MECHANICAL

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MECHANICAL PLAQUE CONTROL
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OBJECTIVES

• Background
• Mechanical plaque control
• (a) Toothbrush
• (b) Dentifrice
• (c) Interdental cleaning aids
• - Dental floss
• - Interdental brushes
• - tooth pik
• (d) Oral irrigation

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• IMPORTANT CHAPTER
• CLINICALLY VERY RELEVANT
• REQUIREMENT FOR PATIENT TEACHING

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Plaque as etiologic factor
Experimental gingivitis study (1965 Löe et al. )
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• The cause and effect relationship between
  supragingival plaque and gingivitis was
  demonstrated by Loe et al (1965).
• When plaque was allowed to accumulate, gingivitis
  developed within 21 days. When plaque control was
  initiated, the gingivitis was reversed (by means
  of efficient plaque control, i.e., brushing and
  flossing) to clinical gingival health
• The removal of microbial plaque leads to
  cessation of gingival inflammation, and cessation
  of plaque control measure leads to recurrence of
  inflammation

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• The removal of plaque also decreased the rate of
  formation of calculus. ( Sanders , 1962)
• Thus eliminating plaque is the key to prevent the
  occurrence of periodontal disease or halting the
  progression of the disease.

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Masses of plaque first develop ( Lang,1973)
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PLAQUE CONTROL

• Plaque control The removal of dental plaque on a
  regular basis and the prevention of its
  accumulation on the teeth and adjacent gingival
  surfaces.
• Position supra- sub-gingival plaque control
• Methods mechanical chemical

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MECHANICAL PLAQUE CONTROL

• OBJECTIVE
• Complete Daily Removal Of Dental Plaque
• With A Minimum Of
• Effort,
• Time,
• And Devices,
• Using The Simplest Methods Possible.

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Self-performed

• Tooth brushing
• Interdental aids
• Dental floss and tape
• Toothpicks
• Interproximal brushes
• Single-tufted brush
• Adjunctive aids
• Dental irrigation devices
• Tongue scrapers
• Dentifrices

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TOOTH BRUSH

• Toothbrush Design
• Methods of toothbrushing
• Frequency and effectiveness of toothbrushing
• Toothbrush wear and replacement
• Electric toothbrushes

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The Toothbrush

• First toothbrush -15th Century in China
• First modern toothbrush - England in 1780 by
  William Addis mass produced

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The Toothbrush

• Nylon toothbrush bristles - 1938 in USA (Du Pont)
• First electric toothbrush -1960s (Broxodent)
• 1987 first rotary action electric toothbrush
•  

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The Toothbrush

• Generally toothbrushes vary in size, design as
  well as in length and arrangements of bristles
  hardness.
• To overcome this variation ADA given
  specification of toothbrushes.
• -------------------------------------------------

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Toothbrush design

• American Dental Association (ADA)
• Length 1 to 1.25 inches
• Width 5/16 to 3/8 inches
• Surface area 2.54 to 3.2 cm
• No. of rows 2 to 4 rows of brushes
• No. of tufts 5 to 12 per row
• No. of bristles 80 to 85 per tuft

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Toothbrush bristles

• Natural hog
• Artificial filaments nylon

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NATURAL ARTIFICIAL
Source Hair of hog/ wild boar Synthetic, plastic material mainly nylon
Uniformity Non uniform Uniform
Diameter Varies Extra soft 0.075mm Hard 0.3 mm
End shape Irregular Rounded
Limitations Standardization not possible Wear rapid irregular Collection of debris microorganisms due to hollow ends Cleaning, rinsing and maintenance easy Wear Durable Repels debris end rounded Resistant to accumulation of microraganisms
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Bristle hardness

• Proportional to the square of the diameter and
  inversely proportional to the square of bristle
  length
• Soft brush 0.007 inch(0.2 mm)
• Medium brush 0.012 inch(0.3 mm)
• Hard brush 0.014 inch(0.4 mm)

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For most patients

• short-headed brushes
• with straight-cut,
• round-ended,
• soft to medium
• nylon bristles
• arranged in three or four rows of tufts
• ARE RECOMMENDED.

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TOOTH BRUSHING TECHNIQUES

• Various toothbrushing technique have achieved
  acceptance by the dental profession.
• Each technique has been designed to achieve a
  definite goal.
• Depending on the individual cases, the techniques
  of toothbrusing may have to be altered to achieve
  the maximum beneficial effects.

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• The efficacy of brushing with regard to plaque
  removal is dictated by three main factors
• The design of the brush
• The skill of the individual using the brush
• The frequency and duration of use
• 
  1986 Frandsen

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Effects and sequel of the incorrect use of
toothbrush
SEQUEL REASON
Gingival erosion Toothbrush stiffness
Gingival recession Method of brushing
Gingival abrasion Brushing frequency
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Toothbrushing methods

1. Horizontal brushing (scrub)
2. Leonard method (vertical)
3. Bass method (Sulcular cleaning)
4. Modified Bass methods
5. Stillman methos (vibratory)
6. Modified Stillman method (roll)
7. Charters method
8. Methods of cleaning with powered toothbrushes

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How to brush?

• Patient is instructed to start with molar region
  of one arch around the opposite side than
  continue back around the lingual or facial
  surfaces of the same arch
• Last surface to be brushed are occlusal.
• Patient instructed to stroke each area ten time
  or spend 10 seconds per area then move on to next
  area.
• Time 2 minutes ( 30 sec per quadrant )

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Method Bristle placement Motion Advantage/ disadvantage
Scrub Horizontal on gingival margin Scrub in anterior position direction keeping brush horizontal Easy to learn best suited for children
BASS Apical towards gingival into sulcus at 450 to tooth surface Short back and forth vibratory motion while bristles remain in sulcus. Cervical plaque removal Easily learned Good gingival stimulation
Charter's Coronally 45o, sides of bristles half on teeth and half of gingiva Small circular motions with apical movements towards gingival margin Hard to learn and position brush Clears inter proximal Gingival stimulation
Fones Perpendicular to the tooth With teeth in occlusions, move brush in rotary motion over both arches and gingival margin Easy to learn Inter proximal areas not cleaned May cause trauma
Roll Apically, parallel to tooth and then over tooth surface On buccal and lingual inward pressure, then rolling of head to sweep bristle over gingiva tooth Doesn't clean sulcus area Easy to learn good gingival stimulation
Stillman's On buccal and lingual, aplically at an ablique angle to long axis of tooth. Ends rest on gingiva and cervical part. On buccal and lingual slight rotary motions with bristle ends stationary Excellent gingival stimulation Moderate dexterity required Moderate cleaning of interproximal area
Modified stillman's Pointing apically at and angle of 45o to tooth surface Apply pressure as in stillmans's method but vibrate brush and also move occlusally Easy to master Gingival stimulation
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Method Bristle placement Motion Advantage/ disadvantage
Scrub Horizontal on gingival margin Scrub in anterior position direction keeping brush horizontal Easy to learn best suited for children
BASS Apical towards gingival into sulcus at 450 to tooth surface Short back and forth vibratory motion while bristles remain in sulcus. Cervical plaque removal Easily learned Good gingival stimulation
Charter's Coronally 45o, sides of bristles half on teeth and half of gingiva Small circular motions with apical movements towards gingival margin Hard to learn and position brush Clears inter proximal Gingival stimulation
Fones Perpendicular to the tooth With teeth in occlusions, move brush in rotary motion over both arches and gingival margin Easy to learn Inter proximal areas not cleaned May cause trauma
Roll Apically, parallel to tooth and then over tooth surface On buccal and lingual inward pressure, then rolling of head to sweep bristle over gingiva tooth Doesn't clean sulcus area Easy to learn good gingival stimulation
Stillman's On buccal and lingual, aplically at an ablique angle to long axis of tooth. Ends rest on gingiva and cervical part. On buccal and lingual slight rotary motions with bristle ends stationary Excellent gingival stimulation Moderate dexterity required Moderate cleaning of interproximal area
Modified stillman's Pointing apically at and angle of 45o to tooth surface Apply pressure as in stillmans's method but vibrate brush and also move occlusally Easy to master Gingival stimulation
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Tooth Brushing

• Three methods widely accepted the modified bass
  method, the modified stillman method( stillman
  1932), and the charters method( Carters 1948) .
• Controlled studied evaluating the most common
  brushing technique have shown that no one method
  is superior
• Recommended is Bass technique , because it
  emphasize sulcular placement of the bristles.
• Plaque control devices should be tailored
  according to individual plaque control needs.

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BASS OR SULCUS CLEANING METHOD

• Most accepted and effective method for the
  removal of dental plaque present adjacent to and
  underneath the gingival margin.
• INDICATIONS
• interproximal areas
• cervical areas beneath the height of contour of
  enamel.
• exposed root surfaces.

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TECHNIQUE

• The bristles are placed at a 45 degree angle to
  the gingiva and moved in small circular motions.
• Strokes are repeated around 20 times,3 teeth at a
  time.
• On the lingual aspect of the anterior teeth, the
  brush is pressed into the gingival sulci and
  proximal surfaces at a 45 angle.
• The bristles are then activated.
• Occlusal surfaces are cleaned by pressing the
  bristles firmly and then activating the bristles.

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Bass method
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ADVANTAGES

• Effective method for removing plaque.
• Provides good gingival stimulation.
• DISADVANTAGES
• Injury to the gingival margin.
• Time consuming.
• Dexterity.

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MODIFIED BASS TECHNIQUE

• INDICATION
• As a routine oral hygiene measure
• Intrasulcular cleansing.

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TECHINIQUE

• Vibratary and circular movements with sweeping
  motion
• Bristles are at 45 to the gingiva
• Bristles are swept over the sides of the teeth
  towards their occlusal surfaces in a single
  stroke.

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ADVANTAGES

• EXCELLENT SULCUS CLEANING.
• GOOD INTER PROXIMAL AND GINGIVAL CLEANING.
• GOOD GINGIVAL STIMULATION
• DISADVATAGES
• DEXTERITY

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MODIFIED STILLMANS TECHNIQUE

• INDICATIONS
• DENTAL PLAQUE REMOVAL
• CLEANING TOOTH SURFACES AND GINGIVAL MASSAGE .
• DISADVANTAGE
• TIME CONSUMING
• DAMAGE EPITHELIAL ATTACHMENT.

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TECHNIQUE

• Bristles are pointed apically with an oblique
  angle to the long axis of the tooth
• Bristles placed on the cervical aspect of the
  teeth
• Short back and forth motion moved in a coronal
  direction.

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CHARTERS METHOD

• INDICATIONS
• Persons having -
• Missing papilla and exposed root surfaces.
• FPD and Orthodontic appliances.
• Periodontal surgery.
• Interproximal gingival recession.

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TECHNIQUE

• A soft/medium multi-tufted tooth brush taken
• Bristles are placed 45 to the gingiva with
  bristles directed coronally.
• Mild vibratory strokes required with bristles
  ends lying interproximally.

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ADVANTAGES

• Massage and stimulation of gingiva.
• DISADVANTAGES
• Poor removal of subgingival bacterial
  accumulations.
• Limited brush placement.
• Requirements in digital dexterity are high.

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The Toothbrush

• The use of hard toothbrush , vigorous horizontal
  brushing, the use of extremely abrasive
  dentifrices may lead to cervical abrasion of
  teeth and recession of the gingiva.( Jepson
  ,1998)
• Toothbrushes need to be replaced every 3 months

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The Toothbrush

• Soft, nylon bristle toothbrush
• clean effectively (when used properly),
• remain effective for a reasonable time ,
• Soft bristle are more flexible and atraumatic
• clean beneath the gingival margin,
• reach farther into the proximal tooth surfaces.

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Lecture II
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Col area
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EMBRASURE

• V-shaped spillway next to the contact area of
  adjacent teeth
• Narrowest at the contact and widening toward the
  facial, lingual, and occlusal contacts

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Powered toothbrushes

• Invented in 1939.
• Motions
• Back and forth
• Circular
• Elliptic
• Combinations

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Cleaning action by

• Mechanical contact between the bristles and the
  tooth
• Low-frequency acoustic energy generates dynamic
  fluid movement and provides cleaning slightly
  away from the bristle tips.

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INDICATIONS

• Children and adolescents
• Children with physical or mental disabilities
• Hospitalized patients, including older adults who
  need to have their teeth cleaned by caregivers
• Patients with fixed orthodontic appliances.

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• Patients who can develop the ability to use a
  toothbrush properly usually do equally well with
  a manual or a powered toothbrush.
• Less diligent brushers do better with powered
  tooth brushes, which generate stroke motions
  automatically and require less operator effort.

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DENTIFRICES

• Aids in cleaning and polishing tooth surfaces.

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• Composition
• Abrasives- silicon oxides, aluminum oxide
• Humectants
• Water
• Soap or detergent
• Flavoring and sweetening agents
• Therapeutic agents such as fluorides and
  pyrophosphates
• Coloring agents and preservatives.

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The term dentifrice is derived from dens
(tooth) and fricare (to rub). A simple,
contemporary definition of a dentifrice is a
mixture used on the tooth in conjunction with a
toothbrush.
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• Dentifrices are marketed as
• Toothpowders
• Toothpastes
• Gels

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Original purpose

• Pleasant taste
• Cosmetic effect
• Remove extrinsic stains

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Abrasives

• Degree of abrasive hardness depends on
• inherent hardness of the abrasive
• size of the abrasive particle
• shape of the particle

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• Other variables
• the brushing technique
• pressure on the brush
• the hardness of the bristles
• the direction of the strokes
• number of strokes

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Abrasives used

• Calcium carbonate
• calcium phosphate
• baking soda (sodium bicarbonate)
• Silicas
• silicon oxides
• aluminum oxides

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Humectants

• Toothpaste consisting only of a toothpowder and
  water results in a product with several
  undesirable properties.
• Over time, the solids in the paste tend to settle
  out of solution and the water evaporates.
• This may result in caking of the remaining
  dentifrice.

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• To solve this problem, humectants were added to
  maintain the moisture.
• Commonly used humectants are
• Sorbitol,
• Mannitol,
• Propylene glycol

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• Advantages
• Long shelf life
• Maintained moisture content
• Nontoxic
• Disadvantages
• Mold or bacterial growth can occur in their
  presence

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Soaps

• Logical cleansing agent.
• The toothbrush bristles dislodge food debris and
  plaque
• The foaming action of the soap aids in the
  removal of the loosened material.

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• Disadvantages of soaps
• irritating to the mucous membrane
• flavor is difficult to mask
• often causes nausea
• soaps are incompatible with other ingredients,
  such as calcium.

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Detergents

• Substitute to soaps
• sodium lauryl sulfate (SLS) is the most widely
  used detergent

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• Advantages of SLS
• Stable
• Possesses some antibacterial properties
• Has a low surface tension which facilitates the
  flow of the dentifrice over the teeth
• Active at a neutral ph
• Flavor is easy to mask
• Compatible with the current dentifrice
  ingredients

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Flavoring and Sweetening Agents

• Flavor, along with smell, color, and consistency
  of a product, are important characteristics that
  lead to public acceptance of a dentifrice.
• The flavor must be
• pleasant,
• provide an immediate taste sensation, relatively
  long-lasting

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• Synthetic flavors are blended to provide the
  desired taste.
• Spearmint,
• peppermint,
• wintergreen,
• cinnamon,
• other flavors give toothpaste a pleasant taste,
  aroma, and refreshing aftertaste

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Sweetening Agents

• In early toothpaste formulations, sugar, honey,
  and other sweeteners were used.
• DISADVANTAGE these materials can be broken down
  in the mouth to produce acids and lower plaque
  pH, they may increase caries RISK.

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• Replaced with
• Saccharin,
• Cyclamate,
• Sorbitol,
• Mannitol

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• Sorbitol and mannitol serve a dual role as
  sweetening agents and humectants.
• Glycerin also serves as a humectant, adds to the
  sweet taste.
• A new sweetener in some dentifrices is xylitol.

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SPECIFIC DENTIFRICES
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Essential-Oil Dentifrices

• The essential-oil ingredients found in Listerine
  mouth rinse are also available in a dentifrice
  formulation.
• The clinical and laboratory data suggest a
  benefit to gingival health and plaque reduction
• This product does not carry the ADA Seal of
  Acceptance

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Therapeutic Dentifrices

• The most commonly used therapeutic agent added to
  dentifrices is fluoride, which aids in the
  control of caries.
• OTC The original level of fluoride -restricted
  to 1,000 to 1,100 ppm fluoride
• total of no more than 120 mg of fluoride in the
  tube
• Requirement that the package include a safety
  closure.

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• Therapeutic toothpastes, dispensed on
  prescription, could contain up to 260 mg of
  fluoride in a tube.

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• OTC safe levels
• 0.22 sodium fluoride (NaF) at a level of 1,100
  ppm,
• 0.76 sodium monofluorophosphate (MFP) at a level
  of 1,000 ppm,
• 0.4 stannous fluoride (SnF2) at a level of 1,000
  ppm.

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• Fluoride levels were increased to 1,500 ppm
  sodium monofluorophosphate in "Extra Strength
  Aim," marketed OTC.
• In published studies, this product was 10 more
  effective than an 1,100 ppm NaF dentifrice.
• A recently introduced prescription dentifrice,
  Colgate Prevident contains 5,000-ppm

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Stannous Salts

• Stannous fluoride (SnF2), specifically the
  stannous ion, has reported activity against
  caries, plaque, and gingivitis.
• While SnF2 has a long record as an anticaries
  agent, long-term stability in dentifrices and
  mouthrinses has been questioned since clinical
  antimicrobial activity has only been demonstrated
  in anhydrous state.

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Triclosan

• Triclosan is a broad-spectrum antibacterial agent
• It is effective against wide variety of bacteria
• A review of the available pharmacological and
  toxicological information
• Triclosan can be considered safe for use in
  dentifrice and mouth rinse products.

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Anticalculus Dentifrices

• Interrupt the process of mineralization of plaque
  to calculus.
• Plaque has a bacterial matrix that mineralizes
  due to the super saturation of saliva with
  calcium and phosphate ions.
• Crystal growth inhibitors may be added to
  dentifrices to provide a reduction in calculus
  formation.

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Antihypersensitivity Dentifrices

• Active agents such as
• potassium nitrate,
• strontium chloride,
• sodium citrate

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Whiteners

• Controversial
• These dentifrices control stain via physical
  methods (abrasives) and chemical mechanisms
  (surface active agents or bleaching/oxidizing
  agents).

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LECTURE 3
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Interdental cleaning aids

• Dental floss
• Interdental brushes
• Wooden or rubber tips

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Embrasures

• Gingival embrasure space a small triangular open
  space
• V-shaped spillway next to the contact area of
  adjacent teeth
• Gingival embrasure space evaluation is critical
  in determining which aid will provide the most
  accurate biofilm control.

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TYPE I

• Embrasure is filled completely by interdental
  papilla.
• Dental floss is effective

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TYPE II

• The height of interdental papilla is reduced.
• Interdental brushes and wooden toothpicks are
  effective.

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TYPE III

• The interdental papilla is missing.
• Interdental brushes and end-tuft brushes are
  effective.

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PLANNING INTERDENTAL CARE

• PATIENT HISTORY OF ORAL HYGIENE
• DENTAL AND GINGIVAL ANATOMY
• PLAQUE SCORES
• SELECTION OF INTERDENTAL AIDS

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DENTAL FLOSS

• Levi Spear Parmly
• REMOVES DENTAL BIOFILM
• REDUCES INTERPROXIMAL BLEEDING
• EFFICIENT IN TYPE I EMBRASURES

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TYPES OF DENTAL FLOSS

• Multifilament vs. monofilament
• Twisted vs. untwisted
• Bonded vs. unbonded
• Waxed vs. unwaxed

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• Monofilament resists breakage or shredding when
  passed over irregular tooth surfaces,
  restorations or calculus deposits.
• Waxed gives strength and durability during
  application.
• Shredding and breakage is rare

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Materials

• Silk loosely twisted, waxed
• Nylon multifilaments, waxed/ unwaxed
• circular (floss) or flat (dental tape)
• Expanded PTFE monofilament, waxed

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Floss Available

• Flattened floss is designed to increase the
  contact surface with the tooth.
• Ultra floss is spongy and soft.
• Round floss is relatively thinner.
• Superfloss contains segments of stiffened-end
  threader, spongy floss and regular floss.

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• Stiffened-end threader can make it easier to
  slide the superfloss through the gap between the
  teeth and fixed orthodontic appliances.
• Spongy floss cleans around the appliances and
  between wide spaces or to floss underneath the
  bridge.
• Regular floss removes plaque from the adjacent
  tooth surfaces.

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How to Floss
Firmly grasp the dental floss with index fingers.
Gently slide the floss in between both sides of
teeth and repeat until finished.
Using 18 inches of dental floss, wrap it lightly
around middle fingers.
Forming a C-shape, carefully slide the floss up
and down between tooth and gum line.
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Common Mistakes

• Not placing the floss under the gum line - Not
  placing dental floss carefully under the gum
  line, the area where plaque accumulation occurs
  most, will not be as effectivein the prevention
  of dental decay and periodontal disease.
• Rushing when flossing the teeth - One cannot
  perform proper flossing when rushingthrough the
  procedure of removing plaque. One should take at
  least 2-3 minutes when flossing.

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Misconception

• Flossing is not just supposed to remove food
  particles from between teeth.
• The primary function of dental floss is to remove
  the invisible film of bacteria that constantly
  forms between teeth i.e. plaque. Flossing should
  be performed between each tooth.

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INTERDENTAL BRUSH

• Open embrasure spaces
• Type II III
• Root concavities

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Root Concavities

• They are trenchlike depression in the root
  surface.
• In health, root concavities are covered with
  alveolar bone.
• In periodontitis, junctional epithelium migrates
  apically with bone and tissue destruction,
  exposing the root concavity to the oral
  environment.

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Interdental brush
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Steps for Use ofthe Interdental Brush

• Hold brush handle between the thumb and the index
  finger
• Gently insert between teeth
• Maintain brush at a 90-degree angle to the long
  axis of the tooth
• Use slight pressure to adapt brush

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• Slide brush in and out of the space
• Adapt brush to the mesial surface of the first
  premolar
• For posterior areas, advise the patient to close
  his or her mouth slightly to relax the cheek.
• It is helpful to bend the brush to facilitate
  insertion.

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Single tufted brush

• A single tuft or group of small tufts, may be 3-6
  mm in diameter
• Flat or tapered
• Handle straight or contra- angled

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Indications

• Type II embrasures
• Fixed dental prosthesis
• For difficult to reach areas

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INTERDENTAL TIP

• Conical or pyramidal flexible rubber tip attached
  to the end of the handle of a toothbrush.
• Soft, pliable rubber tip adapted to the
  interdental area and below gingival margin
• Does not cause damage to epithelial lining.

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INDICATIONS

• Interdental embrasure type II
• Plaque removal at or just below the gingival
  margin.

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WOODEN TIP

• Wooden cleaner is a 2 inch long device
• Made of
• basswood
• birch wood
• It is triangular in cross section
• Indication type III embrasure

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GINGIVAL MASSAGE

• Advantages
• Epithelial thickening,
• increased keratinization,
• increased mitotic activity in epithelium and
  connective tissue
• alteration or removal of plaque

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Oral irrigation devices

• Supragingival irrigation
• Subgingival irrigation

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Supragingival vs. Subgingival Irrigation

• The objective of supragingival irrigation is to
  diminish gingival inflammation by disrupting
  biofilms coronal to the gingival margin.The
  goal of subgingival irrigation is to reduce the
  number of bacteria in the periodontal pocket
  space.

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Dental Water Jet

• Device that delivers pulsed irrigation of water
  or other solution supragingivally and
  subgingivally
• Also known as dental water irrigator, home
  irrigator, water flosser

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Mechanism of Action

• Delivers a pulsating fluid that incorporates a
  compression and decompression phase
• This creates two zones of fluid movement called
  hydrokinetic activity.
• Impact zoneinitial fluid contact with an area of
  the mouthFlushing zonedepth of fluid
  penetration within a subgingival sulcus or
  periodontal pocket

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Benefits of Home Irrigation

• Biofilm removal
• Bleeding reduction
• Gingival inflammation reduction
• Periodontal pathogens reduction
• Reduction in inflammatory and destructive host
  response

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Indications for Recommendation

• Individuals on periodontal maintenance
• Individuals who are noncompliant with dental
  floss
• Individuals with special needs
• Individuals with dental implants
• Individuals with diabetes
• Individuals with orthodontic appliances
• Individuals with prosthetic bridgework and crowns

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Precautions

• Incidence of bacteremia is similar to other oral
  healthcare devices.
• Before recommending a water jet to a patient who
  is at high risk for infective endocarditis,
  dental healthcare providers should consider both
  the patient's overall medical and oral health
  status.
• Consultation with a physician is advisable for
  patients at high risk for infective endocarditis.

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Irrigating Solutions

• Water
• Antimicrobial solutionsChlorhexidineEssential
  oilsOther solutions

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TONGUE CLEANING

• Daily tongue cleaning removes pathogenic bacteria
  on the dorsum surface.
• Reduces bacteria in the saliva
• Improves taste sensation
• Reduces halitosis
• Removes volatile sulfur compounds, which are
  gases that cause halitosis

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• Manual tongue cleaners come in a variety of
  styles.Toothbrush with a thin headTongue
  scrapersAll types are designed to allow
  patients to reach the back of the tongue.

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Any QUESTIONS????