TASKS. 2. Apply a disclosing agent to make the plaque visible.

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1 TASKS EQUIPMENT AND MATERIALS Personal protective equipment Assortment of nylon, soft-bristled toothbrushes Assortment of dental Floss, waxed and nonwaxed Disclosing solution Face mirror 3. Demonstrate how to how to grasp the toothbrush handle (Figure14). Hold the long end of the toothbrush handle directing the bristles up. Press the thumb against the back of the handle. DIRECTIONS: First, practice personal plaque removal following the steps under Demonstrate Toothbrushing and Demonstrate Flossing. Next, role-play teaching plaque removal with a student partner. One student will act as the clinician and the other will be the patient. When you are finished, reverse roles with your partner and repeat the exercise. 1. Seat the patient in an upright position. 2. Apply a disclosing agent to make the plaque visible. 3. Give the patient a mirror and ask the patient to identify areas of plaque accumulation. 4. Ask the patient to clean the teeth using his/her normal at-home routine. 5. If flossing is a part of the patient s normal oral hygiene routine, ask the patient to demonstrate his/her flossing technique on 1-2 teeth selected in each quadrant. 6. Observe the patient s plaque removal techniques and assess their effectiveness. NOTE: If all of the plaque has been removed and there is no evidence of tissue trauma, provide positive reinforcement of the patient s oral hygiene technique. If there is plaque, gingival inflammation or tissue trauma, teach plaque removal using the following steps. First demonstrate on a typodont or tooth model, and then ask the patient to demonstrate proper technique. Figure 14. Grasping the toothbrush handle. Demonstrate Toothbrushing The Modified Bass Method Using appropriate descriptive terms, tell the patient to: 4. Start on the buccal surface of the most posterior teeth in the upper right quadrant. (The outside or cheek-side of the back tooth on the right side). Place the tips of the bristles at a 45 angle to the gingival margin (Figure 15). Note: A 45 angle may be difficult for the patient to conceptualize. Emphasize that the bristles should be placed into the sulcus. 5. Lightly flex the bristles and gently guide the tips submarginally (below the gumline ). Press lightly to spread the bristles around the gingival margin. DEMONSTRATE TOOTHBRUSHING 1. Choose the proper toothbrush for the patient s oral condition. 2. Explain the design features of a proper toothbrush. Figure 15. Positioning of the toothbrush bristles. 8

2 6. Move the brush in a small, circular or back and forth motion to remove plaque from the sulcus. Vibrate the brush in the sulcus. Vibrate means to move quickly in a small, back and forth motion (Figure 16). Count at least 10 vibrations before moving onto the next teeth in sequence. Figure 16. Cleaning the buccal tooth surfaces. 7. Complete all the facial surfaces (outside surfaces) of the upper teeth in sequence (Figure 17). Be sure to overlap tooth surfaces when repositioning the brush head. Figure 18. Brushing the lingual surfaces of the maxillary posterior teeth. 9. Hold the toothbrush in a vertical position for the lingual surfaces of maxillary anterior teeth (inside surfaces of the upper front teeth). Use the same technique. Count at least 10 vibrations before moving onto the next teeth in sequence (Figure 19). Complete the maxillary arch. Figure 17. Brushing the facial surfaces of the maxillary teeth. 8. Next, brush the lingual surfaces of the maxillary teeth. Begin with the most posterior teeth in the maxillary left quadrant. Position the bristles at a 45 angle at the gingival margin. Flex the brush slightly and slide the bristles into the sulcus. Count at least 10 vibrations before moving onto the next teeth in sequence (Figure 18). Figure 19. Brushing the lingual surfaces of the maxillary anterior teeth. 10. Brush the mandibular ( lower or bottom ) teeth using the same sequence and technique. Begin with the buccal surfaces of the most posterior teeth in the mandibular right quadrant. Position the bristles at a 45 angle at the gingival margin. Flex the brush slightly and slide the bristles into the sulcus. Vibrate the brush in the sulcus for 10 seconds (Figure 20). Figure 20. Brushing the facial surfaces of the mandibular posterior teeth. 9

3 11. Complete all the facial surfaces of the mandibular teeth in sequence. Repeat the technique for the lingual surfaces of the mandibular teeth. Begin with the most posterior teeth in the mandibular left quadrant. Repeat the brush position and vibrating motion described previously (Figure 21). 1. Place the side of the brush on the attached gingiva with the tips of the bristles directed apically. Flex the side of the brush lightly against the gingiva. 2. Roll the brush slowly over the teeth moving the tips of the bristles coronally (Figure 23). Repeat the stroke five times before moving on to the next three teeth in sequence. Figure 23 Brushing the facial surfaces with the rolling technique. Figure 21. Brushing the lingual surfaces of the mandibular posterior teeth. 12. Hold the toothbrush in a vertical position for the lingual surfaces of mandibular anterior teeth (Figure 22). Count at least 10 vibrations before moving onto the next teeth in sequence. Complete the lingual surfaces of mandibular teeth in sequence. Cleaning the Occlusal Surfaces 1. With all methods, the occlusal surfaces are cleaned using short, scrubbing strokes. Adapt the tips of the bristles to the occlusal surfaces of the teeth. Place pressure against the occlusal surface for deep penetration of the bristles into the pits and fissures. Use a short, back-and-forth scrubbing motion for 10 seconds before moving on to the next three teeth in sequence (Figure 24). Figure 22. Brushing the lingual surfaces of the mandibular anterior teeth. Toothbrushing Rolling Stroke Method NOTE: Use the rolling method on all maxillary and mandibular teeth after sulcular brushing. Used in conjunction, these two brushing methods achieve effective plaque removal from sulcular, facial, and lingual tooth surfaces. The sequence is the same as for sulcular brushing. The adaptation of the brush and stroke are different. Figure 24. Cleaning the occlusal tooth surfaces. 10

4 DEMONSTRATE FLOSSING 1. Identify flossing as an appropriate plaque removal method for this patient and explain the purpose of dental floss to the patient. Use appropriate descriptive terms when instructing the patient. Substitute words for effective instruction may include where the teeth touch instead of the contact area, gum tissue instead of interdental papilla or side of the tooth instead of proximal tooth surface. Tell the patient to: 2. Dispense about inches (40 45 cm) of dental floss. 3. Loosely wrap the floss around the middle finger of each hand (Figure 25). Wrap most of the floss around one of the fingers. Wind the remainder of the floss around the finger of the other hand; this finger can wind up the floss as it becomes used. Figure 26. The patient uses the index fingers and thumbs to guide the floss into place. A, Holding the floss to clean the mandibular teeth. B, Holding the floss for flossing the maxillary teeth. 4. Leave about 2 3 inches (5 to 7 cm) of floss between your hands. Be sure that your thumbs and index fingers are free. You will control the floss with these fingers when you are flossing the teeth. Figure 27. Inserting the floss interproximally. 7. Wrap the floss in a C shape around the proximal surface of the tooth (Figure 28). Slide the floss under the free gingiva as far as it will go. Keep the floss taught around the tooth surface. Figure 25. Wrapping dental floss. 5. Grasp the floss leaving about one inch (2.5 to 3 cm) of floss between your first fingers (Figure 26). 6. Use a sawing, back-and-forth motion to gently move the floss through the contact (Figure 27). Avoid snapping the floss through the contacts; this could injure the interdental papilla. Figure 28. Adapting the floss to the proximal tooth surfaces. 11

5 Figure 29. Effective use of dental floss to remove proximal dental plaque. Adapted from MediClip image copyright 2003 Williams & Wilkins. All rights reserved. 8. Slide the floss up and down on the tooth surface several times (Figure 29 A & B). 9. Repeat the process to clean the proximal surface of the adjacent tooth (Figure 29C). 10. Pass the floss back through the contact to remove it from the teeth. 11 Floss all the teeth in the mouth using the proper technique (Figure 30). Slide the floss up and down five to six times on each proximal surface. Follow a sequence to be sure to reach all proximal surfaces. 12. When the floss becomes frayed or soiled, unwind fresh floss from the finger of the appropriate hand and take up the used floss on the other finger. 13. Remind the patient to floss the distal surface of the most posterior tooth in each quadrant (Figure 31). At best, the toothbrush will only reach part of the distal surface; dental floss is needed for complete plaque and debris removal in that area. Figure 30. Flossing the posterior teeth. Figure 31. Flossing the distal surface of the mandibular second molar. 12

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