• Dental caries is defined as a chronic infectious disease which results from the demineralization of the inorganic portion and destruction of the organic portion of the tooth. 
• Epidemiology of dental caries can be studied under the following heading: Host, agent and environment All these factors should react over a period of time for dental caries to occur. 
• CARIES FORMATION 
  • Substrate (sugar) + microorganism (s.mutans in plaque) = lactic acid = causing demineralization
  • Remineralization = fluoride, calcium, phosphate
    1. Fl = dentifrice
    2. Ca and PO4 = teeth and saliva
• HOST FACTORS
  • TEETH 
    1. 80% of caries occur on occlusal surfaces
    2. Lower incisors are the least affected teeth 
    3. Malaligned rotated = bristles cannot reach and clean leading to increased caries 
    4. Dentinogenesis and amelogenesis imperfecta = hypoplastic teeth and pitts = more prone to caries
    5. Caries is considered to be bilateral 
  • SALIVA 
    1. COMPOSITION
       1. rich in calcium phosphate and fluoride = decrease in caries
       2. Rich in carbonate = increase in caries attack
    2. pH = 
       1. unstimulated pH is slightly acidic 
       2. High flow rate = pH increases
       3. pH of saliva = main is bicarbonate content 
       4. Sialin, phosphate and ammonia = also determines pH of saliva
    3. QUANTITY 
       1. Normal secretion = 700-800 ml/day 
       2. Aplasia of glands and xerostomia = increase in rampant caries
    4. VISCOSITY 
       1. Mucin responsible for viscous saliva  
       2. Viscosity does not influence caries 
    5. ANTIBACTERIAL PROPERTIES 
       1. Lactoperoxidase = this prevents early microbial colonization of tooth 
       2. Lysozyme = it is a positive enzyme that catalyzed the degradation of negatively charged peptidoglycans matrix of microbial cells 
       3. Lactoferrin = iron binding protein = needed for microbial growth
       4. IgA = inhibits adherence and thereby prevents colonization on mucosal surfaces and teeth by organisms, facilitating their removal of swallowing 
  • AGE = 3 peaks for caries development
    1. 4-8 years = manual dexterity is less
    2. 11 – 19 years = adolescents
    3. 55 – 65 years = root caries
  • Gender = Reasons 
    1. Early eruption of teeth 
    2. More fondness of sweets
    3. Hormonal variations
    4. Morphological differences
  • Familial hereditary 
    1. Good or bad teeth seen in the family 
    2. Morphology, occlusion, salivary flow
  • Emotional disturbances 
    1. Increase stress = decrease salivary flow = increased caries in oral hygiene is not followed 
  • Socio-economic status 
    1. Low SES = increases decayed and increased missing 
    2. High SES = increased filling 
    3. Overall low SES = increase dental caries
    4. Reason = affordability for prevention and treatment 
    5. Caries is considered as disease of poverty
  • TIME FACTOR FOR DEVELOPMENT OF CARIES
    1. Peak susceptibility = 2-4 years after eruption 
• Agent factors
  • Diet 
  • Organisms = S.mutans = pioneer = acidogenic, aciouric, eat/consume sugar 
    1. Extracellular = dextrans and fructans. Responsible for adhesion on tooth
    2. intracellular polysaccharide = glycogen
  • Lactobacilli = secondary organisms, when caries have reached dentin. It kills all S.Mutans creates an environment of very low pH
  • Veillonella = anti caries organism = consumes acid as food = produced by S.Mutans for demineralization

DIET OF DENTAL CARIES

1. Diet = it is defined as type and amount of food eaten daily by an individual
2. Nutrition = defined as seen of the processes by which an individual takes in and utilizes food
3. Carbohydrates

1. Organic compound containing carbon, hydrogen and oxygen 
2. Physical nature of diet = form, clearance, time, retention, oral hygiene
3. Frequency of carbohydrate diet  
4. Types 
   1. Monosaccharides = glucose, galactose, fructose
   2. Disaccharides = sucrose [ glucose+fructose]
   3. Polysaccharides = starch, glycogen 
   4. Polyols of alcohol = xylitol, mannitol and sorbitol

Classification of sugars 

Total sugars 

1. Intrinsic sugar
   1. Sugar molecules inside the cell

1. Fruit and vegetable
2. Extrinsic sugar 
   1. Sugar molecules outsides the cell 
   2. Milk sugar = found in dairy products = lactose
   3. Non milk sugar = honey, fruit juices, table sugar = responsible for the caries

INTRODUCTION

A number of tooth brushing techniques have achieved acceptance by the dental profession. Each technique has been designed to achieve a definite goal. Hence, no procedure can be described as the best. Depending on the individual cases, the techniques of tooth brushing may have to be altered to achieve the maximum beneficial effect.

BRUSHING TECHNIQUES

• The bass method or sulcus cleaning method.
• Modified bass technique
• Modified stillman’s technique
• Fones/circular/scrub method
• Vertical method-Leonard’s method
• Charters method
• Scrub brush method
• The roll technique
• Physiologic method-smith method

The bass method or sulcus cleansing method

It is the most widely accepted and most effective method for the removal of dental plaque present adjacent to and directly underneath the gingival margin.

Indications

• It is most adaptable for-
  • Open interproximal areas.
  • Cervical areas beneath the height of contour of enamel.
• Exposed root surfaces.
• It is recommended for patients with or without periodontal involvement.

Technique

The bristles are placed 45 degrees angle to the gingiva and moved in small circular motions.

Strokes are repeated 20 times. 3 teeth at a time.

On the lingual aspect of anterior teeth,the brush is inserted vertically and the neck of the brush is pressed into the gingival sulci and proximal surfaces at a 45 degree angle.

The bristles are then activated.

Occlusal surfaces are cleaning by pressing the bristles firming against the pits and fissures and then activating the bristles.

Advantages

• Effective method for removing plague.
• Provides good gingival stimulation
• Easy to learn.

Disadvantages

• Overzealous brushing may convert the very short strokes into a scrub brush technique and causes injury to the gingival margin.
• Time consuming
• Dexterity requirement is too high for certain patients

Modified bass technique

Indications

• As a routine oral hygiene measure
• Intrasulcular cleansing.

Technique

This technique combines the vibratory and circular movements of the bass technique with the sweeping motion of the roll technique. The toothbrush is held in a way that the bristles are at 45 degrees to the gingiva. Bristles are gently vibrated by moving the brush handle in a back and forth motion. The bristles are then swept over the sides of the teeth towards their occlusal surfaces in a single motion.

Advantages

• Excellent sulcus cleaning
• Good interproximal and gingival cleaning.
• Good gingival stimulation.

Disadvantages

• Dexterity of wrist is required.

Modified stillman’s technique

Indications

• Dental plaque removal form cervical areas below the height of contour of the enamel and from exposed proximal surfaces.
• General application for cleaning tooth surfaces and massage of the gingiva
• Recommended for cleaning in areas with progressing gingival recession and root exposure to prevent abrasive tissue destruction.

Technique

The bristles are pointed apically with an oblique angle to the long axis of the tooth

The bristles are positioned partly on the cervical aspect of teeth and partly on the adjacent gingiva.

The bristles are activated by short back and forth motions and simultaneously moved in a coronal direction.

20 strokes are applied and procedure is repeated systematically on adjacent teeth.

Disadvantages

• Time consuming
• Improper brushing can damage the epithelial attachment.

Fones method or circular/scrub method-

Indications

• Young children.
• Physically or emotionally handicapped individuals.
• Patients who lack dexterity.

Technique

The child is asked to stretch his/her arms such that they are parallel to the floor.

The child is then asked to make big circles using the whole arm to draw circles in the air.

The circles are reduced in diameter until very small circles are made in front of the mouth.

The child is now ready to make circles on the teeth with the toothbrush making sure that the teeth and gums are covered.

Advantages

• It is easy to learn
• Shorter time is required

Disadvantages

• Possible trauma to gingiva
• Interdental areas are not properly cleaned.
• Detrimental for adults especially who use the brush vigoursly.

Vertical method-Leonard method

• Vertical stroke is used.
• Maxillary and mandibular teeth are brushed separately

Technique

The bristles of the toothbrush are placed at 90 degree angle to the facial surfaces of the teeth.

With the teeth edge to edge, place the brush with the filaments against the teeth at right angles to the long axis of the teeth.

Brush vigoursly without great pressure with a stroke that is mostly up and down on the tooth surfaces with just a slight rotation or circular movement after striking the gingival margin with force.

Enough pressure is used.it is not intended that the upper and lower teeth shall be brushed in the same series of strokes.

The teeth are placed edge to edge to keep the brush slipping over the occlusal or incisal surfaces.

Advantages

Most convenient and effective for small children with deciduous teeth.

Disadvantages

Interdental spaces of the permanent teeth of adults are not properly cleaned.

Charters method

Indications

• Individuals having open interdental spaces with missing papilla and exposed root surfaces.
• Those wearing fixed partial dentures or orthodontic appliances.
• For patients who have had periodontal surgery.
• Patients with moderate interproximal gingival recession.

Technique

a soft/medium multi-tufted tooth brush is indicated for this technique. Bristles are placed at an angle of 45 degrees to the gingiva with the bristles directed coronally. The bristles are activated by mild vibratory strokes with the bristle ends lying interproximally.

Advantages

Massage and stimulation for marginal and interdental gingiva.

Disadvantages

• Brush ends do not engage the gingival sulcus to remove subgingival bacterial accumulations
• In some areas the correct brush placement is limited or impossible, therefore modifications become necessary which add to the complexity of the procedure.
• Requirements in digital dexterity are high.

Scrub brush method

This method of brushing requires vigorous horizontal, vertical and circular motions.it is the virtual free style of the brushing scene.

Disadvantages

• Not very effective at plaque removal
• Tooth abrasion and gingival recession.

The roll technique

This method of brushing is also known as the rolling stroke method or ADA method or the sweep method.it works fairly well for patients with anatomically normal gingival tissues.

Indications

• Children
• Adult patients with limited dexterity.
• Useful for preparatory instruction for modified stillman’s technique since the initial brush placement is the same.

Technique

The bristles are placed at a 45 degree angle. The toothbrush is slightly rolled across the tooth surface toward the occlusal surfaces. This technique requires some flexibility around the wrist.

Advantages

Provides gingival massage and stimulation.

Disadvantages

• Brushing too high during initial placement can lacerate the alveolar mucosa.
• Tendency to use quick, sweeping strokes resulting in no brushing for the cervical third of the tooth, since the brush tips pass over rather than into the area and likewise for the interproximal area.
• Replacing the brush with filament tips directed into the gingiva may produce punctuate lesions.

Physiologic method-smith method

The physiologic method was described by smith and advocated later by bell. It was based on the principle that the toothbrush should follow the physiologic pathway that is followed by food when it traverses over the tissues during mastication.

Technique

Bristles are pointed incisally or occlusally and then moved along and over the tooth surfaces and gingiva. The motion is gentle sweeping from incisal or occlusal surfaces over to facial surfaces and progressing towards and over the gingiva. It is almost an attempt to duplicate natures self-cleansing and gingival stimulation mechanism during mastication of food.

Advantages

• Natural self-cleansing mechanism.
• Supragingival cleaning is good.

Disadvantages

Interdental spaces and sulcular areas of teeth are not properly cleaned.