Dental Plaque : Dental Diseases

and Risk of Coronary Heart

Disease and Mortality

Prepared by :

Nur Ain bt. Mohd Hanifah

Nursyazwani bt. Hassan
Nur Nabilah bt. Zulkifly
 Dental Plaque
A soft,thin film of food debris, mucin and
dead epithelial cells deposited on the teeth,
providing the medium for the growth of
various bacteria.
The component of plaque:
Microorganisms

Extracellular matrix
Components of Plaque
Microorganisms:
Streptococcus mutans and anaerobes.
Extracellular matrix:
Protein,long chain polysaccharides and
lipids.
 The microorganisms nearest the tooth
surfaces convert to anaerobic
respiration(start to produce acid).
Acids released from dental plaque lead to
the demineralization of tooth surfaces.
Saliva is unable to penetrate the build-up-
plaque. So cannot neutralize the acid
produced.
 Classification of Dental Plaque
Two types. Depends on its location on the
tooth surface.

Supragingival
●
At and above the dentogingival junction.

Subgingival
●
Below the dentogingival junction.
Supragingival
Most commonly found at:
i) Gingival third of the crown of the
tooth.
ii) Interproximal areas.
iii) Pits and fissures.
Can be seen by naked eyes.
Acquires nutrition only from saliva and
host diet in oral cavity.
The image shows the dental plaque found on the
gingival third of crown of tooth.
Subgingival
Itis thin.
Acquires nutrition only from the host
cells and gingival crevicular fluid.
Bacteria Involved
Day 1 to 2: Three bacteria involved in
early plaque formation. They are from
Viridans group of Streptococcus.
-Streptococcus mutans
-Streptococcus mitis
-Streptococcus sanguinis
Day 2 to 4 : Gram negative rods
appear.
-Actinomyces species.

Day 4 to 7 : Fusobacteria appear.

Weeks 1 to 2 : Gram negative anaerobes:

Vibrios and Spirochetes.
 Dental Caries
Tooth decay or a cavity

Bacterial processes damage hard tooth structure.

The tissue progressively break down, then forming

dental caries.
 If left untreated:
Pain

Tooth loss

Infection
 Smooth
Root surface
surface
caries
caries

Pits and Classificatio

fissures n of dental
caries caries

Recurre
nt caries
Pits and fissure Root caries due to gingival
caries recession

Smooth surface caries

Smooth Surface Caries
The most difficult type of caries to detect.

Cannot be detected visually or manually by dental

explorer.

Radiograph are needed.

Root Caries
Often occur at or close to cementoenamel junction.

Root surface has exposed due to gingival

recession.

The location of gingival margin were favorable for

caries to occur.
Pits and Fissure Caries
Pits are small,pinpoint depressions found at the end
of grooves.

Fissures are mostly located on occlusal surface of posterior

teeth and palatal surface of maxillary anterior teeth.

The depressions formed are suitable for dental

caries to develop.
Recurrent Caries
Decay process that occur underneath existing dental
restorations.

Caused by improper cavity preparations.

Also caused by inadequate cavity restoration.

 Bacteria Involved
Streptococcus mutans

Lactobacilli acidophilus

Actinomyces viscosus

Nocardia
Bacteria convert glucose,fructose and
sucrose into acid(lactic acid) through
fermentation.
If left contact with tooth,will cause
demineralization.
If demineralization continues,mineral
contents may be lost.
So the organic materials left behind are
disintegrates,will form a cavity or hole.
Diagnosis
Primary diagnosis by using good light
source,dental mirror and dental explorer.
Dental radiograph may show dental caries
before it becomes visible.
Uncavitated is often diagnosed by
blowing air across the suspected area.
Signs and Symptoms
Earliest sign is the appearance of chalky
white spot on the surface of the tooth.
Turn brown and will eventually turn into
cavitation.
When dentinal tubules become exposed,it
will cause pain.
Pain worsen with exposure of heat,cold or
sweet foods and drinks.
Cause bad breath and foul taste.
 Complications
Discomfort or pain

Fractured tooth

Inability to bite down on tooth

Tooth abcess

Tooth sensitivity
Treatment

Filling

●
Used a specific substance to fill up the cavity of the tooth.
●
Examples are silver alloy(amalgam),gold,porcelain and composite resin.
●
Porcelain or composite resin is closely match the natural tooth
appearance(preferred for front teeth).
●
Silver alloy(amalgam) and gold are stronger(often used for back teeth).
 Crown

●
Used if the tooth decay is extensive and limited tooth structure.
●
Often made of gold,porcelain or porcelain attached to the metal.

Root canal

●
Recommended if the nerve in a tooth dies from decay or
injury.
Prevention
Oral hygiene

Dental sealants

Fluoride and topical fluoride

Minimize snacking
GINGIVITIS
Inflammation of the gum tissue

Non-destructive periodontal disease

Response to bacterial biofilm (also called

plaque) adherent to tooth surfaces

In the absence of treatment, gingivitis may

progress to periodontitis which is a destructive
form of periodontal disease.
Pathophysiology
 where the teeth meet the gums there is a crevice called the gingival
crevice

bacteria can colonize this crevice fed by food sugars

asthe bacteria grow, the gingiva (gums) becomes inflamed, swells, and
may bleed

this disease is called gingivitis

the bacteria involved are Bacteroides,Porphyromonas, and Fusobacterium

Certain
herpes viruses: herpes simplex and varicella-zoster virus are
known causes of gingivitis.
• the plaque (biofilm) that forms in the gingival crevice
get calcified forming calculus

• as the disease progresses, the gingival space deepens

into pockets

• healthy gingival pockets are 1-2 mm deep

once the pockets reach 4-6 mm deep, fibers (periodontal
ligament) are degraded, the patient has periodontal
disease

• this can make the teeth loosen and fall out

Sign & Symptoms
Swollen gums

Bright red or purple gums

Gums that are tender or painful to the touch

The stippling that normally exists on the gum tissue

will often disappear and may appear shiny when
the gum tissue becomes swollen and stretched over
the inflamed underlying connective tissue.
Diagnosis
A dental hygienist or dentist :
 will check for the symptoms of gingivitis
 examine the amount of plaque in the oral
cavity.
 look for signs of periodontitis using X-
rays or periodontal probing
Prevention & treatment
regularoral hygiene that includes daily
brushing and flossing .

Interdental brushes are also useful in

cleaning the teeth from plaque.
Complications
Tooth loss
Recurrence of gingivitis
Periodontitis
Infection or abscess of the gingiva or the
jaw bones
Trench mouth (bacterial infection and
ulceration of the gums)
PERIODONTITIS
a bacterially induced, localized, chronic
inflammatory disease, destroys connective
tissue and bone that support the teeth.

affecting 30% to 50% of adults

Pathophsiology
Begins with a microbial infection, followed by a
host-mediated destruction of soft tissue caused
by hyperactivated or primed leukocytes that
cause clinically significant connective tissue and
bone destruction.
Bacterial accumulations on the teeth are essential
to the initiation and progression of periodontitis.
Neutrophils, play a major role in the host
response against invading periodontopathogenic
microorganisms.
Herpes viruses: cytomegalovirus and Epstein-Barr
play a role in the onset or progression of some
types of periodontal disease.

Gram-negative anaerobic bacterial species,

including Porphyromonas gingivalis, which
consistently associate with periodontitis.

Environmental and genetic factors as well as

acquired risk factors such as diabetes mellitus and
exposure to tobacco accelerate inflammatory
processes in periodontitis.
 Sign & Symptoms
Swollen gums that decompress,discolored gums, tender
gums, bleeding gums (spontaneous or after brushing or
flossing).
Long appearance of teeth (gum recession), increased
spacing between teeth, pus between teeth and gums, loose
teeth.
change in tooth sensation when biting because of
increased tooth mobility, bad taste, and halitosis (because
of anaerobic infection).
pain or pain on mastication.
 alveolar bone lesions.
Diagnosis
requires evaluation by a trained examiner
and evidence of gingival inflammation,
loss of connective tissue surrounding the
teeth measured by clinical examination
using a periodontal probe, and bone loss
detected by radiography (Figure 1).
Figure 1
In periapical x-ray A, marginal bone levels (line a) are consistent with
no history of periodontitis. In periapical x-ray B, periodontitis has caused
resorption of approximately 50% to 60% of the bone supporting the
mandibular anterior teeth. The approximate level of bone that would
be expected in the absence of periodontitis is marked by line a, and
the approximate level at the time of the x-ray is marked by line b.
Prevention & treatment
Brushing properly on a regular basis (at
least twice daily)
Flossing daily and using interdental
brushes.
Regular dental check-ups and
professional teeth cleaning
Chronology of Dental Plaque to Coronary
Heart Disease & Mortality

Dental Plaque

Gingivitis
Severe

Periodontitis

Coronary Heart Disease & Mortality

 Coronary Heart Disease and Mortality

Coronary Heart Disease ( CHD ) :

The failure of coronary circulation to supply

adequate circulation to cardiac muscle and
surrounding tissue.

Mortality :

The state of the organ having to die at some time.

(Death)
 History
Journal of Periodontology : In one study researchers looked at 150 individuals
with periodontal diseases and found that the total number of periodontal bacteria
in subgingival plaques was higher in individuals that have suffered from an
acute myocardial infarction (heart attack). The second study found that the same
DNA from different kinds of periodontal bacteria in plaque was also in the
patients’ heart arteries ( Strep. Viridans, Strep. Mutans, P. gingivalis, Strep.
Sainguinis).

British Medical Journal (BMJ), 1989 Mar 25;298(6676):779-81 showed that there
was an unexpected correlation between dental disease and systemic disease (stroke,
heart disease, diabetes). After correcting for age, exercise, diet, smoking, weight,
blood cholesterol level, alcohol use and health care, people who had periodontal
disease had a significantly higher incidence of heart disease, stroke and premature
death.
 Entrance of Bacteria
Gingiva Bloodstream Heart

2 Harsh chewing
Bacteria Periodontitis action or
toothbrushing
1 3
Due to sensitive gums
Bleeding
Open up pore of
Blood vessel
Blood vessel opens
or exposed

Bacteria enter and travel in the bloodstream

Coronary Heart Disease Related Events

Heart Ischemia :
Restriction of blood supply to the Heart Infarction
heart, due to problem in blood
vessel due to thinning / damage

Atheroslcerosis : Mortality
A condition where the artery
wall thickens as result of built
up of fatty materials such as
cholesterol
Dysfunction
Angina :
Severe chest pain due to
ischemia of heart muscle
Mechanisms of Dental Plaque Leads to CHD
and its Related Events
1. Body’s Own Defense Mechanism (Immune System) :

a. Ischemic Heart Disease

b. Thrombogenesis
c. Atherosclerosis
d. Arteries constriction

2. Action of Bacteria in Blood Vessel

3. Infective endocarditis
 1. Body’s Defense Mechanism :
a. Ischemic Heart Disease

Increased Fibrinogen
Periodontal Infection
Increased WBC
Increased vWF

Ischemic Heart
Disease Hypercoagulabilit
y

Increased Blood
Disrupts Blood Flow Viscousity
1. Body’s Defense Mechanism :
b. Thrombogenesis
Streptococcus sanguinis
Porphyromonas Gingivalis
Release toxin

Express Platelet Aggregation-Associated

Protein (PAAP)

Aggregation of Circulating
Platelets

Formation of Thromboemboli
 1. Body’s Defense Mechanism :
c. Atherosclerosis
ICAM-1
ELAM-1
Bacteria VCAM-1 Circulating
Infection Inflammation Monocytes Adhere
to Vascular
Endothelium

Engorged at Monocytes Penetrate

Arterial Intima Endothelium and Migrate
Under Arterial Intima

Atheromatous Thickening of Decrease Blood

Plaque formed Blood Vessel and Flow Through
Narrow the Lumen
 1. Body’s Defense Mechanism :
d. Arterial Constriction
Inflammation

Increase level of C-reactive

Protein (inflammatory markers)
Continuous Inflammation

Continuous Increase of CRP

Constriction of Arteries
Narrowing of Arteries

Decrease amount of Blood Flow and High Pressure of Blood

2. Action of Bacteria in Blood Vessel

Fatty Plaque Already Exist on Arterial

Wall

Bacteria Stick to Fatty Plaque

Plaque Becomes
Thicker

Blockage in Artery
 3. Infective Endocarditis

Infective Endocarditis :
Infection of the endocardial surface of the
heart. The intracardiac effects of this infection
include severe valvular insufficiency, which
may lead to congestive heart failure

Streptococcus Viridants that associated with oral

disease cause transient bacteremias. Bacteria infect
heart and cause Infective Endocarditis. Heart failure
and heart attack occur.
 Dental Precautions
Dental patients who have cardiovascular disease need to take
antibiotics before going to the dentist.

If bacteria reach the arteries during a dental procedure, it can

irritate the arteries just as it irritates gum tissue.

The bacteria may cause arterial plaque to build up in the arteries,

which can affect blood flow.

When blood flow has been compromised, this can cause a heart
attack.

If arterial plaque comes loose, it can cause a stroke if the blockage

occurs in the brain.
Thank You