J Clin Periodont 2003; 30 (Suppl.

5): 7–9 Copyright Ó Blackwell Munksgaard 2003

Printed in Denmark. All rights reserved

ISSN 1600-2865

Section Two
J.-P. Bernimoulin
Recent concepts in plaque Department of Periodontology and
Synoptic Dentistry, Humboldt University,
Berlin, Germany

formation
Bernimoulin J-P: Recent concepts in plaque formation. J Clin Periodontol 2003;
30 (Suppl. 5): 7–9. Ó Blackwell Munksgaard, 2003.

Abstract
Dental plaque is an adherent, bacterial film, and is the main pathological agent for
periodontal diseases. The formation of dental plaque can occur both supragin-
givally and subgingivally. The development of plaque is a three-step process.
Following the formation of a pellicle, pioneer micro-organisms will adhere to it,
proliferate and form colonies. The final stage involves the aggregation of fila-
mentous organisms and spirochetes into a cohesive biofilm. Many products of the
plaque bacteria reach the subepithelial tissue, causing inflammatory responses such
as increased vascularity and leukocyte diapedesis. Both supragingival and subgin-
gival plaque may form a hard, mineralized mass called calculus. The surface of
calculus harbours bacteria, which may exacerbate the inflammatory responses. An
effective oral antiseptic must be active against a wide range of Gram-positive and
Gram-negative bacterial species, including streptococci and fusobacteria. Ideally,
an effective agent would also penetrate the plaque biofilm. Data show that essential Key words: biofilm; planktonic bacteria; supra-
oil and chlorhexidine mouthwashes have the broadest antimicrobial effects. gingival; subgingival; essential oil mouthwash

Bacteria found in the saliva can be
observed as planktonic bacteria (i.e.
single floating bacteria in a liquid
phase). However bacteria found on
the surface of hard structures such as
teeth, restorations, prostheses and
implants form an adherent gelatinous
film called dental plaque (Fine 1988).
Dental plaque, an adherent, bac-
terial biofilm that forms on all hard
and soft tissue, is the principal aetio-
logic agent in caries and periodontal
diseases (Fine 1988). Biofilms are not
unique to the oral cavity and are
found in most liquid or semiliquid
environments, spanning biological,
industrial and environmental systems
(Wilkins 1999). While dental plaque is
perhaps the best studied biofilm and
serves as a good model for other
biofilm studies, a remarkable amount
remains to be learned.
Today dental plaque can be re-
garded as a specialized example of
microbial biofilms that form on sur-
faces in many environmental aquatic
systems (McHugh 1999). The stages
involved in the development of supra-
gingival plaque are shown in Fig. 1.
As can be seen from the above, the
formation of dental plaque in a
healthy subject first occurs supragin-
givally, which then often progresses
subgingivally. It is comprised of a
complex mix of bacteria, numbering
at least several hundred species (Fine
1988).
A comprehensive review of dental
plaque formation was given by List-
garten (1999). A freshly cleaned tooth
surface is soon coated by a film of
saliva. In this acquired organic pel-
licle some salivary components, for
example glycoproteins, proline-rich
proteins, statherin and fibronectin,
promote the adherence of bacterial
cells during the subsequent hours.
These bacteria consist primarily of
Gram-positive coccoid cells that div-
ide and form micro colonies. After a
few days of dental plaque growth,
filamentous bacteria coaggregate to
the initial colonizers and become
embedded in a matrix composed of
salivary components and high pro-
portions of exopolysaccharides of
bacterial origin.
According to studies by Löe et al.
(1965) and Theilade et al. (1996), if
this young supragingival plaque is
allowed to grow without interference
of any oral hygiene practice, some
changes will appear that result in the
establishment of gingivitis after
2–3 weeks (Löe et al. 1965, Theilade
et al. 1966). During these 3 weeks the
bacterial composition of the plaque
changes to a more complex flora
where Gram-negative anaerobic bac-
teria predominate. Spirochetes and
flagellated bacteria are observed
alongside cocci, rods, filaments and
fusiforms. All these bacteria live
together, taking their nutrients from
the saliva and from the gingival cre-
vicular fluid. Moreover, there is
interdependence between the different
species because some of them produce
what others need for metabolism. This
dental plaque is situated at the gingi-
val margin and in the gingival sulcus.
8 Bernimoulin
Fig. 1. Stages of supragingival plaque
development. (a) Step 1: the evolution of
plaque biofilm begins with the formation
of the pellicle, an acellular material on the
tooth surface that is mostly composed of
glycoproteins. In this electron micro-
graph, the pellicle is seen as a black line.
(b) Step 2: pioneer micro-organisms settle
in the pellicle and form colonies. This
micrograph shows 2-day-old microbial
plaque on the enamel of a human tooth.
The bacteria adhering to the pellicle have
multiplied and formed colonies that run
into each other. They have then grown at
right angles to the tooth surface. The
pellicle is first colonized by Gram-positive
aerobic bacteria (mainly cocci), and 2–4
days later it is affected by Gram-positive
rods and filaments, Gram-negative
anaerobic organisms (cocci and fila-
ments), and fusiforms (Fine 1988, Wilkins
1999). This shift toward more anaerobic
organisms greatly increases the patho-
genicity of the plaque biofilm (Wilkins
1999). (c) Step 3: in the final stages of
plaque maturation, spiral forms and
spirochetes appear, and the plaque is
composed mostly of filamentous organ-
isms. These colonies aggregate into
a cohesive plaque biofilm (Fine 1988,
Wilkins 1999).
Several bacterial products are cap-
able of passing through the junctional
epithelium and reaching the subepi-
thelial tissues. The host cells triggered
by the bacterial products react with
the production and release of inflam-
matory mediators (Page 1991). These
mediators are responsible for the
development of local inflammatory
processes such as increased vascular-
ity and diapedesis of leukocytes
through the capillary vessels, in-
creased rate of gingival crevicular
fluid, loss of connective tissue and
swelling.
Such histopathological features
characterize among others the
appearance of a plaque-associated
gingivitis. The inflammatory changes
of the marginal gingiva favour the
development of a dental plaque
located subgingivally in which Gram-
negative anaerobic bacteria prevail.
Regarding the large bacterial
population living in the oral cavity,
certain species of Gram-negative
anaerobic bacteria are considered to
be pathogenic to the dental support-
ive tissues.
Among these periodontal patho-
genic bacteria, Tannerella forsythensis
(formerly Bacteroides forsythus) Fig. 2. Progression to gingivitis: (a) slight,
(Sakamoto et al. 2002), Porphyro- (b) moderate and (c) severe.
monas gingivalis and Treponema den-
ticola were found to be more
prevalent in subgingival plaque taken is the hallmark of periodontitis (see
from periodontitis patients than from Fig. 2) (DePaola et al. 1989).
subjects with good periodontal heath Therefore, the prevention of gingi-
(Socransky & Haffaje 2002). vitis, the early form of periodontal
Both supragingival and subgingival disease, is largely governed by limit-
plaque can form a hard, mineralized ing the development of the oral/
and often tenacious mass called cal- dental biofilm.
culus. The surfaces of these deposits Because plaque flora change as the
harbour pathogenic bacteria that biofilm matures, an effective oral
further exacerbate the inflammatory antiseptic must be active against a
process. Putative periodontopathic wide range of species, including
bacteria include Prevotella intermedia, streptococci and other Gram-positive
Porphyromonas gingivalis, Actinoba- organisms, fusobacteria and other
cillus actinomycetemcomitans, Tan- Gram-negative organisms, and spiro-
nerella forsythensis and Eikenella chetes. Additionally, an antiseptic
corrodons (Wilkins 1999). capable of penetrating the plaque
As subgingival calculus serves as an biofilm would be expected to be more
attachment base for bacteria, it may clinically effective.
contribute to pocket development Essential oil (EO) mouthwashes
and the progression of periodontal have been shown to kill numerous
disease. The living bacteria on its micro-organisms involved in plaque
rough surface are constantly in con- and gingivitis. Specifically, in vitro
tact with the gingival tissue, and act studies show that Actinobacillus
as a biochemical, and possibly phys- actinomycetemcomitans, Actinomyces
ical, source of irritation to the host viscosus, Streptococcus mutans and
tissue (Wilkins 1999). Bacterial by- S. sanguis are killed within 30 s, as
products induce the host response to are Bacteroides species and Candida
produce inflammation and bleeding, albicans (Ross et al. 1989).
which is called gingivitis (Wilkins In both in vitro and in vivo studies,
1999). If left untreated, gingivitis may EO and chlorhexidine (CHX) mouth-
lead to the breakdown of the peri- washes have been shown to have broad
odontal attachment apparatus, which antimicrobial effects, with CHX

mouthwash being more effective. Such
studies have investigated the effects on
Gram-negative and Gram-positive
pathogens, yeasts, and viruses such as
herpes simplex type 1 and type 2, and
influenza A (Ross et al. 1989, Kubert
et al. 1993, Pitts et al. 1983, DePaola
et al. 1996, Jenkins et al. 1994).
EOs are also capable of extracting
bacterial endotoxins, which theoret-
ically may reduce plaque pathogen-
icity (Dennison et al. 1995).
Both EO and especially CHX
mouthwashes penetrate plaque bio-
film and are active against biofilm-
embedded bacteria (Fine et al. 1996,
Pan et al. 2000, Netuschil et al. 1995).
Most importantly, the antibacterial
efficacy of these products is not con-
fined to the rinsing period. Significant
suppression of oral flora is detect-
able for several hours after rinsing
with an EO mouthwash (Ross et al.
1989, DePaola et al. 1996, Fine et al.
2001).
Similarly, for CHX, significant
suppression of the oral flora has been
detectable for more than 12 h after
rinsing (Netuschil et al. 1995, Roberts
& Addy 1981, Addy & Wright 1978,
Schiott 1973).
Acknowledgements
The author would like to acknow-
ledge the following experts for their
editorial contributions: Sebastian
Ciancio, Noel Claffey, Jean-Pierre
Ouhayoun, Marc Quirynen, Antonio
Santos and Robin Seymour.
References
Addy, M. & Wright, R. (1978) Comparison
of the in vivo and in vitro antibacterial
properties of providone iodine and chlor-
hexidine gluconate mouthrinses. Journal of
Clinical Periodontology 5, 198–205.
Dennison, D. K., Meredith, G. M., Shillitoe,
E. J. & Caffesse, R. G. (1995) The antiviral
spectrum of Listerine antiseptic. Oral
Surgery, Oral Medicine, Oral Pathology,
Oral Radiology and Endoddontics 79, 442–
448.
Recent concepts in plaque formation
DePaola, L. G., Minah, G. E., Overholser,
C. D., Meiller, T. F., Charles, C. H.,
Harper, D. S. & McAlary, M. (1996)
Effect of an antiseptic mouthrinse on
salivary microbiota. American Journal of
Dentistry 9, 93–95.
DePaola, L. G., Overholser, C. D., Meiller,
T. F., Minah, G. E. & Niehaus, C. (1989)
Chemotherapeutic inhibition of supra-
gingival dental plaque and gingivitis
development. Journal of Clinical Period-
ontology 16, 311–315.
Fine, D. H. (1988) Mouthrinses as adjuncts
for plaque and gingivitis management. A
status report for the American Journal of
Dentistry. American Journal of Dentistry 1,
259–263.
Fine, D. H., Furgang, D. & Barnett, M. L.
(2001) Comparative antimicrobial activ-
ities of antiseptic mouthrinses against iso-
genic planktonic and biofilm forms of
Actinobacillus actinomycetemcomitans.
Journal of Clinical Periodontology 28, 697–
700.
Fine, D. H., Furgang, D., Lieb, R., Korik, I.,
Vincent, J. W. & Barnett, M. L. (1996)
Effects of sublethal exposure to an anti-
septic mouthrinse on representative plaque
bacteria. Journal of Clinical Period-
ontology 23, 444–451.
Jenkins, S., Addy, M., Wade, W. & New-
combe, R. G. (1994) The magnitude and
duration of the effects of some mouthrinse
products on salivary bacterial counts.
Journal of Clinical Periodontology 21, 397–
401.
Kubert, D., Rubin, M., Barnett, M. L. &
Vincent, J. W. (1993) Antiseptic mouth-
rinse-induced microbial cell surface al-
terations. American Journal of Dentistry 6,
277–279.
Listgarten, M. A. (1999) Formation of dental
plaque and other oral biofilms. In: New-
man, H., N. &. Wilson, M. (eds): Dental
Plaque Revisited, pp. 187–210. Cardiff:
Bioline.
Löe, H., Theilade, E. & Jensen, S. B. (1965)
Experimental gingivitis in man. Journal of
Periodontology 36, 177–187.
McHugh, W. D. (1999) Dental plaque: thirty
years on. In: Newman, H. N. & Wilson,
M. (eds): Dental Plaque Revisited, pp. 1–4.
Cardiff: Bioline.
Netuschil, L., Weiger, R., Preisler, R. &
Brecx, M. (1995) Plaque bacteria counts
and vitality during chlorhexidine, meridol
and listerine mouthrinses. European Jour-
nal of Oral Science 103, 355–361.
Page, R. C. (1991) The role of inflamma-
tory mediators in the pathogenesis of
9
periodontal disease. Journal of Periodontal
Research 26, 230–242.
Pan, P., Barnett, M. L., Coelho, J., Brogdon,
C. & Finnegan, M. B. (2000) Determina-
tion of the in situ bactericidal activity of
an essential oil mouthrinse using a vital
stain method. Journal of Clinical Peri-
odontology 27, 256–261.
Pitts, G., Brogdon, C., Hu, L., Masurat, T.,
Pianotti, R. & Schumann, P. (1983) Me-
chanism of action of an antiseptic, anti-
odor mouthwash. Journal of Dental
Research 62, 738–742.
Roberts, W. R. & Addy, M. (1981) Com-
parison of the in vivo and in vitro anti-
bacterial properties of antiseptic
mouthrinses containing chlorhexidine,
alexidine, cetyl pyridinium chloride and
hexetidine. Relevance to mode of action.
Journal of Clinical Periodontology 8, 295–
310.
Ross, N. M., Charles, C. H. & Dills, S. S.
(1989) Long-term effects of Listerine an-
tiseptic on dental plaque and gingivitis.
Journal of Clinical Dentistry 1, 92–95.
Sakamoto, M., Suzuki, M., Umeda, M.,
Ishikawa, L., Benno, Y. (2002) Reclassifi-
cation of Bacteroides forsythus (Tanner et
al. 1986) as Tannerella forsythensis corrig.,
gen. nov., comb. nov. International Journal
of Systematic and Evolutionary Microbio-
logy 52, 841–849.
Schiott, C. R. (1973) Effect of chlorhexidine
on the microflora of the oral cavity.
Journal of Periodontal Research Suppl. 12,
7–10.
Socransky, S. S. & Haffaje, A. D. (2002)
Dental biofilms: difficult therapeutic tar-
gets. Periodontology 2000 28, 12–55.
Theilade, E., Wright, W. H., Jensen, S. B. &
Loe, H. (1966) Experimental gingivitis in
man. II. A longitudinal clinical and bac-
teriological investigation. Journal of Peri-
odontal Research 1, 1–13.
Wilkins, E. M. (1999) Clinical Practice of the
Dental Hygienist, 8th edn. Philadelphia,
PA: Lippincott Williams & Wilkins
(Chapter 17).
Address:
Jean-Pierre Bernimoulin
Department of Periodontology
and Synoptic Dentistry
Humboldt University
Campus Virchow-Klinikum
Augustenburger Platz 1
13353 Berlin
Germany