The Driving Force

Aug. 1, 2003
You need a quality brush, good brushing discipline and a willing patient who will brush effectively without fail for several minutes. With the proper method for plaque disruption, you can cross the finish line underneath the waving checkered flag for a win-win race against plaque.

by Karen Kaiser, RDH

To win a big auto race such as the Daytona or Brickyard 400, drivers must perfect their driving skills, exhibit extreme concentration, and have an enduring strategy. When this winning concept is applied to tooth brushing, the brusher's skill, concentration, and method become critical in the race for plaque control. Applying the right toothbrush method and brush selection to the patient's unique situation could mean the difference between the racing cup being won or lost. Choose this strategy wisely when recommending homecare routines for your patients. Take into consideration the patient's manual dexterity when brushing to remove plaque, along with the position of the teeth and gingival status.

The dental-hygiene pit stop for regularly scheduled recare should be a high priority for our patients. We give them an all-point pocket inspection, top off rinse fluids, discuss needed maintenance of their mouths, change strategies to win against the competitor —plaque, and let them go back to the speedway until the next mile check - all the while hoping we gave them a competitive edge with our insightful home-care instructions.

In the interim, we expect patients to do all they can to comply with recommended home-care instructions and strive for a perfectly tuned mouth that cleans with ease to avoid a yellow caution flag.

Start your engines

A manual or automatic powered toothbrush for plaque removal remains, in the end, the choice of the brusher. Many studies argue that there is no superior brand or design. The toothbrush that proves to be the leader of the pack is the brand the patient uses consistently and correctly. Manual toothbrushes have a consumer market share of 90 percent, with the power brushes in hot pursuit for a pole position. The competition is fierce, and the goal is to secure our patients as the buyer. As in auto racing, there are many race car designs but, ultimately, the better driver wins the race.

Some of the modifications manufacturers are making with input from hygienists involve:

• Aesthetics
• Functional changes to the chassis (body) of the brush
• Adding different tufts, filaments, and their configurations
• Changes to the heads
• Overall brush designs.

Polished trim filaments with dome bristles, crossing of bristles, as well as a mixing of both manual and power modes are all available to the consumer. Easy-to-grasp handles with thumb rests allow the brusher a favorable angle for the best plaque removal technique, and provide more control in turns and tight corners.

Motivating the patient remains a key component for successful plaque removal. In addition, choosing the preferred make and model of brush and plaque-removal technique remains a deciding factor for success.

First, encourage the patient to begin brushing the areas that need the most improvement (probably the lower lingual and posterior teeth). Frequently missed surfaces may be difficult places for your patient to reach consistently. Help the brusher discover neglected areas by suggesting and using plaque-disclosing solution and the intraoral camera. Work together with the patient on those difficult areas, then show before-and-after images of the disclosure-free zone.

Raising patient awareness can be a motivator in itself. Discuss the benefits that good oral hygiene can have with improved plaque removal, fresher breath and improved smile for a lifetime, not to mention the positive impact on the patient's overall health.

Take a test drive

Take the new toothbrush for a chairside test-drive by demonstrating the best way to remove plaque. Perhaps the brusher is tight coming off the corners — a simple modification like closing the mouth instead of keeping it open wide would improve access to those hard-to-reach apron surfaces. Make brushers aware of how unnecessarily wide they are opening to reach those teeth. Simply slightly closing to relax the cheek muscle does wonders.

In all cases, listen to the patient's needs and offer professional assistance for improvement in those limited-access areas. Furthermore, educate patients to replace brushes regularly (unfortunately many do not change them until the next scheduled visit). Remind the brusher that toothbrush bristles do become worn and lose resiliency with use — removing significantly less accumulated plaque. Like car tires, toothbrushes need rotating.

Make certain the patient has adequate control over the brush's pressure, and maintains an effective position to reach all surfaces. Efforts to correct improper tooth brushing, long-standing harmful habits, and overly aggressive brushing can be met with resistance by patients who do not perceive a potential problem with their daily regimens. Discuss the daily frequency for brushing with your patient and educate them for the most efficient bacterial reduction. Consider the periodontal state as well as caries susceptibility. These conditions are black warning flags to the clinician that the brusher's habits need close monitoring. For some patients, it may not mean brushing 10 times or more a day, but instead focusing on optimal plaque removal a couple of times.

For those hot rod brushers, the speed of the brush is important. But going full throttle may mean an unwanted heavy-handed technique, with missed gingival and tooth surfaces. Set a controlled stop-and-go pace for the patient and soup up their home care. Why not offer a take-home toothbrush timer complete with an affixed logo sticker with the office name, your name, or encouraging brush statements like "Don't Rush to Brush."

Brushers, take your positions

For patients to follow the best routes around their mouths with the most effective bristle placement, a preferred method must be chosen to ensure the individual patient's success and avoid repeated pitfalls. Guiding your patients toward improved gingival health should be motivated through a customized strategy with the goal of effective plaque removal and reduced bleeding. Toothbrushing methods are based on the motion of the brush and its position. While the Bass method is the most widely recommended technique, please choose the strategy wisely when recommending home-care routines for your patients. The challenge remains to select the most appropriate technique for the patient.

• Bass method — The Bass method is the most well known sulcular brushing technique and is the most widely used technique. Adjacent plaque found slightly below the gingival margin is significantly reduced using a Bass technique. For this technique, the toothbrush head rests at a 45-degree (sulcular) angle, bristles directed toward the sulcus with small circular motions performing the plaque removal. For this method, the brush of choice is one with soft nylon trim bristles and end-rounded filaments, as gingival trauma may become a problem.

John O. Butler Co. has a manual toothbrush on the market, the Technique™ Quad-Grip®, with angled thumb pads that easily guide the user into an accurate Bass method. Depending on which quadrant or facial or lingual surface is being brushed, the Quad-Grip thumb pad automatically orients the bristles at a 45-degree angle toward the sulcus. Once patients have been educated on how to efficiently hold the toothbrush, they easily can use the Technique Quad-Grip Toothbrush at home to achieve the Bass technique taught at their continuing care appointment with the dental hygienist.

• Modified Bass method — A modified Bass method combines the circular Bass with a rolling sweep. The toothbrush, again at 45 degrees to the gingiva, is carefully vibrated, using shortened strokes on the tissues to remove the plaque, ending with an up-sweep stroke toward the tooth's occlusal surface. This method must be repeated throughout the mouth, using the same placement, vibratory action and rolling sweep motion to complete a brushing session.

A potential disadvantage to the Bass method is the patient who haphazardly brushes or is overly aggressive. This method could easily degenerate into a scrub brush motion, causing unwanted trauma to the tissue margins. Generally, patients need good dexterity to accomplish the stroke and sweep effectively, so patient selection must be considered. Ideally, open interproximal spacing, exposed root surfaces or reduced height enamel would benefit from this gentle sweeping circle.

• Roll technique — The roll technique, although not as effective for plaque removal alone, also serves a purpose. If abrasion or recession is a factor, this method may have easier handling characteristics than the Bass technique. However, if this method is not executed properly by the brusher, plaque can be left at the margins and between teeth, and may cause sulcular trauma. When dexterity is an issue, this roll technique can be helpful if there is a question about the ability of the brusher to perform more complicated circular motions with the wrist.

In this technique, the brush handle and filaments are directed apical for either mandibular or maxillary teeth. Pressed against the gingivae, the flexed filaments are rolled by a wrist motion toward the biting surface in a single stroke, being careful not to drag the brush head over the gingival margin as the brusher returns to the starting position.

• Stillman technique — The modified Stillman technique incorporates a press-and-roll with the toothbrush bristles placed initially on the gums. This method is considered a gingival-stimulating massage, in addition to offering the benefit of cervical plaque removal. For this press and flex technique, the toothbrush filaments in an apical direction. The filaments are angled by a wrist rotation of approximately 45 degrees. The brusher, using gentle pressure, vibrates and rolls the bristles with a slow and controlled motion interproximally and over the tissues. This method calls for a soft tufted brush and lightly applied pressure.

• Charters method — The reverse of the Stillman method is the Charters method. For the Stillmans technique, the brush is angled to the tissues, whereas in the Charters method, the brush tips are directed away at the chewing surface. The Charters method avoids the interdental papilla. Orthodontic patients, those who are post-perio surgery, and patients with fixed appliances may find the Charters a preferred method to loosen debris.

There are many different routes toward plaque removal and gingival health. Other methods, such as the circular Fones (great for first-time brushers), vertical, horizontal, Smith's and scrub brush, are less often recommended, and can even be destructive. As a clinician, you may find that these methods fit a particular patient's need for care in a given situation, but they generally are not recommended.

For a smooth-running, healthy mouth, you need a quality brush, good brushing discipline and a willing patient who will brush effectively without fail for several minutes. Once you have chosen the proper method for plaque disruption, given hands-on instruction, and proven it to be effective for the patient, you then can cross the finish line, with the checkered flag waving for a win-win situation.

Karen Kaiser, RDH, practices high-tech hygiene at the Center for Contemporary Dentistry in Illinois. She recieved her degree from Forest Park College in St. Louis in 1994. She is a 2002 Award of Distinction recipient from the John O. Butler Company and RDH magazine. She does consulting for 3M ESPE and is on their Dental Hygiene Advisory Panel. She may be contacted by e-mail at kjkaiser@