Dental Calculus
   
     

What is dental calculus?

Calculus is a deposit of calcium phosphate salts on the surface of teeth. Sometimes it is also called tartar but this term is less commonly used these days.

There is no fixed composition of dental calculus because the type and amount of calcium phosphate salt which precipitates onto the tooth surface is affected by a variety of local factors such as

1.

the concentration of calcium and phosphate

2.

the relative amounts of each ion present locally

3.

the pH

4.

the presence of other ionic species such as magnesium

5.

the presence of other calcium phosphate mineral

I could go on, in fact almost any local condition you care to name will have at least some effect on the type of mineral which deposits. It is, therefore, difficult, or even impossible, to be definitive about calculus composition beyond the fact that it comprises a mixture of calcium phosphate minerals such as:

1.

brushite

2.

octacalcium phosphate

3.

tricalcium phosphate

4.

biological apatite

 

 

 

Types of Calculus

The two main types are supra-gingival and sub-gingival calculus although some choose to sub-divide supra-gingival calculus into a number of different types related to its location in the mouth.

Serumnal calculus

Sometimes, calculus, normally the sub-gingival variety, forms from a fluid containing a greater or lesser amount of gingival fluid. This can lead to calculus containing the blood product haem and a variety of its breakdown products. This leads to a brown or brown-green calculus referred to as "serumnal calculus" in recognition of its source.

In the photograph above, serumnal calculus is shown by the arrow labelled with the number "2" and regular calculus is shown as "1". Both are sug-gingival and adjacent.

Calculus Formation

Calculus forms wherever a solution of calcium and phosphate becomes unstable. This can happen in various parts of the body such as the kidney (kidney stones), the gall bladder (gall stones), the bladder (bladder stones) and salivary glands and ducts (sialoliths). When it happens in the mouth the deposit is called dental calculus and sometimes tartar.

Calculus forms most readily within dental plaque in fact it is often referred to as mineralised plaque. The surface of calculus is rough and provides an excellent site for further plaque growth which in turn may become mineralised. Calculus then often has a layered structure.

 

 
Examples of dental calculus

 

Supragingival calculus

Calculus formed adjacent to the opening of the submandibular salivary gland duct. Note the depth of the calculus where a piece has broken off. Note also the staining which is probably not due to serum components but more likely to chromagens such as tannins found in food

 
Gross calculus

An example of gross calculus, again deposited adjacent to the submandibular gland duct. Note the caries of the upper incisors and the gingival inflammation.

 
Very gross calculus

My favourite photograph of calculus. Where does the tongue go?

Plaque Seeding

One way in which calcium phosphate may become destabilsed is by elements of dental plaque acting as seeding agents in much the same way as collagen provides epitactic sites to act as the seed for mineralisation in bone, dentine and cementum formation. Among the many different species of bacteria in dental plaque there is some evidence that the most likely seed is Leptotrichia buccalis.

This only works, of course, if the plaque is bathed in a solution supersaturated with respect to the variety of calcium phosphate minerals depositing at the site. For more on this see the tutorial on salivary calcium phosphate.

 

 
Elevated pH

In addition to the presence of a suitable epitactic site such as that found in dental plaque, calculus often needs an additional impetus to form. This is provided by the extra-alkaline conditions of ductal saliva.

The pH of saliva is dictated by its bicarbonate concentration. Read more about this.

At high flow rates saliva contains large amounts of bicarbonate which starts to reduce the moment the saliva enters the mouth according to this reaction.

 

Obviously the scope for reduction is small because there are few protons available. Nevertheless, ductal saliva and saliva in the immediate area adjacent to the salivary gland ductal openings are at a slightly higher pH which means that the calcium phosphate is less stable here.

The bottom line

If the effect of the presence of plaque with its seeding properties are taken together with the higher pH in the areas adjacent to the salivary ducts it explains why most calculus is found on teeth next to the openings of the parotid and submandibular ducts. This doesn't mean that plaque will not form elsewhere, it will.

 

 

Clinical Implications

Calculus forming at the gingival margin whether it is sub- or supra-gingival will cause inflammation of the gingiva (gingivitis) which may progress to periodontal disease. An example of calculus induced gingival inflammation is shown opposite.

The inflammation is the result of physical irritation of the gingiva as well as the presence of bacterial toxic by-products in the calculus. Remember, most calculus is mineralised plaque which comprises very many different bacterial species. Furthermore, fresh plaque is readily deposited on the calculus surface.

Quite apart from aesthetic reasons, Inflammation and its sequelae are the reason why calculus must be removed.

 

 
Gingival Inflammation

Note the swollen, red appearance of the gingiva. The arrow indicates bleeding on slight probing and illustrates the high degree of the inflammation.

Calculus in the population

Dental calculus is widespread in all age-groups from teenagers onwards throughout the world. However, the levels of calculus are dependent on the population studied and are affected by a number of factors (see table opposite).

Supragingival calculus is minor and is restricted to surfaces adjacent to the salivary ducts in populations which practice good oral hygiene and have access to professional dental care. In this case calculus has a small or neglible effect on oral health. Also in these populations any subgingival calculus is coincident with loss of periodontal attachment but does not seem to be the cause of it. Attachment loss is caused by dental plaque.

In populations which do not practice good oral hygiene and which do not have access to professional dental care, supragingival calculus commonly occurs throughout the dentition and can be present in very large amounts. In these populations supragingival calculus is associated with gingival recession and subgingival calculus, which is also extensive, is directly correlated with enhanced loss of periodontal attachment although the exact relationship is not clear because it is impossible to seperate the different contributions of subgingival calculus and any associated plaque.

So it is not clear if the calculus is the cause of the periodontal inflammation or the result of it.

Removal of subgingival plaque and calculus is the main plank of periodontal therapy.

 

 
Factors affecting the amount of calculus in a population

1.

oral hygiene habits.

2.

access to professional care

3.

diet

4.

age

5.

ethnic origin

6.

time since last dental cleaning

7.

systemic disease

8.

use of prescription medications

Inhibition of calculus formation

This has been the subject of much research since inhibition of calculus formation will reduce the need for professional prophylaxis.

Supragingival calculus formation can be effectively controlled by chemical mineralization inhibitors, applied in toothpastes or mouthrinses. These agents act to delay plaque mineralisation, keeping deposits in an amorphous non-hardened state to aid theirremoval with normal tooth brushing and flossing.

Current formulations in anticalculus dentifrices and mouthrinses utilise either zinc salts or 1% soluble pyrophosphate.

   

 

 

 

 

 

 

 

 

 

SUMMARY

1.

Dental calculus is mineralised plaque

2.

The amount and type of calcium phosphate salts present vary greatly but include brushite, OCP, TCP and apatite.

3.

Supragingival calculus forms from saliva. Subgingival calculus forms either from saliva or crevicular fluid

4.

Calculus which forms from crevicular fluid can contain haem and some breakdown products which make it pigmented. It is called serumnal calculus.

5.

Calculus forms most readily in areas which are adjacent to the openings of the salivary ducts where the calcium phosphate in saliva is least stable.

6.

In populations with poor oral hygiene supragingival calculus can be extensive and result in gingival recession. In these populations subgingival calculus is coincident with loss of periodontal attachment but it is not clear if it is the cause of it.

7.

Calculus formation can be controlled by adding the mineralisation inhibitor pyrophosphate to dentifrices and mouthrinse.

   

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