PLAQUE, CALCULUS
AND CARIES
DR.ASMITA YADAV
DEFINITIONS
Plaque :
“ It is a specific but highly variable structural entity, resulting from
sequential colonization of microorganisms on tooth surfaces, restorations &
other parts of oral cavity, composed of salivary components like mucin,
desquamated epithelial cells, debris & microorganisms, all embedded in
extracellular gelatinous matrix.” WHO-1961
Calculus :
“ It is an adherent calcified or calcifying mass that forms on the
surface of natural teeth & prosthesis.”
Materia alba:
“ It is a deposit composed of aggregate of microorganisms, leucocytes &
dead exfoliated epithelial cells , randomly organized & loosely adherent to the
surfaces of the teeth, plaque & gingiva.”
Classification and composition of dental
plaque and calculus.
CLASSIFICATION
1.SUPRA- GINGIVAL PLAQUE AND CALCULUS :
 Supragingival plaque and calculus is found at or above the gingival margin.
 Supragingival plaque and calculus is in direct contact with the gingival margin is referred to as
2.SUBGINGIVAL PLAQUE AND CALCULUS:
 Sub gingival plaque and calculus is found below the gingival margin, between the tooth and
Composition
COMPOSITION OF DENTAL PLAQUE:
Dental plaque is composed primarily of microorganisms.
These organisms exist within an intercellular matrix.
COMPOSITION OF DENTAL CALCULUS:
Calculus consists of 70–80% mineralised inorganic materials, including amorphous calcium
phosphate, dicalcium phosphate dihydrate, octacalcium phosphate, whitlockite and
hydroxyapatite.
The organic composition consists of proteins, carbohydrates and a minor lipid fraction
Etiologic theories of plaque and calculus
formation:
Theories /hypothesis of plaque formation:
1. Non-specific plaque hypothesis
2. specific plaque hypothesis
3. ecological plaque hypothesis
Nonspecific plaque hypothesis
The nonspecific plaque hypothesis maintains that periodontal disease results from the
the entire plaque flora.”
Thus it lead to concept that control of periodontal disease depends on control of the amount
Specific plaque hypothesis
Specific plaque hypothesis states that only certain plaque is pathogenic, and its
increase in specific microorganisms.
Plaque harboring specific bacterial pathogens results in periodontal disease.
Ecological plaque hypothesis
A change in a key environmental factor (or factors) will trigger a shift in the balance of the
this might predispose a site to disease.
This hypothesis is based on the theory that the unique local microenvironment influences the
microflora.
Theories of calculus formation:
1. Carbondioxide loss theory
2. pH change by ammonia formation
3. The phosphatase theory
4. Seeding theory
stain
calculus
Diseases caused due to plaque and
calculus
1.
Gingival inflammation/GINGIVITIS
2.
Gingival enlargement
3.
Acute gingival infections
4.
Periodontitis
5.
Periodontal abscesses
6.
Bone loss
7.
Tooth loss
gingivitis
periodontitis
Prevention of plaque and calculus.
 Plaque control is the daily removal of dental plaque, oral biofilm and also
prevention of their accumulation on the teeth and other parts of oral cavity.
 It also deals with prevention of calculus formation.
 Plaque control is broadly divided as:
1) Mechanical methods
2) Chemical methods
MECHANICAL PLAQUE CONTROL
Objective: is to complete daily removal of dental plaque with minimum of effort, time and devices
using the simplest methods possible.
These methods include:
1. Tooth brush
•Manual
•Powered
•sonic
2. Dentifrices
3. Interdental cleaning aids
•Dental floss
•Interdental brushes
•Wooden or rubber tips
4. Gingival massage
5.Oral irrigation
6.Tongue scrapers
.
TOOTHBRUSH
Toothbrushes are the most widely used oral hygiene aids.
It is the principal instrument in general use for accomplishing
the goals of plaque control.
The objectives of tooth brushing include:
removal of plaque biofilm and disturbance of its re-formation;
removal of food, debris, and stain from the oral cavity;
stimulation of the gingival tissues;
application of a dentifrice containing specific ingredients to address
caries, periodontal disease, or sensitivity.
The average life of a manual toothbrush is 2 to 3 months
Handle : The part grasped in the hand during tooth brushing.
Head : The working end of a tooth brush that holds the bristles or filaments.
Tufts : Clusters of bristles or filaments secured into the head.
Brushing plane: The surface formed by the free ends of the bristles or
filaments.
Shank : The section that connects head and handle.

The ADA has described the range of dimensions of acceptable brushes as :
* Brush length: 1-1.25 inches
* Brush width: 5/16-3/8 inches
* rows of bristles: 2-4
* 5-12 tufts per row
 Diameter of bristle:
* Soft brush = 0.2 mm
* Medium brush = 0.3 mm
* Hard brush = 0.4 mm
* Ultra soft = 0.075 mm
Manual toothbrush
Powered toothbrush
Sonic toothbrush
Brushing techniques:
Roll: Roll or modified Stillman technique
Vibratory: Stillman, Charters, and Bass techniques
Circular: Fones technique
Vertical: Leonard technique
Horizontal: Scrub technique
 The method most often recommended is the Bass technique because it
emphasizes the placement of the bristles at the gingival margin and directly
below it to reach the supragingival plaque biofilm accessing some of
subgingival biofilm.
Bass technique
 Place the head of a soft brush parallel with the occlusal plane, with the brush head covering
three to four teeth beginning at the most distal tooth in the arch.
 Place the bristles at the gingival margin, pointing at a 45-degree angle to the long axis of the
teeth.
 Exert gentle vibratory pressure, using short, back-and-forth motions without dislodging the tips
of the bristles.
This motion forces the bristle ends into the gingival sulcus area, as well as partly into the
interproximal embrasures.
 The pressure should be firm enough to blanch the gingiva.
Modified bass technique: includes sweeping towards occlusal surface for supragingival cleaning.
DENTIFRICES
According to the American Dental Associations Council on Dental Therapeutics
“A dentifrice is a substance used with a toothbrush for the purpose of cleaning
the accessible surfaces of the teeth.”
plaque removal and applying agents to the tooth surfaces for therapeutic or
preventive reasons.
Various forms of dentifrice available are:
•Paste
•Powder
•Gel
COMPOSITION OF DENTIFRICES
AGENTS
Detergent
MATERIALS USED
Sodium lauryl sulphate
USES
To lower surface tension,penetrate and
loosen surface deposits and strains
Emulsify debris for easy removal by
toothbrush Contribute to the foaming
action.
Cleaning and
polishing agents
Calcium carbonate, dicalcium phosphate
dihydrate,alumina,silica
Act as abrasive, eliminates plaque and
removes stain from tooth surface.
Binding
agents/thickners
Organic hydrophilic colloids, alginates,
magnesium aluminium silicate, colloidal silica
Used for cohesiveness,to provide body
and to prevent ingredients from
seperating.
Humectants
Glycerin ,Sorbitol
Added to retail moisture so that the dentifrice doesn,t
dry out.
Also inhibits bacterial growth and provide flowability
to dentifrice.
Flavouring/col Peppermint,xylitol
ouring agents
Improves taste
Enhances color
Anticalculus
agents
Pyrophosphate,sodium
hexametaphosphate,zinc
Inhibits mineralization of plaque.
Antibacterial
agents
Triclosan, delmopinol,metallic ions
Kills or inhibits bacterial growth.
Desensitizing
agents
Stannuos fluoride, potassium nitrate
Prevents hypersensitivity
Anticaries
agents
Sodium fluoride, stannuos fluoride
Prevention of caries.
TONGUE CLEANERS
The tongue bacteria may serve as a source of bacterial dissemination to other
parts of the oral cavity, e.g. the tooth surfaces and may contribute to dental
plaque formation.
Therefore, tongue cleaning has been advocated as part of daily home oral
hygiene together with the tooth brushing and flossing .
INTERDENTAL AIDS
 In most cases, toothbrushes do not adequately clean interproximal surfaces.
 Interdental cleaning with at least one additional device is necessary for
thorough plaque removal.
 Interdental plaque biofilm control may be accomplished with several different
aids including:
* Dental floss
* Interdental brushes
* wooden or rubber tips
Dental floss
Wooden or rubber tips
ORAL IRRIGATION
 Oral irrigation device include the use of water picks.
 The high pressure, pulsating stream of water through a nozzle is directed to
the tooth surface and subgingivally, washing away debris and plaque
containing bacteria.
CHEMICAL METHODS
 Chemical plaque control should always be regarded as
an adjunct to & not a substitute for mechanical plaque
control.
 It should be related to the individual patients with
predicted risk for oral disease.
 It includes the transport of anti-microbial agents to the
oral cavity using mouthwash,oral rinse, mouth rinses
etc. to reduce & control microorganism.
 For example: chlorhexidine, listriene, triclosan etc
Formulations for chemical plaque control can be classified according to their
effects :
1. Antimicrobial agents: bacteriostatic or bactericidal effects in vitro
2. Plaque‐reducing/inhibitory agents: quantitative or qualitative effect on the
plaque that may or may not be enough to affect gingivitis and/or caries
3. Antiplaque agents: affect the plaque sufficiently to show a benefit in terms of
gingivitis and/or caries control
4. Antigingivitis agents: reduce gingival inflammation without necessarily
affecting dental plaque, including anti‐inflammatory drugs.
CARIES (decay/cavity)
Definition
According to Sturdevant: Dental caries is a infectious microbiologic disease of
the teeth that results in localized dissolution and destruction of calcified tissues.
According to WHO: It is defined as localized post eruptive pathological process
of external origin involving softening of the hard tooth tissue and proceeding to
the formation of cavity.
According to Shafer: It is defined it as a ―microbial disease of the calcified
tissues of the teeth, characterized by demineralization of the inorganic portion
and destruction of the organic substance of the tooth.
Classification of dental caries
The six classes of carious lesions according to G.V. Black are as follows:
Class I: Cavity in pits or fissures on the occlusal surfaces of molars and premolars;
facial and lingual surfaces of molars; lingual surfaces of maxillary incisors (Class I
corresponds to surfaces of a posterior tooth you can clinically see—
occlusal/lingual/buccal surfaces.
Class II: Cavity on proximal surfaces of premolars and molars (Class II
corresponds to surfaces of a posterior tooth you cannot see clinically)
Class III: Cavity on proximal surfaces of incisors and canines that do not involve
the incisal angle (Class III corresponds to surfaces of an anterior tooth you cannot
see clinically)
Class IV: Cavity on proximal surfaces of
incisors or canines that involve the incisal
angle (Class IV lesion is the larger version of
Class III that covers the incisal angle)
Class V: Cavity on the cervical third of the
facial or lingual surfaces of any tooth (Think
of the neck of the tooth)
Class VI: Cavity on incisal edges of anterior
teeth and cusp tips of posterior teeth (Class
VI corresponds to the very top surface of a
tooth)
According to surface involved:
1. Enamel caries
2. Dentinal caries
3. Root caries
According to location on individual teeth
1. Pit and fissure caries
2. Smooth surface caries
According to the rapidity of the process
1. Acute dental caries
2. Chronic dental caries
3. Arrested caries
According to occurrence of caries
1. Primary caries
2. Secondary caries (recurrent)
Based on Chronology :
1. Early Childhood Caries
2. Nursing Bottle Caries
3. Rampant Caries
4. Adolescent Caries
5. Adult Caries
Based on Severity:
1.
Incipient Caries
2.
Occult Caries(Hidden Caries)
3.
Cavitation
Enamel caries
Dentinal caries
Pit and fissure caries
Smooth surface caries
Early childhood
caries
Nurshing bottle
caries
ETIOLOGY
Dental caries is a multifactorial disease of teeth.
The major factors in the etiology of dental caries are as follows:
1.
2.
3.
4.
Diet
microflora
Tooth surface
Time
DIET
Diet has been shown to affect the caries rate in
various ways:
◦ Composition:Carbohydrates
like
sucrose,
fructose and glucose are cariogenic. sucrose is
the most harmful sugar type.
◦ Consistency:Food which is soft and sticky
accumulates on tooth surface more than fibrous
non-sticky food
◦ Frequency:Another factor promoting caries is
the consumption of snacks between meals
MICROFLORA
Bacteria Streptococci are essential for development of
dental caries.
Able to produce a pH low enough (<5) to decalcify tooth
substance.
Able to survive and produce acid at low levels of pH
Able to produce polysaccharides (glucans).
TOOTH
Feature predisposed to the development of
dental caries is presence of deep narrow occlusal
fissure/ buccal and lingual pitsTooth position
Which are malaligned, out of position, rotated or
otherwise not normally situated, may be difficult
to clean and tend to favor the accumulation of
food and debris which subsequently lead to
dental caries.
TIME
Time is another significant factor in the
development of dental caries.
If the tooth surface has been exposed to the acid
produced by the bacteria of the dental plaque for a
long period, this acid will harm and demineralize
tooth surface.
Caries susceptibility of individual tooth
THEORIES OF DENTAL CARIES
There are different theories about the progress of dental caries:
1.
Legend of the worm theory
2.
Endogenous theories
3.
4.
i.
ii.
Humoral theory
Vital theory
Exogenous theory
i.
ii.
iii.
iv.
v.
vi.
i.
ii.
Chemical (acid) theory
Parasitic (septic) theory
Miller’s chemicoparasitic theory – Acidogenic theory
Proteolysis theory
Proteolysis chelation theory
Sucrose – chelation theory
Other theories
Auto immune theory
Sulfatase theory
The Legend of Worms –
Earliest mention is from ancient Sumerian text (5000 BC) known as the “Legend
of worms”.
Caries is caused by worms which drank blood of the teeth & fed on roots in the
jaws.
ENDOGENOUS THEORIES
1. Humoral Theory
Greek physicians
Dental caries is produced by internal actions of acids & corroding humors & an
imbalance in these humors resulting in disease.
i.
ii.
iii.
iv.
Blood (sanguine)
Phlegm (phlegmatic)
Black bile (melancholic)
Yellow bile (choleric)
2. Vital Theory of tooth decay
Hippocrates, Galen Proposed that tooth decay originated like a bone gangrene,
from within the tooth itself.
Penetration of caries into dentin and pulp without detectable catch on the
surface.
EXOGENOUS THEORY
Acidogenic theory Proposed by W.D Miller in 1882
Miller proved after certain experiments that certain bacteria present in mouth, produce acids from
carbohydrates which causes demineralization of the dental tissues.
Consumption of more refined carbohydrates was associated with more caries.
Frequency of carbohydrate foods(snacks and drinks) also contribute to incidence of dental caries
Widely accepted theory
Proteolytic theory Proposed by Gottlieb
According to this theory, the organic or protein elements of tooth are the initial pathways of invasion by
microorganisms
And, caries is essentially a Proteolytic process , in which the microorganisms invade the organic pathways
and destroy them while advancing through them by forming acids.
Hence certain structures of enamel having high organic material composition, like enamel lamellae and
enamel rod sheaths, could serve as a pathway for microorganism invasion through the enamel
Proteolysis – Chelation theory
Schatz et al 1995
Theory states that a simultaneous microbial degradation of the organic
components & the dissolution of the minerals of the tooth by the process
known as chelation.
Chelation is a process involving the complexing of a metallic ion to a complex
substance through a covalent bond which results in a highly stable, poorly
dissociated or weakly ionized compound.
METHODS TO CONTROL CARIES
1. Chemical measures
2. Nutritional measures
3. Mechanical measures
Chemical methods
Chemical measures include:
I. Substances which alter tooth surface or tooth structure
II. Substances which interfere with carbohydrate degradation through enzymatic
alteration
III. Substances which interfere with bacterial growth and metabolism
Chemicals used are:
1.
2.
3.
4.
5.
6.
Fluorides
Iodides
Bisbiguanides
Silver nitrates
Zinc chloride and
potassium ferrocyanates
SUBSTANCES WHICH INTERFERE WITH CARBOHYDRATE DEGRADATION THROUGH ENZYMATIC
ALTERATIONS
- Includes:
1.
Vitamin K (Vitamin K was found to prevent acid formation in incubated mixtures of glucose
and saliva )
2.
Sarcoside )(Sarcoside Sodium-N-lauryl sarcosinate & sodium dehydroacetate were promising
enzyme inhibitors or antienzymes. They have the ability to reduce the solubility of powdered
enamel
SUBSTANCES WHICH INTERFERE WITH BACTERIAL GROWTH AND METABOLISM
Includes:
1. Urea and ammonium compounds
2. Chlorophyll
3. Nitrofurans
4. Antibiotics
5. Anti-Caries vaccines
NUTRITIONAL MEASURES
The chief nutritional measures advocated for the control of dental caries is
restriction of refined carbohydrate intake.
Other measures include –
1. Avoiding sugar that retains of teeth surface
2. Avoiding sugar in between meals
3. Eating of phosphated diets
Mechanical methods
This refers to procedures specifically designed for and aimed at removal of
plaque from tooth surface methods for cleaning tooth mechanically are:
1. Prophylaxis by dentist
2. Tooth brushing
3. Mouth rinsing
4. Use of dental floss or tooth picks
5. Incorporation of fibrous foods in diet
6. Pit and fissure sealants
Clinical features of dental caries
1. Initially symptomless-incipient caries.
2. Frank Hole on the tooth.
3. Pains with cold/ warm water with dentine exposure.
4. When the pulp/nerves becomes exposed: Pains at night and with chewing.
5. Unstimulated pains.
Sequele of dental caries.
Complications of dental caries
If dental caries is left untreated for a more extended period, it may lead to several complications
based on the nature of the carious lesion. Starting from the small inactive white spot lesion, it may
lead to osteomyelitis. If the host immune response is weak, dental caries may result in
inflammation of the pulp leading to:
1.
2.
3.
4.
5.
6.
7.
8.
Apical periodontitis
Periapical abscess
Periapical granuloma
Periapical cyst
Cellulitis
Abscess
Periostitis
Osteomyelitis
Dental caries is not life-threatening, but if the infection spreads through facial planes, patients are
at increased risk of sepsis, airway compromise (Ludwig angina), and odontogenic infections,
which in one study accounted for 49.1% cases of deep neck abscesses that may result in even
death.
Extraoral sinus from
decayed tooth
Periapical granuloma
Treatment
Restorations
Amalgam restoration
Composite restoration
Gold restoration
Glass inomer cement (GIC)
restoration