DENTAL CALCULUS complete power point presenattion

1. DENTAL CALCULUS
DENTAL CALCULUS

2. CONTENTS
 Introduction
 Definition
 Analysis of calculus
- classification
- composition
 Prevalence
 Theories of formation
 Development & mineralization
 Intra oral distribution

3.  Localization & attachment of calculus
 Detection of calculus
 Assessment of calculus
 Inhibition of formation of calculus
 Clinical efficacy of anticalculus agents
 Etiological significance
 Conclusion
 References

4. INTRODUCTION
 Dental calculus, or tartar as it is
sometimes called, is a deposit which
forms on the surfaces of the teeth.
Calculus consists of mineralized
bacterial plaque that forms on the
surfaces of natural teeth & dental
prostheses.

5.  This calculus plays an important role in
maintaining and accentuating
periodontal disease by keeping plaque
in close contact with the gingival tissue
& creating areas where plaque
removal is impossible. Therefore the
clinician must not only possess the
clinical skill to remove the calculus ,but
also must be conscientious about
performing this task

6. Definition
 Calculus is dental plaque that has
undergone mineralization.(Carranza)
 When dental plaque calcifies , the
resultant deposit is called dental
calculus (Grant)
 Mineralized dental plaque that is
permeated with crystals of various
calcium phosphates(Schroeder,1969)

7.  The calcified deposits
consists of mineralized
bacterial plaque that forms
on the surfaces of natural
teeth and dental
prostheses.
 In 1683 Van Leeuwenhoek
described microorganisms
in tartar. He called them
‘animalcules’

8.  Origin of the word “Calculus”
 According to Encyclopedia Britannia, "About 15 BC,
the Roman architect and engineer Vitruvius
mounted a large wheel of known circumference in a
small frame, in much the same fashion as the wheel
is mounted on a wheelbarrow; when it was pushed
along the ground by hand it automatically dropped a
pebble into a container at each revolution, giving a
measure of the distance traveled. It was, in effect,
the first odometer."
 These odometers were used in taxi carriages. Each
time the wheel of the carriage turned, a pebble, a
calculus, dropped from a container into another. In
the end of the ride, the driver counted how many
pebbles had dropped, and that determined the price
of the transportation. This kind of usages of
pebbles gave the word Calculus its present
meaning.

9.  Any solid concretion, formed in any
part of the body, but most frequent in
the organs that act as reservoirs, and
in the passages connected with them;
as, biliary calculi; urinary calculi, etc.
 Urinary calculus

10.  Dental calculus can be considered as
an ectopic mineralized structure.
 (Math.) A method of computation; any
process of reasoning by the use of
symbols; any branch of mathematics
that may involve calculation

11.  ANALYSIS OF CALCULUS
Classification
 According To Relation to the gingival
margin
for clinical convenience
Supragingival calculus (salivary)
Subgingival calculus (serumal)

12. COMPOSITION
 Varying amounts of inorg salts
deposited in an organic matrix.
 Organic content (mature calculus)
- CHO & protiens in
complexes of glycoproteins,
mucoproteins
acid mucopolysaccharides
- desquamated epithelial cells,
bacteria ,WBCs

13.  Between 1.9% and 9.1% of the organic
component is carbohydrate, which consists of
galactose, glucose, rhamnose, mannose,
glucuronic acid, galactosamine, and
sometimes arabinose, galacturonic acid, and
glucosamine.
 Proteins from saliva contain most of amino
acids
 Lipids as cholesterolesters,
phospholipids,free fatty acids &neutral fats
 Little et al 1964,66; CHO-1-9%
PROTIENS-30-40%
LIPIDS-0.2-0.5%

14. INORGANIC CONTENT
 Glock & murray 1958
 Calcium phosphate -75%
 Magnesium phosphate-4%
 Calcium carbonate -3%
 Ca – 40%, P- 20%, Mg – 0.8%
 Trace elements – Na, K, Pb
 Leung & Jensen 1958- 70% of
inorganic str is crystalline (2/3rd
)

15.  Electron microscopy & x-ray diffraction
studies,4 distinct phosphate crystals
 In descending order of % composition
 HA- Ca10(PO4)6 (OH )2 58%
 Whitlockite Ca21(PO4)14 21%
 Octacalcium phosphate 12%
Ca8H2(PO4)6 6 H2O
 Brushite CaHPO4 2 H2O 9%
Trace amounts of Monetite & calcite

16. composition
 Different layers of same calculus has
different compositions
 Supragingival calculus – clearly built
up in layers & yields a great
heterogeneity from one layer to
another with regard to mineral content.
 On average, mineral content-37%
ranges from – 16-51%
some layers max density – 80%

17.  Exterior layers – OCP
 Inner layers – HA
 Proportion of crystal present in a
deposit influenced by many factors
(Schroeder &Bambauer ’66,
Schroeder ’69,Schwartz & Masler’71)

18.  Dynamic translation of mineral deposits in
calculus
 Early calculus & brushite &
supra gingival deposits OCP
 Posterior & whitlockite
Sublingually
 Early –brushite,
 Later- OCP,
 final –HA &W

19.  Sub gingival calculus , some what
more homogenous with equally high
density of minerals.
 On ave, density -58%
 Ranges from – 32-78%,
 max value-60-80%
 Predominant mineral –HA, W
 Ca:P, Na increases

20. PREVALENCE
 2 national surveys –prevalence of calculus
in children.
 O’Brien 1993
 Bhat 1991
 The third National Health and Nutrition
Examination Survey (NHANES) evaluated
9689 adults in the United States between
1988 and 1994.This survey revealed that
91.8% of the subjects had detectable
calculus and 55.1% had subgingival
calculus.

21.  Anerud ,Löe & Boysen 1991-
longitudinal study observed the
periodontal status of a group of Sri
Lankan tea laborers and a group of
Norwegian academicians for a 15-year
period.

22. THEORIES OF CALCULUS
FORMATION
 Salivary pH theory
Burchard 1895
Rapp 1946
Hodge & Leung 1950
 Bacteriologic theory
Goodrich & Moseley 1916
Bulleid 1925,’54,
Naeslund 1925,’26- most comprehensive study
Bibby ’35
Yardeni ’48,Zander ‘60

23.  Physicochemical thoery
 Prinz ’21
 Enzymatic theory
 Phosphatse
 Adamson 1929 – gingival tissue
 Smith 1930 – epithelium of gingiva
 Zander 1941 – endothelial cells of
capillaries & in few CT fibres
 Esterase

24. Epitactic theory
 Mandel 1957 –inter cellular matrix of
plaque
 Active concept
 Best supported
 INHIBITION THEORY(Russel &
Fleisch,1970)

25. DEVELOPMENT &MINERALIZATION
 Plaque acts as a scaffold for
calcification when Ca binds to the
organic matrix & ppt calcium
phosphate salts.
 Inter cellular zones & bacterial
surfaces are the first sites of
crystallization. Later crystals form
within bacteria.
 REVERSAL PHENOMENON

26.  The average daily increment in
calculus formers is from 0.10% to
0.15% of dry weight.
 MINERALIZATION

27.  The following factors increase the rate of
calculus formation:
 Elevated salivary pH
 Elevated salivary calcium concentration.
 Elevated concentration of protein and urea in
submandibular salivary gland secretions
 Higher total salivary lipid levels
 Elevated bacterial protein and lipid
concentration.
 Low individual inhibitory factors.

28. CALCIFICATION PROMOTERS
 Urea -Urea is a product from the
metabolism of nitrogen-containing
substances. Urea can be secreted in
normal saliva at concentrations of
between 5 and 10 mmol/L but can be
as high as 30 mmol/L in patients with
renal disease
 Gingival crevicular fluid contains up to
60mmol/L urea (Golub et al., 1971).

29.  urease is responsible for bacterial urea
hydrolysis. At a neutral pH, urea is
hydrolyzed by urease to NH4
+
and
bicarbonate

30.  The effect of urea metabolism on
plaque pH
 Ammonia produced from ureolysis of
urea contributes to an increased
plaque pH that is an essential factor in
natural calculus formation.

31. Bacteria responsible for the
ureolysis in dental plaque
 Bacteria suspected of having a role in
ureolysis include S. salivarius,
coagulase-negative staphylococci,
Actinomyces viscosus/naeslundii

32.  Among these ureolytic bacteria,
S. salivarius has attracted the most
attention.
 major contributor to ureolysis in natural
saliva .

33. MODES OF ATTACHMENT &
LOCALIZATION
 Zander ’54 described four methods of
attachment,Moskow ’69 suggested the
5th
method.
 1.attachment of organic matrix of
calculus into minute irregularities that
were previously insertion locations of
sharpey’s fibres.
 2. attachment into cemental defects
 3. penetration of MO

34.  4. attachment mediated by organic
pellicle
 5.attachment to cemental tears and
separations.

35.  Localization
Localization : several theories –
localization of supra gingival calculus
in areas of buccal surfaces of upper
molars & lingual surfaces of lower
anteriors
 Burchard 1895,
 Everett ’56
 Leung ’51
 King ’54

36.  Low sucrose conc
 High saliva film velocity
 Higher resting plaque pH

37.  Individual variations

38.  Attachment to implant surfaces
Matarasso et al 1996

39.  INTRA ORAL DISTRIBUTION
 Macpherson ’95
Lower lateral incisor 58-71%
Lower canines 42-46%

40. Detection of sub gingival calculus
 Rationale
 Clerehugh ’96 WHO # 621probe
 Endoscopy
 Electronic calculus detection
 Magnification with eye loupes
 Radiograph
 piezoelectric ultrasonic handpiece with a
conventional scaler insert. The impulse response of
the mechanical oscillation system is analysed by a
fuzzy logic-based computerized algorithm, which
classifies various surfaces. Meissner G et al 2006

41. Assessment Of Calcified
Deposits
 Simplified calculus index (Green &
Vermillion ’64 )
 Calculus component of periodontal
disease index (Ramfjord ’59)
 Calculus surface index (Ennever J,,
Sturzenberger & Radike ’61)
 Calculus surface severity index
(Ennever J et al ’61)

42.  Marginal line calculus index
(Muhleman & Villa ’67)
 Volpe- Manhold index (Volpe A R &
Manhold J H ’62)

43. Inhibition Of Formation Of
Calculus
 Anti calculus efficacy
 Grossman ’54 & Gunson ’55
 Harrison ’63 enzymatic preparations
 Stallard et al ’69 & Volpe et al ’69
antimicrobials & antibiotics
 Stookey et al ’89 cetyl pyridinium
chloride ,chlorhexidine & mixtures of
Cu salts

44.  Formation of supragingival calculus
may be prevented or controlled by
1.Anti microbial agents & enzymes
2. Anti adhesive agents
3. Crystal growth inhibitors (currently
dominating)

45.  CLASSIFICATION OF ANTI- CALCULUS
AGENTS-
1st GENERATION
1)DISSOLUTION
Chelating Agents
 Ethylene diamine tetra acetic acid
 Sodium Hexa Metaphosphate
Acids –Aromatic sulphuric acid
 20% Trichloroacetic Acid
Spring Salts
Sodium Ricinolate
Alkalies

46. 2)ALTERING CALCULUS
ATTACHMENTS
 Silicones
 Ion exchange resins

47.  3.PLAQUE INHIBITION
 Antibiotics Example : Nidamycin
 Antiseptics Example :
Chloramines
 4.MATRIX DISRUPTION
 Enzymes Example : Mucinase
 Trypsin, chymotrypsin
 Carboxypeptidase, lipase, amylase

48.  2nd
GENERATION
 Inhibition of crystal growth
 Vitamin C (By crystal poisoning
mechanism )
 Pyrophosphate
 Pyrophosphate + Sodium fluoride
 Zinc salts
 Bisphosphonates
 Polymers & Co Polymers

49. CALCULUS SOFTENING GEL
 A calculus softening gel is currently
available that may enhance
periodontal instrumentation
effectiveness.
 The active ingredient is disodium
ethylene diamine tetra acetic
acid(EDTA), which is a calcium-
chelating agent.

50. Clinical Efficacy Of Anticalculus
Agents
 4 main ingredients
-Soluble pyrophosphates
-Zn salts (ZnCl2 & Zn citrate)
- Diphosphonates
- Triclosan

51. Mechanisms of Action
 White ’92
 Aspects Of Calculus Inhibition
1.Retention of calculus inhibitor
2.Prevention of deposit adhesion
3.Reducing localized increase in
supersaturation

52.  4. Impact on phase transformation
 5.Activity against crystallite overgrowth

53.  Dentifrices containing Zn salts
 Dentifrices containing pyrophosphate
salts
 Dentifrices containing triclosan
 Dentifrices containing diphosphonate
compound
 Ca lactate containing tooth paste

54. Calculus As An Etiologic
Agent- Historical Perspective
 Hippocrates (460 -377BC)
 Abulcasis (936-1013)
 Paracelsus, 1535

55.  C.G.Davis 1879
 G.V.Black 1886
 Löe, Jensen,Schiött,Theilade 1965-68
 Newman & Socransky ’76-’77

56. CLINICAL IMPLICATIONS
 Wearhaug 1956 surface roughness
alone does not initiate gingivitis
 Calculus always covered by an
unmineralized layer of viable bacterial
plaque

57.  Listgarten & Ellegard 1973
 Allen & Kerr 1965
 Friskopp &Hammerström 1980
 Nyman et al 1986,’88,
 Mombelli ‘95

58. CONCLUSION
 While the bacterial plaque that coats
the teeth is the main etiologic factor in
the development of periodontal
disease, the removal of subgingival
plaque and calculus constitute the
cornerstone of periodontal therapy.

59.  Calculus plays an important role in
maintaining and accentuating
periodontal disease by keeping plaque
in close contact with the gingival tissue
and creating areas where plaque
removal is impossible. Therefore the
clinician must possess the clinical skill
to remove the calculus and other
irritants as a basis for adequate
periodontal and prophylactic therapy.

60. REFERENCES
 Clinical Periodontology – Carranza 7th &
10th
edition
 Clinical Periodontology and implant
dentistry– Lindhe 4th
edition
 Contemporary Periodontics- Genco,
Goldman and Cohen 6th
edn
 Periodontal therapy – Henry M Goldman
& Walter Cohen 6th
ed

61.  Periodontics Grant , Stern & Everett 5th
edn
 Proceedings of the 2nd
european workshop
on periodontology – chemicals in
periodontics, 1996
 Supra gingival dental calculus
Periodontology 2000; 8:125
 Supra gingival calculus & periodontal
diseases Periodontology 2000;15:74