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Deposit Assessment

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Margit Strobl

on 21 November 2016

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Transcript of Deposit Assessment

Non-mineralized deposits (soft deposits)
materia alba
acquired pellicle
food debris
bacterial plaque biofilm
Stains
Class Activities
Group discussion of content for clarification purposes
Deposit Assessment
Deposit Assessment
Stain
Calculus
Plaque biofilm

Mineralized deposits (hard deposits)
Calculus
Materia alba
Looks like cottage cheese
Loosely adherent complex of bacteria and oral debris
Unstructured
Origin: incidental accumulation
Removal: water spray, irrigation/ rinsing

Food debris
Unstructured
Loosely attached particulate matter
Origin: food retention after eating
Self cleansing and brushing

Acquired pellicle
Tenacious, amorphous, acellular film
Origin: saliva and gingival fluids
Forms over exposed firm surfaces of oral cavity such as teeth, calculus, restorations
Usually thickest at gingival margins but can vary in thickness from tooth to tooth/ area to area (Thickness of Acquired Salivary Pellicle as a determinant of the Sites Of Dental Erosion , B.T. Amaechi, S.M. Edgar, A. Milosevic - jdr.sagepub.com Jan 7/10)

Composed of glycoproteins
Contains enzymes, immumoglobulins and organic/
inorganic components of saliva
Removal by polishing – reforms in minutes and is fully formed in 30-90 minutes
highly insoluble coating


within minutes after all external material has been
removed from the tooth surfaces with an abrasive,
the acquired pellicle begins to form. It is composed
primarily of glycoproteins from the saliva that are
selectively adsorbed ( adhere or attach to the hydroxyapatite) by the hydroxyapatite of the tooth surface. The adsorbed material becomes a highly insoluble coating over the teeth, calculus deposits, restorations, and complete and partial
dentures. It can attach supragingival or subgingival. The subgingival is an extension of supragingival pellicle and can become embedded in the tooth structure.

Pellicle formation
Protects against acids – which impacts remineralization and demineralization
Nidis ( nest) for plaque- participates in biofilm formationby aiding in adherence of microorganisms
Provides a surface for calculus attachment
Lubrication- keeps surfaces moist and prevents drying to enhance efficiency of mastication and speech

Significance of pellicle
Bacterial Plaque Biofilm
Definition: complex, well organized, cooperating
community of microorganisms adhering to inert and
living surfaces
covered in an extracellular polymeric substance that protects the biofilm from the host's immune response and from antibiotic/antimicrobial agents
Often resistant to antibiotics because of extracellular
matrix
Biofilm possess primitive communication systems (quorum sensing)
Occasionally portions of microcolonies detach then reattach in another area to begin developing new colonies elsewhere

Dental biofilm is mostly made up of a variety of
microorganisms although biofilms can be one species
Microorganisms arrange in a way that suits their needs and requirements
Varied environments in biofilm – bacteria distribute according to who can survive best in a particular environment
Symbiotic relationships develop between specieis as well

Plaque biofilm formation
A. Pellicle formation and initial adherence
B. Lag phase then Bacterial colonization – includes attachment to
pellicle
C. Maturation (steady state) and detachment
There are three main stages of biofilm formation but the number of stages varies according to the source
of the information

Please note that the stages will be explained a bit differently depending on the soruce
Need a source of energy – usually from sucrose
Microorganisms produce: acid, intracellular
polysaccharides and extracellular polysaccharides
( fructans, glucans)--- These polysaccharides help in
producing the matrix
plaque biofilm metabolism
please see pp 284-286 in Darby Walsh for more information
Dental calculus (or tartar) is oral biofilm that has been mineralized by calcium and phosphate salts from saliva
Supragingival calculus
Calculus above the free gingival margin
Subgingival calculus
Calculus below the free gingival margin, often on the root surface

Definition
structure
Layers: approximately parallel to tooth surface and separated by pellicle
Surface: rough texture
Surface appearance: peaks, valleys and pits (when seen microscopically)
Outer layer: partly calcified
Classification
by:
Location- supragingival or subgingival
Amount- light, moderate, heavy
Stages of formation
Three basic steps of calculus formation
Pellicle
Biofilm maturation- micororgs attach to pellicle, colonies form, grow and merge to form a plaque biofilm layer
Mineralization- mineralization first starts to occur in intracellular matrix----- usually involving filamentous microorganisms
foci (centers) form within the deep layers of the biofilm (close to the tooth surface) and eventually they become large enough to touch
minerals for the mineralization come from saliva (suprag) and gingival sulcus fluid/ inflammatory exudate (subg)-------- sulcus fluid and exudate increase with increase in inflammation so more minerals available for subg biofilm to mineralize

Calculus attachment
Acquired pellicle: Superficial attachment to pellicle because no interlocking or penetration occurs therefore calculus is removed easily
Most frequently occurs on enamel and newly scaled and planed root surfaces
Easily removed

Minute irregularities in tooth surface by mechanical means: (enamel irregularities include cracks, carious defects, etc.)
On cementum- includes tiny spaces where Sharpey’s fibers once attached, scaling grooves, cemental tears
Difficult to be certain all calculus is removed when it is attached by this method because the calculus is locked into the irregularities
Makes distinction between calculus and cementum difficult when debriding root surfaces

Direct contact between calcified intercellular matrix and tooth surface. This occurs when there is an interlocking of inorganic apatite crystals of the enamel and cementum with the mineralizing dental biofilm (calculus)

composition of calculus
Fluoride:
Concentration in calculus varies and is influenced by amount of fluoride in drinking water, topical application, dentifrices and any other form that is received by contact with the external surface of calculus
Crystals:
2/3 of inorganic matter of calculus is crystalline
Predominantly hydroxyapatite
Also contains brushite, whitlockite, octocalcium phosphate

Inorganic components
Mature calculus made up of 70-90% inorganic components
Main components are:
Calcium
Phosphorus
Carbonate
Sodium
Magnesium
potassium
Trace elements are:
Chlorine
Zinc
Strontium
Bromine
Copper
Manganese
Tungsten
Gold
Aluminum
Silicon
Iron
fluorine

Organic components
Nonvital microorganisms
Desquamated epithelial cells
Leukocytes
Mucin from saliva
Other substances identified in organic matrix:
Cholesterol esters
Phospholipids
Fatty acids
Carbohydrate
Keratins
Nucleoproteins
Amino acids

Supragingival:

White/creamy yellow/gray
Bulky
Moderately hard
Quantity is related to a number of factors (OHI, diet, individual tendencies)
Coronal to margin of gingiva
Influenced by tooth position, OHI, etc.

clinical characteristics of calculus
Subgingival:

Light to dark brown/black/green
Flattened to conform with pocket wall
Hard, more dense than supra, brittle/flint like
Quantity related to pocket depth
Apical to gingival margin
Heaviest on proximal surfaces, lightest on facial surfaces

Significance of calculus
Plays important role in the development, promotion and recurrence of gingivitis, perio
Contains pathogenic bacteria that cause inflammation and destruction of gingival tissue (attachment loss)
Rough surfaces of calculus act as reservoir for endotoxins and tissue breakdown products
Predisposing factor in pocket development

why remove it?
Predisposing factor for gingivitis and perio
Plaque haven
Provides a smooth tooth surface conducive to healing
The smoother the surface the easier to maintain

Objectives
1. List and describe the four types of non-mineralized deposits.
2. Discuss the difference between supragingival vs subgingival dental biofilm.
3. Explain the organization of subgingival dental biofilm.
4. Explain the formation of biofilm.
5. Define calculus.
6. Identify where both supragingival and subgingival calculus would be found.
7. Discuss the three stages of calculus formation.
8. Discuss in detail the three ways in which calculus can attach to the tooth surface.
9. Discuss the composition of calculus including both organic and inorganic components.
10. Discuss the clinical characteristics of supragingival and subgingival calculus.
11. Discuss the significance of calculus.
More Objectives
1. Identify the classifications of stains.
2. Discuss a given stain, including appearance, distribution, occurrence, etc.
3. Identify stains in the clinical setting or from a given set of slides.
4. Distinguish between different developmental conditions that stain teeth.
5. Explain how the assessment of soft and hard deposits informs client education.
Describe the effectiveness of plaque and calculus inhibitors according to research.
Classified by location:
Extrinsic: occur on the external (outer) surfaces of the teeth.
The most common extrinsic stains are chlorhexidine stain and tobacco stain.
These can be removed by polishing/scaling
Intrinsic: occur within the enamel of the tooth and cannot be removed by polishing.
Examples: Tetracycline stain and stains from silver amalgams or endodontic (root canal) treatment.
Classification by source:
Exogenous: develop/originate outside the tooth. May be extrinsic and stay on outer surface of tooth or become incorporated within the tooth structure.
Endogenous: develop/originate within the tooth. Always intrinsic and are usually dentin discoloration reflecting through the enamel.

Types of stain
Yellow
Associated with the presence of biofilm
Common to all ages
Most evident when oral hygiene neglected
Etiology: food pigments

Green
Light to yellowish green – very dark green
Embedded in dental biofilm
Three general forms: curved, smeared streaked
Frequently superimposed by soft yellow or gray debris ( materia alba, food debris)
If dark green, it may become embedded in enamel
Enamel under stain may be demineralized
Composition: chromogenic bacteria/fungi, decomposed hemoglobin
produced in dental biofilm
Can occur at any age (primarily in children)
Results from generally poor oral hygiene, chromogenic bacteria and hemoglobin
Clinical approach:
DO NOT SCALE THE AREA
Ask patient to remove biofilm during OHI
Initiate daily fluoride remineralization protocols
more stain....
Black line stain
Black or dark brown in color
Highly retentive ( sticks well)
Black line of stain follows the gingival crest on both facial and lingual surfaces
Composed of microorganisms embedded in intermicrobial substance
Mineralized and attaches by a pellicle like structure
Occurs at all ages but more common in females
Reforms despite GOH

Orange and red
Appear at the cervical 1/3 of tooth
Mostly found on anterior teeth
Rare, especially red
Etiology: chromogenic bacteria

Brown
Etiology: tobacco, betel leaf, antibiofilm agents, stannous fluoride, food/drink
Stannous- light brown/yellowish, results from formation of stannous sulfide in reaction with fluoride and tin (brown tin oxide)
Food: tea, coffee, soy sauce
Anti-biofilm agents: chlorhexidine used in mouthrinses
Betel leaf: dark mahogany brown, can become thick and hard—removed by scaling

even more stain....
Tobacco
Light brown –dark leathery brown/black
Stains dental biofilm and incorporates into calculus deposits
Can penetrate enamel and become exogenous intrinsic stain
Usually distributed on cervical 1/3 of tooth and most frequently on the linguals
Composition: tar and products of combustion, brown pigment from smokeless tobacco

Metallic
Color: green/bluish green, brown/greenish brown, green, yellow/ golden brown depending on the source
Sources: copper, iron, nickel, cadmium, manganese
Usually found on cervical 1/3 of anterior teeth but can occur on all teeth
Formation: industrial worker inhaling metallic dust through mouth and coloring biofilm – OR drug enters biofilm/calculus

Name that stain!
References
Darby M, Walsh M. Dental Hygiene Theory and Practice.4th Ed. St Louis, Missouri: Saunders; 2015
deposit assessment and documentation (random thoughts)
Document the oral hygiene products used and the previous instruction given

The presence of oral biofilm is most commonly assessed by passing a dental explorer over the tooth surface
Disclosing agents are used to make the oral biofilm clinically visible

The client’s ability to manage oral self-care must be assessed through the following means:
Questioning the client about his or her oral care practices
Direct observation
Documenting the client’s oral hygiene status and dental history

How does the deposit assessment inform client education?
please see p 290 in Darby Walsh for more information
please see p290 in Darby Walsh for information
please pp288-290 in Darby Walsh for information
please see table on p 289 of Darby Walsh
Wilkins E. Clinical Practice of the Dental Hygienist. 12th Ed. Philadelphia: Wolter-Klower; 2017.
discussion of how to fill out deposit assessment form
Full transcript