1

2
CONTENTS
Definition
Classification
Composition
Dental plaque as a biofilm
Formation
Growth dynamics of plaque
Structure and physiologic properties
Plaque hypothesis
Clinical significance
Plaque control
Conclusion
References

3
Definition

Soft deposits that form the biofilm adhering to the tooth surface
or other hard surfaces in the oral cavity, including removable
and fixed restorations. Bowen,1976


Bacterial aggregation on the teeth or other solid oral structures.
Lindhe, 2003


Dental plaque is a specific but highly variable structural entity ,
resulting from sequential colonization of microorganisms on
the tooth surfaces, restorations and other parts of oral cavity ,
composed of salivary components like mucin, desquamated
epithelial cells, debris and microorganisms , all embedded in
extracellular gelatinous matrix. WHO, 1961


4
CLASSIFICATION

By location on tooth


supra gingival plaque sub gingival plaque

coronal marginal attached unattached

tooth tissue
epithelium
5

Supragingival plaque


1.Found at or above the gingival margin

2.Inorganic components derived from
saliva

3.Gram +ve organisms predominate

4. Few motile bacteria

5. Metabolism: predominantly
carbohydrates

6. Supra gingival plaque is associated
with calculus formation and root
caries


Subgingival plaque


1.Found below gingival margin

2.Inorganic components are derived
from crevicular fluid

3. Gram ve organisms predominate

4. Motile bacteria are common

5. Metabolism: predominantly proteins

6. Sub gingival plaque is associated
with tissue destruction seen in
periodontitis

6
7
8


Primarily composed of microorganisms.
One gram of plaque contains approx. 2 x 10
11
bacteria.
More than 325 different bacterial species may
be found in plaque.


9
Previous Classification New Classification Reference
Bacteroides gingivalis Porphyromonas gingivalis Shah and Collins,1988
Bacteroides endodontalis
Porphyromonas
endodontalis
Shah and Collins, 1988
Bacteroides intermedius Prevotella intermedia Shah and Collins, 1990
Bacteroides melaninogenicus Prevotella melaninogenica Shah and Collins, 1990
Bacteroides denticola Prevotella denticola Shah and Collins, 1990
Bacteroides loescheii Prevotella loescheii Shah and Collins, 1990
Wolinella recta Campylobacter rectus Vandamme, et al., 1991
Wolinella curva Camplyobacter curvus Vandamme, et al., 1991
10
SELECTED BACTERIAL SPECIES FOUND IN DENTAL PLAQUE
Facultative Anaerobic
Gram-Positive
Streptococcus mutans
Streptococcus sanguis
Actinomyces viscosus
Gram-negative
Actinobacillus
actinomycetemcomitans
Capnocytophypa species
Eikenella corrodens
Porphyromonas gingivalis
Fusobacterium nucleatum
Prevotella intermedia
Bacteroides forsythus
Campylobacter rectus
Spirochetes
Treponema denticola
(Other Treponema species)
11
Non bacterial microorganisms that are found
in plaque include mycoplasma species,
yeasts, protozoa, viruses.

The microorganisms exist within an
intercellular matrix that also contain few
host cells, such as epithelial cells,
macrophages and leucocytes.
12

Takes up nearly 25% of dental plaque volume.
Consists of organic and inorganic materials.
Forms a hydrated gel in which the embedded
bacteria exist and proliferate.
This gel like matrix is a primary characterstic of
biofilms.
Matrix is thought to protect resident bacteria
from substances such as antimicrobial agents,
which may be unable to diffuse through the
matrix to reach the bacterial cells.

13
Organic
constituents
Polysaccharides
Proteins
Glycoproteins
Lipid material
Inorganic
constituents
calcium
Phosphorus
Other minerals
such as sodium,
potassium, and
fluoride.
14
Organic constituents
Polysaccharide Proteins
Adhesive
95% Dextrans
Bacterial
colonization
5% levans
Storage of
polysaccharide
Source of
fermentable
carbohydrate
Albumin
Originating
from GCF
15
Glycoproteins
Lipid material
Important
component of
plaque
pellicle.
Debris from
membranes of
disrupted
bacteria, host
cells and possibly
food debris.
16
Inorganic constituents
Supragingival plaque
Subgingival plaque
Fluoride
Primarily saliva
Crevicular fluid
Fluoridated
tooth pastes
and rinses
Remineralisation of
tooth structure
Prevention of
demineralization of
tooth structure
Inhibition of the
growth of many
plaque
microorganisms
17
DENTAL PLAQUE AS A
BIOFILM

Biofilms defined as matrix enclosed bacterial
populations adherent to each other and/or to
surfaces or interfaces. (costerton,1994)
Formed by a single bacterial species or multiple
bacterial species as well as other organisms &
debris.
Form on any surfaces that is wet.
Exist on any solid surfaces that is exposed to
bacteria-containing fluid.

18
Biofilm structure
The bacteria in a biofilm
are not distributed
evenly, they cluster
together to form sessile
mushroom shaped
microcolonies.

Each microcolony is an
independent community
containing thousands of
compatible bacteria,
with its own customised
living environment.

19
Bacteria in the
center of a
microcolony may
live in a strict
anaerobic
environment, while
other bacteria at the
edges of the fluid
channel may live in
an aerobic
environment

20
A series of fluid
channels penetrates
the extracellular slime
layer.
These provide nutrients
and oxygen for the
bacterial micro colonies
and facilitate
movement of bacterial
metabolites, waste
products, and enzymes
within the biofilm
structure.
21
Each bacterial
microcolony uses
chemical signals to
create a primitive
communication system
used to communicate
with other bacterial
microcolonies.

22
The extracellular slime layer is a protective
barrier that surrounds the mushroom shaped
bacterial microcolonies.
The slime layer protects the bacterial
microcolonies from antibiotics,
antimicrobials, and host defense
mechanisms.
Can be destroyed by simply wiping them off.

23


Can be divided into 3 stages:
Formation of dental pellicle
Initial colonization by bacteria
Secondary colonization and plaque
maturation
24
Formation of dental pellicle
25
Initial phase of
plaque
development
Thin saliva derived
layer
Formed within
nanoseconds after
polishing of teeth
Glycoproteins,
proline rich proteins,
phosphoproteins,
enzymes
Function as
adhesion sites for
bacteria
( receptors)
26
Mechanism
of pellicle
formation
Electrostatic
forces
Hydrophobic
forces
Van der waal
forces
The hydroxyapatite surface consists of negatively charged
phosphate groups that interact directly or indirectly with
positively charged components of salivary and crevicular fluid
macromolecules.
27
Initial colonization of the
tooth surface by bacteria

28
Phase 1
Transport of
the bacteria to
the tooth
surface
Brownian motion,
Sedimentation of
microorganisms,
Liquid flow, Active
bacterial
movement
Phase 2
Initial, reversible
adhesion of
bacterium to the
surface
Van der waal
attractive forces
and Electrostatic
repulsive forces
29
Phase 3 Attachment
Firm anchorage
between bacterium
and structure
established
Bonding is by
extracellular
proteinaceous
components
(adhesions) and
complementory
receptors
(proteins,
glycoproteins)
Streptococci
bind to acidic
proline rich
protein,
amylase etc in
the pellicle.
Actinomyces
viscous possess
fimbrae that
contain
adhesins that
specifically bind
to the proline
rich proteins in
the dental
pellicle
Secondary colonization and
plaque maturation
30
Firmly attached
microorganisms
start growing and
newly formed
bacterial clusters
remain attached
Microcolonies
Intrabacterial
connections
occur
coaggregation
Primary colonizers are
taught to prepare a
favorable environment
for late colonizers
Interaction of protein
and carbohydrates
molecules located on
the bacterial cell surface
31
Primary
colonizers
Streptococcus
sanguis
Actinomyces
viscous
Secondary colonizers
Prevotella intermedia, Prevotella
toescheii, Capnocytophaga species,
Fusebacterium nucleatum,
Porphyromonas gingivalis.
Do not initially colonize the clean
tooth surfaces but adhere to cells of
bacteria already in the plaque mass
32
Interactions of
secondary colonizers
with early colonizers
Coaggregation of
F.nucleatum with
S.sanguis, P.loescheii with
A.viscous, Capnocytophaga
ochracea with A.viscous.
Most studies have focused on interactions between different
gram positive species and between gram positive and gram
negative species.
In the later stages of plaque formation, coaggregation between
different gram negative species is likely to predominate.
Eg of this type of interaction is the coaggregation of
F.nucleatum with P.gingivalis.
GROWTH DYNAMICS OF
DENTAL PLAQUE
Important changes in the plaque growth can be
detected within the first 24 hours.

During the first 2 to 8 hour, Streptococci saturate
the salivary pellicle binding sites,covering 3% to
30% of the enamel surface.

Instead of the expected steady growth during
the next 20 hours, a short period of rapid
growth is observed.



33
After 1 day, the term Biofilm is fully deserved
because organization takes place within it.

As the bacteria densities approaches
approximately 2 to 6 million bacteria/ mm
2
on
the enamel surface, a marked increase in growth
rate can be observed to 32 million bacteria /
mm2.

The thickness of the plaque increase slowly with
time, increasing to 20 to 30 micrometer after 3
days.

34
physiologic properties of
dental plaque
Transition from gram positive to gram negative in
dental plaque is paralleled by a physiologic
transition in the developing plaque.
Early colonizers oxygen lower the reduction
oxidation potential of the environment favors
the growth of anaerobic organisms.
Gram positive sugar as a energy source and saliva
as carbon source.
Anaerobic bacteria amino acids and small
peptides as energy source.



35
Many physiologic interactions among different
bacteria are found in plaque:

Lactate and formate byproducts of metabolism of
streptococci and actinomyces utilized in the
metabolism of other plaque microorganisms.
Growth of P.gingivalis enhanced by metabolic
byproducts produced by other microorganisms , eg
succinate from Capnocytophaga and protoheme
from Camphylobacter.


36
The host also functions as an important source of
nutrients
Eg. Bacterial enzymes that degrade host proteins
result in release of ammonia which may be used by
bacteria as an energy source.
Haeme iron from the breakdown of host
hemoglobin may be important in the metabolism
of P.gingivalis.
Increase in steroid hormone are associated with
significant increase in the proportion of
P.intermedia found in subgingival plaque.
37
38

Periodontal disease results from the
ELABORATION OF NOXIOUS PRODUCTS
BY THE ENTIRE PLAQUE FLORA

According to this theory,
Small amount of plaque = Noxious products
neutralized by host.
Large amount of plaque = large amount of
noxious
products overwhelms the host defense .
39
However this was CONTRADICTED based on
certain conclusions ::

First some individuals with considerable amount
of plaque & calculus, as well as gingivitis never
developed destructive Periodontitis.

Also individual who did present with
Periodontitis demonstrated considerable site
specificity in the pattern of disease, some sites
were unaffected, where as advanced disease was
found in adjacent sites.

40

It states that only certain plaque is pathogenic &
its pathogenicity depends on the presence of or
increase in specific microorganisms. (Loesche W
1976)

It means plaque harbors specific bacterial
pathogens resulting in a periodontal disease bcoz
these organisms produce substances that mediate
the destruction of host tissue E.g. A.
actinomcetemcomitans as a pathogen in localized
aggressive Periodontitis.

41
CLINICAL SIGNIFICANCE
Different regions of plaque are significant to
different processes associated with disease of
teeth and periodontium.
Eg: marginal supragingival plaque is of prime
importance in the development of gingivitis.
Supragingival and tooth associated subgingival
plaque are critical in calculus formation and root
caries.
Tissue associated subgingival plaque is important
in the soft tissue destruction characteristic of
different forms of periodontitis.


42
DETECTION OF PLAQUE

1. Direct vision : -

Thin plaque may be translucent &
therefore not visible.
Thick plaque tooth may appear dull &
dirty.

43
2. USE OF EXPLORER : -
Tactile Examination :
When calcification has started it appears
slightly rough, otherwise it may feel slippery
due to coating of soft , slimy plaque
When no plaque is visible , an explorer can
be passed over the tooth surface & when
plaque is present it will adhere to explorer
tip. This technique is used when evaluating
plaque index.
3. Use of disclosing solutions

44
Plaque control
Removal of microbial plaque and the
prevention of its accumulation on the teeth and
adjacent gingival surfaces.




45

Toothbrushes
Manualtoothbrush
Electricaltoothbrush
Interdentalcleaningaids
dentalfloss
woodentipsorrubbertips
Interdentalbrushes
Proxabrushes
Unituftedbrush
Miniaturebottlebrush
Oralirrigationdevices

46
manual Toothbrushes

According to The American Dental Association:
Brushing surface of 1-1.25 inches
(25.4 to 31.8mm) long

5/16 to 3/8 inch (7.9-9.5mm) wide

2 to 4 rows of bristles

5-12 tufts per row
47

48

49
Filaments

Hard and soft
Natural and synthetic
Multitufted and space tufted

Advantages of nylon filaments over natural bristles

rinse clean and dry rapidly when left in open.
More durable and maintain their form longer.
Ends rounded and closed,repel water and debris.
More resistant to acculumation of bacteria and fungi
than are natural bristles.

50
Methods of brushing




Fones
Stillman
Charter
Bass
Rolling
stroke
Modified
Stillman
Bass
method
Sulcular
method
Roll
Circular Vibratory
51




Smith
Leonard
Vertical Horizontal
Physiologic
Scrub
brush
52
53
Modified Stillman technique
Like the Bass Method
the filaments are
placed at a 45 angle to
the tooth.
Unlike the Bass
Method the filaments
are placed half in the
sulcus and half on the
gingiva.
The same stroke is used
as the Bass
54
cHaRTeRS MeTHOD
Position the filaments
toward the chewing
surface of the tooth
Place the sides of the
filaments against the
enamel and angle them
at a 45 to the tooth.
Vibrate the filaments
gently but firmly,
keeping the filaments
against the tooth.
Reposition on the next
set of teeth.

55
fONeS Technique
Technique that uses large,
sweeping, scrubbing circles
with the toothbrush held at
right angles to the tooth
surfaces.

With the jaws parted, the
palatal and lingual surfaces
of the teeth are scrubbed
in smaller circles.

Occlusal surfaces of the
teeth are scrubbed in an
anteroposterior direction.


56

In subjects not highly
motivated to oral health
care, as well as in those
having difficulty in
mastering a suitable
handbrush, "the use of an
electric brush with its
standard movements may
result in more frequent
and better cleansing of
the teeth".
57
Motions:
Back and forth
Circular
Elliptic
Combinations

Cleaning action by:
1. Mechanical contact between the bristles and the
tooth
2. Low-frequency acoustic energy generates
dynamic fluid movement and provides cleaning
slightly away from the bristle tips.

58

They are adjunct devices which are used to
remove plaque from the interproximal tooth
surfaces.
The specific aids required for interproximal
cleaning depend on various criteria such as
the size of the interdental spaces, the
presence of furcations, tooth alignment, and
the presence of orthodontic appliances and
fixed prostheses.
59

Clinical studies clearly show that, when
toothbrushing is used together with flossing,
more plaque is removed from the proximal
surfaces than by toothbrushing alone.
60



multifilament
Bonded /
non bonded
Thick / thin
Waxed /
non waxed
61
Technique
62
wooden tips
Used as an ideal
substitute to dental
floss in type 2
gingival embrasures.
Inserted into the
gingival embrasures
and remove soft
deposits from teeth.
Also mechanically
stimulate the
gingiva.
Use is restricted to
facial aspect of
anterior teeth.
63

Best choice of plaque removal from
interproximal tooth surfaces in type 2
gingival embrasures.
Design is similar to that of bottle brush.
Used in posterior areas of mouth.
May also be used to clean furcation areas and
root concavities.
64
65
66
Oral irrigation devices
Mainly beneficial in removal of
unattached plaque and debris.
Composed of a built in pump
and reservoir.
When used as an adjunct to
tooth brushing these devices
have a beneficial effect on
periodontal health by retarding
plaque and calculus formation.
They may also be used to carry
antimicrobial agents
subgingivally.
67
68
Chemical plaque control
Ideal requisites
Should decrease plaque & gingivitis
Prevent pathogenic growth
Should prevent development of resistant bacteria
Should be biocompatible
Should not stain teeth or alter taste
Should have good retentive properties
Should be economic

69
1
st

generation
Antibiotics
Phenols
Quaternary
ammonium
compounds
Sanguanarine
rd

Delmopinol
2
nd

generation
Bis-biguanides
(Chlorhexidine)
70
Vehicles for delivery of chemical
agents
Tooth Paste
Mouth rinses
Irrigative
Chewing gum
Varnishes
Gel
Lozenges
71
1
st
Generation Agents

Antibiotics:

Penicillins
Tetracycline
Vancomycin
Kenamycin
Erythromycin
Niddamycin
Spiromycin
Metronidazole

72
Mechanism of Action:
Bactericidal or bacteriostatic action.


Limiting factors of systemic drug
therapy:

Hypersensitivity reactions
Bactericidal resistance

73
Phenols Related essential
oils

eg. Triclosan
Listerine
25-35% - plaque reduction


Mechanism of action :
Act on cytoplasmic
membrane inducing leakage
of cellular constituents and
thereby causing bacteriolysis.



74
Triclosan is included in
tooth paste to reduce
plaque formation.
Used along with Zinc citrate
or co-polymer Gantrez to
enhance its retention
within the oral cavity.
Delays plaque formation.
It inhibits formation of
prostaglandins &
leukotrienes there by
reduce the chance of
inflammation.


75
Quaternary ammonium
compounds :

Eg. Benzathonuim chloride
Benzalkonium chloride
Acetyl pyridinium

They are cationic, antiseptics & surface active agents.


Side effects:

burning sensation of oral mucosa
brownish discoloration of teeth
recurrent ulceration
discoloration of tongue

76
Mechanism Of Action:

Positively charged molecule reacts with
negatively charged cell membrane
phosphates and thereby disrupts the
bacterial cell wall structure of
microorganisms.

77
Sanguanarine
(Natural products/ Herbal extracts)

It is benzophenanthradine alkaloid found in
commercial mouth rinse paste.

Mechanism of action:
Inhibiting the growth of bacteria.

pH is 4.5 and alcohol content of 11.5%
78
Metal salts
Zinc Salts
Tin Salts (Stannous fluoride)
Sodium fluoride
Copper salts

Adverse effects
Metallic taste
Dryness of Mouth
Yellow brown discoloration of teeth and tongue

Have a plaque inhibitory capacity as they reduce
glycolytic activity in micro-organisms & delay bacterial
growth.

79
nd

Bisbiguanides:

eg. Chlorhexidine gluconate 0.2 %
Alexidine
Cationic Chlorophenyl biguanide

Suggested for oral use by Schroder in 1969

pH 3.5

It is a cationic effective against gram +ve ,gram-ve,
fungi, yeasts & viruses.

Its superior action is due to its property of sustain
availability i.e. substantivity.

80
Mechanism Action

It prevents pellicle formation.
It prevents adsorption of bacterial cell wall on to the
tooth surface.
It prevents binding of mature plaque.

81
Metabolism of Chlorhexidine
Glauconate
Bacteriostatic
(Reversible effects )

Cationic Chlorhexidine
molecule is attached towards
negatively charged bacterial
cell surface & it is adsorbed by
phosphate containing
compounds.

The cationic Chlorchexidine
molecule added integrity of
bacterial cell memb. enter into
cell memb.

Permeability of inner memb
will increases & there will be
leakage of low molecular weight
components.

Bactericidal
(irreversible effects )

Increase concentration of
chlorhexidine

Coagulation and
precipitation of the
cytoplasm by the
formation of phosphated
complexes, adenosine
phosphate & nucleic acid.

82
Properties:

Bacteriostatic at low conc.

Bactericidal at high conc.

It exhibits antibacterial activity for 5 hrs &
supresses salivary bacterial count for over 12
hrs. after a single use.
Plaque reduction upto 80-90%.
Potent antifungal agent in oral cavity.

European Formula - 0.2%
USA Formula - 0.12%

83
Adverse effects (chlorhexidine)
Brownish staining of teeth & restoration which is
reversible.
Has a bitter taste.
Loss of taste sensation which is transient
Painful desquamative lesions of the oral mucosa
with burning
sensation.
Parotid swelling rarely cause side- effects
Condition subside in a few days by discontinuing
the mouth
wash.
Rarely hypersensitivity.

84
3
rd
Generation
Delomopinol:-

Inhibits plaque growth reduce gingivitis
It interferes with plaque matrix formation &
also reduces bacterial adherence.
It is indicated as pre- brushing mouth rinse as it
weakens binding of plaque to the tooth surface.

85
Conclusion
More than 500 bacterial strains have been identified in
dental biofilm. Most forms of periodontal disease are caused
by specific pathogens, particularly gram-negative bacteria.
The recognition that dental plaque as a biofilm helps to
explain why periodontal diseases have been so difficult to
prevent and to treat. Periodontal pathogens within a biofilm
environment behave very differently from free-floating
bacteria. The protective extracellular slime matrix makes
bacteria extremely resistant to antibiotics, antimicrobial
agents, and host defense mechanisms. Mechanical removal
is the most effective treatment currently available for the
control of dental plaque biofilms.

86
Refrences
CLINICAL PERIODONTOLOGY - CARRANZA ( 10
th
edition)

CLINICAL PERIODONTOLOGY AND IMPLANT DENTISTRY- LINDHE

ESSENTIALS OF PREVENTIVE AND COMMUNITY DENTISTRY- SOBEN
PETER ( 3
RD
edition)

SHAH HN, COLLINS DM: PROPOSAL FOR RECLASSIFICATION
OF BACTEROIDES ASACCHAROLYTICUS, BACTEROIDES GINGIVALIS,
AND BACTEROIDES ENDODONTALIS IN A NEW
GENUS, PORPHYROMONAS. INTERNATIONAL JOURNAL OF
SYSTEMATIC BACTERIOLOGY 1988; 38(1):128-131.



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