Dental Plaque & Periodontal Health

Dental Plaque in Relation to Periodontal Disease

• The periodontium includes the periodontal ligament with Sharpey's fibers, which are collagen fibers connecting cementum to bone.
• The biologic width is important for restorations; disturbing it can lead to chronic inflammation.

Describing Healthy Gingiva

• In a healthy state, gingiva is pink or may have melanin pigmentation.
• Color change can indicate early periodontal disease.
• Healthy gingiva is knife-edged to the tooth and tight, with pointed papilla in the anterior and more rounded papilla in the posterior.
• Healthy gingiva is firm, resilient, and tightly adapted to tissues.
• Attached gingiva has a stippled texture due to connective tissue being pulled.
• Healthy gums have a sulcus depth less than 3 mm.
• Gingival health is classified as pristine (no bleeding) or incipient (<10% bleeding).

Gingivitis Explained

• Gingivitis is clinically visible inflammation of the gingival tissues caused by dental plaque biofilm.
• Inflammation is confined to the gingiva and does not extend to the periodontal attachment or beyond the mucogingival junction.
• Gingivitis is reversible by reducing dental plaque levels.
• Clinical signs include redness in the gingival margins and papilla, bleeding (one of the first signs related to disease severity), swelling from fluid in tissues, changes in consistency, and hyperplastic tissue.

Periodontitis Explained

• Chronic periodontitis involves destruction of the supporting tissue around the tooth and crest of bone.
• Destruction includes the periodontal ligament, alveolar bone, and cementum, leading to clinical attachment loss (CAL).
• Periodontitis progresses in episodic bursts, not at a constant rate.
• Periodontitis leads to a gradual destruction of periodontal ligament fibers & alveolar crest, resulting in CAL, which is measured from the cementoenamel junction to the gingival margin plus probing depth.
• Recession and pocket depth factor into CAL measurement.
• Factors such as an increase in periodontal probing depth, periodontal pockets, and bone loss are indicators of periodontitis.
• The primary pathogen is Porphyromonas gingivalis which destroys bone with the least resistance.

Progression of Periodontal Disease

• The progression of periodontal disease depends on the body's immune system.
• It starts with undisturbed bacterial plaque in the gingival sulcus which progresses from biofilm-induced gingivitis to periodontitis.

Severity of Chronic Periodontal Diseases

• Severity are categorized as biofilm-induced gingivitis to mild, moderate, severe, and advanced periodontitis.
• Necrotizing Gingivitis (NG): Etiology includes a suppressed immune system, specific bacteria, poor oral hygiene, calculus, smoking, alcohol, nutritional deficiencies, stress, and fatigue. Symptoms include ulcerated papilla, pain, foul odor, bleeding, and tissue sloughing.
• Necrotizing Periodontitis (NP): The most severe biofilm-related condition, generally stemming from a suppressed immune system. Symptoms include NG symptoms, plus necrotic destruction into attached gingiva, periodontal ligament & bone also bone cratering and ulcers on lips & tongue.
• Necrotizing Stomatitis (NS): similar to NP but spreads to mucosa, muscle, and skin.

Risk Factors and Periodontal Diseases

• Risk factors are local, systemic, and host factors that are interconnected to predispose periodontal diseases.
• Local risk factors include calculus, oral habits, tooth-related factors, appliances, poor restorations, traumatic occlusion, recession from frenum attachment, and xerostomia
• Systemic Risk factors are hormonal influences (puberty, pregnancy, menopause, hormone therapy), tobacco and cannabis use, diseases/conditions (diabetes, leukemia, neutropenia), and prescription and illicit drugs.
• Host risk factors include genetics, age, gender, and race
• Host responses influence disease through systemic factors interrelating with local factors. While they do not cause such diseases themselves, they lower the resistance of periodontal tissues making them more susceptible.

Systemic Influences

• Systemic factors such as hormonal changes, tobacco and cannabis use, and systemic diseases like diabetes and leukemia can modify the host response to bacterial plaque, thus influencing the progression of periodontal diseases.
• Certain drugs can also have effects like hyposalivation or gingival overgrowth, indirectly impacting periodontal health.

Risks of Tobacco and Cannabis Smoking

• Cannabis, like nicotine, can be addictive with similar withdrawal symptoms.
• Cannabis smokers inhale more deeply and hold smoke longer, leading to greater amounts of carbon monoxide and tar damaging the respiratory system, causing cough, phlegm, chest illness, and lung infections.
• Cannabis smoke is often unfiltered making it more toxic and carcinogenic than cigarette smoke.
• Cannabis smoking can cause impairments in attention, thinking, learning, and memory, potentially leading to permanent brain damage in young people and increased chances of dropping out of school or missing work.
• Heavy cannabis use can cause hallucinations and paranoia and may trigger or worsen schizophrenia.
• Teens are particularly susceptible to cannabis's negative effects, potentially interfering with school performance and increasing risky behaviors.
• Teens tend to simultaneously use cannabis and alcohol which increases impairment and has unpredictable negative side effects.

Tobacco Cessation Program

• Components include the 5 A's: Ask, Advise, Assess, Assist, Arrange follow-up or referral.
• Dental Assistants responsibilities include suggesting medical professional implementation for clients wishing assistance, providing literature, and asking if they would like the Smokers Helpline contact.

Fluoride

• Fluoride is a chemical element of the halogen family in the form of a non-toxic soluble compound that can be absorbed by the body
• "nature's cavity fighter" being a mineal that occurs naturally in food and water
• Sources of fluoride are: water, seafood, tea, and coffee and products such as toothpaste, mouth rinses, supplements and professionally applied fluorides.

Fluoride: Development and Maintenance of Teeth/Bones

• Optimal fluoride is the amount required to prevent caries activity being 0.7 – 1.2 mg/L (ppm) of water in Canada.
• Benefits include incorporation into developing teeth, topical fluoride accelerates enamel maturation, promotes remineralization, can reduce enamel solubility, and enhances remineralization as well as retarding demineralization and reduces hypersensitivity.

Preventing Dental Decay

• Mechanisms to prevent decay, include reducing enamel solubility by introducing firmly bound fluoride into the apatite crystals.
• Promotes remineralization to rebuild weakened enamel by attracting calcium and phosphate ions to help reaction in the demineralization-remineralization process

Systemic vs Topical Fluoride

• Used to fluoridate water, NaF (sodium fluoride) is a type of systemic fluoride
• For the absorption of ingested fluoride, 86-90% is absorbed in the bloodstream. Ingestion of milk of magnesia will reduce absorption as the contents are not fluoride-based.
• Systemic fluoride has no effect on tooth structures.
• Topical Fluoride includes Sodium Fluoride (NaF), Acidulated Phosphate Fluoride (APF), and Sodium Fluoride varnish which react with crystals.
• Benefits are after eruption during the period to penetrate enamel surface and react which helps form fluorhydroxyapatite.

Fluoride Needs

• Advantages are time saved through risk factor identification. and communication as a result.
• Helps determine if professional fluoride therapy is needed.

Home Fluoride

• Consist of chewable tablets, lozenges, and drops while.
• Canadian guidelines recommend supplements for children older than 6 months when recommended by a dentist.
• The majority of Canadians as well as pregnant women don't require supplements.

Sodium, Acidulated, and Stannous Fluoride

• Sodium Fluoride (NaF), Acidulated Phosphate Fluoride (APF), and SnF2 are all types of professionally applied topical solutions
• Factors such as caries risk, tooth eruption, gag reflex, age affect decisions to administer

Fluorosis

• Fluorosis originates from high intake during tooth development, which affects proper crystal and cell formation.
• Intake should not exceed 0.05-0.07 mg F/kg of body weight per day

Professional Fluorides

• Topical Fluorides, that are often administered when a fluoride needs assessment indicates high risk
• Varnish is preferred, applied post-removing plaque and is contact or light-cured with reapplication every 3-4 months.
• The Tray method, where teeth must first be cleaned and dried and trays with a small fluoride filling are left for 4 minutes. Children require less material.

Toothpaste Fluoride

• Help with caries compared to less brushing, 1/day results in a 21% reduction, 2/day in 30%, and 3/day in 45% fewer caries.
• High ppm for fluoride is for efficient cleaning
• Risk of the amount swallowed for the young's, is excessive causing potentially fluorosis.

Acute Fluoride Toxicity

• A possible risk depends on amount, weight, and age where high intake exceeds levels and can lead to poisoning or even death.
• A orally absorbed amount of 5 mg F/kg body weight. Symptoms occur within 30 minutes leading to death after 4 hours treated in time.

Chronic Fluoride Toxicity

• Manifest from the long term causing dental fluorosis from longer absorption during tooth development.
• Emergency Treatment for Toxicity: Less than 5mg/kg: Give calcium orally (e.g., milk) and observe.
• If more than 5mg/kg: Immediately call 911, induce vomiting, give calcium orally, and monitor the client at the hospital.

Promotional Oral Health

• Client programs that encourage, educate, assist, repeats and reinforces guidelines specifically regarding preparation and education.

Specific Education Guidelines

• Active partner in the client's oral health through understanding their needs, responsible partner and complimenting the patients succeeds.
• Step 1 is requesting questions to learn more about habits. Step 2 is inviting parents or a legal guardian into the patient and emphasizes techniques and aids.

Homecare

• Adapt instruction to individual needs, with examples as well as visual aids
• Give demonstrations in order to involve skill understanding through reinforcement.

Children Oral Hygiene

• Children at 8 and before must still involve parental help to monitor, and help manage fluoride management.
• Children at 8 or above have to monitor fluoride as well as have flossing. A recommendation summary could include disclosing, analyzing brushing, and modifying as needed.

Oral Hygiene Implementation

• A general demonstration towards 5 steps:

1. Information Gathering
2. Planning
3. Assist
4. Demonstrations
5. Feedback

Adult Care

• Tools that are recommended are brushes, rubber, and balsa.
• Types of Embrasures that are recommended include dental floss, proxy brush, and end-tuft brush.
• Active Ingredients that are found with benefits and is the active recommendation

Types of Rinses

• Cosmetic helps briefly suppress and prevent oral debris.
• Therapeutic Contains an active ingredient that aids in preventing/arresting caries or for antifungal purposes such fluoride for rinses.

Oral Recommendations

• Mouthwash can occur during a dental procedure, taking impressions or radiographs.
• A steady stream helps with oral irrigation and removes plaque especially with tools

Home Care

• Care often depends on the need of a general, orthodontic, dental, and overall
• General consideration for depth of recession, amount of deposits, tooth medical.

Oral Piercing

• Avoid or consider to use automatic brushes, less or non abrasive toothpaste for geriatric clients.

Plaque Indices

• Method used often to help compare indices.
• O'leary is a simple method to detect plaque presence on the individual.
• It requires staining surfaces and dividing numbers of plaque containing surfaces by available.