Periodontal Health Definition of Calculus

¶ … Periodontal Health

Definition of Calculus (Supra Gingival and Subgingival)

Implications of the Removal of Dental Calculus

Periodontal Health Can be Established without Removal of Dental Calculus

Maintaining periodontal health is important for a number of reasons. Left untreated, periodontitis has been shown to have a wide range of adverse healthcare outcomes, including increased incidences of cardiovascular disease and other heart problems, stroke, diabetes mellitus and low birth weight in preterm infants. Termed the "silent killer" dental disease by some authorities, periodonititis is an insidious condition that can affect people largely without their knowledge for many years without exhibited any discernible symptoms. Likewise, the accumulation of dental calculus that is typically associated with the aging process can take years without discernible symptoms beyond the appearance issues this accumulation presents. It has been shown, though, that periodontal health can be established and maintained without the removal of dental calculus. Therefore, because healthcare resources are by definition scarce, it is important to ensure that the removal of calculus is predicated on sound evidence-based care guidelines. To this end, this paper provides a review of the relevant peer-reviewed and scholarly literature concerning periodontal health, calculus (supragingival and subgingival) and the implications of the removal of dental calculus. A summary of the research and important findings are presented in the conclusion.

Review and Analysis

Definition of Periodontal Health

Generally speaking, the term "periodontal disease" is used to describe the production of harmful factors and bacterial growth that, over time, attack the tissue that surrounds and supports the teeth and the term "periodontal" refers to "around the tooth" (Lewis 2002:16). The disease process starts with the formation of plaque, a process that is ongoing and which is largely indiscernible (Lewis 2002). According to Lewis, "When it accumulates to excessive levels, it can harden into a substance called tartar (calculus) in as little as 24 hours" (Lewis 2002:16). Calculus is particularly difficult to remove because it is tightly bound to teeth and can only be removed by professional cleaning (Lewis 2002). Both gingivitis and periodontitis represent the two primary forms of gum disease, with each condition being characterized by processes that take place under the gumline (Lewis 2002). While gingivitis typically occurs prior to the onset of periodontitis, not all cases of gingivitis progress to periodontitis (Lewis 2002). Beginning in the 1960s, the most popular measure of periodontal health was based on variance in periodontal index (PI) scores and this measure remains an important indicator today (Cheraskin 2003).

The general definition provided by the World Health Organization indicates that periodontal health is "a state of being free from chronic mouth and facial pain, oral and throat cancer, oral sores, birth defects such as cleft lip and palate, periodontal (gum) disease, tooth decay and tooth loss, and other diseases and disorders that affect the oral cavity" ("Oral health" 2010:1). Other indicators of periodontal health, though (at least in animals), also include that amount of plaque and calculus, changes in the gingiva, probing depth, evaluation of attachment, and grade of mobility ("Periodontal indices" 2007). While plaque is the primary cause of periodontal disease, the American Academy of Periodontology (AAP) says that other factors are thought to increase the risk, severity, and speed of gum disease development, including the following:

1. Tobacco use -- one of the most significant risk factors associated with the development of periodontitis. People who smoke are seven times more likely to get periodontitis than nonsmokers, and smoking can lower the chances of success of some treatments.

2. Hormonal changes -- may make gums more sensitive and make it easier for gingivitis to develop.

3. Stress -- may make it difficult for the body's immune system to fight off infection.

4. Medications -- can affect oral health because they lessen the flow of saliva, which has a protective effect on teeth and gums. Some drugs, such as the anticonvulsant medication diphenylhydantoin and the anti-angina drug nifedipine, can cause abnormal growth of gum tissue.

5. Poor nutrition -- may make it difficult for the immune system to fight off infection, especially if the diet is low in important nutrients. Additionally, the bacteria that cause periodontal disease thrive in acidic environments. Eating sugars and other foods that increase the acidity in the mouth increases bacterial counts.

6. Illnesses -- may affect the condition of your gums. This includes diseases such as cancer or AIDS that interfere with the immune system.

7. Clenching and grinding teeth -- may put excess force on the supporting tissues of the teeth and could speed up the rate at which these tissues are destroyed (Lewis 2002:19).

According to Zacharczenko, "Periodontitis is the 'silent killer' dental disease. It can progress for years without symptoms. It is estimated that the majority of middle-aged and elderly Americans have some degree of this disease" (1998:56). Left untreated, there are numerous implications and adverse healthcare outcomes associated with periodontal disease, studies have linked ongoing periodontitis with diabetes mellitus, cardiovascular disease, stroke; infective endocarditis as well as low-birth-weight in preterm babies (Zacharczenko 1998). The research to date also indicates that some people are predisposed to periodontal disease, and although the precise reasons remain unclear, it is thought that genetics, diet, lifestyle, and oral hygiene all play a role to varying degrees, but the extent of oral cleanliness has not been demonstrated to be predictive of gum disease (Zacharczenko 1998). Other recent research has shown that immune defenses in the human body mediate the extent and severity of the bone destruction that results from bacterial growth in periodontium, and the preferred treatments for periodontal disease typically involve dental scaling/root planing, various surgeries and aggressive home care regimens (Zacharczenko 1998). The goal of these interventions is to reduce the amount of placque, pockets of gum disease and calculus surrounding the involved teeth but Zacharczenko emphasizes that, "The inflammatory components responsible for the decimation of dental alveolar bone have never been adequately addressed. These components include collagenase, prostaglandins, and other mediators that induce bone loss" (Zacharczenko 1998:56). The effects of calculus in these disease processes are discussed further below.

Definition of Calculus (Supra Gingival and Subgingival)

Calculus. A good description of calculus is provided by Hopkins who reports, "With aging the teeth become both longer and looser, a condition that really has its beginning some time earlier when a colorless film of sticky, bacterially produced material called plaque forms on the tooth surfaces without the owner's knowledge and -- in time -- turns into deposits of tartar, or calculus" (1994:31). The potential consequences of calculus accumulation are also noted by Hopkins who advises, "As the stuff forms, it crowds, irritates, loosens and eventually pushes back the gumline. Inflammation and infection set in around the tooth's root, and the gum slowly recesses" (1994:31). Over time, this process can cause tooth to become looser, opening the way for the onset of other conditions that can adversely affect periodontal health. In this regard, Hopkins concludes that, "As the infected area widens and deepens, the bone in which the tooth is set shrinks away. This makes the tooth's pocket deeper and gives the roots less anchorage. Sometimes it is years before the patient really knows what is happening" (1994:31). How far the disease process has progressed largely dictates what type of methods and procedures are used to treat periodontitis. In those cases where the condition is treated in its early stage, scaling and root planing may be sufficient (Hopkins 1994). Calculus accumulations are usually removed with various scraping instruments or machine-driven buffing pads; in other cases, ultrasonic vibration is used to remove calculus deposits (Hopkins 1994). According to Hopkins, "Removal of calculus below the gumline and root planing are usually done by a dentist or periodontist. Root planing consists of removing plaque and calculus from the root to provide a smooth surface to which the gum may reattach" (1994:31).

There remains a paucity of knowledge among the general public in general and among adolescents in particular concerning plaque and calculus. A recent study by Yuen, Wiegland, Slate, Magruder, Salinas and London (2008) investigated the level of dental health knowledge among adolescents and found that this lack of knowledge, though, did not appear to be a contributing factor to higher prevalence rates of periodontal disease. According to these researchers, "Some confusion may have no detrimental impact on the dental health of the adolescents. For example, not fully understanding the difference between plaque and calculus, and the functions of dental sealant and fluoride, may not necessarily contribute to poor dental health as long as a proper daily oral hygiene routine with fluoridated toothpaste is maintained" (Yuen et al. 2008:15).

Supragingival. As the term implies, supragingival calculus refers to calculus located above the gumline ("Calculus removal" 2010). Supragingival calculus is not regarded as being a direct cause of periodontal disease; in addition, there has been a decrease in prevalence levels of calculus levels in recent years due in part to decreased tobacco use, improvements in oral cleanliness and the increased use of anti-tartar and therapeutic toothpastes (Sheiham 2001). Nevertheless, an individual may prefer to have this type of calculus removed for other reasons or otherwise as part of a long-term treatment regimen. For example, Bennett and Mccrochan note that, "When the American Dental Association later approved Warner-Lambert's mouthwash, Listerine, by stating that 'Listerine Antiseptic has been shown to help prevent and reduce supragingival plaque accumulation and gingivitis. . ., ' sales rose significantly" (1993:398). It remains unclear, though, what effect, if any, that supragingival calculus has on gingival inflammation. For instance, Mandel and Gaffar report that, "Although there is no doubt that gingivitis can develop in the absence of supragingival calculus, it is not clear to what extent the presence of mineralized deposit enhances gingival inflammation" (1986:249). Although the composition of the material is the same, the location of calculus below the gumline is termed "subgingival" and this condition is discussed further below.

Subgingival. Because of its location below the gumline, researchers have increasingly focused on treatment modalities that could treat subgingival calculus. The results of clinical studies concerning the efficacy of various treatment modalities reported by Cooley and Lewkowicz include the use of Elyzol dental gel with subgingival scaling. These early studies, though, were flawed in several ways, and appeared to be biased favor of using Elyzol gel for the initial treatment or as a replacement for the subgingival scaling. According to these researchers, "As the gel is an antiobiotic, it is reasonable that the gel should be applied only if the mechanical treatment fails to solve the pocket. Moreover, the study groups in the studies seem to have been poorly defined" (Cooley & Lewkowicz 2003:63). The results of a more recent randomized clinical and microbiological slit-mouth design study (Stelzel & Flories-de-Jacoby 1996) concerning the efficacy of metronidazole 25% dental gel compared to subgingival scaling on recall subjects showed that there were no statistically significant differences between the two treatment modalities. Some of the limitations of this study concerned the relatively few subjects involved (n=30) and smokers were included in the sample which may have influenced the study's outcomes (Cooley & Lewkowicz 2003).

According to Zacharczenko (1998), many prescription drugs have also been introduced in recent years to treat periodontal disease and the inflammatory response that is associated with the condition. These products include Peridex (chlorhexidine gluconate, Zila) and Perioguard (chlorhexidine gluconate, Colgate Oral Pharmaceuticals) rinses and over-the-counter, non-prescription alternatives such as Colgate's Total and Viadent Advanced Care toothpastes that are designed to treat initial colonization of bacterial growth on teeth as wel as plaque accumulations and gingivitis (Zacharczenko 1998). One such product, PerioChip (chlorhexidine gluconate 2.5 mg, Astra), has been introduced as a treatment for adult periodontal disease (Zacharczenko 1998). The product is described by Zacharczenko as "a biodegradable, subgingival, sustained-release chip, measuring 4mm x 5mm x 350 microns" (1998:56). The product is inserted into a periodontal pocket by the treating dentist and simply degrades over the next week to 10 days, at which point the treatment is complete (Zacharczenko 1998). The active ingredient in the PerioChip, chlorhexidine, is a powerful bactericidal agent and has been shown to be highly effective in treating periodontal disease (Zacharczenko 1998). It should be noted, though, that the PerioChip treatment is intended to be part of a more comprehensive treatment regimen and is intended to supplement traditional periodontal therapeutic interventions (Zacharczenko 1998).

The focus of a study by Alaluusua, Calderara, Gerthoux, Lukinmaa, Kovero, Needham, Patterson, Tuomisto and Mocarelli (2004) was to determine the effect of dioxins on human organogenesis, including periodontal health in general and the percentage of subgingival calculus sites in particular. Although it was determined that dioxins could affect the organogenesis process in human in general, exposure did not affect the number of subgingival calculus sites (Alaluusua et al. 2004:1313).

Finally, a summary of epidemiological studies concerning supragingival calculus reviewed by Mandel and Gaffar (1986) are provided in Table 1 below.

Table 1

Summary of Supragingival Calculus Epidemiological Studies

Author/Date

Key Findings

Comments

Ainamo (1970)

Subjects were 154 U.S. Army recruits (age 19-22 yrs); author found a high positive correlation between both subgingival and supragingival calculus as well as gingivitis. Author also found that there was a higher correlation between calculus related plaque and gingivitis compared to carcinogenic plaque.

Author used retention index that distinguishes between the types of plaque that are associated with calculus and those that are associated with caries.

Alexander (1971)

This study examined the distribution pattern of supragingival and subgingival calculus, bacterial plaque and gingival inflammation in 200 dental students and 200 dental clinic patients. Author found that the papillae exhibited the highest prevalence of gingival inflammation and the buccal margins the lowest.

This pattern coincided with the highest prevalence of subgingival calculus on the interproximal surface and the lowest on the buccal.

Buckley (1980)

Examined 300 adolescents (15-17 hrs) evenly distributed by sex and age and found that subgingival calculus was more prevalent in supragingival but shown the same distribution pattern. Also found a strong correlation between the buccal and lingual gingival indices and their respective plaque and supra- and subgingival calculus indices.

There was a higher degree of correlation for gingival indices vs. plaque than for gingival indices vs. calculus.

Lennon & Clerehough (1984)

229 children followed from ages 14-16, authors found that the presence of subgingival calculus on mesio-buccal sites was the best predictor of future attachment loss.

Screening tests based on subgingival calculus would tend to have low sensitivity, in other words it would miss some subjects who would go on to develop loss of attachment but it would have high specificity. Authors indicate this is an area that needs further research.