Kylie Siruta, RDH MSDH ECP October 11, 2010

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Name and describe types of deposits Discuss the formation, removal, and significance of the acquired pellicle Describe the clinical appearance and distribution of dental biofilm Categorize the types of dental biofilm according to their location Describe the steps of dental biofilm formation Identify the organisms present in plaque according to location and pathogenic effects Differentiate between caries-producing, calculus-producing, and periodontal disease-producing dental biofilm Define dental calculus Describe the composition of calculus Describe the stages of biofilm mineralization Understand the theories of calculus formation Describe the modes of attachment of calculus to the tooth Compare supra-gingival and sub-gingival calculus according the color, consistency, distribution, form, radiographic appearance, and occurrence Describe the significance of calculus Classify specific stains and discolorations according to intrinsic/extrinsic and exogenous/endogenous Describe for each stain and discoloration the clinical appearance, distribution on the tooth, composition, occurrence, formation-etiology, procedure for removal

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Acquired Pellicle Microbial Biofilm Materia Alba Food Debris


Tenacious membranous layer that is amorphous, acellular, and organic 
Also known a the dental cuticle

Invisible film of glycoproteins formed from the saliva and adsorbed by the tooth ƒ Forms over exposed tooth surfaces, restorations, and calculus ƒ Usually varies in thickness from 01.-0.8 m
Often thickest near the gingival margin


Highly insoluble 
Forms within minutes after all external material has been

removed from the tooth surface (constantly renewed)

ƒ 3 Types  Surface pellicle. insoluble Not visible until disclosing solution has been applied  Surface pellicle. or other colors  Subsurface pellicle Continuous with surface pellicle Embedded in tooth structure. stained Takes on extrinsic stain and becomes brown. grayish. particularly where tooth surface is partially demineralized . translucent. unstained Clear.

ƒ Significance  Positive or Negative? Protective barrier against acids Nidus for bacteria Keeps tooth lubricated Mode of attachment for calculus .

ƒ ƒ ƒ A dense. and viruses . non-mineralized complex mass of colonies in gel-like intermicrobial matrix Adheres firmly to the acquired pellicle Contains many types of microorganisms. primarily bacteria  More than 500 species of bacteria in dental biofilm  Other organisms may include yeasts. protozoa.

ƒ ƒ Review of morphologic forms of bacteria Answers on page 295 (Wilkins) .

Proteins. Fluoride  80% is water . Lipids Inorganic Calcium. Phosphorus.ƒ Composition  20% is microorganisms and intermicrobial matrix Includes both organic and inorganic solids Organic Carbohydrates.

Formation of the pellicle Bacteria attach to the pellicle Bacterial multiplication and colonization Biofilm growth and maturation Matrix formation . 2.ƒ Stages of Plaque Formation 1. 3. 5. 4.

ƒ Changes in Biofilm Microorganisms  Days 1 to 2 Primary Colonizers Consist primarily of cocci Streptococcus mutans and Streptococcus sanguis  Days 2 to 4 Secondary Colonizers Cocci still dominate but increase in quantity Increased filamentous forms grow into and replace many of the cocci  Days 4-7 Filaments increase in numbers More mixed flora appears with rods. and fusobacteria Plaque near the gingival margin thickens and develops more mature flora with spirochetes and vibrios . filamentous forms.

along with cocci and filamentous forms Gingivitis evident clinically Crevicular fluid increases in volume  Biofilm removal health within a few days! . more gram negative and anaerobic organisms appear Signs of gingival inflammation begin Pathogenic potential to cause inflammation  Days 14-21 Vibrios and spirochetes prevalent in old plaque.ƒ Changes in Biofilm Microorganisms  Days 7-14 Vibrios and spirochetes appear and white blood cells increase As plaque matures.

Wilkins. page 298 .

ƒ Subgingival Biofilm  Results from apical proliferation of microorganisms from supragingival biofilm  Differences in microorganisms: More anaerobic Motile organisms Predominately gram negative ƒ Review Table 17-2 on page 296 (Wilkins)  Comparing Supragingival and Subgingival Biofilm .

ƒ Subgingival Biofilm  3 Types Tooth Surface Attached Biofilm Gram positive rods and cocci Unattached Biofilm Motile. gram negative organisms and numerous white blood cells Invade the underlying connective tissue . gram negative organisms Epithelium-Associated Biofilm Many virulent pathogens.

ƒ Factors Favoring Biofilm Accumulation           Tooth surface irregularities Tooth contour Tooth position Dental Prosthesis Gingiva Personal Oral Care Drugs Diet Tobacco Xerostomia .

) Chemical (rinses) .ƒ Significance of Biofilm Accumulation  A primary etiology for Gingivitis Periodontitis Caries Calculus Pellicle + Plaque + Calcium Phosphate ƒ Removal of Dental Biofilm  Goal is to disrupt and reduce microorganisms and colonies Prevention of the above conditions  Methods of Removal: Mechanical (instrumentation. etc. toothbrushing.

resembles cottage cheese Contributes to halitosis Can be removed with water spray or oral irrigator  Dental biofilm cannot . loosely-connected soft deposit composed of bacteria and cellular debris that forms over biofilm Unaesthetic clearly visible  White.ƒ ƒ ƒ ƒ A bulky.

ƒ ƒ Food particles found on the cervical third and proximal embrasure spaces Can be removed with water rinses  Dental biofilm cannot .

Sodium. Phosphate.ƒ ƒ Biofilm that has become mineralized by calcium and phosphate salts within the saliva Composition:  75-85% Inorganic Calcium. leukocytes . Carbonate. Potassium  15-25% Organic Non-vital microorganisms. Magnesium. desquamated epithelial cells.

ƒ Composition of Calculus compared to Teeth and Bone:  Significance: Consider effects of instrumentation on these surfaces Consider difficulties differentiating calculus from cementum Consider modes of attachment Surface Enamel Calculus Dentin Cementum Bone Percent Inorganic 96% 75-85% 65% 45-50% 45-50% .

ƒ Distribution of Calculus (Supragingivally)  Forms on the clinical crown coronal to the gingival margin  Most frequent sites: Lingual of mandibular anterior teeth Buccal of maxillary 1st and 2nd molars Areas of malocclusion/crowding Around prosthetic devices ƒ Distribution of Calculus (Subgingivally)  Forms on the tooth surface apical to the gingival margin  Generalized or localized on single teeth or a group of teeth  Proximal surfaces have heaviest deposit .

flint-like  Harder. gray  Shape determined by gingival contour  Moderately hard dark green. creamy yellow. more dense than supragingival See Table 18-1 on page 312 (Wilkins) . black  Shape conforms with pocket wall  Brittle. or ƒ Subgingival  Light to dark brown.ƒ Supragingival  White.


subgingival calculus doe not develop by direct extension from supragingival calculus Results from deposition of mineral salts into a biofilm organic matrix 1. Biofilm formation and maturation 3. Mineralization .ƒ Formation  Unlike subgingival biofilm. Pellicle formation 2.

ƒ Mineralization  Supragingival Source of elements for mineralized derived from saliva  Subgingival Gingival sulcus fluid (crevicular fluid) and inflammatory exudate supply minerals for mineralization Heavy calculus formers have higher levels of calcium and phosphorous than light calculus formers Light calculus formers have higher levels of parotid pyrophosphate (an inhibitor of calcification) .

ƒ Formation Time  Mineralization can begin as early as 24-48 hours  Average time: 12 days Mature mineralized stage  Rapid calculus formers: 10 days  Slow calculus formers: 20 days .

carious defects Difficult to determine if all calculus is removed  Direct contact between calcified intercellular matrix and tooth surface Interlocking of inorganic crystals of tooth with the mineralizing dental biofilm Difficult to distinguish between calculus and cementum (subgingival calculus) .ƒ Modes of Attachment  Acquired Pellicle Superficial. mostly on enamel (supragingival calculus)  Irregularities in Tooth Surface Includes cracks. no interlocking or penetration Easily removed.

ƒ Significance  Subgingival calculus is always covered by masses of active dental biofilm Biofilm is in constant contact with the diseased pocket epithelium and promotes gingivitis/periodontitis  Rough surface and permeable structure acts as a reservoir for toxic microbial and tissue breakdown products  Predisposing factor in pocket development since it is a haven for dental biofilm .

ƒ Prevention  Professional removal  Personal oral hygiene  Anti-calculus dentifrices (tartar control) .

ƒ 3 Ways Stain/Discoloration Occurs:  Stain adheres directly to the surface  Stain contained within calculus and soft deposit  Stain incorporated within the tooth structure .

ƒ Classification by Location  Extrinsic located on external surface of the tooth May be removed  Intrinsic located within the tooth surface Cannot be removed by scaling or polishing ƒ Classification by Source  Exogenous develops or originates from sources outside the tooth Can be extrinsic or intrinsic  Endogenous develops or originates within the tooth Will always be intrinsic .

ƒ Endogenous Intrinsic Stains  Result of: Heredity/Genetic Factors Example: Imperfect tooth development  Amelogenisis imperfecta results in partial/completely missing enamel due to disturbance of ameloblasts during development  Dentinogenisis imperfecta dentin abnormal as a result of disturbances in odontoblastic layer during development  Enamel hypoplasia  Systemic hypoplasia chronologic hypoplasia resulting from ameloblastic disturbance of short duration Developmental disturbances Example: high fever during tooth development Trauma Example: internal bleeding of the tooth into tubules .

ƒ Endogenous Intrinsic Stains  Result of: Drugs Tetracycline Staining  Discoloration of child s teeth result from drug being administered during 3rd trimester (can be transferred through the placenta) or to a child during infancy and/or early childhood  Color may be light green to dark yellow or gray-brown  Discoloration depends on dosage and amount of time used  May be generalized or limited to specific parts of the teeth that were developing at the time of administration .

ƒ Endogenous Intrinsic Stains  Result of: Fluoride (Dental Fluorosis) Occurs during periods of pre-eruptive periods of tooth development with ingesting excessive amounts of fluoride  Monitor intake from birth-6 years of age  Many sources of fluoride .

ƒ Exogenous Intrinsic Stains  Restorative Materials Silver amalgam Endodontic therapy  Drugs Stain from stannous fluoride  Stains in the Dentin Carious Lesions .

ƒ Exogenous Intrinsic Stains  Vital and non-vital     bleaching Composite restorative materials bonded as overlays Veneers Crowns Enamel microabrasion .

ƒ Exogenous Extrinsic Stains  Most frequently observed stains Includes: Yellow Green Black Line Tobacco Coffee/Tea/Soda Others (Less Common): Orange Red Metallic .

ƒ Exogenous Extrinsic Stain  Yellow Stain Most evident with poor oral hygiene Usually food pigments .

and gingival hemorrage Demineralized underneath .ƒ Exogenous Extrinsic Stain  Green Stain Occurs in 3 forms Small curved line following contour of gingiva Smeared irregularly Streaked Results from poor oral hygiene. chromogenic bacteria.

pigments found in food and marijuana  Black Line Stain Highly retentive stain that forms along the gingival-third of teeth Occurs at all ages and is found most often in females Etiology Iron compounds in saliva or gingival fluid  Orange and Red Stain Orange stain is rare. wine. resins.ƒ Exogenous Extrinsic Stain  Gray/Green Stain Occurs around gingival-third of teeth Etiology: Oils. occurs at gingival-third of incisor teeth Etiology: chromogenic bacteria Red stain Etiology: food stuffs such as raspberries. . etc.

ƒ Exogenous Extrinsic Stain  Tobacco Stain Range in appearance from tan-dark brown-black Covers cervical 1/3-1/2 of most teeth Occurs most often on lingual surfaces Commonly found in pits/fissures and other enamel irregularities Directly proportional to the amount of use/day Composed of tar products and/or brown pigment from smokeless tobacco May penetrate enamel over time and become intrinsic .

Chlorhexidine . soda Antimicrobial Agents .ƒ Exogenous Extrinsic Stain  Brown stain Etiologies: Stannous fluoride Food stuffs tea. coffee.

ƒ Exogenous Intrinsic  Stain Removal Professional prophylaxis/maintenance Scaling Abrasive polishing agents Air/Powder Polishing Home Products Whitening dentifrices  Concentrated soft silica Professional/Home Bleaching .

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