role of dental calculus

1. ROLE OF DENTAL CALCULUS
AND OTHER LOCAL
PREDISPOSING FACTORS IN
PERIODONTAL DISEASE.
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2. INTRODUCTION
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3. CALCULUS
Mineralized bacterial plaque that forms on the surfaces of natural teeth and dental
prostheses.
 Most important contributing factor
- Provides fixed nidus .
- Keeps plaque in close contact with the gingival tissues
Albandar et al 1998 – aggressive periodontitis – areas with detectable sub gingival
calculus – greater loss of periodontal attachment loss.
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4. Definitions
 Calculus is a hard deposit that forms by mineralization of dental
plaque and is generally covered by a layer of unmineralized plaque
 When a dental plaque calcifies the resulting deposit is called calculus
(GRANT)
 Dental calculus is defined as the calcified or calcifying deposits that
are found attached to the surfaces of teeth and other solid structures in
the oral cavity. (LINDHE)

5.  According to location
1. Supragingival calculus
2. Subgingival calculus
 According to source of mineralization
1. Salivary calculus
2. Serumal calculus
 Depending on the rate of formation (Muhlar and Ennever 1962)
1. Heavy calculus former
2. Moderate calculus former
3. Slight calculus former or Non calculus former.
Classification
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6.  SUPRAGINGIVAL CALCULUS  SUBGINGIVAL CALCULUS

7. Difference between supragingival and subgingival calculus
SUPRA GINGIVAL CALCULUS
• coronal - gingival margin
• White or whitish yellow
• Hard , Clay like
• Easily detached from
tooth surface
• Saliva- mineralization
• Composition
SUB GINGIVAL CALCULUS
• Below - crest of the
marginal gingiva .
• Dark brown or greenish
black in color
• Hard and dense,flint like
• Firmly attached to the tooth
• Serum trasudate – GCF
furnishes the minerals
• Composition

8. Third National Health and Nutrition Examination
Survey (NHANES III) evaluated 9689 adults in the U.S. between 1988 & 1994
91.8% of the
subjects had
detectable
calculus and
55.1% had
subgingival
calculus. Prevalence
of sub-
gingival
calculus
increased
with age
Males-
significantly
more
subgingival
calculus,
more teeth
with calculus
than females
More often
on mesial
than buccal
surfaces
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9. Distribution of dental calculus on
dentition
Lingual
surfaces of the
lower anterior
teeth.
Buccal
surfaces of
the upper
molars

10. Theories Regarding The Mineralization
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 Physiochemical theory (Booster
mechanism)
 Bacterial theory.
 Epitactic theory/ Seeding theory.
 Inhibition theory.
 Transformation.
 Enzymatic theory.

11.  Prinz -1928.
 BOOSTER CONCEPT
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PHYSIOCHEMICAL THEORY:
1 • THE SALIVARY pH THEORY
2
• COLLOIDAL PRECIPITATION
THEORY
3 • PRECIPITATION OF PROTEINS

12. The Salivary pH Theory
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Calculus formation
Precipitation of calcium phosphate salts
Lowered precipitation constant
Increased pH of the saliva
Loss of carbon di-oxide
Formation of ammonia
Dental plaque bacteria / protein denaturation Burchard (1895-1898)
Postulated the rise in
pH caused due to loss
of CO2 from the saliva
Rapp , 1946
Carbonic anhydrase in
the saliva leads to
increased uptake of
CO2 .
As CO2 is lost, there is
precipitation of calcium
and phosphates.

13. Colloidal
precipitation
Salivary
calcium
and
phosphat
e ions
Colloida
l
proteins
Formation
of super
saturated
solution
Stagnatio
n of saliva
Settling
of
colloida
l
protein
s
Precipit
ation of
CaPO4
salts
Calcium
formation
 Prinz, 1921
 Colyer and Sprawson
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14. Precipitation Of Proteins
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Proteins
Amino acids
Ammonia
Saliva pH increases
Precipitation of Calcium and phosphate crystals

15.  Mineralization of plaque stars extracellularly around both gram
positive and negative organisms or intracellularly.
 Filamentous organisms form intracellular apatite crystals,
 Calculus formation spreads , until the matrix and bacteria are
calcified
 Some believe that , bacteria actively participate in the
mineralization of calculus by forming phosphatases, changing
the plaque pH
 Not accepted… formation of calculus in germ free animals
 The prevalent opinion is that these bacteria are only passively
involved and are simply calcified with other plaque components
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BACTERIAL THEORY (Naeslund
1926 )

16. EPITACTIC CONCEPT
15-5-2017
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Synonyms :
Seeding theory
Heterogenous
nucleation
Neuman W et al 1958.
Mandel et al, 1957;
Wasserman et al
1958

17.  Amorphous non-crystalline deposits and
brushite can be transformed to octocalcium
phosphate and then to hydroxyapatite (Eanes
et al, 1970).
 Controlling mechanism may be
pyrophosphate
(Fleisch et al, 1968).
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TRANSFORMATION THEORY

18.  Calcification - only at specific
sites.
 calcification occurs- inhibition is
altered or removed.
 PYROPHOSPHATE - inhibits
calcification
 preventing the initial nucleus from
growing, possibly by “poisoning”
the growth centres of the crystal.
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INHIBITION THEORY:

19. ESTERASE
Dental plaque bacteria / WBC macrophages /
desquamated epithelial cells
Release of enzyme esterase
Hydrolysis of free fatty esters
Fatty acids + calcium – magnesium
Formation of soaps
Formation of less soluble calcium phosphate
salts
Precipitation of calcium phosphate salts
Calcium formation 15-5-2017
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20. Attachment of calculus
Attachme
nt to tooth
surface
(Zander,
1953)
organic pellicle
to enamel*
Mechanical
locking into
surface
irregularities*
Close
adaptation to
gentle sloping of
unaltered
cementum
surface
Penetration
of calculus
into
cementum*
Moskow (1969)
suggested a fifth
method.
Attachment to
cemental tears
and separations
Shroff (1955 the
type of calculus
attachment
probably depends
on the length of
time the calculus
has been on the
tooth
Calculocementum
( Selvig G 1970)
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21. Anatomic factors
 Furcation's
 Cervical Enamel Projections And
Enamel Pearls
 Root Trunk Length
 Size Of Furcation Entrance
 Bifurcation Ridges
 Bicuspid Teeth
 Palatal Groove
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22. Anatomic factors
 Favours retention of bacterial deposits
 Difficult - periodontal debridement and oral hygiene
procedures.
 Furcal invasions vary in horizontal and vertical depth as a
result of such features as cervical enamel pearls, root
trunk length, furcation entrance dimensions, root
anatomy and variations in the anatomy of the roof of the
furcation.
Anatomic factors
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23. 1) Cervical enamel projections and enamel pearls
 Ectopic deposits of enamel apical
cemento enamel junction
Hou and Tsai –
Prevalence of cervical enamel projections in
molars with and without furcation
involvement.
- Molar with Cervical enamel projection–
82.5% - furcation involvement.
- 17.5% - absence of cervical enamel
projection
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24. Cervical Enamel Projections
Masters and Hoskins - 1964
Grade 1: short but distant change in
the contour of the CEJ extending
towards the furcation
Grade 2: approaches the furcation,
without making contact with it.
Grade 3: extends into the furcation.
Roussa –
• Grade 1 and 2 – more prevalent.
• Mandibular second molars
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25. 2) Enamel Pearls
 Less prevalent than cervical
enamel projections
 Contribute to etiology of
furcation involvement
 Moskow and Canut –
prevalence - 1.1 – 9.7%.
 maxillary third molars.
 mandibular third molars and
maxillary second molar second
most common sites.
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26. 3) Root Trunk Length
 The severity of furcation involvement -
between the amount of attachment loss and
the distance from the cemento enamel
junction to the furcation entrance – the root
trunk length.
 The shorter the root trunk length
 the earlier the exposure
 more difficult the plaque control.
 Hou et al :
Type A – third or less of the cervical area of the
root.
Type B- include up to half of the length of the
root
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27. 3)Root Trunk Length
Hue et al : Prevalence
Maxillary first molars – type B ( 47.1%) or type A (41.0%)
than type C (11.9%)
Mandibular first molars - type A (83.5%)
Maxillary and mandibular second molars – Type B (60.%,
52.6%)
Others - maxillary molars (3.6 – 4.8mm from CEJ) > mandibular
molars (2.4 – 3.3mm )
the shortest distance - found in the mandibular first molars-
exposure of the furcation at an early stage of periodontitis.
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28. 4 ) Size Of Furcation Entrance
 . Bower, 1979 reported that 81% of all
furcation entrance diameters
measure < 1 mm, with 58% < 0.75
mm, which is less then width of curettes.
 Chui et al - 49% - <0-75mm.
 Additional challenge in management of
molar furcation approach
 Difficult to debride.
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29. 5)Bifurcation Ridges
 Described by Everett et al, 1958
 Sveirdstrom & Wennstrom, 1988 - morphology of bifurcation
ridges
- Pits and ridges – roof of furcation – complicate therapy
- Intermediate ridges – connect mesial and distal roots – cementum
- buccal and lingual ridges – dentin with overlying layers of
cementum.
- Central bifurcation ridge – mandibular molars.
 Hou & Tsai, 1997 - ridges are strongly associated with
attachment loss in furcations
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30. Bifurcation Ridges
 Fluting of roots / root concavities - molars.
 Roof of furcation's, coronal and apical to
furcation's and on interproximal root
surfaces.
 Vermino, 1980 - 78% - palatal aspect of
the buccal root of maxillary first
premolars .
 Progression of attachment loss -
harbouring bacterial plaque.
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31. 6)Bicuspid teeth
 maxillary first bicuspids - two roots – buccal and palatal
 Joseph et al :
- furcal concavity - palatal aspect of the buccal root - 62 % of
bifurcated teeth.
78% reported by Gher and Vernino.
The mean furcation width was 0.71mm
 Concavities was found on the proximal surfaces of all teeth
studied, with a deeper concavity on the mesial than the distal
aspect.
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32. 7)Palatal Groove
 The radicular lingual / palatal groove - infolding of the inner
enamel epithelium and Hertwing’s epithelial root sheath
create a groove that passes from the cingulum of maxillary
incisors apically onto the root.
 Cruz Filho - 3% lingual surface of the maxillary lateral incisor
-
< 1% of maxillary central incisors - buccal and
or lingual surfaces
 Other report the prevalence of 0.79
21% in both maxillary incisors and 1.9 – 14% in lateral incisors
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33. • Incisors - shallow U shaped groove
• Kogon –
half of the grooves extend more than 5mm apical to
the CEJ
Act as funnels – accumulation of plaque
- Withers et al 1981
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34. Iatrogenic Factors
 Deficiencies in the quality of dental restorations or prosthesis
are contributing factors to gingival inflammation and
periodontal destruction.
 Location of gingival margin for restoration
 Space between the margin of restoration and unprepared
tooth
 Contour of restoration
 Occlusion
 Materials used
 Procedure and design
Iatrogenic Factors
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35.  Margins of restorations
 Over Contoured Crown
 Design Of Removable Partial Dentures
 Restorative And Endodontic Procedures
Iatrogenic Factors
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36. 1)Margins Of Restorations
 Over hanging margins
1) increases plaque formation
retentive areas
1) Changed the ecologic balance
2) Compromises hygiene practice.
Subgingival margins
 Waerhaug - restorations placed in a sub gingival location -
detrimental to periodontal health.
 Increased plaque, severe gingivitis and deeper pockets.
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37. 2)Over Contoured Crown
 Leads to accumulation of plaque and prevent the self-
cleaning mechanisms of oral tissues .
 proximal contacts , contour of the marginal ridges ,
developmental grooves - prevent interproximal food impaction
– prevent periodontal disease.
 Hancock et al 1980 – food impaction – periodontal pathosis.
 Jernber G et al 1983 - probing depth , clinical attachment loss
– increased in open contact and food impaction.
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38. 3)Dental Materials
 Restorative materials are not in themselves injurious to the
periodontal tissues
 Self curing acrylics
 Silicate
 Kourkouta et al – highly glazed porcelain – less plaque than
enamel
 Composites – more likely to harbor bacterial plaque.
 Wang et al 1998 – metal pontics – higher amount of periodontal
pathogens than porcelain.
 Plaque accumulation maintained – finished and polished surfaces.
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39. 4)Design Of Removable Partial Dentures
 Favor the accumulation of plaque.
 Quantitative and qualitative
changes
 Increase in spirochetal
microorganisms
 Mobility of abutment teeth, gingival
inflammation, pocket formation
increase
 Studies by Zlataric et al
Zlataric et al
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40. 5)Restorative And Endodontic Procedures
 Rubber dam clamps, matrix bands, burs – lacerate
the gingiva – inflammation
 Gingival retraction cord – impacted debris – foreign
body reaction.
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41. Miscellaneous Factors – Malocclusion
• Poorly aligned teeth themselves are not associated with a greater degree of gingivitis
• complicate oral hygiene procedures - increased plaque accumulation - subsequent gingival
inflammation.
• Behfelt et al - direct relationship between tooth displacement and gingival inflammation
• Reduced interproximal spaces – less effective removal of plaque
• Extreme anterior overbite - palatal recession in maxillary incisors.
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42. Miscellaneous Factors – Vertical Root Fracture
 Longitudinal , confined to the root of the
tooth.
 Mesiodistal, buccolingual plane – occur at
any point along the root.
 Narrow, isolated periodontal pocket. Recurrent
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43. Mucogingival deformities – Aberrant frenal attachment
 Aberrant frenal attachments may be a problem, especially in
shallow vestibules or areas of minimal attached gingiva.
 frenum is stretched - the muscle attachments may pull the
marginal tissue away from the tooth - accumulation and apical
migration of bacterial plaque – gingival recession
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44. Miscellaneous Factors – Orthodontic Therapy
Orthodontic therapy affects the periodontium
by
 Favouring plaque retention
 Directly injuring the gingiva as a
result of overextended bands
 Creating excessive forces,
unfavourable forces, or both on
the tooth and supporting
structures.
 Modify the gingival ecosystem
- Orthodontic band
- Excessive orthodontic forces – necrosis
of PDL and adjacent alveolar bone ,
apical root resorption.
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45. Habits and self – inflicted Injuries
 important factors in initiation and progression of
periodontal diseases
 Mechanical form of trauma can arise from
1) Improper use of toothbrush and oral jewellery.
- Whittle and lamden - tongue piercing - lingual
recession with pocket formation and bone loss
were seen.
- Tooth brush trauma – acute and chronic.
2) Wedging of tooth picks between the teeth
3)Application of finger nail pressure against the
gingiva
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46. Habits and self – inflicted Injuries
 Acute gingival inflammation - sensitivity or non specific tissue
injury.
 Simple erythema - painful vesicle formation - ulceration.
 Strong mouth washes, topical application of corrosive drugs such
as aspirin or cocaine, and accidental contact with drugs such as
phenol or silver nitrate.
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47. Smokeless tobacco
 Snuff and chewing tobacco – two forms
 Localized gingival recession, clinical attachment loss,
leucoplakia, and possibly enhanced susceptibility to
severe periodontitis.
 The incidence of gingival recession among adolescents who use
smokeless tobacco has been reported as 42% compared to 17%
among non users.
 The NHANES III - effect of smokeless tobacco on the periodontium -
double the incidence of severe periodontitis.
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48. Smokeless tobacco
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49. Radiation therapy
 Cytotoxic effects on both normal cells and malignant cells.
 >60 Sv – salivary production impaired – xerostomia –
greater plaque accumulation and reduced buffering
capacity by saliva.
 Periodontal attachment loss and tooth loss has been
reported to be greater in cancer patients who were treated with
high-dose unilateral radiation as compared with the non radiated
control side of the dentition
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50. Tobacco smoking
 Smoking is strongly related to severity of diseases and to
recurrent and refractory diseases.
 Numerous studies have shown the association of smoking
with periodontitis.
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51. Conclusion
 The primary goal of periodontal therapy is to produce an environment that is conducive
to oral health.
 It is absolutely necessary that a clinician looks beyond oral cavity for factors which
may complicate the disease process.
 This will enable us to help our patients reach the common goal of Prevention and
management of periodontal disease which in turn improves the general health as well.
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