A NOTE ON DENTAL CALCULUS

Dental calculus

For the periodontal diseases:

•     The primary etiologic factor is: Is the dental plaque.
•       The associated factor: is the dental calculus, it helps in new formation of the plaque.
•       The modifying factor: is a systemic disease, it aggravates the disease when the plaque is presents.

 Calculus:

•    Is a mineralized dental plaque that occurs in the tooth surfaces & dental prosthesis, it has many forms:
•    Bridging over the gingival margin.
•     Follow the festooning shape of the dentition.
•     Lobular form.
•     In case of malalignment :àprotected area for the plaque à calculus

 Classification:

             Supragingival                  &               subgingival calculus..

         Generally: both can occur together or one may appear alone.

Subgingival calculus: 

•      Gingival fluid origin.
•       Below the crest of the gingival margin.
•       Hard, dark& flint like.
•       Greenish black or dark brown in color.
•       Firmly attached to the tooth, can’t be seen and detected by explorer No.621 probe.
•       Extent nearly to the base of the pocket in chronic periodntitis, but doesn’t reach the Junctional epithelium.

 Supragingival calculus:    

•     Saliva origin.
•    Coronal to the gingival margin. Can be composed of supra &sub gingival calculus.
•    Hard, clay like consistency, White, white yellowish in color& its color may be affected by the tobacco or food stain.
•     Easy to be seen in the oral cavity, may be generalized or localized.
•     Easy to be removed &usually recurrent especially in the: Lower incisors. 

• Most common location :near to the orifices of the S. glands’ ducts

Parotid gland’s duct ”stenson”----->opposite to buccal surface of maxillary molars.

Submandibular “bartholine” & sublingual “wharton” ducts ----->Lingual surface of lower incisors.

it’s shape : either covers the occlusal surfaces or  bridge like structure over interdental papilla.

                                                Calculus contents:

Inorganic contents:70-90%		Organic contents
2/3 of the calculus inorganic component is in crystalline form ;there are  4 types of crystals . The crystals are: hydroxyappatite ,58% à magnesium white locate,21%  àmost in post octacalcium phosphate,12% Brushite, 9% àmost in mandibular anteriors. Detected more frequently in supragingival calculus. Constitute the bulk. Generally 2 or more crystals are detected in the calculus. Incidence of 4 crystals à varies with age of calculus.		Mixture of  : Protein-poly saccharide complex + desquamated host cells (leukocytes & host cells) + microorganisms. Carbohydrates (1.9-9.1%): Glucose , glactose   ,mannose ,arabinose ,rhamnose glucoric acid ,glactouric acid glucoseamine & glactose amine. à all are present in saliva except : Rhaminose  &  arabinose . Salivary proteins (5.9-8.2%): Most are amino acids. lipids 0.2%:nutral fat ,fatty acids ,cholesterol ester, phospholipids & cholesterol.
*Contents:	The differences     Supra gingival calculus	Between: Sub gingival calculus
hydroxyappatite: Ca Ph : Mg white: brushite: ratio of Ca/Ph: sodium contents: salivary proteins:	Equal.   More. Less. More. Low.   Increase with the depth of PD pocket. Yes	Equal Less. More Less. Higher. No.

Calculocementum:

Is the calculus has morphological appearance similar to cementum. This is because the calculus is interdigitates the cementum & no differences between them.

Mode of attachment of the calculus to the tooth surface:

• Close adaptation under surface depression.
• In sub gingival calculus.
• By organic pellicle (very weak)
• Penetration of the bacteria to the cementum.
• Mechanical interlocking to the surface irregularities: resorption lacuna or caries, in the cementum by sharpies fibers.                          

Calculus formation:

Calculus is the dental plaque that undergoes mineralization.

Calcification starts                      4-8 hrs   after plaque.

50 % become mineralized after   2 days.

60-90                                          12 days.

• Plaque can be daily removed at home by brushing but the calculus is
• not ,it is only removed clinically by the dentist .

• Calculus formation à the bacterial action will stopped (adv) but it will act as stagnation area for new plaque accumulationà (protection for plaque). 

• Early plaque contains small amount of inorganic material but it will increase as the plaque develops into calculus. 

• All plaque doesn’t necessarily undergo calcification.

• It reaches a plateau of maximal mineral by 2 days.

• Microorganisms are not always essential in calculus formation. 

• Plaque has ability to conc. The Ca at  2-20 times it’s level in saliva. 

• There is a suggestion that Ph is more critical than Ca in plaque mineralization.

• Early plaque of heavy former àmore Ca ,3 times Ph &less K than non calculus former.

An Introduction to Dental Trauma Management

Facial trauma that results in fractured, displaced, or lost teeth can have significant negative functional, esthetic, and psychological effects on children. Dentists and physicians should collaborate to educate the public about prevention and treatment of traumatic injuries to the oral and maxillofacial region.

The greatest incidence of trauma to the primary teeth occurs at 2 to 3 years of age, when motor coordination is developing. The most common injuries to permanent teeth occur secondary to falls, followed by traffic accidents, violence, and sports. All sporting activities have an associated risk of orofacial injuries due to falls, collisions, and contact with hard surfaces. The AAPD encourages the use of protective gear, including mouthguards, which help distribute forces of impact, thereby reducing the risk of severe injury.

Dental injuries could have improved outcomes if the public were aware of first-aid measures and the need to seek immediate treatment. Because optimal treatment results follow immediate assessment and care, dentists have an ethical obligation to ensure that reasonable arrangements for emergency dental care are available. The history, circumstances of the injury, pattern of trauma, and behavior of the child and/or caregiver are important in distinguishing nonabusive injuries from abuse.

Practitioners have the responsibility to recognize, differentiate, and either appropriately manage or refer children with acute oral traumatic injuries, as dictated by the complexity of the injury and the individual clinician’s training, knowledge, and experience. Compromised airway, neurological manifestations (eg, altered orientation), hemorrhage, nausea/vomiting, orsuspected loss of consciousness requires further evaluation by a physician.

To efficiently determine the extent of injury and correctly diagnose injuries to the teeth, periodontium, and associated structures, a systematic approach to the traumatized child is essential. Assessment includes a thorough medical and dental history, clinical and radiographic examination, and additional tests such as palpation, percussion, sensitivity, and mobility evaluation. Intraoral radiography is useful for the evaluation of dentoalveolar trauma. If the area of concern extends beyond the dentoalveolar complex, extraoral imaging may be indicated. Treatment planning takes into consideration the patient’s health status and developmental status, as well as extent of injuries. Advanced behavior guidance techniques or an appropriate referral may be necessary to ensure that proper diagnosis and care are given.

All relevant diagnostic information, treatment, and recommended follow-up care should be documented in the patient’s record. A standardized trauma form can guide the practitioner's clinical assessment and provide a way to record the essential aspects of care in an organized and consistent manner. Well-designed and timely follow-up procedures are essential to diagnose and manage complications.

After a primary tooth has been injured, the treatment strategy is dictated by the concern for the safety of the permanent dentition. If determined that the displaced primary tooth has encroached upon the developing permanent tooth germ, removal is indicated. In the primary dentition, the maxillary anterior region is at low risk for space loss unless the avulsion occurs prior to canine eruption or the dentition is crowded. Fixed or removable appliances, while not always necessary, can be fabricated to satisfy parental concerns for esthetics or to return a loss of oral or phonetic function.

When an injury to a primary tooth occurs, informing parents about possible pulpal complications, appearance of a vestibular sinus tract, or color change of the crown associated with a sinus tract can help assure timely intervention, minimizing complications for the developing succedaneous teeth. Also, it is important to caution parents that the primary tooth’s displacement may result in any of several permanent tooth complications, including enamel hypoplasia, hypocalcification, crown/root dilacerations, or disruptions in eruption patterns or sequence. The risk of trauma-induced developmental disturbances in the permanent successors is greater in children whose enamel calcification is incomplete.

The treatment strategy after injury to a permanent tooth is dictated by the concern for vitality of the periodontal ligament and pulp. Subsequent to the initial management of the dental injury, continued periodic monitoring is indicated to determine clinical and radiographic evidence of successful intervention (ie, asymptomatic, positive sensitivity to pulp testing, root continues to develop in immature teeth, no mobility, no periapical pathology). Initiation of endodontic treatment is indicated in cases of spontaneous pain, abnormal response to pulp sensitivity tests, lack of continued root formation or apexogenesis, or breakdown of periradicular supportive tissue. To restore a fractured tooth’s normal esthetics and function, reattachment of the crown fragment is an alternative that should be considered.

To stabilize a tooth following traumatic injury, a splint may be necessary.

Flexible splinting assists in healing.

Characteristics of the ideal splint include:

1. easily fabricated in the mouth without additional trauma;

2. passive unless orthodontic forces are intended;

3. allows physiologic mobility;

4. nonirritating to soft tissues;

5. does not interfere with occlusion;

6. allows endodontic access and vitality testing;

7. easily cleansed;

8. easily removed.

Instructions to patients having a splint placed include to:

1. consume a soft diet;

2. avoid biting on splinted teeth;

3. maintain meticulous oral hygiene;

4. use chlorhexidine/antibiotics if prescribed;

5. call immediately if splint breaks/loosens.