Deposits:Dental Biofilm, Calculus, and Stain

Kylie Siruta, RDH MSDH ECP

October 11, 2010

Session Objectives 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

Soft Deposits (Non-mineralized) Acquired Pellicle Microbial Biofilm Materia Alba Food Debris

Acquired Pellicle 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

Forms over exposed tooth surfaces, restorations, and calculus

Usually varies in thickness from 01.-0.8μm Often thickest near the gingival margin

Highly insoluble Forms within minutes after all external material has

been removed from the tooth surface (constantly renewed)

Acquired Pellicle

3 Types Surface pellicle, unstained▪ Clear, translucent, insoluble▪ Not visible until disclosing solution has been applied

Surface pellicle, stained▪ Takes on extrinsic stain and becomes brown,

grayish, or other colors Subsurface pellicle▪ Continuous with surface pellicle▪ Embedded in tooth structure, particularly where

tooth surface is partially demineralized

Acquired Pellicle

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

Dental Biolfilm

A dense, 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, and viruses

Dental Biofilm

Review of morphologic forms of bacteria

Answers on page 295 (Wilkins)

Dental Biofilm

Composition 20% is microorganisms and

intermicrobial matrix▪ Includes both organic and inorganic solids▪ Organic – Carbohydrates, Proteins, Lipids▪ Inorganic – Calcium, Phosphorus, Fluoride

80% is water

Dental Biofilm Stages of Plaque

Formation1. Formation of the

pellicle2. Bacteria attach to the

pellicle3. Bacterial multiplication

and colonization4. Biofilm growth and

maturation5. Matrix formation

Dental Biofilm 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, filamentous forms, and

fusobacteria▪ Plaque near the gingival margin thickens and develops more

mature flora with spirochetes and vibrios

Dental Biofilm Changes in Biofilm Microorganisms

Days 7-14▪ Vibrios and spirochetes appear and white blood cells

increase▪ As plaque matures, 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, along

with cocci and filamentous forms▪ Gingivitis evident clinically▪ Crevicular fluid increases in volume

Biofilm removal – health within a few days!

Dental Biofilm

Wilkins, page 298

Dental Biofilm

Subgingival Biofilm Results from apical proliferation of

microorganisms from supragingival biofilm

Differences in microorganisms:▪ More anaerobic▪ Motile organisms▪ Predominately gram negative

Review Table 17-2 on page 296 (Wilkins) Comparing Supragingival and

Subgingival Biofilm

Dental Biofilm Subgingival Biofilm

3 Types▪ Tooth Surface Attached Biofilm▪ Gram positive rods and cocci

▪ Unattached Biofilm▪ Motile, gram negative organisms

▪ Epithelium-Associated Biofilm▪ Many virulent pathogens, gram

negative organisms and numerous white blood cells▪ Invade the underlying connective

tissue

Dental Biofilm Factors Favoring Biofilm Accumulation

Tooth surface irregularities Tooth contour Tooth position Dental Prosthesis Gingiva Personal Oral Care Drugs Diet Tobacco Xerostomia

Dental Biofilm Significance of Biofilm Accumulation

A primary etiology for▪ Gingivitis▪ Periodontitis▪ Caries▪ Calculus▪ Pellicle + Plaque + Calcium Phosphate

Removal of Dental Biofilm Goal is to disrupt and reduce microorganisms and

colonies▪ Prevention of the above conditions

Methods of Removal:▪ Mechanical (instrumentation, toothbrushing, etc.)▪ Chemical (rinses)

Materia Alba A bulky, loosely-connected

soft deposit composed of bacteria and cellular debris that forms over biofilm

Unaesthetic – clearly visible White, resembles cottage cheese

Contributes to halitosis Can be removed with water

spray or oral irrigator Dental biofilm cannot

Food Debris

Food particles found on the cervical third and proximal embrasure spaces

Can be removed with water rinses Dental biofilm cannot

Calculus (Mineralized Biofilm) Biofilm that has become mineralized

by calcium and phosphate salts within the saliva

Composition: 75-85% Inorganic▪ Calcium, Phosphate, Carbonate, Sodium,

Magnesium, Potassium 15-25% Organic▪ Non-vital microorganisms, desquamated

epithelial cells, leukocytes

Calculus

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 PercentInorganic

Enamel 96%

Calculus 75-85%

Dentin 65%

Cementum 45-50%

Bone 45-50%

Calculus 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

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

Calculus

Supragingival White, creamy

yellow, or gray Shape determined

by gingival contour Moderately hard

Subgingival Light to dark brown,

dark green, black Shape conforms

with pocket wall Brittle, flint-like Harder, more dense

than supragingival

See Table 18-1 on page 312 (Wilkins)

Calculus

Calculus

Formation Unlike subgingival biofilm, subgingival

calculus doe not develop by direct extension from supragingival calculus▪ Results from deposition of mineral salts into a

biofilm organic matrix1. Pellicle formation2. Biofilm formation and maturation3. Mineralization

Calculus

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)

Calculus

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

Calculus Modes of Attachment

Acquired Pellicle▪ Superficial, no interlocking or penetration▪ Easily removed, mostly on enamel (supragingival calculus)

Irregularities in Tooth Surface▪ Includes cracks, 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)

Calculus

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

Calculus Prevention

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

Dental Stains

3 Ways Stain/Discoloration Occurs: Stain adheres directly to the surface Stain contained within calculus and soft

deposit Stain incorporated within the tooth

structure

Dental Stains 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

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

Dental Stains 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

Dental Stains 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

Dental Stains

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

Dental Stains

Exogenous Intrinsic Stains Restorative Materials▪ Silver amalgam▪ Endodontic therapy

Drugs▪ Stain from stannous

fluoride Stains in the Dentin▪ Carious Lesions

Dental Stains Exogenous Intrinsic

Stains Vital and non-vital

bleaching Composite

restorative materials bonded as overlays

Veneers Crowns Enamel micro-

abrasion

Dental Stains

Exogenous Extrinsic Stains Most frequently observed

stains▪ Includes:▪ Yellow▪ Green▪ Black Line▪ Tobacco▪ Coffee/Tea/Soda

▪ Others (Less Common):▪ Orange▪ Red▪ Metallic

Dental Stains

Exogenous Extrinsic Stain Yellow Stain▪ Most evident with poor oral

hygiene▪ Usually food pigments

Dental Stains

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, and gingival hemorrage▪ Demineralized underneath

Dental Stains Exogenous Extrinsic Stain

Gray/Green Stain▪ Occurs around gingival-third of teeth▪ Etiology:▪ Oils, resins, 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, occurs at gingival-third of incisor teeth▪ Etiology: chromogenic bacteria

▪ Red stain Etiology: food stuffs such as raspberries, wine, etc.

Dental Stains 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

Dental Stains

Exogenous Extrinsic Stain Brown stain▪ Etiologies:▪ Stannous fluoride▪ Food stuffs – tea, coffee, soda▪ Antimicrobial Agents - Chlorhexidine

Dental Stains

Exogenous Intrinsic Stain Removal▪ Professional prophylaxis/maintenance▪ Scaling▪ Abrasive polishing agents▪ Air/Powder Polishing

▪ Home Products▪ Whitening dentifrices

Concentrated soft silica▪ Professional/Home Bleaching

References Little, J.W., Falace, D.A., Miller, C.S., Rhodus, N.L. (2008) Dental

management of the medically compromised patient, 7th ed. Mosby. ISBN# 9780323045353.

Miller, C.H. & Palenik, C.J. (2010) Infection control and management of hazardous materials for the dental team, 4th ed. Mosby. ISBN#9780323056311.

Mosby’s dental drug reference, 9th ed. (w/CD only) (2010). ISBN # 9780323065207.

Nield-Gehrig, J. S. (2007) Fundamentals of periodontal instrumentation & advanced root instrumentation, 6th ed. Lippincott Williams & Wilkins. ISBN# 9780781769921.

Nield-Gehrig, J. S. (2006) Patient assessment tutorials. Lippincott Williams & Wilkins. ISBN# 9780781775168.

Wilkins, E. (2009). Clinical practice of the dental hygienist, 10th ed. Lippincott Williams & Wilkins: Baltimore, MD. ISBN# 100781763223.

MATC Dental Hygiene Clinic Handbook. 1st Edition. 2010.

Photos: Wilkins, E. (2009). Clinical practice of the dental hygienist, 10th ed.

Lippincott Williams & Wilkins: Baltimore, MD. ISBN# 100781763223.