Brushing up on plaque removal

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  Posted by: Dental Design      16th October 2023

Why biofilm management is crucial for patients wearing orthodontic devices

The fact that scientists recently pieced together the genomes of two unknown species of bacteria from DNA fragments found in calcified tooth plaque from Neanderthal remains[i] goes to show just how resilient tartar can be. It also demonstrates that the problem of plaque build-up is as old as time itself. 

As you know, less than half of plaque is removed with brushing every day leaving about 60% after brushing to promote rapid regrowth. The regrowth rate for brushing with dentifrice is 27% lower than for brushing without it.[ii]

The type of brush that’s used is important too. The bristle tuft arrangement – flat trim, multilevel, angled – and brushing duration contribute to efficacy.[iii]

Indeed, one study showed that plaque removal increased with brushing time, tending towards a maximum removal at longer brushing times. At the extremes, brushing for 180 seconds removed 55% more plaque than brushing for 30 seconds. Brushing for 120 seconds removed 26% more plaque than brushing for 45 seconds. Interestingly, the use of dentifrice did not increase plaque removal during 60 seconds of brushing.[iv]

Dentifrice dividend

However, adding antibacterial ingredients within dentifrice is helpful for biofilm management.[v] When combined with fluoride (for caries prevention), antibacterial pastes provide an efficacious option for combating oral diseases.[vi]

Stannous fluoride has antibacterial effects against species associated with plaque, gingivitis, caries, and malodour, and it reduces plaque, gingival inflammation and bleeding. Stannous fluoride and sodium hexametaphosphate inhibit calculus and stain formation. Triclosan/copolymer fluoride dentifrices help reduce gingival inflammation and gingival bleeding when compared with conventional fluoride dentifrices.[vii]

While dental plaque grows naturally on the tooth surface and forms part of the mouth’s defence against exogenous microorganisms by serving as a colonisation barrier, it is vital to keep it under control. The accumulation of plaque poses several risks to oral health. Firstly, it can lead to tooth decay or dental caries. When plaque comes into contact with sugars and carbohydrates from food, acids are produced, attacking tooth enamel and leading to cavities. Additionally, bacteria in plaque can cause gingivitis. If not addressed, gingivitis can progress to periodontitis.[viii]

For patients who wear orthodontic devices or retainers, plaque removal is even more difficult. In orthodontic treatment, fixed appliances consisting of metals and polymers produce surfaces that differ from those of the natural oral hard and soft tissues. This creates retention areas in which it is difficult to perform mechanical plaque control. In addition, fixed appliances increase the amount of dental biofilm and cariogenic bacteria (Streptococcus mutans and Lactobacilli).[ix]

However, advancements in orthodontics have led to the development of devices that are easier to clean. For instance, clear aligners can be removed during brushing and flossing, reducing the chances of plaque build-up. Additionally, self-ligating braces and ceramic braces are designed to limit plaque retention compared to traditional braces.[x]

When it comes to retainers, the type worn significantly influences the overall periodontal health of patients as a clinical difference can be seen between the devices regarding plaque and calculus accumulation. Fixed retainers, both glass-fibre reinforced and steel wire retainers accumulate the most plaque compared to removable aligners.[xi]

Additional tools

Apart from regular brushing, flossing and mouthwash, there are additional tools that can aid in plaque control for wearers of orthodontic devices. Orthodontic wax can be used to cover irritating brackets or wires. Interproximal brushes and water flossers can also help remove plaque from hard-to-reach areas.

Certain dietary habits can exacerbate plaque build-up. While difficult, patients should be encouraged to limit the intake of sugary and acidic foods and beverages to reduce the risk of both tooth decay and plaque formation. Sticky and hard foods should also be avoided as they can damage braces and make cleaning more difficult. A balanced diet with plenty of fruits, vegetables and dairy products, which contribute to stronger enamel, remineralisation and gingival health, can be suggested.[xii]

Given the cleaning challenges when wearing orthodontic appliances, it is important that patients are taught accurate oral hygiene. Dental professionals attending Curaden Academy’s upcoming iTOP (individually trained oral prophylaxis) event in Bristol on 18th November will get to learn the revolutionary prevention-oriented programme that focuses on controlling the primary cause of oral diseases: biofilm. iTOP follows the golden standard in prevention: “Clean teeth cannot get sick.” Dental professionals play a pivotal role in instructing, motivating, and educating patients and iTOP equips them to be oral health heroes.

The problem of plaque build-up when wearing orthodontic devices is a significant concern, but with the right techniques and tools, it can be effectively managed. Maintaining a diligent oral hygiene routine and adopting a healthy diet are essential factors in preventing plaque accumulation. By practising good oral care habits, patients can ensure optimal oral health during their orthodontic treatment and beyond.

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[i] New Scientist

[ii] De la Rosa M, Zacarias Guerra J, Johnston DA, Radike AW. Plaque growth and removal with daily toothbrushing. J Periodontol. 1979 Dec;50(12):661-4. doi: 10.1902/jop.1979.50.12.661. PMID: 294479.

[iii] Slot DE, Wiggelinkhuizen L, Rosema NA, Van der Weijden GA. The efficacy of manual toothbrushes following a brushing exercise: a systematic review. Int J Dent Hyg. 2012 Aug;10(3):187-97. doi: 10.1111/j.1601-5037.2012.00557.x. Epub 2012 Jun 6. PMID: 22672101. [Abstract accessed October 2023]

[iv] American Dental Hygienists’ Association [Accessed October 2023]

[v] Marinho VT, Dos Reis AC, da Costa Valente ML. Efficacy of Antimicrobial Agents in Dentifrices: A Systematic Review. Antibiotics (Basel). 2022 Oct 14;11(10):1413. doi: 10.3390/antibiotics11101413. PMID: 36290071; PMCID: PMC9598644. [Accessed October 2023]

[vi] Randall, J., Seow, W. and Walsh, L. (2015), Antibacterial activity of fluoride compounds and herbal toothpastes on Streptococcus mutans: an in vitro study. Aust Dent J, 60: 368-374. [Accessed October 2023]

[vii] Marinho VT, dos Reis AC, da Costa Valente ML. Efficacy of Antimicrobial Agents in Dentifrices: A Systematic Review. Antibiotics. 2022; 11(10):1413. [Accessed October 2023]

[viii] Vyas T, Bhatt G, Gaur A, Sharma C, Sharma A, Nagi R. Chemical plaque control – A brief review. J Family Med Prim Care. 2021 Apr;10(4):1562-1568. doi: 10.4103/jfmpc.jfmpc_2216_20. Epub 2021 Apr 29. PMID: 34123892; PMCID: PMC8144784.[Accessed October 2023]

[ix] Saengphen T, Koontongkaew S, Utispan K. Effectiveness of a Combined Toothbrushing Technique on Cariogenic Dental Biofilm in Relation to Stainless Steel and Elastomeric Ligatures in Orthodontic Patients: A Randomized Clinical Trial. Healthcare. 2023; 11(5):731. [Accessed October 2023]

[x] Al-Anezi SA. Dental plaque associated with self-ligating brackets during the initial phase of orthodontic treatment: A 3-month preliminary study. J Orthod Sci. 2014 Jan;3(1):7-11. doi: 10.4103/2278-0203.127550. PMID: 24987657; PMCID: PMC4072391.[Accesssed October 2023]

[xi] Quinzi V, Carli E, Mummolo A, De Benedictis F, Salvati SE, Mampieri G. Fixed and removable orthodontic retainers, effects on periodontal health compared: A systematic review. J Oral Biol Craniofac Res. 2023 Mar-Apr;13(2):337-346. doi: 10.1016/j.jobcr.2023.02.015. Epub 2023 Mar 9. PMID: 36937559; PMCID: PMC10020103.[Accessed October 2023]

[xii] Tungare S, Paranjpe AG. Diet and Nutrition to Prevent Dental Problems. [Updated 2023 Jul 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: [Accessed October 2023]

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