HYGIENE AND PREVENTION
BACTERIAL PLAQUE AND CALCULUS
At birth, the human being has a sterile mouth. However, this state is very short-lived, as the newborn quickly acquires a bacterial flora from the environment through food, contact with the mother, the objects he introduces in the mouth, etc.
This causes a permanent bacterial flora to be installed in the mouth, made up of many different species, some of which are somehow harmful to the health of the mouth.
The bacteria of the oral cavity live clinging to the surfaces of our teeth, on the mucous membranes, on the tongue. They accumulate in quantity, forming a pasty lattice also composed of protein filaments.
This structure is called Bacterial Plaque. Plaque is deposited preferably around the collar of the teeth, where they emerge from the gum, in the areas between one tooth and the other (interdental space) and on the surface of the tongue. Some plaque bacteria live by capturing sugars and carbohydrates present in the mouth while chewing food, and emit lactic acid and other substances as waste.
Lactic acid is able to corrode the surface of the enamel and causes it to dissolve: this is the pathological mechanism of the caries.
The substances emitted by plaque bacteria also have an offensive action on the gum, causing gingivitis and, in a more advanced stage, periodontitis. Plaque tends to harden easily, forming a hard layer on the teeth, called Calculus.
THE FLUOROPROPHYLAXIS
The best form of caries prevention is fluoroprophylaxis: it consists in the daily intake through the diet of an additional dose of a salt, known as Sodium Fluoride. It is now known that the fluoride taken through this intake path makes the teeth extremely more resistant to caries. In particular, it happens that the enamel crystals, composed of a calcium agglomerate known as hydroxyapatite, change while they are forming, assuming the state of fluorhydroxyapatite, a crystal much more resistant to the action of lactic acid.
But in order to obtain these more resistant teeth, it is necessary that the fluoride becomes part of the composition of the enamel while it is formed, that is, before the tooth even comes out. This is why fluoroprophylaxis must be implemented "from the inside" through the diet and from childhood to have its maximum effectiveness.
The protocol of the WHO (World Health Organization) provides:
from 0 to 2 years 0.25 mg per day
from 2 to 4 years 0.50 mg per day
from 4 to 12 years 1 mg per day
There are many inexpensive products for fluoroprophylaxis. For newborns, recently the drops formula is also available, instead of traditional tablets. A useful warning is to take the fluoride separated from milk, because if mixed, the treatment loses its effectiveness.
Opinions do not agree on the advisability of giving fluoride to adults: in fact, the adult has already formed enamel, therefore the intake of fluoride does not change its structure, however it may have some internal benefit on dentin.
The fluoride taken by pregnant women makes sense, but it is difficult to dose, because a part of it is absorbed by the mother instead of the fetus, and in any case the actual quantity that passes the placenta in practice is not measurable with certainty. Apart from these considerations, the usefulness of passing a certain dose of fluoride to the fetus is relative, since only from the 20th week does the enamel of the milk dental buds begin to form.
The standard protocol is therefore generally accepted as more than sufficient.
BASIC ORAL HYGIENE
The purpose of oral hygiene is the removal of bacterial plaque and the maintenance of the health of the mouth. This is carried out with mechanical aids which are: toothbrushes, dental floss, interdental brushes (for special cases), and with special products, such as toothpastes and mouthrinses.
a) THE TOOTHBRUSH
The toothbrush should have synthetic bristles (nylon) in general of medium hardness, except for special indications or contraindications (eg thin gums and elongated collars). The bristles of the toothbrush do not have to be natural, as the animal hair retains more bacteria. The toothbrush is used by placing the tip (and not the length) of the bristles against the collar of the tooth, and making a movement towards the tooth itself, in a certain sense, as if you wanted to "squeeze" the gum. The movement must have the right force and must never damage the gum. This operation must be repeated on all teeth, both from the external and internal side (palate and tongue). To make it faster, you can use the toothbrush as if you were drawing "circles" around the gum collar of the teeth, extending them over the surface. Lastly, the portion of the chewing surface of the teeth is added.
A complete cleaning of the mouth also implies the care of the tongue, as it is a receptacle for numerous microorganisms. In fact, by removing residues and microorganisms from the lingual surface, the patient contributes to the complete cleaning of the mouth, to the reduction of bacteria available for plaque formation and to a lower risk of halitosis. For this purpose you can use the traditional toothbrush or the special tongue scraper.
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b) THE ELECTRIC TOOTHBRUSH
Most oral hygiene maneuvers can be performed with good manual technique. However, the newer electric toothbrush models, especially those with the small rotating head, actually add a certain quality to cleansing and plaque removal. By following the instructions of the device, it is possible to guide the head along the arch, gradually embracing the individual teeth and, by tilting in a simple way, to be more effective of a normal toothbrush in the most angled and difficult to reach areas.
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c) THE TOOTHPASTE
The removal of the plaque is a mainly mechanical fact, so much that (in theory) a simple toothbrush wet with water would be enough; toothpaste is not essential for this. However, washing with the help of a toothpaste brings other additional benefits. Toothpastes contain substances that can help with oral hygiene. Fluoride can help to strengthen the surface of the enamel, and also makes the teeth less sensitive, while other substances provide an antiseptic or surfactant action. In general, toothpastes can be divided into pastes or gels. Gels are by far the least abrasive to enamel, while pastes have abrasive additives: so one thing to watch out for when buying toothpaste is its graininess.
In theory that should be shown on the tube, but not all brands comply with this obligation. A toothpaste that, when rubbed between the fingers, or between the tongue and the palate, gives a "sandy" impression, is more abrasive and is (for example) absolutely not recommended in case of very exposed teeth collars.
SPECIAL ORAL HYGIENE
a) THE DENTAL FLOSS
The use of dental floss contributes to gum health by removing plaque and thus reducing the narrowing of the interproximal spaces. It has been shown that there is no difference in the effectiveness of a waxed and unsaxed thread for plaque removal.
Generally speaking, the smooth surface provided by the wax coating helps prevent soft tissue trauma and glides more easily through the contact point of the teeth, reducing the possibility of floss snapping or fraying.
Dental floss is generally used AFTER passing the brush, since the latter, by cleaning the most visible surfaces of the teeth, tends to push between one tooth and the other material and plaque that must be removed.
USE OF THE FLOSS: after having wrapped the two ends of the floss on the middle fingers leaving a space of about 2 cm, place it between one tooth and the other. Move the floss between teeth in a short back and forth motion to pass the contact point and gently reach the base of the tooth. Bend the wire into a C-shape by embracing first one tooth and then the other; finally, slide the wire horizontally or vertically and then exit the interproximal space with a back and forth movement.
Superfloss: it is a particular dental floss consisting of a semi-rigid end which has the purpose of facilitating its entering the interproximal spaces in the presence of bridges or orthodontic appliances.
b) THE INTERDENTAL BRUSH
In particular interdental areas, where access for normal dental floss is prevented by the presence of a bridge (for example), the use of this tool is useful. It consists of a plastic handle to which tufts with radial bristles are applied, arranged transversely to the stem, and which is somewhat reminiscent of a bottle cleaning tool. There are various shapes (conical or cylindrical) and diameters. The one that flows most in the space to be cleaned and that rubs the adjacent dental surfaces sufficiently will be used.
c) THE MONOBRISTLE TOOTHBRUSH
It is a toothbrush consisting of a single tuft of bristles or a group of small tufts. It is indicated for the cleansing of open interproximal areas, for implant posts, bridges, orthodontic appliances, fixed prostheses or for areas that are difficult to reach with a traditional toothbrush.
d) THE MOUTHRINSE
It is an adjuvant in the implementation of hygiene, even if not essential. Mouthwashes with fluoride help to strengthen the surface of the enamel, while those with chlorhexidine (available in various concentrations) have an antiseptic action. The latter in fact find an excellent application in mouths with objective problems of diseases such as gingivitis or periodontitis.
Even in the patient who has received oral surgery, the use of a good chlorhexidine mouthwash is recommended to 2% in the post-operative phase
PROFESSIONAL HYGIENE - GENERALS
The operator who carries out these procedures must by law have a special university degree as a hygienist, or must have a degree in dentistry. For no reason the person who performs the oral hygiene session can be a normal dental assistant.
The dental hygienist is therefore a professional who, cooperating with the dentist, works in the preventive field, promoting the health and general well-being of the patient; in the educational field by instructing and motivating according to individual needs, and finally, in the therapeutic field, by implementing all those procedures aimed at fighting diseases of the oral cavity.
It is also critically important to recognize that clinical services, both dental and dental hygiene, have little chance of long-term success if the patient's cooperation in maintaining daily personal care and regular appointments for professional care, fails.
The hygiene session is normally carried out every six months, but it will be care of the hygienist and / or dentist to regulate the times, adapting them to the needs of the patient.
The hygiene session consists in a more thorough removal of plaque and calculus (the latter, in reality, cannot be removed with only personal hygiene maneuvers at home!).
PROFESSIONAL HYGIENE - TECHNIQUE
The sequence we show is not necessarily rigid and of course can vary from operator to operator, however the essential lines and devices used are those described.
a) PLAQUE DETECTOR
It is a coloring substance that has the effect of highlighting the presence of bacterial plaque in the mouth in various shades (generally red). The effect of a rinse with a detector is to completely color the tongue (home to the largest bacterial flora of the mouth) and the areas of the tooth collars. It indicates the points of greatest plaque accumulation with better evidence.
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b) AIR-FLOW APPLIANCE
The latest innovation in professional plaque removal and deep cleansing of tooth surfaces is the "Air-Flow" technology. It is a device that sprays a mixture of air, water and a biodegradable and biocompatible powder into the mouth: erythritol. This fine jet (similar to a hydro-cleaning) is able to completely remove plaque, as well as clean food stains and pigmentations. It is so delicate in its use that it can also be used in surgery, with open gingival tissues, without causing any damage. However, it is not suitable for removing calculus; for this purpose other methods and specific equipment are used.
c) CALCULUS SCALER
It is an electric mechanical instrument equipped with interchangeable metal tips that vibrate moved by an ultrasonic generator. The vibration of the tip, applied to the calculus concretions, causes them to detatch, freeing the surface of the tooth. There are various types and models, all generally well tolerated. To facilitate scaling, these instruments are equipped with a water jet, which makes the detached fragments flow towards the surgical aspirator, allowing better comfort for the patient. In particularly sensitive cases, the hygiene session can also be performed with the aid of a light anesthesia.
d) COURETTE
It is a steel tool that is used manually by the hygienist to detach smaller scales of calculus positioned where the scaler does not reach. There are various shapes and sizes, and each operator chooses those of his preference, depending on the task they have to perform: someone even prefers them to the ultrasonic scaler.
In general, however, it is a tool that allows greater refinement because, in addition to completing the detachment of the calculus from the surfaces of the teeth, it gives the possibility to carry out what is called "root planing" (a root smoothing): this operation makes the tooth root smoother and less receptive to the formation of new calculus.
e) RUBBERS AND PASTES
Depending on the preferences of the hygienist, rotating instruments called rubbers, toothbrushes (equally rotating) can be used in association or not with polishing pastes. These small devices help to complete the polishing of the surfaces of the teeth, preventing more plaque accumulation and therefore the formation of new calculus.
f) OTHER TOOLS
The hygienist also uses mouthrinses (usually chlorhexidine) as adjuvants and, of course, uses dental floss to free the spaces between one tooth and the other of all loose calculus residues or to remove polishing pastes etc.
