Chapter 17) Dental Soft Deposits, Stains, and Calculus

Dental Biofilm and Other Soft Deposit Examples:

• dental biofilm (soft deposits)

  • acquired enamel pellicle

  • microbial (bacterial) biofilm

  • materia alba

  • food debris

  • calculus (hard mineralized deposits)

    • supragingival

    • subgingival

Pellicle Formation:

thin, acellular tenacious film/formation 30-90minutes

Types of Pellicle:

supra and subgingival pellicle

Significance of Pellicle:

protective, lubricates, acts as a nidus of attachment for bacteria and calculus

• salivary proteins > high affinity for hydroxyapatite of enamel > pellicle formation

Removal of Pellicle:

• patient oral self-care (tooth brushing/flossing)

• polishing procedures

Oral microbiome composed of:

• microorganisms

• their genetic makeup

• environments of oral cavity (multi-teeth, gingival sulcus, attached gingiva, tongue, oral mucosa, lips and hard and soft palates)

Good Oral Microbiome:

microorganisms perform pro and anti-inflammatory activities which maintain homeostasis

Bad Oral Microbiome:

the matrix protects the biofilm from the host’s immune system and antimicrobial agents

Formation of Biofilm: Stage 1 Formation

• Initial attachment of planktonic bacterial cells to the pellicle

• . Cells are “not committed” and its reversible

Formation of Biofilm: Stage 2 Bacterial Multiplication and Colonization

Microorganisms attach themselves and multiply “irreversible manner of microorganisms”

Formation of Biofilm: Stage 3 Matrix Formation

EPS secreted by cells form a Matrix (protects biofilm)

Formation of Biofilm: Stage 4 Biofilm Growth

Cell-to-cell communication (Quorum sensing)

Formation of Biofilm: Stage 5 Maturation

Bacterial colonies mature and release planktonic cells to spread and go elsewhere in the mouth

Changes in Biofilm Microorganisms: Days 1-2

gram-positive cocci present

Changes in Biofilm Microorganisms: Days 2-4

Cocci still dominate but gram-positive filamentous form and slender rods join the surface.

• Within 72 hours, biofilm has matured>inflammation initiation

Changes in Biofilm Microorganisms: Days 6-10

• Filaments increase, heavy leukocytes

• Gram-negative bacteria

• EPS secreted by bacteria> to 3-deminsional biofilm structure

Changes in Biofilm Microorganisms: Days 10-21=

clinically evident gingivitis

Supragingival Biofilm:

• Made up of two layers

  • (basal layer) gram-positive aerobic bacteria

  • greater variability layer forms on top of basal layer

Subgingival Biofilm:

I. Made up of four layers

II. Predominantly spirochetes and gram- negative anaerobic and motile organisms

III. From top layer, bacteria invades connective tissue.

Composition of Dental Biofilm: Inorganic Elements

• calcium and phosphorus

• fluoride

Composition of Dental Biofilm: Organic Elements (found in EPS)

• Carbohydrates (glucans)> tenacious adherence

• Proteins & small amount of lipids

Microorganism and EPS make up __% of the biofilm, the other is _% water

80, 20

_____ transports the minerals during the mineralization and demineralization processes

Saliva

Clinical Aspects: Distribution of Biofilm (surface and location)

• supragingival biofilm

• gingival biofilm

• subgingival biofilm

• fissure biofilm

Clinical Aspects: How to Detect Biofilm

• direct vision

• use of explorer or probe

• disclosing agent

• clinical record (slight, moderate, heavy)

Dental Caries:

• Cariogenic Microorganisms in Biofilm

• The pH of Biofilm

  • Critical pH enamel=5.5

  • Critical pH dentin & cementum= 6.2-6.4

Effect of Diet on Biofilm:

high cariogenic diet, biofilm gradually increases its pH lowering ability

Materia Alba:

• Clinical Appearance and Content

  • Soft whitish or grayish-white deposit

  • Clinically visible w/o disclosing agent

  • Unorganized accumulation of living and dead bacteria, cells, leukocytes, salivary proteins.

• Prevention

  • Removable with water spray device or tongue action.

Food Debris:

• Collection at cervical third and proximal embrasures

• Vertical food impaction

• Contributes to general unsanitary condition and initiation of dental caries

Supragingival Calculus:

Location: clinical crowns, implants, dentures, etc

Distribution: most frequent sites→ lingual of lower anterior teeth and facials of maxillary 1st and 2nd molars

Subgingival Calculus:

Location: clinical crown apical to the gingiva margin/dental implants

Distribution: localized or generalized/heaviest deposits on hard-to-reach areas for patient

___/_____ gives subgingival calculus its dark black color

GCF/blood

Calculus Detection: Supragingival

• visual

• compressed air-directly on calculus causes ‘chalky’ appearance

Calculus Detection: Subgingival

• visual

  • air

  • tissue color change

• tactile

  • probe

  • explorer

• radiographic

• dental endoscopy

Slight to Moderate Calculus:

Heavy Calculus/Stain:

Radiographic Calculus:

Mature calculus contains mostly ______ content

inorganic

Major Inorganic Components:

Calcium (Ca), Phosphorus (P), Carbonate (CO3), Sodium (Na), and Magnesium (Mg)

Trace Elements in Inorganic Calculus Composition:

Zinc (Zn, Strontium (Sr), Iron (Fe), Potassium (K),

Fluoride in Inorganic Calculus Composition:

binds to hydroxyapatite crystals

Inorganic Calculus Composition Crystals:

2/3 of inorganic content is crystalline (apatite)

Inorganic Calculus Compared with Teeth and Bone

dental enamel is the most mineralized tissue in the body

Steps of Calculus Formation:

pellicle forms, biofilm forms, then biofilm mineralizes

Calculus Formation: Mineralization

• source elements differ between supra and subgingival calculus

• saliva is source element for supra calculus

• GCF and inflammatory exudate is source for subgingival

Calculus Formation: Structure of Calculus

• layers parallel to the tooth surface

• detectable with explorer and probe

Calculus Formation: Formation Time

Approximately 12 days and can begin as early as 24-48 hours

Types of Calculus Deposits:

• crusty, spiny, nodular

• ledge or ring

• thin, smooth veneers

• finger- and fern-like formations

• individual islands/spots

• supragingival or subgingival deposits

Attachment of calculus determines the difficulty of _______

removal

Attachment by means of an acquired pellicle

superficial, non-interlocking attachment, easily removed

Attachment to Minute Irregularities in the tooth surface by mechanical locking into undercuts

dentin and cementum irregularities

Attachment by direct contact between calcified intercellular matrix and the tooth surface

interlocking of inorganic apatite crystals of the enamel and cementum with the calculus

Debate over whether subgingival calculus plays a role in periodontal disease

• Rough texture of calculus acts as a reservoir for endotoxins and tissue breakdown products.

• Biofilm in contact with pocket > to inflammation

Microorganisms in biofilm layer perpetuate inflammatory state supragingivally and subgingivally

Increased flow of GCF, resulting in mineralized biofilm

Daily control of biofilm essentials:

Brushing and flossing, antimicrobial mouth rinses

Personal Dental Biofilm Control:

patient education on self oral care

Regular Professional Continuing Care:

at the dentist, maintenance appointments

Anti-calculus Dentifrice and Mouth rinses-Chemotherapeutic anti-calculus agents include:

A. pyrophosphates (anti-tartar)

B. zinc citrate (anti-tartar)

C. pyrophosphates + triclosan (antimicrobial)

Dental Stains and Discolorations Occur in 3 General Ways:

1. Adhere directly to surfaces

2. Contained within calculus and soft deposits

3. Incorporated within tooth structure or restorative material

Significance of stain is its ______ effect

cosmetic

Classification of Stains:

Extrinsic, Intrinsic, Exogenous, Endogenous

Recognition and Identification of Dental Stains:

• medical and dental history

• food dairy

• oral hygiene habits

Application of Procedures of Stain Removal

• Stains directly on tooth surface

• Stains incorporated within tooth deposits

• Stains incorporated within the tooth

Extrinsic Stains Categories:

• directed extrinsic stains

• indirect extrinsic stains

Most Frequently Observed Stains:

• yellow

• green

• black line

• tobacco

Yellow Stain:

• Clinical Features

  • dull, yellowish discoloration of biofilm

• Distribution on Tooth Surfaces

  • localized or generalized

• Occurence

  • common in all ages

  • more evident with lack of personal care

• Etiology

  • usually dietary sources

Green Stains:

• Clinical Features

  • light yellowish-green in biofilm

• Distribution on Tooth Surfaces

  • primarily facial, gingival 1/3 of maxillary teeth

• Composition

  • chromogenic

• Occurrence

  • any age, primary childhood

Black-Line Stain (Extrinsic)

• Clinical Features

  • continuous or interrupted line, 1mm wide

• Distribution on tooth surfaces

  • facial and lingual but rarely on max anterior facials

  • forms along gingival 1/3 near gingival margin

• Composition and Formation

  • microorganisms embedded in intermicrobial substance

  • attachment by pellicle-like structure, mineralization is similar to the formation of calculus

• Occurrence

  • all ages, more common in children

  • more common in females

  • frequently in clean mouths

• Recurrence

  • quantity less with meticulous oral hygiene care

Tobacco Stain:

• Clinical Features

  • light brown to dark leathery brown or black

• Distribution on tooth Surface

  • cervical 1/3, primarily lingual surfaces

• Composition

  • tar and products of combustion and brown pigments from smokeless tobacco

• Predisposing factors

  • smoking

  • chewing tobacco

  • inadequate oral hygiene

Brown Stains:

• Brown Pellicle

  • chemical alteration of the pellicle from staining

• Stannous Fluoride

  • can cause staining with continuous care

• Antimicrobial Agents

  • chlorhexidine

• Betel/Acreca

  • betel nut chew

• Swimmer Stain

  • chlorine or bromine in swimming pools

Orange and Red Stains:

• Clinical Appearance

  • orange/red stains and cervical 1/3 of tooth

• Distribution on Tooth Surfaces

  • more frequently on anterior teeth than posterior

• Occurrence

  • rare (red more than orange)

• Etiology

  • possibly chromogenic bacteria

Metallic Stains:

• Metals or Metallic Salts from Metal-Containing Dust of Industry

  • copper or brass: green or blusish-green

  • iron: brown to greenish-brown

  • nickel: green

    • Prevention: wear a mask while working

• Metallic Substances Contained in Drugs

  • iron: black (iron sulfide) or brown

  • manganese (from potassium permanganate)= black

    • prevention: take meds through a straw or tablet form to prevent contact with teeth

Endogenous Intrinsic Stains:

Pulpless or Traumatized Teeth

• Clinical Appearance

  • wide range; light yellow-brown, slate gray, reddish brown, dark brown, bluish-black, black, orange, or greenish tinge

• Etiology

  • blood-pigment from decomposed hemoglobin and pulp tissue penetrate and sicolor the dentinal tubules

Disturbances in Tooth Development: Hereditary Genetic

• Amelogenesis imperfecta: enamel partially or completely missing

• Dentinogenesis imperfecta (Opalescent dentin): dentin abnormality due to disturbance in odontoblastic layer during development

Disturbances in Tooth Development: Enamel Hypoplasia

damage to the tooth germ during development

Disturbances in Tooth Development: Dental Fluorosis

AKA mottled enamel

Drug-Induced Stains and Discolorations: Tetracycline

intrinsic staining via vertical transmission or absorbed while teeth are developing

Drug-Induced Stains and Discolorations: Minocycline

intrinsic staining post tooth eruption

Exogenous Intrinsic Stains: Restorative Materials

• silver amalgam

• endodontic therapy

  • tooth colored restorations stained with extrinsic staining substances

Exogenous Intrinsic Stains: Stain in Dentin

discoloration resulting from a carious lesion

Exogenous Intrinsic Stains: Other Local Causes

• enamel erosion

• attrition of occlusal forces

Documentation:

• Clinical description of appearance of teeth relative to biofilm, materia alba, or food debris

• Extent of supragingival and subgingival deposits

• Color, type, extent, and location of stains

• Personal patient care procedures demonstrated

Factors to Teach the Patient:

• Location and properties of biofilm and calculus

• Effects of personal oral care procedures

• Biofilm control procedures

• Sources of cariogenic foodstuff in the diet

• What calculus is and how it forms

• Etiology of individual’s dental stains

• Advantages of smoking cessation

• Effect of tetracyclines

• Select products approved by ADA or CDA

Does anterior or posterior surfaces have the least amount of biofilm?

Anterior

What is the Critical pH for enamel?

5.5

What is the critical pH for dentin and cementum?

6.2-6.4