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