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Methods of oral care products according to caries risk profile

The determination of the individual's caries risk profile, followed by the individual-specific prophylaxis approach, is extremely important. Today there are many different oral care products. It is necessary to propose products suitable for the individual's needs. The use of oral dental health care products with mechanical plaque control is essential. Mechanical plaque control is essential for daily oral care and should be supplemented with oral care products.

Abstract:

It is important to maintain preventive approaches based on individual needs after assessing the caries risk profile.  There are many different oral care products available today. It is necessary to advise patients proper products, based on individual needs.

Mechanical plaque control is essential to maintain daily oral hygiene, but it must be supported by oral care products. It is important for the dentist to provide patients with instructions about the most effective use of these products, their purposes, and techniques for use.

In modern restorative dentistry; firstly, it is very important to determine the individual risk profile of caries and then individual prophylaxis approach.

Developing scientific technology provides consumers with a wide range of oral and dental care products.

The oral and dental health of each individual should be considered unique to the individual and care products should be consciously recommended for the continuity of dental and gum health.

In this article, oral dental health care products; Toothbrushes, toothpaste, mouthwashes, inter-toothbrushes, a tongue brush, floss, gels and chewing gum are evaluated under the headings of caries risk profile reported areas of use.

ORAL CARE PRODUCTS

Toothbrushes:

Plaque removal effects of toothbrushes are continuously investigated and various changes are made in the direction of these studies.

The patient's oral structure, gingival health and dexterity are important to determine the type of toothbrush to be recommended. The size of the brush and the tip of the brush should be determined by the person and age. There are three types of toothbrush: soft, medium and hard depending on the hardness of the bristle bundles.

In general, manual brushes are recommended for people with normal dexterity, individuals with poor dexterity, pediatric patients, and electric brushes for mentally and physically disabled individuals are recommended.

Rotary head brushes should be avoided in cases of erosion. Soft brushes for erosion cases, medium hardness and rotating head brushes for patients with a high risk of caries, soft or medium hardness brushes for individuals with periodontal disease, corrugated brushes gripping brackets for patients undergoing orthodontic treatment and prosthesis brushes for patients using removable dentures should be recommended. Brush bristles that change colour as they are used to prevent people from using the same brush for a long time are also preferred.


Electric Toothbrushes:

The electric toothbrushes produced today to provide the opportunity to reach the maximum area on the tooth surface due to their back and forth movements. Studies have shown that the cleaning rate in interproximal areas is higher than in the manual brush. Effective and correct use of electric toothbrushes prevents dental plaque formation. It has been found to be more effective in terms of plaque cleansing activity, especially in orthodontic patients. The use of an electric toothbrush is different from the use of a manual toothbrush. The electric brush should only be contacted at a 45-degree angle to the teeth and gum tissues, and no excessive pressure should be applied. The brushing time with the electric toothbrush is approximately 4 minutes for the entire mouth. They can be used by more than one person since the brush part of the electric toothbrushes can be changed.


When should children start brushing their teeth?

When the baby is 6 - 8 months old (ie when the first teeth appear in the mouth), cleaning should begin. After breakfast and before going to bed at night to wipe the teeth with a clean cheesecloth or gauze, soft toothbrushes produced for babies or brushes applied to the finger with the help of paste-free cleaning will be appropriate. It is very difficult to have a technique for brushing teeth in preschool children. What is important at this age is to give the child the habit of brushing teeth. When children brush their teeth, they often brush their visible or easily accessible faces. However, in order to prevent caries, the interfaces and chewing surfaces of the teeth should be cleaned much better. For this reason, it is necessary to control the parents during brushing.


TOOTH PASTES

Toothpaste is one of the most used substances for oral health in the world. In the content of toothpaste; abrasives, moisturizers, binders, foaming agents, sweetening agents, preservatives, therapeutic agents and water. The size and quantity of the grain structure of the particles forming the toothpaste structure is directly proportional to the wear on the tooth surface during tooth brushing. Proposing replacement of toothpaste from time to time will prevent continuous exposure to the same abrasive.

Fluorine, menthol, sodium fluoride, triclosan and so on. were added to increase the effects of toothpaste. 90% of toothpaste produced in the USA, Canada and other developed countries contain fluoride. The presence of fluoride in dental plaque, dental structures and saliva are extremely important for remineralization. Research has shown that the incidence of tooth decay is reduced in populations using a toothpaste containing flüoride. Many different kinds of toothpaste are offered to consumers. These; toothpaste for children, toothpastes for sensitive teeth and gums, toothpaste for preventing dry mouth, toothpaste for reducing halitosis, toothpaste for smokers. From the dentist's point of view, there is no best or ideal paste, the patient's oral condition should be taken into consideration when recommending toothpaste. In adult patients with low caries risk, toothpaste of 1000 - 1450 ppm is sufficient to prevent caries. Toothpaste containing fluoride and antiplaque agents should be recommended in adult patients with a high risk of caries (5000 ppm). In addition to antibacterial toothpastes, herbal and anti-tartar pastes can be recommended for individuals with periodontal disease. In the case of gingival recession, cement is exposed, gel-shaped toothpaste with minimum abrasive properties should be preferred. In patients receiving orthodontic treatment, antibacterial toothpaste should be combined with mouthwashes. Toothpaste containing fluorine and special salivary enzymes, low or no sodium lauryl sulfate and abrasive agents should be preferred in patients with a dry mouth; In addition, soft toothbrushes should be recommended in these patients, saliva flow rate increase other products (mouthwash, chewable tablet, spray, moisturizing gel) should be used. Toothpaste with whitening properties should be used as a support for professional whitening processes for a short time.


Which toothpaste should be used in children and how much?

Toothpaste is not recommended for infants and children with low risk of caries until the age of 2 in terms of risk of swallowing. Toothpaste should be used after 2 years of age. Lentil-sized putty will be enough for scrubbing. Toothpaste containing fluoride at a concentration of 500 ppm or less are suitable for children under 6 years with low caries risk. Standard 1000 ppm toothpaste can be used for children under 6 years of age who are at high risk of caries.


MOUTH GARAGES

In dentistry, mouthwashes are used to prevent, treat and assist professional practice. Oral mouthwashes should be evaluated according to their contents and recommended to patients according to individual needs. Dental biofilm, defined as a complex and dynamic microbial ecosystem, plays an important role in the development of dental caries and periodontal diseases. Mechanical cleaning is essential for continuity of oral and dental health. Oral care products benefit only when applied together with mechanical cleaning.

Mouthwashes are used when:

  • as an adjunct to remineralization
  • acute mucosal and gum infections
  • period of recovery after periodontal surgical procedures
  • after surgical procedures
  • in children with a high risk of caries and disabled individuals older than 6 years

Mouthwashes are generally of the same content as toothpaste and do not contain abrasives unlike pastes, but may contain a preservative and alcohol. Active ingredients in mouthwash; fluoride and fluoride compounds are calcium and phosphate, sodium lauryl sulfate, triclosan, metal ions (zinc, tin), hydrogen peroxide, aminoglycosides and glycosoxidase, essential oils (menthol, eucalyptol), chlorhexidine, pyrophosphate and potassium salts. Many types of mouthwash reduce the number of bacteria present in the mouth thanks to the antibacterial agents they contain and are used therapeutically for the treatment of gingivitis and periodontitis. For this purpose, chlorhexidine and benzydamine HCl containing mouthwashes are preferred.

Mouthwashes relieve symptoms of painful ailments such as aphthomatous ulcers, candida infections. Chemotherapeutic treatment methods for the prevention of dental caries are also recommended to people at high risk of caries. This approach envisages the use of two well-known products (fluoride and chlorhexidine) for antimicrobial protection.  Fluoride and chlorhexidine have a strong antimicrobial effect against MS.  This antimicrobial activity provides long-term suppression of MS. 

Clinical observations have shown that local fluoride is one of the most successful anticarcinogenic agents. Solutions, gels, toothpaste and mouthwashes are local agents used. With these local agents, the time of exchange of the enamel surface is important for efficacy because short-term changes do not yield the required amount of fluoride and some of the fluoride is removed by saliva.


Fluoride Mouthwashes:

The use of fluoride-containing mouthwashes is recommended due to their effects on remineralization and bacterial plaque. Fluoride mouthwashes for individuals over 6 years; Recommended daily (0.05% NaF) or weekly (0.20% NaF). Fluoride-containing mouthwashes are recommended for orthodontic treatment, high risk of caries, treatment of dry mouth and radiation therapy. Usage protocol; is shaken for 4 minutes in the mouth and completely expectorated.  The reason why mouthwashes cannot be recommended in protective programs for children under 6 years; This is because the oral muscles in children of this age do not have the coordination of both shakings during the specified time and being able to completely (without swallowing) the mouthwash.


Fluoride-containing gels and foams:

Fluoride-containing gels and foams can be applied with application spoons or brushed on the teeth. These products must be applied by the dentist in the practice environment. However, children and adults with a high risk of caries are also advised to use these products at home. When home care is recommended to pediatric patients at home, it should be performed under adult control.

Mouthwash, gel or varnishes combined with fluoride toothpaste have been reported to be 23% effective in preventing caries in individuals with high risk of caries.


Products Containing Chlorhexidine:

Chlorhexidine is one of the most studied and studied antimicrobial agents for more than 40 years. Chlorhexidine is used as a mouthwash, toothpaste and varnish as antiplaque and anticarcinogenic agent in dentistry.

Chlorhexidine is a broad-spectrum antibacterial agent that acts on Gram-negative and gram-positive bacteria. Streptococci have been reported to be more sensitive than staphylococci. Studies on individuals with a high risk of caries have been shown to suppress mutans streptococci for a long time and reduce caries formation.

Chlorhexidine is also effective against yeasts and viruses. To reduce the number of mutans streptococci and Porphyromonas gingivalis found in patients with root surface caries, it is used in patients receiving herpetic mouth lesions, prosthetic patients with candida infections, and radiotherapy and chemotherapy for head and neck cancers. Also effective for HIV and Hepatitis B virüs. 

The advantage of chlorhexidine over other agents is its ability to bind to many surfaces in the oral cavity. The positively charged chlorhexidine binds mostly to the oral mucosa, microorganisms or anions such as sulfate, phosphate, carboxyl groups in the pellet. It provides more binding to soft tissues. This feature allows chlorhexidine to bind to bacterial surfaces, affects adhesion, initiates bacterial destruction. It provides a long-lasting effect with its ability to bind into the plaque, accumulation and release from soft tissues. 

Soft tissues in the mouth are important structures for the retention of chlorhexidine. Chlorhexidine levels increase in saliva 24 hours after administration. Chlorhexidine has been reported to have an affinity for salivary mucins in vitro and is effective in explaining the in vivo mechanism of the drug. Chlorhexidine molecules can attach to oral surfaces through reversible electrostatic binding and are released slowly as the concentration of saliva from the retention sites decreases and the relative concentration of saliva calcium increases. The bactericidal effect when chlorhexidine is first applied shows the bacteriostatic effect as a result of adsorption of pellet covering enamel surface.

S.mutans can be suppressed for a long time with chlorhexidine gels or mouthwashes, but this suppression depends on the concentration of chlorhexidine and the frequency of exposure to chlorhexidine.

The long-term use of antiplaque agents includes the risk of changes in the ecology of oral flora and the formation of resistant bacterial strains.


Combination of Fluoride and Chlorhexidine

Some researchers have reported that the combined use of chlorhexidine and fluoride has a longer-lasting antibacterial effect.

The mechanisms of action of fluoride and chlorhexidine alone are different, and their combined use has been reported to produce synergistic effects, and optimum protection of enamel and dentin has been achieved with uniform varnish application. Another advantage of combined use is that it can be applied at a lower concentration than when used alone. Fluoride applications have been reported to aid in the treatment of chlorhexidine in suppressing mutans streptococci. It is reported that chlorhexidine does not interfere with the physicochemical effects of fluoride with enamel or fluoride uptake by enamel. It has also been reported that in vivo plaque deposition is further inhibited by the combined use of chlorhexidine and fluoride than with the use of fluoride mouthwash alone. The combined use of chlorhexidine and fluoride is recommended for the high risk of caries because of these advantages.

The protocol for the use of chlorhexidine mouthwashes in individuals at high risk of caries and in older children; It is rinsed for 30 seconds with 10 ml mouthwash before going to bed for 2 weeks to repeat every 3 months. Use of alcohol-containing preparations in children is contraindicated. Yellowish discolouration and taste problems in long-term use have been reported as side effects of chlorhexidine. 

Dry mouth may develop due to many reasons, but it is a common finding in patients receiving radiotherapy.

The main approach to be taken into consideration in the prevention of dental caries is the use of fluorides with mechanical plaque control. Neutral fluoride preparations and chlorhexidine preparations are often used in these patients. Preparations with NaF are the agents that should be preferred in patients undergoing radiotherapy in terms of both being at neutral pH and being used together with other mouthwashes.


DENTAL FLOSS

It is not possible to reach every surface of the teeth with toothbrush and toothpaste. Especially interproximal areas cannot be cleaned with manual toothbrushes. Auxiliary hygiene materials should be used to clean these areas. Dental floss is the most commonly used material. Special dental flosses are produced for the underbody of prosthetic restorations. These products play an important role in oral care. The surfaces of the filling and prosthetic teeth must be cleaned especially by using dental floss. In such environments, food accumulation and calculus formation increase, causing underfill caries and gum disorders. 

Dental flosses are held between the thumbs or index fingers of both hands and inserted between the teeth, cleaning the surfaces of both adjacent teeth. In the case of bridge bodies, underneath the body can be cleaned with ropes produced under the body. When using floss, the patient should be told about the correct usage method as it may cause irritation of the gums.


INTERFACE BRUSHES

They are special brushes used to clean the teeth and under the bridge. Interfacial brushes effectively clean large gaps, teeth and under bridges thanks to a specially angled brush handle and interchangeable brush heads. It is the material that facilitates oral hygiene for people who have diastemas between their teeth due to periodontal disease. In orthodontic treatment, the toothbrush is often insufficient and the interface brush and the wires should be cleaned.

The tapered or cylindrical interchangeable brush heads allow effective and safe cleaning of the bacterial plaque. Soft spongy brush nozzles can be used for postoperative care, implant care, oral lesions and wounds, and for medication applications.


TONGUE BRUSHES

When oral and dental health is considered as a whole, the tongue is an organ that needs to be cleaned. As a result of the researches, it was found out that tongue is one of the reasons and the predominant one is bad breath. It is known that the present papillary structure and formations of the tongue form a suitable ground for the growth and growth of microorganisms. The anatomical structure of the tongue is the most suitable site for sulfur compounds that produce odour. For these reasons, cleaning the tongue, removing bad breath and reducing the number of microorganisms are important in terms of preventing and reducing intraoral infections. 

After each tooth brushing, brushing with appropriate brushes on the tongue can be recommended especially for patients suffering from bad breath. The use of tongue brushes is in the form of brushing the upper surface of the tongue from the back to the front.