Topic 3

Dental deposits. Professional oral hygiene.

Types of dental deposits

After tooth eruption, various materials gather on its surfaces, these substances are
frequently called tooth – accumulated materials/deposits.
In the International Classification of Diseases (ICD-10) the following types
of dental deposits are presented:
They are also classified as: Soft deposits (non-mineralized) - the cuticle,
pellicle, soft plaque and dental plaque; Hard deposits (mineralized) - supragingival
and subgingival calculus.
Non-mineralized dental deposits
Primary enamel cuticle (Nasmith’s membrane, reduced enamel epithelium)
is the derivate of enamel organ. After amelogenesis the cells of enamel organ play
the role in tooth eruption. They can produce desmolytic enzymes for elimination of
the bone and soft tissues , allowing eruption of the tooth without bleeding. The
cuticle represents the basal lamina of enamel epithelium. This is a thin membrane
on the enamel surface. On the occlusial surface it is usually worn away by
mastication and cleaning. But in the neck area the cuticle stays on the enamel and
plays the role in dento-gingival junction development.
Pellicle is a thin layer of salivary glycoprotein, which is formed on the enamel
surface during 2 hours after professional cleaning.
Formation of the Pellicle: The surface of enamel is charged negatively in the
normal oral pH range, and is due to the structure of hydroxyapatite, in which
phosphate groups are arranged close to the surface of the enamel. Thus postively-
charged ions e.g. calcium are attracted to the enamel surface forming a hydration
layer with unevenly distributed charges. As calcium is the predominant ion in the
hydration layer, the resulting net charge of the hydration layer is positive. Thus, the
hydration layer will attract negatively charged macromolecules with acidic side
chains and end groups of phosphate or sulfate. The amino acids aspartate and
glutamate, which are negatively charged at physiological pH, also have a high
affinity for the postively charged hydration layer of the tooth surface.
The exact composition of the hydration layer is dependent on several factors
including pH, ionic strength and the types of ions present in the saliva; usually the
hydration layer contains mainly calcium and phosphate ions in the ratio 10:1. Other
ions present include sodium, potassium and chloride.
 The main role of the pellicle is protective in nature. The pellicle protects the
enamel against acid, abrasion and attrition, and serves as a diffusion barrier. On the
other side, pellicle promotes the attachment of microorganisms to the tooth surface.
Soft plaque is unstructured deposition, easy removable by rinsing or
brushing. Soft plaque consists food debris, epithelial cells of the oral cavity and
some micro-organisms. Usually soft plaque looks like a white or cream-colored
soft mass deposited around the necks of the teeth. It is also called “materia alba” or
“Food debris”.
Dental plaque is a colony of microorganisms, which is fixed on the enamel
surface. It is also called dental biofilm. Dental plaque is a highly organized
bacterial system, where the different microorganisms form so called microbial
associations. The plaque bacteria produce organic acids, which cause enamel
demineralization and caries development. At the other side, bacteria damage
periodontal tissues and cause marginal periodontitis.
The plaque formation has some stages:
- Adhesion and proliferation (or primary colonization). First bacteria,
which can attach to the pellicle, are Streptococcus sanguis, Actinomices
viscosus and Streptococcus mutans.
- Formation of microcolonies (secondary colonization). New
microorganisms attach to microorganisms already present in the plaque
on the enamel surface forming colonies.
- Growth of plaque, formation of microbial associations (biofilm).
- Maturation. Biofilm develops a primitive circulatory system. In addition
to microorganisms mature plaque contains the epithelium of the oral
mucosa, leukocytes, macrophages, erythrocytes. Bacteria and cells form a
matrix, which is composed of salivary glycoproteins and glycoproteins of
gingival fluid, polysaccharides (dextrans and levans), proteins (mainly
albumin of gingival crevicular fluid), lipids (of disrupted cell
membranes). Streptococci can secret special protective layer.
IN DEEP LAYERS of mature plaque anaerobic conditions are formed. Bacteria
use sugars as energy sours. One of the products of anaerobic glycolysis is lactic
acid. The local pH becomes acidic and enamel demineralization starts. The plaque,
which can produce acid is called cariogenic.
Dental plaque is usually transparent. To visualize plaque it is nessesary to
dry the tooth surface. The enamel coated with plaque has no natural shine. Also
special dyes – plaque detectors can be used.
Pigmented plaque
 Pigmented plaque is the result staining by different pigments. Most often,
plaque gets color from light-brown to black from tea or coffee, as well as smoking.
The composition of tobacco smoke contains particles of resins with size of 0.4
microns, which can penetrate into the dental plaque forming so called «plaque of
smoker». Brown plaque staining can be also caused by using a mouthrinse,
containing chlorhexidine. Some bacteria and fungi can stain dental plague in
orange or even green.

Mineralized dental deposits

Dental calculus is mineralized dental plaque. It is caused by precipitation of
minerals from saliva and gingival crevicular fluid (GCF) in plaque on the teeth.
Calculus is composed of both inorganic (mineral) and organic (cellular and
extracellular matrix) components. The mineral proportion of calculus ranges from
approximately 40–60%, depending on its location in the dentition, and consists
primarily of calcium phosphate crystals organized into four principal mineral
phases: octacalcium phosphate, hydroxyapatite, whitlockite, and brushite. The
organic component of calculus is approximately 85% cellular and 15%
extracellular matrix. The cells within calculus are primarily bacterial, the organic
extracellular matrix in calculus consists primarily of proteins and lipids.
Depending on the location, there is subgingival and supragingival calculus.
Supragingival calculus is located above the level of gingival margin.
Supragingival calculus is lighter, has lower density and formed faster, then
subgingival calculus. Supragingival calculus is also called salivary as the source of
its mineralization is saliva. Supragingival calculus is localized mainly closed to the
place of the ducts of large salivary glands: on the lingual surfaces of the lower
anterior teeth and on the buccal surfaces of the upper molars.
Subgingival calculus is localized on the surface of the tooth root, below the
level of the gingival margin. This type of plaque observed in patients with
periodontitis. Subgingival calculus is called serum, as a source of its mineralization
is the gingival fluid which is essentially a filtrate of blood serum. For disclosing of
subgingival plaque it is necessary to use a periodontal probe.
Calculus is the cause of development of periodontal diseases. In addition to
chronic injury of marginal gum tissues, the rough surface of the calculus is ideal
surface for further plaque formation. Around the calculus so-called "microbial
envelope is formed.

Basic principles of professional oral hygiene.

 The Professional oral hygiene procedure means the removing of all dental
deposits using special instruments and devices.
For dental plaque removing usually rotary brushes with cleaning paste are used.
For pigmented plague removing doctor can use rotary brush with spatial
abrasive paste or air-abrasive method (sand-bluster). During air-flow procedure
under the pressure of flow of air, water and special abrasive powder the deposit is
removed. Non-mineralized plaque is removed from the dental surfaces, crowns and
bridges, fillings or interdental spaces. Some air-abrasive devicas have special tips
for subgingival plaque removing.
The procedure has some contraindications:
- deseases of respiratory system, asthma
- kidney disease and no salt diet
- numerous caries
- different exacerbated (inflammatory!) illnesses of oral mucosa
- exacerbated periodontitis
- viral diseases, e.g. tuberculosis, HIV, hepatitis, etc.
If a patient has some aesthetically restored teeth, they have to be polished (in
order to renew surface gloss).

Hard plaque (dental calculus) is removed from the surface of a tooth using an
ultrasonic device and special manual instruments.
The main manual instruments for supragingival calculus removing are
following:
- Dental hoes
- Dental chisels
- Different scalers
Instruments for subgingival calculus removing are following:
- Curettes
- Files
The main action of ultrasonic and sonic scalers is mechanical: the high
vibrational energy crushes and removes calculus. Other actions include: creating
shockwaves that disrupt bacterial cells, or using turbulence to disrupt biofims, and
irrigation — the therapeutic washing and flushing of the periodontal pocket and
root surface with cooling water. Both power and hand scaling techniques require
an experienced clinician with good tactile sensitivity (sense of touch) to remove
deposits effectively and to promote healing. The plaque which is located deeply in
the pockets of the gums is removed by means of instruments intended for
periodontal treatment. The teeth of patients with implants should be cleaned with
special plastic curettes in order not to destroy the surface integrity.
Stages of professional oral hygiene
1. Antiseptic rinsing of mouth cavity (chlorhexidine digluconate or another
special antiseptic solutions).
2. The professional oral hygiene is done with regional anesthesia if necessary.
3. Removing of supragingival calculus with hand instruments or ultrasonic
scaler. In order to avoid damage to the gums with a sharp instrument all
movements are made from the gum to the cutting edge of tooth.
4. Removing of pigmental plague using rotary brush or Air-flow. Proximal
surfaces are cleaned with strips, or with abrasive paste and sandblaster
handpiece (Air-flow, ProphyFlex).
5. Teeth and restorations polishing
6. Haemostasis procedure, antiseptic rinsing (1% hydrogen peroxide solution).
7. Application of remineralizing solution or periodontal dressing if needed.
8. Removal of subgingival plaque is best done during the second visit - after
the inflammation has decreased and swelling of the gums has reduced. To
remove the subgingival dental plaque dentist may use manual curette or
special attachments for ultrasonic handpiece tips. Periodontal pockets after
removing dental deposits should be treated with antiseptic solution,
sometimes, periodontal dressing is necessary.