Bacterial Plaque and Its Relation to Dental Diseases

Natalie Mick
Kirkwood Community College

A large portion of problems that occur in the mouth start out with the presence of plaque
and are enhanced by continued poor oral hygiene. If left alone, plaque can lead to serious issues
such as calculus, caries and decay, gingivitis, and periodontal disease. While some of these
conditions are reversible, there are others that have lasting effects and can turn out to be very
expensive to remedy. No one looks forward to someday losing their teeth and we generally do
all that we can to hang on to them as long as possible. It all begins with getting rid of the culprit.
Plaque, also referred to as biofilm, is defined as a dense, organized bacterial system,
embedded in an intermicrobial matrix, held together by glucan (Clark, 2014). In other words, it
is the layer of bacteria that accumulates on teeth in the form of a film. Plaque is soft and
typically white in color. It is made up of approximately 80% water and 20% organic and
inorganic solids. The exact composition varies among individuals, but these solids are some
combination of calcium, phosphorus, fluoride, carbohydrates, proteins, and lipids.
There is a specific 4-step process of plaque formation. First a layer is formed on the
tooth enamel called acquired pellicle. This forms usually within about 20 minutes of plaque
removal, such as tooth brushing and flossing. It is generally not visible, but when using a
disclosing solution, this pellicle is lighter in color than plaque that has been sitting on the teeth
for a longer period of time. While acquired pellicle itself is not necessarily good or bad, it is the
progression of accumulation that can be detrimental to oral tissue health. This first layer is what
bacteria attaches itself to and multiplies in the second step of plaque formation. Colonies of
bacteria form and continue piling on top of each other in layers. In the first few hours, the
bacteria mainly consist of gram positive cocci and rods such as streptococcus sanguis and
streptococcus mutans. It is at this time that biofilm is seen in measurable amounts. The third
step is the biofilm growth and maturation stage in which the layers grow thicker and more

plentiful. Step four is where the final matrix forms with the addition of sugars to help hold
everything together. Around days seven through fourteen, gram negative sprirochetes and
vibrios begin to be more widespread and inflammation is evident. Around thirty days with no
plaque removal, biofilm has reached its maximum accumulation (Clark, 2014). Plaque is
directly responsible for periodontal disease. The best way to disrupt the plaque matrix and keep
any diseases from progressing is by mechanical removal with a toothbrush and floss, which is
why it is so important to do these things at least once every 24 hours.
Calculus is one of the next phases of dental ailments that occurs if biofilm is not fully
removed from the teeth. Although calculus is not directly responsible for periodontal disease, it
does shelter the plaque that is the cause. Calculus, sometimes referred to as tartar, is essentially
hardened plaque. It cannot be removed with a toothbrush or floss and is what dental hygienists
spend a majority of their time removing during a patients visit. On average, calculus is formed
in twelve days. The most frequent places for calculus to accumulate are surfaces of the teeth
nearest the salivary glands. The two most common surfaces are the lingual surface of the
mandibular anteriors and the buccal surfaces of the maxillary first and second molars. Calculus
is, like plaque, composed of organic and inorganic components and water. The majority is
inorganic, such as calcium, phosphorus, carbonate, sodium, magnesium, potassium and even
fluoride if the concentration in the mouth is high enough. Water and organic components, for
example epithelial cells, leukocytes, and mucin from saliva, only make up about 10-30% of the
calculus (Wilkins, 2013). Calculus ranges in color from white, yellow, or gray supragingivally to
brown, dark green, or black subgingivally. It is best seen when dried with the air/water syringe
and making use of transillumination.

Dental caries as defined by the World Health Organization are a localized, posteruptive,
pathologic process of external origin involving softening of the hard tooth issue and proceeding
to the formation of a cavity (Wilkins, 2013). In order for caries to arise, there must be
microorganisms, cariogenic foodstuffs, and a susceptible tooth surface all present (Clark, 2014).
It begins as an infection of sorts with bacteria that use the sugars in foods to make acids. The
acids cause the pH of the biofilm to lower, thus causing demineralization of the enamel. If the
pH is not given time to climb back up to normal levels, the break down will continue. Eating
cariogenic foods such as those that are high in sugar or are highly acidic and products that are
soft and gummy will also contribute to carious lesions. Fluoride is a great way to fill the open
spaces left on the enamel after an acid attack. This is why it is good to drink fluoridated water,
use toothpaste with fluoride, and have regular fluoride treatments at the dental office.
Gingivitis is a common and mild form of gum disease that causes gingival irritation,
redness and swelling (Gingivitis). Bleeding also occurs with gingivitis but is most often times
painless. Normal gum tissue is firm and pink in color. Gingivitis causes the gums to be bright
red and have a puffy, shiny appearance. This condition is also caused by biofilm retention. Two
to four days after the initial irritation occurs, an inflammatory response happens in which white
blood cells move to the affected area to begin fighting the infection. The movement of gingival
sulcus fluid increases, collagen begins early stages of breakdown, and the connective tissue fills
with fluid (Wilkins, 2013). This condition is reversible and absolutely preventable. The sooner
you see a dentist, the sooner you can begin reversing the signs and symptoms. It takes a
collaborative effort by both clinician and patient to maintain oral health and keep from regressing
back to gingivitis. It can take anywhere from 10 days to 3 weeks for gingivitis to arise, but if the
patient and clinician intervene with effective plaque removal, it can subside in just 7 days. There

are some factors that put some people at more of a risk for gingivitis than others. Some of the
most common factors are smoking, xerostomia, decreased immunity, hormonal changes,
medications, and of course poor hygiene habits.
The next step on the downhill course to periodontal disease is periodontitis. Periodontitis
is defined by the Mayo Clinic as a serious gum infection that damages the soft tissue and
destroys the bone that supports your teeth (Periodontitis). Gingivitis is generally the starting
point for periodontitis, and when steps are not taken to reverse gingivitis, the gums can begin to
recede. Gingival recession can lead to sensitivity and wearing away of the cementum below the
gum line. Once the gums have receded, it is common for a person to experience alveolar bone
loss. This occurs because now that the gums have fallen away from the teeth a little, there are
now larger periodontal pockets for plaque to accumulate and multiply. Since the gum tissue is
not tight against the tooth, the cementum is now exposed, leaving it open for plaque to adhere to.
Once the infection moves in to the teeth and deeper into the sulci, it can spread to the bone. If
the surrounding bone begins to deteriorate, the teeth will become loose and can either fall out or
will need to be removed. It is very important to brush and floss at least once a day and continue
with regular cleanings at the dental office to prevent periodontitis. Not only can you lose your
teeth and need implants or dentures, but periodontitis is also found to play a role in susceptibility
to heart attacks, strokes, and respiratory problems (Periodontitis).
All of these previously mentioned conditions are fully preventable. Education is the best
tool for prevention and is to be taken very seriously by dental professionals. If patients do not
have basic oral hygiene knowledge, it is our job as hygienists to teach them. First of all, patients
need to be taught how to successfully and thoroughly remove plaque. This is achieved by
brushing and flossing at least once daily. Brushing twice a day is better, but plaque needs to be

disrupted at least once in 24 hours. It is possible that the patient needs to be taught the proper
way to brush as well. Brushing does not always get plaque that builds up in interproximal
spaces, especially if the individual has tight contacts. The best remedy for this is flossing. If
regular floss is hard to use, other forms of auxiliary aids should be recommended.
Caries are also prevented by simple plaque removal, but such things as sealants, diet
changes, and, as previously mentioned, fluoride contribute to maintaining a healthy mouth.
Since most of carious lesions occur on the occlusal surfaces of posterior teeth, sealants are
painted on these surfaces by the dentist to help seal out biofilm and acid. The sealant is a plastic
resin that expands over the pits and fissures and can last several years (Sealants). According to
the World Health Organization, in industrialized countries, 60-90% of schoolchildren and a
majority of adult are affected by caries (Oral Health). Since such a large number of children
develop cavities, these sealants are placed on the teeth in early years. Altering diet is another
good start to keeping teeth free of caries. Eliminating or at least cutting back on sugar intake is
very important. If unable to carry that out, one should consider drinking water after eating or
drinking to speed up the process of returning the mouths pH to normal levels. Many people also
think that snacking on small amounts of food throughout the day is a good way to maintain a
healthy weight. That may be so, but since they never give their mouth enough time to rise to a
normal pH, they are putting themselves at risk for caries. It is better to eat that king size candy
bar in one sitting rather than having a little bite every hour.
Of all the ailments that could manifest within the human body, it seems silly to let
something such as plaque potentially destroy the entire mouth. It may be easy one morning if
youre running late to forget or even just not have time to brush your teeth, but it is not
something that can be made a habit of. Controlling plaque and daily plaque removal are the best

ways to prevent more serious conditions such as dental caries, gingivitis, and periodontitis from
happening. Besides removing calculus for patients, the most important thing a hygienist can do
for their patients is to give them an education on proper oral hygiene and make sure that they
understand the consequences of not keeping their oral tissues clean and healthy.

References

American Dental Association. (n.d.). Sealants. Mouth Healthy. Retrieved November 14, 2014,
from www.mouthhealthy.org/en/az-topics/s/sealants
Clark, S. (2014) Preventive Dentistry, Kirkwood Community College.
Mayo Clinic Staff. (n.d.). Gingivitis Diseases and Conditions. Retrieved November 13, 2014,
from http://www.mayoclinic.org/diseases-conditions/gingivitis/basics/definition/con20021422
Mayo Clinic Staff. (n.d.). Periodontitis. Diseases and Conditions. Retrieved November 13, 2014,
from http://www.mayoclinic.org/diseases-conditions/periodontitis/basics/definition/con20021679
Wilkins, E. (2013). Clinical practice of the dental hygienist (11th ed.). Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins.
World Health Organization. (n.d.). Policy Basics. Oral Health. Retrieved November 13, 2014,
from http://www.who.int/oral_health/policy/en/