe if I, okay. I figured it out now. Technology is super fun. It will be better than expert.

All right. All right. I should be sharing now.

So here we go with our modified bath. and in case you want to go shopping. So when you saw that herp, then brush that, sweep that biofilm away, that's when it becomes modified. So if we stay with just those vibratory motions and we don't add that swipe away, then we just have the bass.

Okay. So here we are with the bass and then we make it modified. Since this guy has a flip top head, I really wonder why they can't open his mouth more.

But they're not. But I hope this gives you the idea of how that brushing method. And then this is actually occlusal brushing. So this is separate, but they're showing you occlusal brushing right here.

So that's just brushing, you know, back and forth that occlusal surface. So they're actually doing a modified bass. They're showing you the bass and they're also showing you that occlusal brushing. So I do want you guys to see the lower, especially the lower anterior.

Okay. So hopefully you guys get the idea of that tooth brushing technique. So now I'm going to go back to my presentation.

I almost think if I stay in this view, I hope this doesn't mess you guys up, that I might be better off when I go to, when I go to the video for the next one. So I'm going to kind of stay in this view. I hope that's okay.

All right, so that is the bass and the modified bass method. So next thing we're going to talk about is the Stillmans and the modified Stillman method. This is another method that is very... very recommended.

So we definitely use this a lot. So this is also considered another circular brushing technique along with the modified bass. Um, what are its purposes and indications?

Well, this method is for massage and stimulation, as well as cleaning the cervical areas. The modified Stillman method adds a rolling stroke to the vibratory stroke to clean the crowns of the teeth. So dental biofilm removal is effective from the cervical area below the height contour of the crown and from exposed proximal surfaces. The general application for cleaning two surfaces and massaging the gingiva. This is probably one of the most recommended or prescribed toothbrushing methods.

This is good for the general public. When they have a lot of dental work, then I will go to the bass or the modified bass. If they don't, you know, I just have some occlusals or maybe some MODs or things like that, composite restorations, then I will stick with this modified Stillman's.

And I do always add in the modified. I don't usually just recommend the Stillman without the modified and the same with the modified bass. Okay, so what is the procedure of this tooth brushing method? We're going to place the side of the brush on the attached gingiva.

So just kind of flat, exactly like what it's showing here, the facial. And then the filaments are directed apically for the maxillary. That would be up.

And then for the mandibular, that's going to be down. And when the plastic portion of the brush head is level with the occlusal plane, generally the brush is at the proper height. Okay.

So if you see the occlusal plane here in A, you can see where the plastic is. Okay. And that's how we're going to. place the toothbrush.

The strokes. So we take and press to flex the filaments. The sides of the filaments are pressed lightly against the gingiva and blanching of the tissue occurs. So it does blanch slightly. We angle the filaments, turn the handle by rotating the wrist.

So the filaments are directed at an angle with approximately 45 degrees. Okay. We activate the brush and use a rotating motion.

maintaining light pressure on the tooth surface. We count to 10 slowly and vibrate that and then rotate the handle. So roll and vibrate the brush, turn the wrist and work the vibrating brush slowly down over the gingiva and the tooth. So then we will repeat that as we go on to the next section of teeth.

And usually we are just concentrating on about two or three teeth at a time. Now one of the differences between this method and the modified bath is the anterior portion. When we get to the anterior, we will position the brush somewhat vertically using the toe of the brush for the anterior lingual area and then we will press and vibrate and roll and repeat. Okay, so what kind of limitations are there for the Stillman's or modified Stillman method? We have to have careful placement of a brush with the round and rounded filaments to prevent any tissue laceration.

We have to make sure that our patient or our patient understands they need to have light pressure because the patient might try to move the brush into the rolling stroke too quickly. And that can be pretty ineffective and it really won't get as much biofilm off as we want them to. So let's see here if I figured it out. If I'm in this view, it won't even let me click it.

Okay. But I think what I can do is say link. I do have to stop sharing again and reshare, but I'm there quicker. Stop share.

And now share. Here we go. Hi there, my name is Nicole.

Today in this oral hygiene instruction video, we will go over two brushing methods. First is the Stillman's brushing method. Stillman's brushing method was designed for massage and stimulation as well as cleaning the cervical areas of the teeth. We will position our toothbrush on the tissues directly and angle the toothbrush filaments slightly apical or going towards the root of the teeth.

Now a slight... Circular movement is done several times while applying light pressure, just enough to show the tissues to turn white. So that's the blanching of the tissue that she's referring to. After several movements, the overlap moves to the next area, still doing circular motions using light pressure.

The linguals are done the same. We angle the toothbrush, we apply the light pressure, and do the small circular movements. For the anteriors, we angle the toothbrush, do small circular movements, massaging the tissue, and we continue to overlap when we move to the next area.

The second technique is the modified stillman method. In this method only a small modification is added which is the roll method. We again place the brush at a 45 degree angle directly on the gingival tissue and make small circular movements. But now we'll roll the toothbrush down to the crown of the tooth. This will be especially helpful for patients with gingival recession to achieve adequate gingival stimulation as well as maximum cleanliness.

Don't forget to overlap and clean all surfaces of your mouth. Anteriors, we again use angulation to fit into the area and roll up on the mandible. Maxilla, we angle it to fit and roll up using the heel. The only thing that I would almost tell you about this method that I would kind of change. and that is the linguals of the mandibular anteriors and the maxillary anteriors.

You see her using more of the heel, and you see all this bristle across her whole palate. For some patients, they won't be able to handle that because it could stimulate the gag reflex. So you may actually be more here towards the front third of the toothbrush, towards the toe third of the toothbrush, and using that portion. to do your vibrations and then pulling that up in a way.

So I just wanted to add that in. Okay so that is it for that one. So I am going to go ahead and stop sharing and go back to screen one. Okay.

And now we, no, we're not back to our screen sharing. I don't know what I'm screen sharing now. I'm sorry, guys. Okay, now we're back.

Okay, I don't know what it was sharing. Maybe it was just fine, but it looked weird to me. All right, so that is a Stillman and modified Stillman.

So hopefully you guys understand. the difference between those. So we're going to go on and talk about a few more.

The next one is we're going to talk about is the roll or the rolling stroke method and the purposes and indications for this. This does remove biofilm, material, alba, and food debris from teeth without emphasizing the gingival sulcus. So we're really just focusing more on the teeth.

This is usually used in conjunction with the Bass method and the Stillman's method. So if you think about what this is called, the roller rolling stroke method, remember how we had the bass method and then we added in the modified part. So that's the rolling. OK, so now this technique is just the rolling. All right.

This can be really helpful when there's a question about the patient's ability to master and practice a more complex method. So if our patients can't do those modified bass or those modified Stillman. methods just because of limited dexterity or other reasons, then this in and of itself can be a toothbrushing method that we would recommend. So how would we do this?

Well, we would direct the filaments apically. We would place the side of parallel and against the gingiva. And that, and we would get that plastic height, right?

But instead of doing those vibratory strokes into the sulcus, we are just going to roll the brush slowly over the teeth. And as the brush is rolled, the wrist is turned slightly and the filaments remain slightly flexed and follow the contour of the tooth. Then we go on to the next area and we do the same, all right? So the limitations I'm sure you can kind of guess are that we're not going to get much interproximal or insulfate cleaning. The brushing is going is can sometimes the brush will be placed too high and that can hit the alveolar mucosa and the alveolar mucosa you remember that's that movable tissue and that can be easily abraded.

Also, patients tend to do this very quickly. And so effective biofilm removal can sometimes be not that effective. So I'm going to go ahead and play our video on the rolling stroke method.

Stop sharing. And then I'm going to start sharing. And here we have the rolling method.

Okay, so that... is that. So I will stop sharing and then again I will reshare. Okay. All right.

So that is our rolling or the roll or the rolling stroke method. So now let's go on to our charters method. So our charters method is um is the method that is going to be helpful in teaching, can be helpful in teaching children proper home care and was used to be something that was recommended in that regard.

The purpose is to loosen debris and dental biofilm to stimulate the marginal and interdental gingiva, aid in biofilm removal from proximal surfaces, and remove dental biofilm from abutment teeth and under the gingival border of a fixed partial or denture. So again, it can be helpful also with some dental work. The biggest difference, and I like this picture right here that I put on this page because it shows a comparison of two different toothbrushes.

So we talked about the modified bass technique, right? We were We're going at a 45 degree angle to the sulcus. So basically when we look at the Charter's method, it's the opposite. So now we're taking and we're angling down into the tooth instead of up at the tissue.

Okay, so we're starting with a different direction of our filaments. All right, so that is going to help you hopefully understand the difference between the Stillman and the Bass, which is more like this. And then of course the, um, the charters being more like this. All right. So the bristles are gently pushed between the teeth, um, being careful not to injure the gingiva with the bristles between the teeth.

We use as little pressure as possible and make three or four small rotary movements with the bristles. The side of the bristles should come in contact with the gingiva to massage them. And we remove the bristles from the interproximal area.

and then place it into the next. And then we repeat that every two to three teeth. So what are the limitations?

Well, I think that one thing you're probably seeing is that we're not directing the filaments underneath the gingival sulcus. So we're not getting a lot of sulcular cleaning done. Okay.

In some areas, correct placement of a brush in this manner can be difficult. All right, so let's go ahead and we'll play the charters method. So this is, like I said, something that used to be recommended a lot for children.

a huge fan of recommending it for children, but it is something that your textbooks recommend as one of the methods that can be. Stop sharing. I don't think you guys are seeing it.

Okay. Now you should be. The Charter Seek Neat is mainly used by ortho patients.

It is used to clean around the brackets and to remove plaque under abutment teeth of a fixed bridge. So patients with a bridge can also use this method to reach under the contact of a bridge. Brushing directly over the surface of the teeth will not work for an ortho patient because the bristles will not reach the edges of the bracket, leaving areas unclean.

Contraindication for Charter's method is that you can get subgingival cleaning. For the Charter's technique, the bristles are placed at a 45 degree angle toward the occlusal or incisal surface of the tooth. The bristles should touch the surface of the bracket. at the junction of the three gingival margin and tooth. A circular vibration motion or wiggling the toothbrush then activates this method.

Brush two to three teeth for about 10 seconds slowly overlapping to the next section. So I'm sure you guys are getting from this video that this is a really great method. for our orthodontic patients. Brackets for maxillary teeth or in this case above the brackets for mandibular teeth. Just brush through those surfaces of the teeth as you normally would and this should reach into the top or under the bracket.

For maxillary teeth the same information would apply just making sure that the bristles are facing the incisal edge. Okay, so that is a great video to show the Charter's Method. So you might want to write on your PowerPoint, like this is the one that I would recommend for my patients with braces.

All right, so I am going to go ahead and stop sharing again and then go back to reshare. Okay. All right, so moving on to the horizontal method.

So the horizontal method, so sometimes we'll see this done by children, but we really don't recommend this tooth brushing technique. It might be effective when the child is young, like six or seven, and they're not putting much pressure, but this is also known as the scrub brush technique and we do not scrub brush technique our patients. So if you recommend someone a horizontal tooth brushing method you are going to have to come up with a pretty good rationale as to why you would recommend that. So how is this toothbrush done? We direct the bristles at right angles to the tooth, replace the brush head, at 90 degree angle to the long axis of the tooth.

And we do both the facial and the lingual, and we are just going in horizontal strokes, okay, all the way around. And that is the horizontal method. The limitations of this is that it can remove biofilm or plaque, but it does not reach interproximally.

And this is one of the biggest concerns is the cervical abrasion. that can happen if there is excessive pressure along with um you know abrasive toothpaste that's used so not a toothbrushing method that's recommended but um but it's out there so i did not find a video on that because it's people don't make videos on it because it's something we usually tell people to stay away from all right so next we're going to talk about the um phones method so the phones method This to me is our kids method. Okay, so you see I have all the little kids down there in the picture. This is the one that I would recommend to kids when I'm first teaching them how to brush because usually they don't have the dexterity and or the ability to do the vibratory motions and do all of those with the modified bass and stillman's technique. So the Phones method is the way to go.

So the Phones method, another name for it, is a circular method of brushing. So indications, purpose is going to be for children. The procedure is going to be to place that toothbrush at a 90 degree angle to the long axis of the tooth on the buccal and the lingual and gently press the bristles against the teeth. The strokes are going to be in. a circular motion and we're going to do those several times and then the brush is moved to a new area.

Usually when we're doing the buccal surfaces, we'll have the patient bite their teeth together and we'll do the circles and then go around and we'll do the circles on the lingual. The limitations, the plaque removal is not as much plaque and biofilm is removed. then as is removed on our soft, on our soft filler brushing techniques. So that is definitely a limitation. All right.

So we're going to go ahead and play this one. Stephen George Holiday's Door Wait with Michael here to everyone on your list and we're going to see if it's guaranteed at the end of the day. If anyone is looking for fresh heading, they have certain options as well. We're going to look towards the end of the day. When I show you your heading, I want you to try out the long-term care solution.

I'm going to give you a chance. Once you get your team, you want to switch sides with them. You can't say no to that.

You will be doing the same circular motion, just at a smaller diameter. where you'll get more creature anterior teeth. If you have greased your anterior teeth, you are unable to turn the brush to the left and the right to get the anterior teeth. I'm on this area of the mouth where my anterior teeth are.

I'll mention the new year's total in July, which will be released on November 1st. As we develop the facial side of your teeth, you want to switch sides once you've reached the identity of the same person and over the age. Grab that one too, and press it to the maxilla, keeping the same angle, and pressing it to the base of your elbow.

Just like the magic 13, you will want to turn your attention to the angle you are using to feel the difference between your knees. Once the section is completed, you will want to move to the side, so do the same movement towards the end of the chain, and press it to the maxilla. Okay, so make sure you have that handle coming up out of the mouth though, because the way she has it is back towards their head and no one can do a toothbrush that way. The toothbrush handle needs to be coming up and out of the mouth, but hopefully you got the idea of the phones method or circular brushing technique. All right.

So stop share and reshare. Okay. Okay.

So now next we're going to talk about the Leonard's method. The Leonard's method is also considered the vertical method. This also may work well for small children. And in this toothbrushing method, they're going to place the toothbrush at a 90 degree angle to the long axis of the tooth on the buccal and lingual. And they're going to press the bristles gently against the teeth.

The teeth are edge to edge. The strokes are going to be in an up. and down motion with light pressure on the two surfaces. And then you're going to move from one area of the mouth to the next.

The limitations on this are going to be that this is much like the rolling stroke, except for there is minimal plaque removal from the interproximal and from the sulcular areas. So you're going to get limited removal of that biofilm there, but another good alternative for our kids. All right, so those are the methods of manual toothbrushing that we would recommend.

So we don't recommend these methods when we go to our power toothbrush. That's a little different. So before I go on and leave this topic, I want to play you one more video.

And it is a video of a... combination, sorry guys, I'm trying to find the video, a combination of all the most recommended toothbrushing methods, which is the modified bass, the charters, the modified Stillman's, and the phones method. Those are the four most prescribed or recommended toothbrushing techniques. So I do want to play this for you just to give you one last look and hopefully you'll be able to see what I'm doing. you are understanding and grasping these different techniques.

So stop sharing and then reshare. Oh, there we go. It's exciting, right?

Okay, here we go. This is our BAS method. There's no talking in this video, so it's just kind of showing it.

BAS method by itself. This is our charters method. Remember, this is a great one for ortho because think about the brackets that are sitting there or could be sitting there. This is our modified Stillman. So now she's going to add in that roll.

And this is our phones. So our big circle brushing. Okay. So.

Usually a very good thing to go by. I like this here down at the bottom of this video. Bass is good for everyday use.

Bass is good for everyday use. Charter is good for bridges, crowns, ortho type of appliances. A modified Stillman's is good for recession, also good for those appliances and phone, or I'm sorry, the VAS is the one that's good for the appliances as well. And then phones is good for our small children with limited dexterity because they can do those big circles. And I will tell you a lot of times students kind of get a little mixed up with the modified Stillman's and the modified VAS because they do look very similar, but really it.

the biggest thing is the brush placement at the beginning. Okay. So if you look back at the brush placement at the beginning, when you are with the modified bass, you are going in at that 45 degree angle. When you are at the modified Stillmans or Stillmans, you are more like right next to the tooth with your toothbrush, and then you'll slightly angle in.

So that's really where the differences come in. All right. So let's go back to my PowerPoint here.

Okay. Here we go. All right.

So let's talk about power toothbrushes. We know we have the, we all have the Oral-B Braun electric toothbrush. I think we have the Genius version. We do know that electric toothbrushes are very effective. And there's been a lot of studies that show that it removes quite a bit more biofilm than a regular manual toothbrush.

So definitely patients can benefit from a power toothbrush. However, there are things to keep in mind. The patient has got to have a way to power up and recharge these toothbrushes. They've got to be able to afford these toothbrushes, right?

And they've got to want to use these toothbrushes. So that is sometimes the issue. or the barrier that we face with power toothbrushes is the cost.

Now I will tell you there are toothbrushes out there that are battery operated that are a little cheaper that patients can purchase but please do your research before you recommend one of those because sometimes you're better off to recommend that manual toothbrush. Whatever you recommend to your patients, make sure you've researched what you're recommending to them, because if they have any questions or concerns, they're going to, they're going to come back to you as the expert. So make sure you're researching whatever you're recommending. Okay.

Um, so we know effectiveness of power toothbrushes is definitely very good. They're great, um, recommended for patients who brush too hard. They're great recommended. for patients who have periodontal disease. They're great recommended for patients who don't brush enough, right?

And who have poor oral hygiene. So it really satisfies a lot of patients'needs. It also works really well for patients with limited dexterity because the toothbrush actually does all the work.

So the way we brush with a power tooth brush brush, we don't have a name to the actual method. We recommend the electric tooth brushing technique. Okay, so it doesn't matter which toothbrush you're using. Our techniques are going to be the same, but the design of the heads are a lot of times different. So it's important that you look at the design of the head and recommend something that works for your patients, because sometimes patients would prefer more of a toothbrush type of head.

Um, that is more rectangular. And if so, they're going to want something more like a sonic hair type toothbrush. And then there are patients who would, would rather have something smaller and round that mimics our prophy cup. And therefore they would, they would prefer maybe our oral be brown.

All right. So when we use the electric toothbrush, we're going to place the bristles at a 45 degree angle to the tooth. So just like we would place it for. that modified bass technique. We are going to move the brush over the bristles.

So we're actually just the guide of the toothbrush. So once we place it, so it's half like on the tissue and half on the tooth and that the filaments are directed into the sulcus, then we turn it on and we concentrate on only about two teeth at a time. Okay. And then we are just the guide. We do not brush with it.

So getting patients to understand that they should not be brushing with the electric toothbrush, no horizontal back and forth. We're just guiding it to the next spot and then guiding it to the next spot. Okay. And that's how we're going to recommend our patients use the electric toothbrush. There's no modified.

Patients don't need to roll that away from their tissue. They just need to hold it there and let it massage and remove the biofilm. Many power toothbrushes actually have. timers build into them. And usually they are for two minutes and they will signal when the patient has met that.

A lot of them will also go off every 30 seconds to let you know it's time to switch to a new quadrant. Some people don't like the vibrations of an electric toothbrush. So that's something to keep in mind. The sounds, the vibrations, sometimes people have a lot of sensitivity. with an electric toothbrush.

And there are, there are patients who have certain, um, intellectual disabilities, maybe such as autism or, um, those types of, of, um, mental, um, disabilities that sometimes can't handle those vibrations. Okay. And, and they affect them negatively. So you have to make sure that, that your patient is, um, willing and able to use a power toothbrush before that you recommend them.

So those are some of the limitations. As far as instruction, when I'm instructing someone on an electric toothbrush, I will, if I have a model in my office, I will usually demonstrate that on a typodont. So I'll take that electric toothbrush and I'll demonstrate it on a typodont and then I'll let them do it. I'll let them play with the buttons, turn it off and on, all of that.

And then I will also usually come up with. a, I'll find a video from the manufacturer. So from Sonicare or from Oral-B and I will play the video from that, their website and show them the benefits of that toothbrush.

So that can be something that is really effective and something that they can go back and always watch later too. So this next picture I have, or this next slide goes over the different trim files, profiles of tooth. electric toothbrushes. So there are quite a bit of different heads for our toothbrushes. So when we're looking here at these top four, we're looking at electric toothbrushes that are more like that Sonicare type brand, right?

Even these two. But when we're looking here, we're looking more at that Oral-B, you know, that round circular motion. Down here, this electric toothbrush was something that was recommended.

a while ago. I wouldn't say a long time ago, but it definitely was in my career. It's called the Rotadent. You don't see it as much anymore. You don't see it recommended much.

I feel like Sonicare and probably Oral-B have kind of taken over the market there and they're not really out there as much. So I'm not really going to share too much about that. Child toothbrushes profile. So here's it. Here's the different, when we're looking at the oral B bronze, sometimes for pediatric we'll have, because these patients may have mixed dentition, they might have different brush lengths to be able to reach into different areas.

And then an adult is more of a flat profile for that oral B. Now, sometimes the middle of those bristles will kind of dip in and kind of hug the tooth, almost like our prophy cup. All right, so next thing we're going to talk about is supplemental brushing. So supplemental brushing, extra brushing, okay?

I don't really think of these as extra brushing. I think of these as required brushing, but they're called supplemental, so we'll go with it. So first I'm going to go over occlusal brushing. I'm going to kind of go a little out of order. Occlusal brushing we already saw on the videos, and that is just that back and forth motion on the occlusal brushing.

So when we do the modified stillmans or when we do the modified bass or when we do the charters, we always want to also recommend the occlusal brushing. So our patients need to brush that occlusal surface because we have those deep grooves and pits and fissures that we want those our patients to clean so that they can prevent decay. Okay.

Next, we want to go over the difficult to reach areas. So sometimes we have to make adaptations for our patients. Um, and, uh, that would be because they might have an area that is either hard to access because of dexterity or because the area is just hard to reach.

Maybe it's wisdom teeth, right? So sometimes we will use some disclosing solution and then we will look and find out like, okay, where are our patients hard to reach areas? Especially if we have them brush and then do it, then we can see exactly where those hard to reach areas are. So The distal surfaces of the most posterior teeth is usually one of those spots that has that very hard to reach area.

So at best, the brush may only reach the distal line angle. So sometimes we'll recommend something called a single or an N-tufted brush. And so that we will talk about more in Chapter 27. But that type of toothbrush has a very long handle with just a few bristles on it.

and sometimes can be used to get back there. Another thing that I will sometimes recommend is a child's toothbrush because the patient can, because the head is smaller on the toothbrush, the only problem is now we don't have a long handle. Teeth that are facially displaced, especially canines and premolars, things like that might sometimes be hard to reach areas.

And these areas might be areas that, that might get on the other hand, abraded as the patient brushes, because they stick out a little bit more buckly. So the, the The patient is constantly hitting those as they're going around, creating recession and creating abrasion. So lingually inclined teeth, such as the maxillary anterior teeth, sometimes those can be difficult.

Exposed root surfaces can be difficult because they kind of go in, right? That you have the tooth and the enamel, and then the root surface kind of goes in and thins out there. Overlap. black teeth or wide embrasures can sometimes be an issue, which may require the use of vertical brush position and surfaces of teeth next to edentulous areas. So it's just really important to take a look in your patient's mouth to find out, you know, maybe we need to combine a couple methods to brush to make sure that we get all those areas.

Maybe we need to recommend some sort of supplemental aid for them to be able to clean around the areas that we need. The next thing I want to talk about is tongue cleaning, because tongue cleaning is a very important part of brushing that patients don't sometimes do. So the dorsum of the tongue is an ideal environment for harboring bacteria, and it's a key component of the overall oral self-care process. Okay, so getting that tongue clean is really just as important as getting our teeth cleaned, both with our toothbrush and with our floss.

So we know that the tongue contains papilla, right? We have filiform papilla, we have fungiform papilla, we have circumvallate papilla. So these papilla provide a surface area for the microflora of the mouth to kind of adhere to the tongue.

Some people actually even have fissured tongues and they can be several millimeters deep. And in that, they can actually get bacteria caught and they can have bacterial growth. So anaerobic bacteria is involved sometimes in volatile sulfur compounds, which we've talked about.

And those compounds are directly related to bad breath or halitosis. And those a lot of times reside on the tongue. Okay. So when patients complain of bad breath or halitosis, it's usually because they need to step up their tongue cleaning. And if that doesn't help, They might have to see a gastrointestinal specialist because it might be stomach related.

So periodontal pathogens often are found on the dorsum of the tongue and the microorganisms and the saliva are the same as found on the tongue. So we really need to get that tongue clean because even if we get our teeth clean, if we don't clean our tongue, then that bacteria is now going to go onto the teeth from our tongue. Okay. So the tongue can be, have a coating on it.

It can be a whitish or a brownish layer, and that is actually something that should be removed. Okay. That is bacteria, it's food debris, it's blood cells, it's disquamous epithelial cells, and it needs to be removed. The composition of the coating is affected by factors, including periodontal status, salivary flow, age, tobacco use, and oral hygiene.

And the tongue coating, as we talked about, is definitely a major cause of halitosis. All right. So we need to reduce that bacterial load.

All right. So to do that, what we need to do is we can use a toothbrush or we can use a specific device that is specifically for tongue cleaning. All right.

So I'm actually going to play my video on. tongue cleaning. I thought I put it in here.

It doesn't matter since I've had to stop them anyways. Okay. Stop sharing. In addition to your other teeth cleaning routines, I want you to start cleaning your tongue. The tongue has dead skin and blood cells, food debris, metabolites, and microorganisms.

So what you do is place this two-in-one Toki cleaner toward the most posterior area. So this is a device that is specifically for tongue cleaning. You can find all different types of brands in the grocery store.

So definitely do some research on tongue cleaners. These harbor microorganisms that release the oil sulfurtosin. Thank you.

Another added bonus is to start cleaning those little red, gray, and brown taste buds called fungiparvapilla. Doing this will help you better perceive taste. So I recommend adding tongue cleaning to your daily regimen.

Okay, so that is that. All right, so that's just one, like I said, one of the methods that you could use. They all kind of look that way, kind of have like that round area and you kind of pull it forward.

You can also use a toothbrush. Some toothbrushes actually have on the opposite side a rubber tongue scraper so you can hold that horizontally and take it down your tongue. But at least having them even take their toothbrush and bring it down their tongue and to bring down any bacteria. Now, they should definitely be holding it horizontally and not vertically as to bring down as much as they can and going back as far as they can.

um, comfortably without gagging. All right. And then I believe my next slide is just occlusal brushing, which we already went over.

And then we have, I have some pictures of our tongue cleaning. So this is that toothbrush I was talking about with the rubber on the back that you can use and kind of pull down the tongue. And if for some reason you don't have that rubber and the patient doesn't want to buy a tongue scraper.

then they can always turn that toothbrush around and use the bristles to pull down. They might not be able to get as much off as they can with something that's specific for tongue cleaning. This here is the plastic, kind of like you just saw in the video, and that can be used to pull down the tongue. It's just another brand of tongue scraper. So definitely tongue scraping is something we should recommend to all of our patients.

So toothbrushing for special concerns. So there are certain times when we have to give special toothbrushing considerations. And that might be to our patient who has some sort of oral inflammation or traumatic lesion. It might be following periodontal surgery, might be following a dental extraction, or it might be on someone who has a blood disorder.

Okay, so if we go back to the acute. oral inflammatory traumatic lesion, we want to make sure that we tell our patients to brush all the areas of the mouth that are not affected. And if tolerable, to clean the affected area with an extra soft tissue. Because getting that bacteria out of there and reducing the bacteria in the mouth is definitely going to speed up the healing process.

Rinsing with a mild, warm saltwater solution can also be recommended for our patients. And we can always consider having the dentist prescribe an antimicrobial rinse like chlorhexidine to aid in the reduction of the bacterial load. Once the area has been healed, then the patient should definitely resume regular biofilm control measures.

Following periodontal surgery, it's going to depend on the type of surgery that the patients undergo. the patient does need to perform oral self-care in the areas not involved in the surgery as usual. They need to follow directions provided by the periodontal office for care of the surgical area.

Sometimes it will be to stay away from that area for a few days, sometimes not. Rinsing and brushing the surgical area may not be recommended until at least 24 hours after surgery, at which time care can be taken to avoid the gingival areas when brushing. If a gingival graft was done, no brushing may be allowed until the post-operative follow-up appointment. So it's important to keep that in mind if you're working in a general office and someone comes in who has had periodontal surgery, which they probably won't be because they're getting their cleanings probably at the periodontist for just a little while, at least, to keep them under close observation.

But we should always ask them what kind of recommendations were given to them by their periodontist. An antimicrobial rinse like chlorhexidine may have been prescribed to aid with healing. So oral self-care process might be modified, but it is important that they keep the other areas of their mouth clean. Following dental extractions, clean the teeth adjacent to the extraction site the day following the surgery. Brush areas not involved in the surgery as usual, keeping the bacteria count low in the mouth.

Beginning 24 hours after surgery, they should start allowing the patient to rinse with warm salt water after meals and at snacks to prevent and remove debris from adhering to the extraction sites. But the actual pre and post surgical instructions will be given to the patient at the time of their surgery. Sometimes even rinsing can be an issue for our patients with dental extractions.

because we don't want them to be pulling out or removing the blood clot that was there. So oral self-care of our neutropenic patient or a low white blood cell count patient. This is a patient who they don't have a lot of white blood cells because maybe they've undergone chemotherapy, radiation therapy, maybe they've had a bone marrow transplant. And because of that...

They don't have enough white blood cells in their blood to fight off infections. So these patients need to keep the bacteria out of their mouth, but we don't want to do anything to stir up bleeding because then bacteria will, of course, get into the bloodstream and they're not going to be very effective at fighting that off. But there, and there are some oral complications that go along with that. So mucositis.

which is an inflammation or an ulceration of the mucous membranes of the mouth and throat, xerostomia, dry mouth, using dysgousia, which is changes in taste, fungal and viral infections, they can be affected by trismus, which is difficulty opening or not being able to open very wide. They may have diffuse pain and they might have an aggravation of existing periodontal disease. So there are a lot of oral care recommendations that we have for these patients.

We are going to get into these really in depth when we talk about our patients with these conditions next semester in theory, because we're going to look at many different special needs patients and what we need to do with them as far as self-care and as far as creating a dental hygiene. care plan for patients who need us to make accommodations. So adverse effects of toothbrushing, we can have adverse effects of toothbrushing if patients are not doing it correctly. So we can have gingival abrasion.

This is going to result sometimes from the toothbrush, if they're using bristles that are too hard, sometimes it can be from the pressure, okay? And sometimes it can... actually be from the abrasive paste that they're using, but it can create trauma of the gingiva and also recession of the gingiva where we are seeing the root surface of the tooth.

On hard tissue lesions, so this is considered dental abrasion. So these lesions result from mechanical abrasion and typically look like this. wedge-shaped indentations in the cervical areas with a smooth and shiny surface.

We typically see these on the facial surfaces, especially of the canines and premolars and sometimes the first molars. These teeth can be very sensitive. These teeth can be more susceptible, this area can be more susceptible to decay. So it's important that we educate the patient about the abrasion and advise them to use a soft.

bristle toothbrush with a less abrasive dentifrice and then demonstrate the type of toothbrushing that we would recommend. Power toothbrushes are also a great recommendation because many of them do have pressure sensors if the patient starts brushing too hard. The other thing that we have to keep in mind is bacteremia, right? So we know that we have to keep that in mind with things that we do, but keep in mind that even things like toothbrushing and flossing can cause a bacteremia.

So that suggests that daily oral activities, including chewing, toothbrushing, flossing, can produce transient bacteria. So something to just keep in mind with our patients that have a lot of health concerns. Even more of a reason for them to keep their mouth as clean as possible to prevent bacteria from being in their mouth so that their tissue is not bleeding and bacteria is not getting into the bloodstream. and causing them further complications. So next thing we need to teach our patients about is the care of their toothbrushes.

So when do we replace it? How do we store it? How do we clean it? So supply of toothbrushes, I think it's always great to keep a supply of toothbrushes on hand, and I recommend my patients do that.

Because if they are ill, they really should go ahead and switch out toothbrushes, even if it hasn't been two or three months. Usually good to have an extra toothbrush for work or school or for travel. So having a good supply of toothbrushes at home really is beneficial.

Brush replacements. So whether it be an electric toothbrush head or an actual toothbrush. Manual toothbrush. Toothbrushes need to be replaced every two to three months, depending on the way those bristles look.

If the bristles start to look displaced after two months, we need to throw it away and get a new one. If it looks displaced after three months, we need to get a new one, okay? If for some reason they're frayed and displaced after one month, then they need to get a new one, all right?

Um, cleaning toothbrushes. So after each use, our toothbrushes need to be rinsed and they need to be set out so they can dry. Okay.

So we don't want them to rinse them off and put them in a drawer because then we can get bacteria and mold and all that kind of stuff that can grow on them. So we definitely want to keep it out and, um, let them air dry. So as far as storage, um, usually being kept in open air with the head.

upright is a good position to keep our toothbrush in. We don't want to keep it in contact with any other toothbrushes because yes, we can catch bacteria from another person. So our toothbrushes should not touch.

Don't store toothbrushes in closed containers only if you're using it to take on vacation. But then of course, you know, once you get to wherever you're going, you need to take that toothbrush and take it out so that it is so that it has air and it's not wet in a container. All right. So last thing is just documentation. So this is just for you, for your patients.

When patients come in, we always document all the recommendations we are making to their patient oral hygiene instructions. We will recommend a certain type of toothbrush. We'll recommend methods. We might recommend supplemental aids.

We will write all of that down and we will explain why we recommended those methods. And there are times when we will take plaque scores. So that is when we use the disclosing and we take a score.

And then we take a score again at a previous visit or not previous, a next visit, a future visit and see how things have improved, hopefully. So I hope that information makes sense. I hope that helps you in kind of thinking about toothbrushes and which ones to pick and what kind of methods to pick a little bit more than a lot of people ever think goes in, goes behind, you know, picking out that, that special method for our patients.

Transcript for:Oral Infection Control: Toothbrushing Essentials

Transcript for:
Oral Infection Control: Toothbrushing Essentials