Dental Calculus and Gum Disease

Introduction:

Almost every individual is suffering from one or more oral diseases. Gum disease accounts for almost 50 % of the total oral diseases. Individuals present with inflammatory gingival conditions characterized by a lot of bleeding either on brushing or on provocation. Every individual (except aggressive periodontitis) has dental calculus in his or her teeth, which is associated with gum disease. Dental calculus is present both on natural and artificial dentition and is totally responsible for halitosis and tooth mobility.

Dental calculus is nothing but mineralized plaque which arises from the biofilm. Biofilm has a lot of bacteria ranging from obligate gram-positive aerobe (oxygen-lovers) to facultative anaerobes (survivors in the presence or absence of oxygen). These bacteria acquire antibiotic resistance through Quorum sensing (Prosser, 1999), that is, the mechanism in which microbes communicate with each other and become resistant to antibiotic therapy.

Biofilm becomes organized to form a complex structure that calcifies to form calculus. It is hard in nature and is found to be responsible for inflammation (marked redness) and infection (characterized by bleeding) of gums. It is present on teeth, dentures, and restorations. It causes halitosis (bad breath) and makes teeth (prosthesis also) vulnerable to decay and extractions. Treatment of dental calculus involves scaling, followed by oral hygiene reinforcement.

Microbiology:

Microbes are responsible for any type of infection in the body. The oral cavity is sterile at birth. Dental plaque also harbors a lot of bacteria. Among them, the major are red-complex bacteria, namely Porphyromonas gingivalis, Treponema pallidum, and Tannerella Forsythus. They are clinically significant because they are present at sites where there is a lot of bleeding.

Composition:

Calculus comprises mainly calcium phosphate and crystals, which further consist of hydroxyapatite and octacalcium phosphate (both forming approximately major portions). Rhamnose is absent in calculus, while whitlockite and brushite are in major quantities in posterior and anterior teeth. Octacalcium phosphate is present outside, while calcium phosphate complex (comprising Ca, K, and Ph crystals) is present inside.

Formation:

It takes about four to eight hours for plaque to form after eating food. 50 % plaque is calcified in two days, while it takes 12 more days to convert and calcify 60 to 90 % plaque to calculus. Calculus was observed in germ-free animals also. Pyrophosphate is an inhibitor of calculus formation and, therefore, forms a major component of toothpaste.

Types:

1. Supragingival Calculus - Supragingival is yellowish or light brownish in color and is present above the gingiva. Supragingival is soft in nature and, therefore, easy to remove. They are easily visible, arise from the saliva, be removed only by scalers, and responsible for gingivitis.
2. Subgingival Calculus - Subgingival is blackish-green or dark brownish in color. Subgingival calculus is hard and gritty (flint-like) and is not easily removable. They are not visible, arise from gingival crevicular fluid, curettes and scalers can both be used, and cause gingivitis and periodontitis.

Position:

Calculus is present on almost every surface, whether natural or artificial. It is present on overhanging restorations, dentures, mal aligned teeth, and retainers. Calculus is predominantly present on the upper buccal surface (molars), lower lingual surface (mandibular molars), and mandibular anterior teeth (incisors).

Why This Calculus Formation Occurs Continuously and on Selective Surfaces Only?

The reason behind this continuous deposition is the location of salivary glands at the proximity of these teeth. We have a submandibular gland (Wharton’s duct) in the mandibular molar teeth, while a sublingual gland (Bartholin duct) is located on mandibular anterior teeth. The parotid gland (Stenson’s duct) is located near the second maxillary molar and, therefore, is prone to develop calculus.

Treatment Options:

Calculus is hard and is not removable by brushing alone. So, it is removed by scalers (both hand and ultrasonic scalers). Hand scalers offer two main advantages. They have better tactile sensation than ultrasonic scalers and cause less post-operative sensitivity to patients. But, they are time-consuming. Ultrasonic scalers are less time consuming, but they cause more post-operative sensitivity. Secondly, because of the presence of aerosols in them, they are contraindicated in certain medical conditions like asthma, tuberculosis, and cardiac patients (having pacemakers).

All dental clinicians use ultrasonic as an adjunct to hand scalers since it can decrease the chances of post-operative sensitivity and will provide them good tactile sensitivity. Patient satisfaction is also met with this technique.

After the treatment, patients should be prescribed a good antibacterial mouthwash (Chlorhexidine 0.2 %) to maintain oral health and create an ideal harmony in the oral cavity. It is usually prescribed for one to two weeks post-operatively.

In addition, warm saline rinses six hours a day are also prescribed whenever there are excessive bleeding and chances of postoperative infections. Analgesics are usually not required. Sometimes desensitizing pastes are also prescribed for one to two months.

Follow-up:

After scaling, the patient has to consult the clinician after a week so that the status of healing and proximity of tissues is evaluated. This follow-up time can be increased to two to four weeks in case of refractory and aggressive periodontitis (both advanced gum diseases involving bone also). In these cases, sometimes surgical techniques are often performed to achieve ideal gum symmetry. So ideally, it is recommended to visit your dentist at least 6 months after scaling because, in a normal patient, it takes six months to calcify plaque to calculus and again cause recurrence.

Post-operative Instructions:

Patients are requested to follow post-operative instructions in a nice manner since the success of any therapy, whether dental or medical, depends upon both clinician and patient.

1. They must practice proper brushing techniques twice a day according to their conditions evaluated by the dentist.

2. They should always have diet control as prescribed by the dentist and should maintain proper oral hygiene in a meticulous way. In case of recurrence, they should respond to the dentist as soon as possible.

Precautions During Treatment and Post-Operative Treatment:

Avoid smoking, as smoking causes stains over dental calculus. Diet should be enriched with fibrous and coarse food to enhance masticatory efficiency and inhibit (not totally) plaque formation.