Flossing Technique

Flossing is an essential part of oral hygiene that helps remove plaque and food particles from between the teeth and along the gumline, areas that toothbrushes may not effectively clean. Proper flossing technique is crucial for maintaining gum health and preventing cavities.

Flossing Technique

1. Preparation:

   • Length of Floss: Take 12 to 18 inches of dental floss. This length allows for adequate maneuverability and ensures that you can use a clean section of floss for each tooth.
   • Grasping the Floss: Hold the floss taut between your hands, leaving a couple of inches of floss between your fingers. This tension helps control the floss as you maneuver it between your teeth.

2. Inserting the Floss:

   • Slip Between Teeth: Gently slide the floss between your teeth. Be careful not to snap the floss, as this can cause trauma to the gums.
   • Positioning: Insert the floss into the area between your teeth and gums as far as it will comfortably go, ensuring that you reach the gumline.

3. Flossing Motion:

   • Vertical Strokes: Use 8 to 10 vertical strokes with the floss to dislodge food particles and plaque. Move the floss up and down against the sides of each tooth, making sure to clean both the front and back surfaces.
   • C-Shaped Motion: For optimal cleaning, wrap the floss around the tooth in a C-shape and gently slide it beneath the gumline.

4. Frequency:

   • Daily Flossing: Aim to floss at least once a day. Consistency is key to maintaining good oral hygiene.
   • Best Time to Floss: The most important time to floss is before going to bed, as this helps remove debris and plaque that can accumulate throughout the day.

5. Flossing and Brushing:

   • Order of Operations: Flossing can be done either before or after brushing your teeth. Both methods are effective, so choose the one that fits best into your routine.

Classification of Periodontal Pockets

Periodontal pockets are an important aspect of periodontal disease, reflecting the health of the supporting structures of the teeth. Understanding the classification of these pockets is essential for diagnosis, treatment planning, and management of periodontal conditions.

Classification of Pockets

1. Gingival Pocket:

   • Also Known As: Pseudo-pocket.
   • Formation:
     • Formed by gingival enlargement without destruction of the underlying periodontal tissues.
     • The sulcus is deepened due to the increased bulk of the gingiva.
   • Characteristics:
     • There is no destruction of the supporting periodontal tissues.
     • Typically associated with conditions such as gingival hyperplasia or inflammation.

2. Periodontal Pocket:

   • Definition: A pocket that results in the destruction of the supporting periodontal tissues, leading to the loosening and potential exfoliation of teeth.
   • Classification Based on Location:
     • Suprabony Pocket:
       • The base of the pocket is coronal to the alveolar bone.
       • The pattern of bone destruction is horizontal.
       • The transseptal fibers are arranged horizontally in the space between the base of the pocket and the alveolar bone.
     • Infrabony Pocket:
       • The base of the pocket is apical to the alveolar bone, meaning the pocket wall lies between the bone and the tooth.
       • The pattern of bone destruction is vertical.
       • The transseptal fibers are oblique rather than horizontal.

Classification of Periodontal Pockets

1. Suprabony Pocket (Supracrestal or Supraalveolar):

   • Location: Base of the pocket is coronal to the alveolar bone.
   • Bone Destruction: Horizontal pattern of bone loss.
   • Transseptal Fibers: Arranged horizontally.

2. Infrabony Pocket (Intrabony, Subcrestal, or Intraalveolar):

   • Location: Base of the pocket is apical to the alveolar bone.
   • Bone Destruction: Vertical pattern of bone loss.
   • Transseptal Fibers: Arranged obliquely.

Classification of Pockets According to Involved Tooth Surfaces

1. Simple Pocket:

   • Definition: Involves only one tooth surface.
   • Example: A pocket that is present only on the buccal surface of a tooth.

2. Compound Pocket:

   • Definition: A pocket present on two or more surfaces of a tooth.
   • Example: A pocket that involves both the buccal and lingual surfaces.

3. Spiral Pocket:

   • Definition: Originates on one tooth surface and twists around the tooth to involve one or more additional surfaces.
   • Example: A pocket that starts on the mesial surface and wraps around to the distal surface.

Significant Immune Findings in Periodontal Diseases

Periodontal diseases are associated with various immune responses that can influence disease progression and severity. Understanding these immune findings is crucial for diagnosing and managing different forms of periodontal disease.

Immune Findings in Specific Periodontal Diseases

1. Acute Necrotizing Ulcerative Gingivitis (ANUG):

   • Findings:
     • PMN (Polymorphonuclear neutrophil) chemotactic defect: This defect impairs the ability of neutrophils to migrate to the site of infection, compromising the immune response.
     • Elevated antibody titres to Prevotella intermedia and intermediate-sized spirochetes: Indicates an immune response to specific pathogens associated with the disease.

2. Pregnancy Gingivitis:

   • Findings:
     • No significant immune findings reported: While pregnancy gingivitis is common, it does not show distinct immune abnormalities compared to other forms of periodontal disease.

3. Adult Periodontitis:

   • Findings:
     • Elevated antibody titres to Porphyromonas gingivalis and other periodontopathogens: Suggests a heightened immune response to these specific bacteria.
     • Occurrence of immune complexes in tissues: Indicates an immune reaction that may contribute to tissue damage.
     • Immediate hypersensitivity to gingival bacteria: Reflects an exaggerated immune response to bacterial antigens.
     • Cell-mediated immunity to gingival bacteria: Suggests involvement of T-cells in the immune response against periodontal pathogens.

4. Juvenile Periodontitis:

   • Localized Juvenile Periodontitis (LJP):
     • Findings:
       • PMN chemotactic defect and depressed phagocytosis: Impairs the ability of neutrophils to respond effectively to bacterial invasion.
       • Elevated antibody titres to Actinobacillus actinomycetemcomitans: Indicates an immune response to this specific pathogen.
   • Generalized Juvenile Periodontitis (GJP):
     • Findings:
       • PMN chemotactic defect and depressed phagocytosis: Similar to LJP, indicating a compromised immune response.
       • Elevated antibody titres to Porphyromonas gingivalis: Suggests an immune response to this pathogen.

5. Prepubertal Periodontitis:

   • Findings:
     • PMN chemotactic defect and depressed phagocytosis: Indicates impaired neutrophil function.
     • Elevated antibody titres to Actinobacillus actinomycetemcomitans: Suggests an immune response to this pathogen.

6. Rapid Periodontitis:

   • Findings:
     • Suppressed or enhanced PMN or monocyte chemotaxis: Indicates variability in immune response among individuals.
     • Elevated antibody titres to several gram-negative bacteria: Reflects an immune response to multiple pathogens.

7. Refractory Periodontitis:

   • Findings:
     • Reduced PMN chemotaxis: Indicates impaired neutrophil migration, which may contribute to disease persistence despite treatment.

8. Desquamative Gingivitis:

   • Findings:
     • Diagnostic or characteristic immunopathology in two-thirds of cases: Suggests an underlying immune mechanism.
     • Autoimmune etiology in cases resulting from pemphigus and pemphigoid: Indicates that some cases may be due to autoimmune processes affecting the gingival tissue.

Periodontal Fibers

Periodontal fibers play a crucial role in maintaining the integrity of the periodontal ligament and supporting the teeth within the alveolar bone. Understanding the different groups of periodontal fibers is essential for comprehending their functions in periodontal health and disease.

1. Gingivodental Group

• Location:
  • Present on the facial, lingual, and interproximal surfaces of the teeth.
• Attachment:
  • These fibers are embedded in the cementum just beneath the epithelium at the base of the gingival sulcus.
• Function:
  • They help support the gingiva and maintain the position of the gingival margin.

2. Circular Group

• Location:
  • These fibers course through the connective tissue of the marginal and interdental gingiva.
• Attachment:
  • They encircle the tooth in a ring-like fashion.
• Function:
  • The circular fibers help maintain the contour of the gingiva and provide support to the marginal gingiva.

3. Transseptal Group

• Location:
  • Located interproximally, these fibers extend between the cementum of adjacent teeth.
• Attachment:
  • They lie in the area between the epithelium at the base of the gingival sulcus and the crest of the interdental bone.
• Function:
  • The transseptal fibers are primarily responsible for the post-retention relapse of orthodontically positioned teeth.
  • They are sometimes classified as principal fibers of the periodontal ligament.
  • Collectively, they form the interdental ligament of the arch, providing stability to the interproximal areas.

4. Semicircular Fibers

• Location:
  • These fibers attach to the proximal surface of a tooth immediately below the cementoenamel junction (CEJ).
• Attachment:
  • They go around the facial or lingual marginal gingiva of the tooth and attach to the other proximal surface of the same tooth.
• Function:
  • Semicircular fibers help maintain the position of the tooth and support the gingival tissue around it.

5. Transgingival Fibers

• Location:
  • These fibers attach to the proximal surface of one tooth and traverse the interdental space diagonally to attach to the proximal surface of the adjacent tooth.
• Function:
  • Transgingival fibers provide support across the interdental space, helping to maintain the position of adjacent teeth and the integrity of the gingival tissue.

Classification of Embrasures

1. Type I Embrasures:

   • Description: These are characterized by the presence of interdental papillae that completely fill the embrasure space, with no gingival recession.
   • Recommended Cleaning Device:
     • Dental Floss: Dental floss is most effective in cleaning Type I embrasures. It can effectively remove plaque and debris from the tight spaces between teeth.

2. Type II Embrasures:

   • Description: These embrasures have larger spaces due to some loss of attachment, but the interdental papillae are still present.
   • Recommended Cleaning Device:
     • Interproximal Brush: For Type II embrasures, interproximal brushes are recommended. These brushes have bristles that can effectively clean around the exposed root surfaces and between teeth, providing better plaque removal than dental floss in these larger spaces.

3. Type III Embrasures:

   • Description: These spaces occur when there is significant loss of attachment, resulting in the absence of interdental papillae.
   • Recommended Cleaning Device:
     • Single Tufted Brushes: Single tufted brushes (also known as end-tuft brushes) are ideal for cleaning Type III embrasures. They can reach areas that are difficult to access with traditional floss or brushes, effectively cleaning the exposed root surfaces and the surrounding areas.

Dark Field Microscopy in Periodontal Microbiology

Dark field microscopy and phase contrast microscopy are valuable techniques in microbiological studies, particularly in the field of periodontal research. These methods allow for the direct observation of bacteria in plaque samples, providing insights into their morphology and motility. This lecture will discuss the principles of dark field microscopy, its applications in periodontal disease assessment, and its limitations.

Dark Field Microscopy

• Definition: Dark field microscopy is a technique that enhances the contrast of unstained, transparent specimens, allowing for the visualization of live microorganisms in their natural state.
• Principle: The method uses a special condenser that directs light at an angle, creating a dark background against which the specimen appears bright. This allows for the observation of motility and morphology without the need for staining.

Applications in Periodontal Microbiology

1. Alternative to Culture Methods:

   • Dark field microscopy has been suggested as a rapid alternative to traditional culture methods for assessing bacterial populations in periodontal plaque samples. It allows for immediate observation of bacteria without the time-consuming process of culturing.

2. Assessment of Morphology and Motility:

   • The technique enables direct and rapid assessment of the morphology (shape and structure) and motility (movement) of bacteria present in plaque samples. This information can be crucial for understanding the dynamics of periodontal disease.

3. Indication of Periodontal Disease Status:

   • Dark field microscopy has been used to indicate the status of periodontal disease and the effectiveness of maintenance programs. By observing the presence and activity of specific bacteria, clinicians can gain insights into the health of periodontal tissues.

Limitations of Dark Field Microscopy

1. Analysis of Major Periodontal Pathogens:

   • While dark field microscopy can visualize motile bacteria, it is important to note that many major periodontal pathogens, such as Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Bacteroides forsythus, Eikenella corrodens, and Eubacterium species, are motile. However, the technique may not provide detailed information about their specific characteristics or pathogenic potential.

2. Differentiation of Treponema Species:

   • Dark field microscopy cannot differentiate between species of Treponema, which is a limitation when identifying specific pathogens associated with periodontal disease. This lack of specificity can hinder the ability to tailor treatment based on the exact microbial profile.

3. Limited Quantitative Analysis:

   • While dark field microscopy allows for qualitative observations, it may not provide quantitative data on bacterial populations, which can be important for assessing disease severity and treatment outcomes.