Dental Biofilm and Soft Deposits Flashcards
What are the soft deposits?
Dental biofilm
Acquired enamel pellicle
Materia Alba
Food debris
What are the hard deposits?
Calculus- Supra/Subgingival
What are dental biofilm and soft deposits responsible for?
Patients risk factor for being diagnosed with gingivitis, inflammatory periodontal disease and dental caries
What is gingivitis?
Inflammation of gum tissue
What is inflammatory periodontal disease?
Inflammation of the tissue and gum tissue below the gum line (bone. ligament)
What is the acquired pellicle?
Thin translucent film formed of proteins, carbohydrates and lipids
Thickest near the gingival margin
How does the pellicle form?
Formation begins within minutes of eruption or removal of hard/soft deposits
Salivary proteins highly attracted to the hydroxyapatite of the tooth surface
What is the pellicle composed of?
Glycoproteins (protein based layer)
Gingival crevicular fluid
How does the supragingival pellicle appear?
Translucent and insoluble. Not readily visible without disclosing agent
Can take on extrinsic staining
What is the subgingival pellicle?
Continuous with supraginigival pellicle and can become embedded in tooth structure, especially where tooth surface has become rough or demineralized
What are the significances of the pellicle?
Provide protection
Lubrication
Nidus for Bacteria
Attachment of Calculus
Protective qualities of the pellicle
Provides a barrier against acids
Lubricating qualities of the pellicle
Keeps surfaces moist and prevents drying- increases efficiency of speech and mastication
Pellicle as Nidus for bacteria
Aids in adherence of microorganisms in biofilm formation
Role of pellicle in calculus attachment
Just one mode of attachment for calculus
Can the pellicle be removed?
Not resistant enough to withstand vigorous brushing.
Abrasive toothpastes, whitening products and intake of acidic foods and beverages can also interfere with pellicle formation
Composition of dental biofilm
Microorganisms and extracellular polymeric substance make up 20%
Other 80% is water
Inorganic elements of biofilm
Calcium and phosphorus
Fluoride
Organic elements in biofilm
Carbohydrates (Glucans: dextran, fructans or levans)
Proteins (from gingival sulcus fluid)
Characteristic of Biofilm
Encapsulated in EPS, form a matrix and micro-colonies
Matrix protects the biofilm from hosts immune system and antimicrobial agents
Water channels supply nutrients to the microcolonies
Can adhere to anything in the mouth
Main cause of malodor
Stage 1 of Biofilm Formation
Formation: Begins initial attachment to pellicle
Stage 2 Biofilm Formation
Bacterial Multiplication and Colonization: Increasing numbers, forming communities and beginning communication with each other.
Growing in layers upward and outward to create 3D plaque
Stage 3 Biofilm Formation
Matrix Formation: Anchors bacteria to the tooth. Protects bacterial community and allows it to keep growing
Can be seen supra/subgingivaly
What are the components of Extracellular Polymeric Substance (EPS)?
Polysaccharides, glucans, fructans or levans
Sticky, cement biofilm more firmly to teeth
Stage 4 Biofilm Formation
Biofilm Growth: Mass of thickness in the biofilm. Will start to cause gingivitis at this point if left undisturbed
Stage 5 Biofilm Formation
Maturation: Mature biofilm releases planktonic cells that spread and colonize other areas
What type of bacterial growth is promoted by the pellicle, EPS and biofilm architecture? What happens if it is left undisturbed?
Anaerobic gram negative bacteria
Numbers increase rapidly, chance for potential disease activity increases
Days 1-2 of Biofilm formation
Early biofilm, primarily gram positive bacteria
Streptococci
Days 2-4 Biofilm formation
Slender rods join cocci colonies and start to build on each other and layer
Days 4-7 Biofilm Formation
Increase in numbers and size and thickness
Near gingival margin. Disclosing agent will reveal nice thick layer of plaque
Days 7-14 Biofilm Formation
Inflammatory response has been activated, # of WBC’s increases
You will see swelling and inflammation of the gingival tissue
Days 14-21 Biofilm Formation
Biofilm embeds into the gingival tissue and connects to connective tissue
Can break down ligaments and bone
Bleeding will be seen when patient is brushing and flossing
Location of supra and subgingival biofilm
Middle thirds of the teeth to gingival margin and down under the gums and on pits and fissures
Where do we see the heaviest deposits of biofilm?
Gingival 1/3 and proximal Crowded teeth Rough Surfaces/ Existing Calculus Poor restorations Mandibular anteriors
Where do we see the least heavy biofilm deposits?
Palatal surfaces of maxillary teeth
Significance of biofilm in dental caries
Cariogenic microorganisms are responsible for breaking down the enamel and eventually the dentin and cementum
Streptococcus mutans and Lactobacilli
What are the two types of bacteria primarily responsible for the initiation and progression of carious lesions?
Streptococcus mutans
Lactobacilli
What condition combined with cariogenic bacteria increases risk of demineralization?
Xerostomia (saliva can help remineralize the enamel)
Significan of the pH of biofilm
Acid formation begins immediately once a cariogenic substance is taken into the biofilm resulting in a rapid drop in pH
pH for demineralization= 5.5
For exposure on a root surface or dentin= 6.2-6.4
Why is it critical to remember the critical pH levels in biofilm?
If a patient has recession AND xerostomia they are more at risk for decay in the gingival 1/3 because pH is HIGHER than compared to enamel
What happens when pH drops?
Enamel starts to break down and that increased exposure time puts you at risk for more caries
Effects of diet on biofilm
Cariogenic foods (anything sugar related) induces acid formation and causes pH to drop
What is materia alba?
White, spongy, cottage cheese-like material that loosely adheres to the teeth.
When visible we know it has been growing undisturbed for a long time as it is easily removed
What is materia alba composed of and what are its effects in the mouth?
Dead bacteria, epithelial cells, proteins, food, WBC’s
When in contact with gingiva, contributes to gingival inflammation
When does food impaction occur?
When there is an open contact, food may be forced straight down between the teeth. In closed contacts food is just pushed to the side
Horizontal food impaction
Food debris stuck between teeth
Vertical food impaction
Food debris is forced into the interdental papillae or the pocket
What is calculus?
Hard, calcified deposit to the tooth
Cannot be removed with routine home care
Location and distribution of Supragingival calculus
Starts at gingival 1//3 and builds up
More common on anterior linguals and buccal maxillary molars because of proximity to saliva ducts
Location and distribution of subgingival calculus
Located under gum line, along root surface and on implant posts
Heaviest in areas that are difficult for the patient to reach on their own
Components of mature calculus
Organic and inorganic components. The more mature it is the more inorganic components it will have
Major inorganic components of calculus
Calcium, phosphate, carbonate, sodium, magnesium
Trace elements: zinc, silicone, fluoride, iron, potassium
Fluoride in calculus
Tends to be higher in subgingival calculus
Crystals in calculus
2/3 of inorganic content will contain crystaline– predominantly a form of hydroxyapatite
Hard like bone, very difficult to remove
Organic content of calculus
Microorganisms, desquamated epithelial cells, WBC’s and mucin from saliva
Mineralization stage of calculus formation
Early formation. Adheres to pellicle. Colonies form and build on each other.
If left for 24-72 hours more develops close to underlying tooth surface (expands, unites)
Phosphate crystals bond to enamel and cementum
Sources of mineral in calculus
From elements found in saliva (supra)
Sungingival forms with exudate (natural flora under gum tissue)
Crystal formation
Typically forms w/ intracellular matrix onto tooth surface w/ bacteria and all adhere
Mechanics of Mineralization
Affected by salivary flow and saturation of saliva (does it have an increase of phosphate salts?)
Structure of Calculus
Forms in Layers parallel to tooth surface
Is rough and can be easily felt with explorer or probe
Outer layer highly calcified
Types of calculus deposits
Crusty, spiny, nodular Ledge or ring Thin, smooth veneers Finger and fern-like formations Calculus islands
Calculus formation time
Average time for soft deposit to mature and mineralize is about 12 days
Mineralization can begin in 24-48 hrs if home care is ineffective
Attachment of calculus
Can attach to the pellice, to minute irregularities on the tooth surface, or by direct contact between calcified intercellular matrix and the tooth surfce
Attachment by means of acquired pellicle
Superficial attachment and can be easily removed
Attachment to minute irregularities in tooth surface by mechanical locking into undercuts
In dentin: cracks, lamellae, carious defects
In cementum: Spaces left at previous locations of sharpey’s fibers, root grouping from improper scaling, cement tears
Attachment by direct contact btw calcified intercellular matrix and the tooth surface
Interlocking or organic apatite crystals of the enamel and cementum w/ the mineralizing dental biofilm
How and when will we see supragingival calculus?
Can be seen with direct examination. May have some color associated with it.
Compressed air will deflect the gingival margin and dry the calculus making it appear chalky and white and easier to see
How will subgingival calculus appear upon visual examination?
Dark edges of calculus will be seen at gingival margin (stained)
Gentle air blast deflects the gingival margin to see into pocket
Transillumination may also be used
Personal biofilm control in the prevention of calculus
Remove biofilm by brushing, flossing and other methods
demonstrate appropriate hygiene aids for patient. Follow up and commend their success. ID dietary behaviors that may enhance biofilm growth
Regular professional continuing care in the prevention of calculus
Regular appointments to supplement home care
Anticalculus dentifrice and mouthrinse in prevention of calculus
Dentifrices aim to inhibit calculus crystal growth, may lessen formation. DO not have an effect on existing deposits
Chemotherapeutic rinses for tartar control inhibit mineralization
What do we document when inspecting calculus?
Location :supra/subgingival
Extent: Slight, moderate, heavy
3 Ways dental stains occur
- Adhere directly to surfaces
- Contained within calculus and soft deposits
- Incorporated within the tooth structure or restorative material
Extrinsic staining
On external surface and may be removed by toothbrushing, scaling and/or polishing
Intrinsic staining
Occur within the tooth surface and cannot be removed by scaling/polishing
Only removable with certain whitening procedures
Exogenous sources
Develop from sources outside the tooth
Can be extrinsic or intrinsic
Endogenous sources
Develop within the tooth.
Always intrinsic and usually are discolorations of the dentin
Removal of stains on the tooth surface
Remove as much as possible with brushing, debridement and/or polishing
Avoid excessive polishing on tenacious stains, use least abrasive agent
Removal of stains incorporated in tooth deposits
Stain can be removed with removal of calculus or soft deposit
Removal of stains within the tooth
Cannot be removed by scaling/polishing
What are directed extrinsic stains?
Caused by compounds, organic chromogens, attached to pellicle producing a stain
What are indirect extrinsic stains?
From chemical interaction with the tooth surface
What are the most frequently observed stains?
Yellow, green, black line and tobacco
Yellow stain
Dull, yellowish discoloration of bio film. Generalized or localized and common to all ages. More evident when personal oral care is neglected
Green stain
Light or yellowish green to dark green, in bedded in bio film. On gingival margins on flat tooth surfaces - grooves in enamel
Chromogenic bacteria and decomposed hemoglobin
Black line stain
Forms along with gingival third near the gingival margin. Highly retentive, calculus like and sticky
Mostly on facial and lingual surfaces. can recur despite regular removal
Linked to bacterial growth and dietary habits and also iron supplements
Tobacco stain
Diffuse staining on dental biofilm. Follows contour of gingival crest. Wide, firm, tar like.
Located on cervical third to central third of crown. May penetrate an animal and become exogenous intrinsic
Primarily on lingual surfaces
Brown stains
Chemical alteration of pellicle
From poor hygiene, Stanis fluoride or anti-microbial agents such as chlorhexidine
May not be removable if from anti-microbial agents or fluoride. Weigh risk versus benefit
Red stain
Possibly from chromogenic bacteria
Metallic stains
From drugs or metallic salts from metal containing dust of industry
Endogenous intrinsic stains
- On Pulpless or traumatized teeth. Not all will discolor but may if not treated
- Often from decomposed hemoglobin
- Can also be genetic: Amelogenic imperfecta, dentinogenesis imperfecta
- Enamel hypoplasia
- Drug induced stains
Drug-induced stains and discolorations
Tetracycline: if taken while pregnant
Monocycline: causes blue gray darkening lock to crowns. Changes development of tooth when taken
What do exogenous intrinsic stains result from?
Stain into the following development and may occur when the stain penetrates enamel defect and exposed dentition to become intrinsic
Ex. Developmental defects, acquired defects, dental caries, restorative materials
Which restorative Materials cause exogenous intrinsic stains?
Silver amalgam
Endodontic therapy: sealants, endodontic medicaments, Portland cement-based materials, antibiotic paste
Other causes of exogenous intrinsic stains
Enamel erosion from acidic foods, eating disorders, Gerd
What is the CCP indice?
Simplified oral hygiene index.
Student will assess patient for presence of plaque/dental biofilm
Student will complete simplified oral hygiene index on all patients at each appointment
What is the purpose of the simplified oral hygiene index?
To assess oral cleanliness by estimating tooth surface is covered with debris and/or calculus
Two components of the simplified oral hygiene index
- simplified debris index (DI-S)
- simplify the calculus index (CI-S)
Posterior teeth to be examined in simplified oral hygiene index
Facial surfaces of maxillary molars and lingual surface of mandibular molars (1st molar)
Anterior teeth to be examined during simplified oral hygiene index
Facial surfaces of maxillary right and mandibular left central
What is the procedure for scoring soft debris on the simplified oral hygiene index?
Run side of the tip of probe or explore across tooth surface to estimate area covered in debris. Disclosing agent may also be used
What is the procedure for scoring calculus on the simplified oral hygiene index?
Use explore to estimate surface area covered by supragingival calculus. Record only definite deposits
