MUDr. Hana Poskerová, Ph.D. Stomatologická klinika FN u sv. Anny a LF MU v Brně Dental microbial plaque and Oral hygiene Healthy periodontal tissue • Gingiva - pink, pale, firm - does not bleed (even after stimulus, PBI under 15/28) - stippling - attached gingiva suffucient amount Healthy periodontal tissue • Probing depth max 3 mm • RTG (X-ray) - lamina dura is present - distance CEJ - margin of alveolar bone 1-2 mm Healthy gums ? Etiology of perio diseases • Etiologic factor and causative agent DENTAL microbial PLAQUE • Contributing factor - dental calculus - local irritant factors • Risk factors (smoking) • Host factors (immunity, systemic diseases) Prevalence of Dental diseases • Dental caries • Periodontal diseases DENTAL microbial PLAQUE DENTAL microbial PLAQUE - soft deposits (bacterial mass) that form the biofilm adhering to the tooth and other intraoral surfaces - may be removed by mechanical means only DENTAL microbial PLAQUE • Composed of bacteria in a matrix • Microorganisms (75 %) a their products • Matrix (25%) - bacterial (extracellular polysacharids) and salivary origin (salivary glycoproteins and mucopolysacharids) - calcium, phosphates (mineralization of plaque) • DENTAL microbial PLAQUE - microbial community - coexistence of different populations in the biofilm - bacteria communicate in different ways (coagregation, adherence, provid nutrients, exchange of genetic material) - this symbiosis gives new features and greatly increases the resistance of dental plaque - can be removed by mechanical means only Materia alba • Collection of debris • A white cheeselike accumulation of food debris, microorganisms, desquamated epithelial cells, and blood cells deposited around the teeth at the gumline Plaque Retention factors • Dental calculus (plaque carrier) • Faulty restorations - overhanging fillings - non-fitting crowns • Orthodontic anomalies - crowded teeth • Orthodontic appliances • Partial Dentures These factors impair hygienic conditions • Anatomical deviations of mucous membranes - lip frenula - shallow vestibulum, - gingival reccesions • Mouth breathing, Tobacco use DENTAL microbial PLAQUE • Composition and formation rate depends on - quality of OH - quality of saliva - food, smoking - immunity DENTAL microbial PLAQUE • coronar, fissural • supragingival plaque - in gingival region • subgingival plaque - sulcus gingivalis of healthy periodontium - periodontal pocket DENTAL microbial PLAQUE Supragingival plaque - caries - dental calculus - increase amount of bacterias in oral cavity Subgingival plaque - adherent plaque (root surface) - non adherent plaque (swimming) - zone of plaque near gingival epithelium • Subgingival plaque (sulcus × pocket) Adherent plaque (enamel, root surface) - composition resembles the supragingival plaque (G+ and Gcocci, Actinomyces sp., rods and filaments) - can become mineralized Non adherent plaque - freely moving - G - anaerobs (motile and nonmotile rods), larger number of spirochets, - no intermicrobial matrix, - important role in the progression of periodontitis, - bacterial invasion (AAC, PG, TF) Plaque Formation • Acquired Pellicle Formation • Primarily Bacterial Colonization • Growth of Plaque (sec. colonization) • Maturation of Plaque 1/ Plaque Formation • Acquired Pellicle Formation - minutes, 1-2 microns thick - amorfous film from salivary glycoproteins - increases the efficiency of bacterial adhesion 2/ Plaque Formation • Primarily Bacterial Colonization - bacterial adhesion by single microorganisms - extracellular polymeric substances and fimbriae, enable them to attach rapidly upon contact - become established within 24 hours - G+ aerobs, cocci (Streptococcus sanguis), G+ rods, G+ fillaments (Actinomyces sp.) - immature plaque - less adherent 3/ Plaque Formation • Growth of Plaque in next few days (sec. colonization) • bacterial mass increases in quantity due to adhesion of new bacteria (surface receptors on G+ cocci and rods allow adherence of G- (Fusobacterium nucleatum) and synthesis of extracellular polymers • multiplication of adhering bacteria and growth of extracellular matrix • increasing of thickness - diffusion is more difficult poor diffusion of oxygen - anaerobic conditions • G- cocci, G+ G- rods and filaments (fusobacteria), aerobs and anaerobs 4/ Plaque Formation • Maturation of Plaque - formation of more complex and mature biofilm - stable bacterial biofilm - different morphotypes - cocci, motile rods, spirochetes (filamentous organisms predominate) multiplication of bacteria, new bacterial species - mature plaque - very pathogenic Plaque Formation Aerobs Anaerobs G+ G – Cocci Spirochets • DENTAL microbial PLAQUE - microbial community - coexistence of different populations in the biofilm - bacteria communicate in different ways (coagregation, adherence, provid nutrients, exchange of genetic material) - this symbiosis gives new features and greatly increases the resistance of dental plaque - can be removed by mechanical means only • Nonspecific plaque hypothesis - plaque is regarded as a bacterial mass - proliferating mixed infection • Specific plaque hypothesis - specific virulent bacteria in plaque cause periodontitis • Amount of the plaque • Virulence of the plaque • Host defence Amount of plaque Host defence Dental microb. plaque Clinical symptomes Connective tissue and bone metabolism Inflammatory immune responce Antigens LPS virulent factors PMNL, PL Cytokines MMP GENETIC FACTORS NON - GENETIC FACTORS PG TF TD AAC serotype b – in the aggressive course of periodontitis AAC Perio pathogens • Aggregatibacter (Actinobacillus) actinomycetemcomitans • Porphyromonas gingivalis • Tannerella forsythia • Treponema denticola • Prevotella intermedia • Fusobacterium nucleatum • Peptostreptococus micros b. Tannerella forsythia ability to invade tissue Pathogenity of plaque - hard dental tissue • Bacteria in DP produce acids (dental caries) Pathogenity of plaque – soft tissue • Bacteria in DP produce various pathological substances (direct / indirect effect) • Direct effect - enzymes (proteolytic enzymes colagenase, hyalouronidase) - endotoxines (LPS of bacterial wall,) - exotoxines (leukotoxin – AAC) - ability to invade tissues (AAC, PG, TF) • Indirect effect - bacterial chemotaxins, antigens - host inflammatory response to antigens of dental microbial plaque - regulation of production of proinflammatory mediatores (IL –1,6, TNF, PGE) Pathogenity of plaque Pathogenity of plaque • depends on - amount and composition of plaque - virulence of microorganisms - ability to invade tissues (direct invasion - true infection, AAC, PG, TF) - immunity reaction of organism accumulation of plaque along the gingival margin leads to inflammatory reaction of the soft tissue Host defence reaction • Acute non-specific host response - first and rapid reaction • Specific immunity reaction - recognition of forign antigen - specific immunity reaction against this antigen Acute nonspecific host response • Inflammation • PMNL - chemotaxis, diapedesis, adherence to bacteria, phagocytosis, microbicidal activity complement system Specific immunity reaction • Lymfocytes - T cells - cell mediated reaction - B cells - antibody response upon contact with antigen they differentiate into plasma cells (production of antibodies) - defense cells recognize antigen Antigen - antigen presenting cells - lymph nodes proliferation of relevant specific cells Inicial phase Activation of macrofages, local inflammatory reaction The lymphocytic inflammatory infiltrate dominates Inicial periodontitis Dental biofilm and systemic diseases • Bacteriemia • Inflammatory mediators 95% of atheromas had bacterial D.N.A from periodontal pathogens https://www.efp.org/news-events/news/oral-health-and-general- health-29938/ Dr. Jiří Sedelmeyer Calculus - calcified dental plaque • Calculus is formed by the deposition of calcium and phosphate salts in bacterial plaque • salts are present in saliva, in crevicular fluid Calculus - calcified dental plaque • calculus is always covered by an unmineralized layer of bacterial plaque • good place for plaque accumulation • reservoir and retention web for bacteria and endotoxins Calculus - calcified dental plaque • inorganic compounds (40% - 80%), as well as proteins and carbohydrates, microorganisms • the mineralization starts in centers intracellulary in bacterial colonies or extracellulary from matrix with crystallization nuclei (different crystals of calcium phosphate) • time required for the formation of calculus is individually variable • rate of formation depends on the quality of saliva and on the level of OH Differences • Supra - gingival calculus • Sub - gingival calculus - location - the origin of minerals - color - diagnosis - removing Origin of minerals and Location • Supragingival calculus - excretion ducts of the major salivary glands - on the lingual surfaces of the mandibular incisors - on the buccal surfaces of maxillary molars - origin - saliva • Subgingival calculus - on the root surfaces below the gingival margin - can extend deep into periodontal pockets - origin – sulcular fluid • Supragingival plaque coronar, fissural, gingival part • Subgingival calculus - on the root surfaces below the gingival margin - can extend deep into periodontal pockets 1/ Gingivitis - symptoms • gingival bleeding • redness to livid colour • swelling • gingiva turgor loss • tenderness or pain - 95 % of all gingivitis is plaque induced g. - reversible - alv. bone is not resorbed However, a large part of gingivititis is not recognized!!! 2/ Periodontitis - inflamation of gingival tissue extends into the junctional epitelium - attachment damage - loss of alveolar bone periodontal pocket - irreversible Incipient periodontitis • Clinical symptoms are mild - bleeding from gingiva after irritating - oedema - redness - probing up to 6 mm - mild bone resorption Intermediate periodontitis Advanced periodontitis - deep periodontal pockets over 6 mm - periodontal abscess - mobility of teeth - teeth tend to shift - tooth loss - advanced bone resorption - bad breath Advanced periodontitis bone resorption periodontal abscess teeth shifted periodontal pocketperiodontal pocket with pus exsudation Man, 35 yers old Woman, 72 years old Periodontit is with an aggressive course Periodontitis with a slow chronic course Examination of perio tissue • Examination of oral hygiene (plaque, calculus), gingiva, measurement of periodontal pocket..... • PBI • API • CPITN Aproximal Plaque Index API • used with individual patients after staining • records presence (+) or absence (-) of plaque in interdental spaces as a percentage • 4 quadrants • 7 interdental spaces in each quadrant •28 masurement sites in complete dentition • I. and III. quadrant from oral aspect • II. and IV. quadrant from facial aspect API Aproximal Plaque Index API • number of locations with plaque / number of evaluated areas  100 (%) • 28/28  100  100% Bad OH • 0/28  100  0% Very good OH • Good motivation ability + + + + – – – – – – + + + + + + + + – – – – – – + + + + 47 46 45 44 43 42 41 31 32 33 34 35 36 37 17 16 15 14 13 12 11 21 22 23 24 25 26 27 Index API number of locations with plaque / number of evaluated areas  100 (%) API  16 / 28  100  56 % Interdental Hygiene Index HYG • reverse • number of locations without plaque / number of evaluated areas  100 (%) • 28/28  100  100% Very good OH • 0/28  100  0% Bad OH – – – – + + + + + + – – – – – – – – + + + + + + – – – – 47 46 45 44 43 42 41 31 32 33 34 35 36 37 17 16 15 14 13 12 11 21 22 23 24 25 26 27 Index HYG number of locations without plaque / number of evaluated areas  100 (%) API  12 / 28  100  44 % Education Motivation Instruction Education - Motivation Instruction - explanation of microbial etiology - explanation of the symptoms Education - Motivation - Instruction • demonstration of bleeding gingiva (PBI) • demonstration of plaque (API) Motivation - bleeding - plaque Special tablets or rinses can colour plaque Oral hygiene products • Toothbrush • Single toothbrush • Dental floss • Interdental cleaners • Toothpaste (fluorid, antimicrobial agents, anticalculus agents) • Oral irrigators • Mouth rinses Recommendation ADA • brush your teeth twice a day with fluorid toothpaste • clean between teeth daily with floss or an interdental cleaner • replace your toothbrush when bristels are frayed • brush the outer, inner, chewing and interdental surfaces Professional hygienic care • History - Examination - Diagnosis • Education - Motivation • Oral hygiene instruction and monitoring • Elimination of plaque retentive areas • Plaque and calculus removing • Control Toothbrush • Short head • Medium or soft, multitufted, straight bristels ? Tooth brushing techniques • Fones method • Charters method • Stilmann method • Bass method We clean only the occlusal surfaces horizontally Tooth brushing techniques • Charters method • Modified Charters • bristles are perpendicular to the tooth + vibration Tooth brushing techniques • Stilmann method Tooth brushing techniques • Bass method intrasulkular Electric Toothbrushes • Rotary oscillating brushes • Sonic brushes - are not necessary - selection always individual - professional training is recommended (in case of inappropriate use, insufficient cleaning is likely, or the risk of gingival recessions - gingival biotype!) • Horizontal toothbrushing • Hard bristels • Toothbrushing too frequently - abrasion of the tooth structure - gingival recession (root exposure, hypersensitivity) Consequences of improper toothbrushing „ siwak“ Single toothbrush Suitable for cleaning hardto-reach places: - oral areas - irregularly errupted teeth - crowded teeth - third molars - fixed ortho appliances - fixed prosthetic restorations, - implants ... Single toothbrush „ siwak“ Retention of plaque • Crowded teeth • Orthodontic apliances (braces) • Implants Interdental hygiene (dental floss, interdental cleaners) Hidden caries, gingivitis - periodontitis Dr. Jiří Sedelmeyer Flossholder Superfloss Floss - waxed, unwaxed Flossing- break off about 15 - 20 cm - roll floss around middle fingers - hold the floss between thumbs and index finger - guide floss between your teeth - curve it into a C shape against one tooth - slide it into the space between the gum and the tooth - move the floss up and down - do not forget back side of last tooth Flossing Interdental cleaners Dr. Jiří Sedelmeyer Interdental cleaners IAP probe In patients with periodontitis, the furcation area can also be cleaned with interdental toothbrushes You forgot about interdental spaces !!! Irrigators water sprays don‘t remove plaque !!! How to clean bridges How to clean orthodontic appliances How to clean implants Toothpastes • Abrasives (RDA) • Detergents, surfactants, dyes • Taste correction • Fluorides (NaF, Aminofluoride, SnF, sodium monofluorophosphate) • Antimicrobial components (triclosan, CPC, CHX) • Calculus inhibitors (ZnCl) • Adstringent factors • Desensitizers • Bleaching agents Mouthwash ????? • Antiseptic/antiinflammatory - chlorhexidine • Against tooth decay - with fluorine content • Desensitization Mouth wash CHX - antibacterial, antiviral, antifungal effect • 0,2% max 2 weeks • 0,12% 0,1% 0,06% • Unpleasant side effects - stainig of teeth nd tongue - taste disturbances - mucosal desquamation • Adjunct during initial therapy • Desinfection of oral cavity before dental treatment • In handicapped patients • Periodontal surgery Conclusion Clean tooth can not be ill