DENTAL PAQUE AND CARIES

 INTRODUCTION

Tooth decay (dental caries) is an erosive process that begins with the action of bacteria on
fermentable carbohydrates in the mouth, which produces acids that dissolve tooth enamel.
Despite the fact tooth enamel is the hardest substance in the human body, caries and periodontal
disease can occur for several reasons. Contributing factors include nutrition, soft drink
consumption, and genetic predisposition (Hinkle and Cheever 2018)

In addition, the extent of damage to the teeth may be related to the following:

 Presence of dental plaque, which is a gluey, gelatin-like substance that adheres to the
teeth. The initial action that causes damage to a tooth occurs under dental plaque.
 Length of time acids are in contact with the teeth
 Strength of acids and the ability of the saliva to neutralize them
 Susceptibility of the teeth to decay
 Dental decay begins with a small hole, usually in a fissure (a break in the tooth’s enamel)
or in an area that is hard to clean. Left unchecked, the decay extends into the dentin.
Because dentin is not as hard as enamel, decay progresses more rapidly and in time
reaches the pulp of the tooth.

Dentists can determine the extent of damage and the type of treatment needed using x-ray
studies. Treatment for dental caries includes fillings, dental implants, or extraction, if
necessary. In general, dental decay can occur in anyone. Older adults are subject to decay
from drug-induced or age-related oral dryness.

 DENTAL PLAQUE

Dental plaque is a biofilm of microorganisms (mostly bacteria, but also fungi) that grows on

surfaces within the mouth. It is a sticky colorless deposit at first, but when it forms tartar, it is

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 often brown or pale yellow. It is commonly found between the teeth, on the front of teeth,
behind teeth, on chewing surfaces, along the gumline (supragingival), or below the
gumline cervical margins (subgingival) (Darby and Walsh, 2010).

Dental plaque is also known as microbial plaque, oral biofilm, dental biofilm, dental plaque
biofilm or bacterial plaque biofilm. Bacterial plaque is one of the major causes for dental
decay and gum disease (Darby and Walsh, 2010). Progression and build-up of dental plaque
can give rise to tooth decay – the localised destruction of the tissues of the tooth by acid
produced from the bacterial degradation of fermentable sugar – and periodontal problems
such as gingivitis and periodontitis  hence it is important to disrupt the mass of bacteria and
remove it (Verkaik et al.,).

Plaque control and removal can be achieved with correct daily or twice-daily tooth
brushing and use of interdental aids such as dental floss and interdental brushes (Darby and
Walsh, 2010).

 COMPONENTS

Different types of bacteria are normally present in the mouth. These bacteria, as well
as leukocytes, neutrophils, macrophages, and lymphocytes, are part of the normal oral cavity
and contribute to the individual's health (Darby and Walsh, 2010). Approximately 80–90% of
the weight of plaque is water. While 70% of the dry weight is bacteria, the remaining 30%
consists of polysaccharides and glycoproteins (Marsh and Bradshaw, 1995).

 CLASSIFICATION OF DENTAL PLAQUE

 Supragingival biofilm

Supragingival biofilm is dental plaque that forms above the gums, and is the first kind of plaque
to form after the brushing of the teeth. It commonly forms in between the teeth, in the pits and
grooves of the teeth and along the gums. It is made up of mostly aerobic bacteria, meaning these
bacteria need oxygen to survive. If plaque remains on the tooth for a longer period of time,
anaerobic bacteria begin to grow in this plaque (Chetrus and Ion, 2013)

 Subgingival biofilm

Subgingival biofilm is plaque that is located under the gums. It occurs after the formation of the
supragingival biofilm by a downward growth of the bacteria from above the gums to below. This
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plaque is mostly made up of anaerobic bacteria, meaning that these bacteria will only survive if
there is no oxygen. As this plaque attaches in a pocket under the gums, they are not exposed to
oxygen in the mouth and will therefore thrive if not removed (Wilkins, 2009)

 CONSEQUENCES OF PLAQUE BUILD UP

 Dental caries

 Others are Gingivitis, Periodontitis e,t.c

 DENTAL CARIES

Tooth decay (also known as cavities or caries) is an erosive process that begins with the action of
bacteria on fermentable carbohydrates in the mouth, which produces acids that dissolve tooth
enamel (Hinkle and Cheever 2018). It is also known as cavities or caries, is the breakdown
of teeth due to acids produced by bacteria. The cavities may be a number of different colors from
yellow to black.[1] Symptoms may include pain and difficulty with eating (Laudenbach and
Simon, 2014). The cause of cavities is acid from bacteria dissolving the hard tissues of the teeth
(enamel, dentin and cementum). The acid is produced by the bacteria when they break down
food debris or sugar on the tooth surface.

 Simple sugars in food are these bacteria's primary energy source and thus a diet high in simple
sugar is a risk factor. If mineral breakdown is greater than build up from sources such as saliva,
caries results. Risk factors include conditions that result in less saliva such as: diabetes
mellitus, Sjögren syndrome and some medications. Medications that decrease saliva production
include antihistamines and antidepressants. Dental caries are also associated with poverty,
poor cleaning of the mouth, and receding gums resulting in exposure of the roots of the teeth
(Schwendicke, 2015).

Worldwide, approximately 3.6 billion people (48% of the population) have dental caries in
their permanent teeth as of 2016. The World Health Organization estimates that nearly all adults
have dental caries at some point in time (WHO,2012)

 Classification

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Caries can be classified by location, etiology, rate of progression, and affected hard tissues
(Sonis and Stephen, 2003).

 Class I: occlusal surfaces of posterior teeth, buccal or lingual pits on molars, lingual
pit near cingulum of maxillary incisors
 Class II: proximal surfaces of posterior teeth
 Class III: interproximal surfaces of anterior teeth without incisal edge involvement
 Class IV: interproximal surfaces of anterior teeth with incisal edge involvement
 Class V: cervical third of facial or lingual surface of tooth
 Class VI: incisal or occlusal edge is worn away due to attrition

 RISK FACTORS ((Hinkle and Cheever 2018;Bernard 2021;)

 Nutrition
 Genetic predisposition
 Preexisting tooth defects,
 low saliva flow,
 an acidic oral environment,
 frequent exposure to carbohydrates and sugar in the diet, and
 Inadequate exposure to fluoride.

 CAUSATIVE FACTORS
 Bacteria:
The most common bacteria associated with dental cavities are the mutans streptococci, most
prominently Streptococcus mutans and Streptococcus sobrinus, and lactobacilli. However,
cariogenic bacteria (the ones that can cause the disease) are present in dental plaque, but they are
usually in too low concentrations to cause problems unless there is a shift in the balance, This is
driven by local environmental change, such as frequent sugar intake or inadequate biofilm
removal (toothbrushing). If left untreated, the disease can lead to pain, tooth loss and infection
(Marsh et al., 2015)
 Dietary sugars:

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Bacteria in a person's mouth convert glucose, fructose, and most commonly sucrose (table sugar)
into acids such as lactic acid through a glycolytic process called fermentation(Holloway and
Moore, 1983).
 Exposure:
The frequency with which teeth are exposed to cariogenic (acidic) environments affects the
likelihood of caries development. After meals or snacks, the bacteria in the
mouth metabolize sugar, resulting in an acidic by-product that decreases pH. As time progresses,
the pH returns to normal due to the buffering capacity of saliva and the dissolved mineral content
of tooth surfaces. During every exposure to the acidic environment, portions of the inorganic
mineral content at the surface of teeth dissolve and can remain dissolved for two hours
(University of California, 2006).
 Other Factors are:
Teeth disorders and diseases like Molar incisor hypo-mineralization, Amelogenesis
imperfecta,etc
Reduced salivary flow
Intrauterine and neonatal lead exposure
Use of tobacco (Gemmel et al., 2002)

 PATHOPHYSIOLOGY
Teeth are bathed in saliva and have a coating of bacteria on them (biofilm) that continually
forms. The development of biofilm begins with pellicle formation. Pellicle is an acellular
proteinaceous film which covers the teeth. Bacteria colonize on the teeth by adhering to the
pellicle-coated surface. Over time, a mature biofilm is formed and this create a cariogenic
environment on the tooth surface (Banerjee And Ajivit, 2011) The minerals in the hard tissues of
the teeth (enamel, dentin and cementum) are constantly undergoing processes of
demineralization and remineralization. Dental caries results when the demineralization rate is
faster than the remineralization and there is net mineral loss. This happens when there is an
ecologic shift within the dental biofilm, from a balanced population of micro-organisms to a
population that produce acids and can survive in an acid environment (Fejerskov, 2008).

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  SIGNS AND SYMPTOMS

A person experiencing caries may not be aware of the disease. The earliest sign of a new
carious lesion is the appearance of a chalky white spot on the surface of the tooth, indicating an
area of demineralization of enamel. This is referred to as a white spot lesion, an incipient carious
lesion or a "micro-cavity" (Richie, 2011). As the lesion continues to demineralize, it can turn
brown but will eventually turn into a cavitation ("cavity"). Before the cavity forms, the process is
reversible, but once a cavity forms, the lost tooth structure cannot be regenerated. A lesion that
appears dark brown and shiny suggests dental caries were once present but the demineralization
process has stopped, leaving a stain. Active decay is lighter in color and dull in appearance
(Johnson, 2007).

As the enamel and dentin are destroyed, the cavity becomes more noticeable. The affected areas
of the tooth change color and become soft to the touch. Once the decay passes through the
enamel, the dentinal tubules, which have passages to the nerve of the tooth, become exposed,
resulting in pain that can be transient, temporarily worsening with exposure to heat, cold, or
sweet foods and drinks.[15] A tooth weakened by extensive internal decay can sometimes
suddenly fracture under normal chewing forces. When the decay has progressed enough to allow
the bacteria to overwhelm the pulp tissue in the center of the tooth, a toothache can result and the
pain will become more constant. Death of the pulp tissue and infection are common
consequences. The tooth will no longer be sensitive to hot or cold but can be very tender to
pressure.Dental caries can also cause bad breath and foul tastes.In highly progressed cases, an
infection can spread from the tooth to the surrounding soft tissues. Complications such
as cavernous sinus thrombosis and Ludwig angina can be life-threatening (New York University,
2006).

 DIAGNOSIS

The presentation of caries is highly variable. However, the risk factors and stages of
development are similar. Initially, it may appear as a small chalky area (smooth surface caries),
which may eventually develop into a large cavitation. Sometimes caries may be directly visible.
However other methods of detection such as X-rays are used for less visible areas of teeth and to
judge the extent of destruction. Lasers for detecting caries allow detection without ionizing

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radiation and are now used for detection of interproximal decay (between the teeth) (James et al.,
2001).

Primary diagnosis involves inspection of all visible tooth surfaces using a good light

source, dental mirror and explorer. Dental radiographs (X-rays) may show dental caries before it
is otherwise visible, in particular caries between the teeth. Large areas of dental caries are often
apparent to the naked eye, but smaller lesions can be difficult to identify. Visual
and tactile inspection along with radiographs are employed frequently among dentists, in
particular to diagnose pit and fissure caries. Early, uncavitated caries is often diagnosed by
blowing air across the suspect surface, which removes moisture and changes the optical
properties of the unmineralized enamel (Rosenstiel and Stephen, 2008).

At times, pit and fissure caries may be difficult to detect. Bacteria can penetrate the enamel to
reach dentin, but then the outer surface may remineralize, especially if fluoride is present. These
caries, sometimes referred to as "hidden caries", will still be visible on X-ray radiographs, but
visual examination of the tooth would show the enamel intact or minimally perforated.
The differential diagnosis for dental caries includes dental fluorosis and developmental defects of
the tooth including hypomineralization of the tooth and hypoplasia of the tooth. The early
carious lesion is characterized by demineralization of the tooth surface, altering the tooth's
optical properties. Technology utilizing laser speckle image (LSI) techniques may provide a
diagnostic aid to detect early carious lesions (James et al., 2001).

 MEDICAL MANAGEMENT (my.clevelandclinic.org)

Good oral hygiene, including regular brushing and flossing, removes plaque and prevents tartar
buildup. During a dental examination, your dental professional will scrape plaque and tartar from
your teeth. Your provider may also recommend:

 Dental sealants to keep plaque from forming on the top chewing surfaces of teeth.
 Dry mouth medications to increase saliva production.
 Fluoride treatments to slow the growth of plaque-causing bacteria and stop tooth decay.
 Prescription toothpaste or antibacterial mouthwash (chlorhexidine)

 SURGICAL MANAGEMENT

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The surgical management of dental caries has traditionally involved removal of all soft
demineralised dentine before a filling is placed. However, the benefits of complete caries
removal have been questioned because of concerns about the possible adverse effects of
removing all soft dentine from the tooth consequently, partial caries removal reduced incidence
of pulp exposure by 77% compared to complete caries removal (www.ncbi.nlm.nih.gov)

 NURSING MANAGEMENT

Provide a mouth care routine including toothbrushing at regular intervals with a soft-bristle
toothbrush and fluoride toothpaste.

 Brushing teeth in an up-and-down manner

 Brushing of teeth at least twice a day
 Including the gums and tongue in oral care
 Replacing the toothbrush as bristles wear down
 Advise an ultrasonic toothbrush as an alternative for patients with dexterity problems
 Teach gentle flossing teeth with unwaxed dental floss
 Instruct the patient to rinse the mouth with warm saline or an antiplaque mouth rinse.
 Encourage to avoid high-sugar foods.
(nurseslabs.com)

 COMPLICATIONS OF DENTAL PLAQUE AND CARIES

 Periodontal diseases (periodontitis, gingivitits)

 Periapical abscess, sometimes accompanied by fever and swelling of the face.

 Bad breath.

 Loss of the decayed tooth.

 Difficulty chewing food.

 Difficulty with pronunciation.

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  Sudden and sustained pain (sometimes violent) in the teeth and jaw.

 PREVENTION

Measures used to prevent and control primary dental caries include applying fluoride varnish/gel
(Marinho, et al., 2015), using fluoride toothpaste, applying dental sealants (Twetman, 2015), and
ensuring community water fluoridation (HHS, 2000; HHS, 2014). Other recommendations
include implementing daily oral hygiene practices, seeking routine professional dental treatment,
refraining from smoking and excessive alcohol use, making good dietary choices, and managing
related systemic diseases (HHS, 2016). Mouth Care Healthy teeth must be cleaned on a daily
basis. Brushing and flossing are particularly effective in mechanically breaking up the bacterial
plaque that collects around teeth.
Mastication (chewing) and the normal flow of saliva also aid greatly in keeping the teeth clean.
Because many ill patients do not consume adequate nutrients, they produce less saliva, which in
turn reduces this natural tooth-cleaning process. The nurse may need to assume the responsibility
for brushing the patient’s teeth. Merely wiping the patient’s mouth and teeth with a swab is
ineffective. The most effective method is mechanical cleansing (brushing). If brushing is not
possible, it is better to
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wipe the teeth with a gauze pad and then have the patient swish an antiseptic mouthwash several
times before expectorating into an emesis basin. A soft-bristled toothbrush is more effective than
a sponge or foam stick. Flossing should be performed daily. To prevent drying, the lips may be
coated with a water-soluble gel. Diet Dental caries may be prevented by decreasing the amount
of sugar and starch in the diet. Patients who snack should be encouraged to choose less
cariogenic alternatives, such as fruits, vegetables, nuts, cheeses, or plain yogurt. Brushing after
meals is recommended. Fluoridation Fluoridation of public water supplies has been found to
decrease dental caries. Some areas of the country have natural fluoridation; other communities
have added fluoride to public water supplies. As of 2012, 67.1% of Americans receive
fluoridated water (Centers for Disease Control and Prevention, 2013). Studies suggest that by
instituting a community water fluoridation program, tooth decay is reduced by 25% in both
children and adults (Weno, 2015). Fluoridation may also be achieved by having a dentist apply a

9
concentrated gel or solution to the teeth; adding fluoride to home water supplies; using
fluoridated toothpaste or mouth rinse; or using sodium fluoride tablets, drops, or lozenges. Pit
and Fissure Sealants The occlusal surfaces of the teeth have pits and fissures—areas that are
prone to caries. Some dentists apply a coating to fill and seal these areas on the primary and
permanent molars to protect them from potential exposure to cariogenic processes. These
sealants can last at least 48 months and significantly prevent tooth decay (Ahovuo-Saloranta, et
al., 2013).

 ACTUAL NURSING DIAGNOSIS

1. Acute pain related to damaged/decayed tooth as evidenced by inability to chew
2. Impaired dentition related to tooth sensitivity secondary to dental caries as evidenced by
unpleasant smell of breath and difficulty in breathing.
 RISK NURSING DIAGNOSIS
1. Risk for dry mouth related to tobacco use as evidenced by low saliva flow and
appearance of dental plaque.
 NURSING CARE PLAN
 Assessment: a young female of 21 years, conscious but in obvious pain, has been having
tooth ache for the past one year but got worse 3 days prior to the visit, met with elevated
body temperature of 37.8 degrees Celsius, blood pressure slightly high at 132 over 88
mmHg. Patient looked slightly malnourished on examination due to difficulty in
chewing. On examinating a tooth was discovered to be damaged with the gum swollen.

 Diagnosis 1: Acute pain related to damaged/decayed tooth as evidenced by inability to

chew

 Diagnosis 2: Anxiety related to acute pain secondary to decayed tooth as evidenced by

patient asking lots of question.
 Planning: the patient will be reassured and calmed, made comfortable and pain reduced
within an hour of nursing intervention, patient will also be taught oral hygiene.

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  Intervention: the patient was reassured, kept on a well-made bed and an analgesic given,
taught patient oral hygiene and adequate nutritional intake.
 Evaluation: care plan was achieved as the patient is able to chew and much more
comfortable and calm after intervention.

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