Manual and Power Toothbrushing, Interdental and Antimicrobial Adjuncts

The dental professional should assist the patient in choosing a manual or power toothbrush the patient likes to successfully access all areas of the oral cavity, as long as they use a soft-bristled toothbrush. If using a manual toothbrush, the modified Bass technique should be used with a vibratory back and forth movement and very short strokes. In this modified technique, the brush is held at a 45-degree angle where the abutment post meets the gingival tissue (Figure 5).49

Figure 5. Modified Bass Method.
Photo showing modified bass technique.

Oscillating-rotating power toothbrushes (Figure 6) and sonic power toothbrushes (Figure 7) do not damage polished implant surfaces and also can be safely used to clean all surfaces of the dental implant. Many power toothbrushes are equipped with soft interchangeable bristle heads. The shorter and pointed tips are ideal for reaching proximal areas of the dental implant.49 It’s recommended the toothbrush head be dipped in a chlorhexidine gluconate solution. Research studies show a reduction in certain bacteria by 54-97% after six months of use. One oral hygiene implant study examined manual interproximal cleaning aids (Figure 8).6 Results demonstrated no change in surface appearance or irregularities of the dental implant.

Figure 6. Oral-B®.
Image showing Oral-B power toothbrush.
Courtesy of Crest + Oral-B
Figure 7. Sonicare®.
Image showing Sonicare power toothbrush.
Courtesy of Philips Sonicare
Figure 8. Proxabrush® Interdental System.
Image showing Proxabrush interdental system.
Courtesy of Sunstar Americas, Inc.

Interproximal brushes with small brush heads (Figure 9) may also be used to clean the dental implant surfaces. However, they must be plastic-coated, as metal can damage or contaminate an dental implant’s titanium surface.16-17 An interdental brush (Figure 10) can be used to massage the gingival tissue around the dental implant to increase blood flow of the surrounding gingiva. The patient should be instructed to insert the tip interproximally and applying a gentle rotary motion.

Figure 9. GUM® End-tuft Brush.
Image showing GUM end-tuft brush.
Courtesy of Sunstar Americas, Inc.
Figure 10. Oral-B® Interdental Brush.
Image showing Oral-B interdental brush.
Courtesy of Crest + Oral-B

There are many different types of interdental aids. One type of flossing aid (Figure 11) has a wide band of ribbon with one end designed for use as a threading device, can be threaded around dental implants. Another type of interdental aid is made specifically for dental implant care (Figure 12) and can be used in conjunction with chlorhexidine gluconate. Used in the manner of a “shoe-shine rag” (e.g., a side-to-side motion), the interdental aid polishes the back and sides of the dental implant. In areas with a bridge, floss may be used with a floss threader (Figure 13).

Figure 11. Oral-B®.
Image showing floss threading.
Courtesy of Crest + Oral-B
Figure 12. Postcare®.
Image showing floss threading of dental implants.
Courtesy of Sunstar Americas, Inc.
Figure 13. Floss Threader.
Image showing packaged floss threader.

The oral irrigator is a beneficial adjunct for removing plaque and debris around dental implants. However, caution must be exercised by the patient when using this device. Incorrect use and excessive water pressure can damage the biological seal. Patients must receive detailed manufacturer’s instructions. It’s recommended to use manufacturer’s videos as well.

Specific pathogenic bacteria in dental plaque plays a major role in both adult periodontitis and peri-implantitis.7 The regular use of chemotherapeutic agents, such as chlorhexidine gluconate or phenolic compounds may be used as an irrigant. Chlorhexidine gluconate is a safe adjunct to other oral hygiene procedures in the maintenance of dental implants. An American Dental Association-accepted chlorhexidine gluconate mouthrinse can be effective due to its binding activity to gingival tissues and on titanium abutment surfaces. Treating soft tissue around dental implants with chlorhexidine gluconate mouthrinses will aid in fibroblastic attachment to dental implant surfaces. The acquired pellicle acts as a chemical reservoir source, releasing chlorhexidine gluconate over a prolonged period of time in concentrations sufficient to maintain bacteriostasis.8 About 90% of the cultivable bacteria are inhibited for about five hours with a 0.12% concentration of chlorhexidine gluconate rinsing for 30 seconds. Because staining often accompanies long-term use of chlorhexidine gluconate rinses, it can be applied with a cotton swab around the dental implant as well. Patients should be advised that chronic chlorhexidine gluconate use also can diminish taste sensation. Studies show that chlorhexidine gluconate has no effect on the dental implant surface itself. Disclosing solutions and tablets are a valuable aid in revealing the presence of plaque to the dental implant patient. Inspection of disclosed areas assists the patient in identifying areas of plaque retention and provides immediate feedback on the effectiveness of oral hygiene procedures.