JOHSR

Suchetha Aghanashini et al 10.5005/jp-journals-10042-1034

Review Article

A Comprehensive Review on Dental Calculus

1
Suchetha Aghanashini, 2Bhavana Puvvalla, 3Darshan B Mundinamane, 4SM Apoorva, 5Divya Bhat, 6Manjari Lalwani

ABSTRACT casks and also called as Tartar, Disambiguation, Calcis,

Dental calculus is a hard deposit that is formed by calcification of Odontolithiasis and Fossilized plaque.
dental plaque primarily composed of calcium phosphate mineral
salts which is deposited on natural teeth and restorations and is CASE REPORT
covered by a layer of unmineralized plaque. These hard deposits
may form coronal to or apical to the gingival margin, hence named • Hippocrates (460–377 BC) was the foremost person
accordingly as supragingival and subgingival calculus respec- whose writings showed a relation between dental
tively. The distribution of calculus is very versatile and it differs deposits and oral diseases. He noted the harmful
from individual to individual, from tooth to tooth, and from surface
to surface. So, a thorough knowledge on prevalence of calculus
effects of calculus (pituita) on gums and teeth.
is important for the clinician in outlining the treatment plan. It is • Albucasis (936–1013) evidently illustrated the asso-
a well-known fact that calculus is itself not an inducing agent for ciation between calculus and disease and advocated
pathological changes that occur in gingival tissues; instead it is thorough removal of deposits.
covered by a layer of unmineralized plaque which is proven to
• Paracelsus a Swiss/German physician and alchemist
be the key etiological agent involved in these pathogenic mecha-
nisms. But, attributing to the porosity of calculus and its ability to introduced the term tartar as a description for a variety
retain bacterial antigens makes it an important contributing factor of stony concretions that form in humans.
in initiating and accentuating periodontal disease progression. In • For nearly 5,000 years, calculus was considered to be
this review, we made an attempt to discuss various aspects of the prime etiologic agent in periodontal disease. In the
calculus composition, its formation, and its etiological significance
in periodontal disease progression.
past 25 years, however, calculus has been overthrown
by plaque, and the hardened criminal has come to be
Keywords: Calculus, Gingival margin, Periodontal diseases,
viewed as a fossilized remnant of minor significance.
Prevalence, Unmineralized plaque.
This shift in perception became mainly apparent in
How to cite this article: Aghanashini S, Puvvalla B,
the 1960s and was largely a response to two lines of
Mundinamane DB, Apoorva SM, Bhat D, Lalwani M. A
Comprehensive Review on Dental Calculus. J Health Sci Res investigation.
2016;7(2):42-50. 1. Reports on experimental and electron microscopic
Source of support: Nil studies of developing plaque and calculus confirmed
that supra- and subgingival calculus were mineralized
Conflict of interest: None
plaque covered by a layer of unmineralized bacteria
2. The experimental demonstration in humans that
INTRODUCTION
plaque permitted to accumulate in the absence of oral
Periodontitis is a chronic inflammatory disease of sup- hygiene results in a gingivitis, which is reversible on
porting tissues of tooth which is caused by specific the resumption of tooth cleaning.
microorganisms in a susceptible host.1 Bacterial plaque
and calculus are considered as major etiological agents CLASSIFICATION
in the initiation and progression of periodontal diseases.2
• According to location
Calculus is defined as a hard deposit that is formed by
– Supragingival calculus
mineralization of dental plaque on the surfaces of natural
– Subgingival calculus
teeth and dental prosthesis, generally covered by a layer
• According to source of mineralization
of unmineralized plaque.3 Calculus is derived from Greek
– Salivary calculus
words Calcis-lime stone, Tartar-white encrustation inside
– Serumal calculus (Jenkins, Stewart 1966)
• According to surface
1
Professor and Head, 2,6
Postgraduate Student, 3,4
Reader – Exogenous
5
Senior Lecturer – Endogenous (Melz 1950)
1-6
Department of Periodontology, DA Pandu Memorial RV • According to initiation and rate of accumulation,
Dental College and Hospital, Bengaluru, Karnataka, India calculus formers are classified as:
Corresponding Author: Bhavana Puvvalla, Postgraduate – Noncalculus formers
Student, Department of Periodontology, DA Pandu Memorial – Slight calculus formers
RV Dental College and Hospital, Bengaluru, Karnataka, India – Moderate calculus formers
Phone: +917411244744 e-mail: [email protected]
– Heavy calculus formers.4

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A Comprehensive Review on Dental Calculus

Table 1: Differences between supragingival vs subgingival calculus5

Sl. no. Feature Supragingival calculus Subgingival calculus
1 Defined as Tightly adhering calculus deposit that forms on the Calcified deposit that forms on the tooth surface
crowns of the teeth coronal to the gingival margin below the free margin of gingiva
2 Location Forms coronal to the gingival margin Deposits present apical to the crest of marginal gingiva
3 Source Derived from the salivary secretions – salivary calculus Derived from the gingival exudate – seruminal calculus
4 Distribution Symmetrical arrangement on teeth, more on facial Related to pocket depth, heavier on proximal
surfaces of maxillary molars and lingual surfaces of surfaces
mandibular anterior teeth
5 Color It is white, yellow in color Brown/greenish black in color
6 Consistency Hard and clay like Hard and firm/flint or glass like
7 Composition More brushite and octa calcium phosphate Less brushite and octa calcium phosphate. More
Less magnesium whitelockite magnesium whitelockite
8 Other contents Sodium content is less Sodium content increases with the depth of the pocket
Salivary proteins are present Salivary proteins are absent
9 Visibility Clinically visible Not visible on routine clinical examination
10 Attachment Easily detached from the tooth Firmly attached to the tooth surface

COMPOSITION OF CALCULUS the world. Several studies assessed calculus applying

the CPITN index for estimating the population need
Calculus consists of both inorganic and organic
for periodontal care. There are also additional studies
components.
that helped us in defining the prevalence of calculus.7
Inorganic Contents (70–90%) Among8 various studies, a study done by Anerud et al
in 1991 for a 15-year period observed the periodontal
Principle elements: status of two groups: (1) Sri Lankan tea laborers group
• Calcium – 39% and (2) Norwegian academicians group. Ready access to
• Phosphorous – 19% preventive dental care is available for Norwegian group
• Carbon dioxide – 1.9% in contrary to Sri Lankan individuals. They noticed
• Magnesium – 0.8% that calculus accumulation was symmetrical and was
• Trace amounts of Na, Ba, Zn, Str, Br, Cu, Ag, Al, Fe, Fl first accumulated on facial surface of maxillary molars
Components: and lingual surfaces of mandibular incisors. With the
• Calcium phosphate – 75.9% increase in age, the deposition of supragingival calculus
• Calcium carbonate – 3.1% continues reaching to a maximal calculus score around
• Magnesium phosphate – traces and other metals 25 to 30 years of age, and by age 45, almost all the teeth
Crystal forms: would have been covered by calculus except premolars
• Hydroxyapatite (HA) – 58% in some instances. Norwegians enjoyed the privileged
• Octa calcium phosphate (OCP) – 21% dental services and showed approximately 70% of inter-
• Magnesium whitelockite (MWL) – 12% proximal calculus free sites by the age of 40 to 50 years.
• Brushite (BS) – 9% Hence, concluding that individuals who did not practice
Supragingival calculus – HA and OCP are detected good oral hygiene are at a higher risk of attachment
most frequently. loss and ultimately tooth loss when compared to teeth
Subgingival calculus – MWL is present in high con- without calculus.
centrations and same HA content. More recently, NHANES III survey evaluated 9,689
Mandibular anterior region – BS is more common. adults in the United States between 1988 and 1994 and
Posterior areas – MWL is more common (Table 1).6 observed that 91.8% of the subjects had noticeable calcu-
lus and 55.1% had subgingival calculus.9
PREVALENCE
FORMATION OF CALCULUS
An emphasis on the prevalence of calculus is important
as it not only provides an outlook of health but also helps After the tooth eruption or a dental prophylaxis, pellicle
us in plotting the treatment required and professional proteins rapidly adsorb onto the enamel surface which
services accordingly. There are a multitude of recent favors bacterial adhesion and subsequent development
reports available on prevalence of calculus from all over of biofilm occurs. Maturation of biofilm proceeds with
Journal of Health Sciences & Research, July-December 2016;7(2):42-50 43
Suchetha Aghanashini et al

the characteristic microbial maturation of initial Gram- Mechanism 2

positive coccoidal organisms followed by outgrowth
of filamentous bacteria leading to the development of
plaque. Mineralizing agents from saliva and GCF for
supra- and subgingival calculus respectively enter the
biofilm leading to mineralization of plaque intercellular
matrix. Hereafter, calcium ions from saliva are removed
by chelation promoting binding of calcium with carbo-
hydrate/protein complexes leading to the precipitation
of crystalline calcium phosphate salts, and coalescence
of these crystals aids in the formation of calcified mass,
thereby leading to calculus formation.5

THEORIES OF CALCULUS FORMATION

Many theories were proposed to better understand the
mechanism of calculus formation. They are as follows:
• Booster mechanism Epitactic Theory
• Epitactic concept In saliva the concentration of certain ions like calcium
• Inhibition theory and phosphate is not high enough to precipitate but is
• Transformation theory ample enough to promote the growth of hydroxyapatite
• Bacterial theory crystals once an initial seed or nucleus is formed. The
• Enzymatic theory term epitactic refers to crystal formation through seeding
by another compound which is similar to hydroxyapatite
Booster Mechanism crystals, leading to precipitation of calcium salts from
the metastable solution of saliva. Seeding agents provoke
Mechanism 1
small foci of calcification enlarge and coalesce to form
Major salivary ducts secrete saliva at a high CO2 tension, the calcified mass. Intercellular matrix or plaque plays
about 54 to 65 mm Hg; but the pressure of CO2 in atmo- an important role. Calcification will be initiated by a
spheric air is only about 0.3 mm Hg. As a result of large carbohydrate/protein complex which removes calcium
disparity in CO2 tension, saliva emerging from the sali- from saliva by chelation process and binds with the nuclei
vary ducts loses CO2 to the atmosphere. pH in saliva will that stimulates subsequent deposition of minerals.
increase when CO2 escapes since pH in saliva depends
largely on the ratio between bicarbonates and free car- Inhibition Theory
bonic acid. Phosphoric acid dissociation increases with This theory assumes about calcification as occurring
rise in the alkalinity, thus increasing the concentration only at specific sites because of existence of an inhibit-
of less soluble secondary and tertiary phosphate ions. ing mechanism at noncalcifying sites. According to this
This boost in phosphate ions concentration leads to a theory, the sites where calcification occurs, the inhibi-
situation where solubility product of calcium phosphate tor is apparently altered or removed. Pyrophosphate is
is exceeded and crystals form (Flow Chart 1). thought to be one possible inhibiting substance and other
possible inhibiting substances include polyphosphates.
Flow Chart 1: Booster mechanism Alkaline pyrophosphatase is the enzyme involved in
controlling mechanism which hydrolyzes the pyrophos-
phate to phosphate (Russell and Fleisch 1970) and this
pyrophosphate prevents the initial nucleus from growing
and inhibits their calcification possibly by poisoning the
growth centers of the crystals.

Transformation Theory
Most noticeable hypothesis states that hydroxyapatite
need not arise exclusively via epitaxis or nucleation. Octa
calcium phosphate is formed by the transformation of

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A Comprehensive Review on Dental Calculus

amorphous noncrystalline deposits and brushite and the lacunae of both supra- and subgingival calculus.
then transformed to hydroxyapatite (Eanes et al 1970). It Bacteria are not essential for calculus formation, but they
has been suggested that controlling mechanism in trans- enable its development. Hence, high amount of calculus
formation mechanism can be pyrophosphate (Fleisch indicates that oral hygiene has been poor for months or
et al 1968). even years.6

Bacteriological Theory ETIOLOGICAL SIGNIFICANCE OF CALCULUS

According to this theory, the primary cause of calculus IN PERIODONTAL DISEASE
formation is oral microorganisms and their involvement It is a quite challenging task to distinguish the effects
in attachment to the tooth surface. Leptotrichia and acti- of calculus and plaque on gingiva, because the former
nomyces have been considered most often as the causative is always covered by a layer of plaque. There is always a
microorganisms. correlation between the presence of calculus and preva-
lence of gingivitis though greater association was found
Enzymatic Theory between plaque and gingivitis. This association may lead
According to this theory, calculus formation is the resul- to initiation and progression of periodontal diseases.
tant of the action of phosphatases derived from either The rough calculus surface may not, in itself, induce
oral tissues or oral microorganism on some salivary inflammation in the adjacent periodontal tissues, instead
phosphate containing complex, most probably phospheric it serves as an ideal substrate for subgingival microbial
esters of the hexophosphoric group.5 colonization11 and also
• acts as a niche which harbors bacterial plaque
CALCULUS ATTACHMENT • acts as an irritant to the periodontal tissues
• distends the periodontal pocket wall
The following four modes of attachment have been
• inhibits the ingress of polymorphonuclear leukocytes.
described
So, regardless of its primary or secondary relationship
1. Attachment by means of organic pellicle on enamel
in pocket formation, i.e., periodontal disease progression
2. Mechanical interlocking in cemental resorption
and although the principal irritating features is its surface
lacunae
plaque rather than its interior, calculus is a significant
3. Close adaptation of calculus undersurface depressions
pathogenic factor in periodontal disease.6
to gently sloping mounds on the unaltered cementum
But, various studies have emphasized on the aspect
surface
that whether sterilized section of calculus has some
4. Penetration of calculus bacteria in cementum. But this
role in periodontal disease progression. Among various
mode of attachment was not acknowledged.6
studies, a study conducted by Don Allen and Kerr (1965)
tested the sterility of calculus and its reaction and com-
ATTACHMENT OF CALCULUS ON IMPLANT
pared with unsterile calculus in guinea pigs histologi-
• Calculus attachment to pure titanium is less intimate cally. A portion of calculus obtained from periodontitis
than to root surfaces structure. patients and the calculus is autoclaved to achieve ster-
• Smooth machined implants have less micro porosities ilization and then put in a hotair oven to evaporate the
for retention. This would mean that calculus may be moisture which had accumulated in them as a result
chipped off from implants without affecting it.10 of autoclaving. This portion of sterilized calculus in
injected into the intraperitoneal tissues of a group of
MICROBIOLOGY OF DENTAL CALCULUS guinea pigs and the other group received an injection of
The average microscopic count of bacteria in unmineral- unsterilized calculus. Results showed that the response
ized dental plaque has been calculated to be up to 2.1 × 10 mg sterile human calculus is a granulomatous, foreign body
wet weight. Lactate dehydrogenase and alkaline and reaction whereas to unsterile human calculus is a sup-
acid phosphatase activities have been identified in dental purative reaction with a tendency for abscess formation
plaque suggestive of a boosted calcification by the plaque concluding that sterile calculus is a mild irritant and has
enzymes. In supragingival calculus, viable aerobic and no etiological significance when compared to calculus
anaerobic bacteria have been detected while subgingival with microorganisms.12
calculus provides an excellent environment for further In dental research, the association between dental
microbial adhesion and growth. Periopathogens, such calculus with periodontal health has doubtlessly been
as Aggregatibacter actinomycetemcomitans, Porphyromonas one of the most studied topics. For several millennia past
gingivalis, and Treponema denticola have been found within to 1960, dental calculus was considered to be a primary
Journal of Health Sciences & Research, July-December 2016;7(2):42-50 45
Suchetha Aghanashini et al

etiologic factor in the initiation and progression of peri- vs calculus and a higher degree of correlation for subgin-
odontal diseases. gival than for supragingival calculus.
In the decade of 1970s, the enhanced understanding Furthermore, Lennon and Clerehugh17 in a 2-year
of the microbiological contribution to periodontal disease longitudinal study elucidated the role of subgingival
decline interest in calculus as a specific etiologic agent. calculus in periodontal disease in teenagers. This inves-
The last decade has seen renewed interest in supra- and tigation included 229 children in the age group of 14
subgingival calculus effects on disease processes, on the to 16 and the authors concluded that the presence of
one hand, due to the commercial success of toothpastes subgingival calculus was the best predictor of future
sold for the control of supragingival calculus, and on attachment loss.
the other hand, due to the success of phase I periodontal Axelsson and Lindhe22 during a 6-year longitudinal
therapy (scaling and root planing, with subgingival study in 555 adults observed that whether occurrence
calculus debridement) in treating early periodontal of caries and periodontal disease progression can be
disease as documented by TEN CATE and MANDEL prevented by maintaining oral hygiene and repeated
and GAFFEN13 prophylaxis. Each prophylactic session is given every
Ainamo (1970) found a high positive correlation 2 months during the first 2 years, and every 3 months
between calculus (both supra- and subgingival and thereafter and included a complete scaling and root
gingivitis) in 154 army recruits between the ages of planing, combined with oral hygiene instructions. The
19 and 22. He employed the retention index (RI) which study concluded that subjects who utilized proper oral
hygiene techniques had negligible signs of gingivitis
discriminates between plaque associated with calculus
and periodontal tissue attachment loss and developed
and plaque associated with caries and noted a positive
no new carious lesions. Similar strategies of frequent
correlation between the RI and gingivitis. A higher
recalls are characteristic of all the adult plaque control
correlation was noted between gingivitis and calculus-
studies at Goteborg.18-21 All these studies highlighted that
related plaque than with cariogenic plaque. Ainamo14 also
the plaque control and professional oral prophylaxis had
spotted attention to his finding that there was increased
certainly played an important role in maintaining the
gingivitis as well as calculus deposits on oral than on
gingival and periodontal health.
facial surfaces of lower second premolars and first and
Tagge et al23 in 22 patients assessed clinically and
second molars. One possible justification is that this is
microscopically, the soft tissue response in suprabony
the area where the salivary influence is greatest, hence,
periodontal pockets after treatment by root planing and
supragingival calculus is most abundant and suggests
oral hygiene vs oral hygiene measures alone. All the
that the pathogenicity of calculus plus overlying plaque
therapies decreased the incidence and severity of gin-
may be greater than that of plaque alone. givitis along with pocket depth. However, root planing
Alexander (1971) observed the regional distribution combined with oral hygiene measures resulted in a
of bacterial plaque, supra- and subgingival calculus, statistically significant improvement when compared to
and gingival inflammation in 200 dental students and personal oral hygiene measures alone. This is because the
200 patients visiting a dental clinic. He noticed that the tooth brushing limited its effectiveness by the presence
prevalence of gingival inflammation is greatly exhibited of subgingival deposits on the nonroot-planed surfaces
in the papillary areas and the buccal margins the lowest that resulted in no significant pocket reduction and gain
which coincides with the greatest prevalence of sub- in attachment levels than in those treated by root planing
gingival calculus on the interproximal surface and the with oral hygiene prophylaxis.
buccal margins the lowest, concluding that the surfaces Hellden et al24 studied advanced periodontal disease
with calculus exhibited more gingivitis than the surfaces in 12 patients. The presence of plaque, gingival inflamma-
with plaque alone.15 tion, probing depths, and attachment levels was assessed
Buckley16 examined the prevalence of subgingival and for all teeth in 12 patients with chronic, advanced peri-
supragingival calculus among 300 teenagers, aged 15 to odontitis. After the initial examination, patients were
17, evenly distributed by age and sex. He found greater given detailed oral hygiene instructions and divided
prevalence of subgingival calculus when compared to into four groups.
supragingival but showed the same distribution pattern. Group 1: No treatment,
A strong correlation was found between the buccal and Group 2: Scaling and root planing alone,
lingual gingival indices and their respective plaque and Group 3: Administration of tetracycline alone, and
supra- and subgingival calculus indices. Pearson corre- scaling and
lation analysis indicated a higher degree of correlation Group 4: Root planing combined with the administration
for gingival indices vs plaque than for gingival indices of tetracycline.

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A Comprehensive Review on Dental Calculus

Following initial therapy all patients were reexamined of the same dimension as the filamentous organisms were
at 8 and 25 weeks. Both plaque index (PI) and gingival found penetrating into the calculus.
index (GI) scores were recorded which decreased signifi- Friskopp30 in a further study also noted cavities of
cantly in all groups. In group 2 the GI scores were signifi- noncalcified material of the ultrastructure of supragin-
cantly lowered and also there was significant reduction gival calculus, and subgingival deposits tended to be
in probing depth. It was also observed that there was more homogeneous.
a trend to gain of attachment in the treated areas, sug- Shirato et al31 reported the presence of tubular holes
gesting that removal of calculus led to improvement in in calculus. These holes appeared to be areas of uncalci-
gingival health.24 fied bacteria which is surrounded by calcified matrix.
Morrison et al25 in their 90 subjects examined the There were also areas where the bacteria were calcified
effects of initial, nonsurgical, periodontal treatment (the but were surrounded by a noncalcified space. All of the
hygienic phase) on the clinical severity of periodontitis in morphologic studies attest to the porous nature of the
pockets varying from l to >7 mm. The results showed that calculus deposits.
there is a significant reduction in inflammation follow- Patters et al32 assayed the bone resorbing activity
ing removal of the plaque and calculus deposits and the (using an organ culture system) and the presence of
improvement was great enough to call for reassessment antigens of Bacteroides gingivalis in plaque, calculus,
of the need for surgery in some instances. In evaluating cementum, and dentin obtained from roots of extracted
the various factors involved in the hygienic phase, it was teeth from patients with severe periodontitis. Significant
eminent that the changes in plaque scores could not be stimulation of bone resorption was found in the prepara-
correlated with attachment level gain and pocket depth tions from periodontally involved cementum and in all
reduction and the authors considered a very important samples of calculus. The levels of bone resorbing activity
to the success of the hygienic process is the significant were higher. This study provides the strongest evidence to
reduction in subgingival calculus. date of the pathogenic potential of subgingival calculus.32
Chawla et al26 investigated the effect of various dental An experimental study to know the permeability of
prophylaxis regimens in 1,605 subjects between the age human and rat dental calculus is done by Baumhammers
group of 12 and 26 over a period of 2 years. The results et al 28 in which they used a series of dyes, titrated
showed that scaling along with oral hygiene instructions endotoxin, and titrated glycine. The results showed that
at 6-month intervals provided the maximum benefit. the human calculus was partially permeated in one
Concluding, that the removal of bacterial plaque alone did hour and completely permeated by the dyes in 24 hours.
not show significant improvement in periodontal health Radioautographs showed progressive penetration
but the removal of calculus was directly correlated with of the titrated glycine and endotoxin with time. This
the improvement in periodontal health. They also spotted led to hypothesis that dental calculus can act as a reser-
out that this did not mean that regular oral hygiene mea- voir for irritating substances from microbial plaque and
sures are not important, but rather that “viable bacterial tissue lysis.
plaque, retained on and around the retention areas pro-
vided by calculus, unless removed, may not obviously INDICES USED FOR CALCULUS DETECTION33
be as effective.”
Oral Calculus Index (OCI) (Greene and
A morphologic study by Jones27 and Bauhammers
Vermilion, 1964)
et al 28 in their scanning electron microscopic (SEM)
studies observed the marked roughness of the outer It is the component of the oral hygiene index. An explorer
surface of calculus leading to retention of bacterial is used to estimate the surface area covered by supragin-
plaque. gival calculus and to probe for the subgingival calculus.33
A comparative st udy done by Friskopp and Scores are assigned according to the following criteria:
Hammarstrom29 used SEM in their study of supra- and • No calculus
subgingival calculus. The morphology of supra- and sub- • Supragingival calculus covering more than one-third
gingival calculus on extracted teeth was studied using of the exposed tooth surface
SEM. The differences were observed in the nature of • Supragingival calculus covering more than one-third
microbial coverings. Supragingival calculus is dominated but not more than two-thirds of tooth surface
by filamentous organisms, oriented at right angles to the • Supragingival calculus covering more than one-third
surface whereas subgingival calculus was covered by but not more than two-thirds of tooth surface and/or
cocci, rods, and filaments with no distinct pattern of ori- a continuous band of subgingival calculus.
entation. When sodium hypochlorite was used in some of After the scores for debris and calculus are recorded,
the specimens they lost their soft covering and channels the index values are calculated. For each individual, the
Journal of Health Sciences & Research, July-December 2016;7(2):42-50 47
Suchetha Aghanashini et al

debris scores are totaled and divided by the number of CALCULUS DETECTION
surfaces scored.
• Visual examination
– Gentle air blast
Calculus Index – CI (Ramfjord, 1959)
– Transillumination
The scores on calculus for each individual tooth examined – Gingival tissue color change
are added and the sum divided by the number of the teeth • Tactile examination
examined to yield the index on calculus. The following – Probe
teeth were selected as indicators 16, 21, 24, 36, 41, and 44. – Explorer
Calculus recorded as follows: • Radiographs
• No calculus
• Supragingival calculus extending only slightly below Visual Examination
the free gingival margin (not more than 1 mm)
Good lighting helps us to easily visualize supra- and
• Supragingival calculus covering more than one-third
subgingival calculus just below the gingival margin.
but not more than two-thirds of tooth surfaces
When light deposits of supragingival calculus are wet
• Supragingival calculus covering more than two-thirds
with saliva they are frequently difficult to visualize.
of exposed tooth surfaces.
Supragingival calculus can be dried using compressed
air until it is readily visible and chalky white. Air may
Calculus Surface Severity Index (CSI)
also be directed into the pocket in steady stream to visu-
(Ennener et al, 1961)
alize the subgingival deposits by deflection of gingival
The CSI assesses the presence or absence of calculus on margin away from the tooth surface.
the four surfaces of the four mandibular incisors. Each
surface is given a score of 1 for the presence of calculus Tactile Exploration
or 0 for the absence of calculus. Maximum score for each
Requires the skilled use of fine pointed explorer or probe.
subject is 16. In applying the scoring method, calculus was
The explorer is held with light but stable modified pen
considered to be present in any amount, supragingival
grasp. The pads of the thumb and the middle finger
or subgingival, and it could be detected either visually
should perceive the slight vibration conducted through
or by touch. If the examiner was uncertain about the
the shank.
presence of calculus on a given surface, the surface was
Fine-pointed explorer or probe is used for tactile
called calculus free.
sensation and is held with light but stable modified pen
grasp. Slight vibrations are perceived by pads of the
Calculus Rating (Volpe and Manhold, 1962)
thumb and the middle fingers through the shank.
Calculus formation in vivo is performed using a colored Method: First, a stable finger rest is established and
periodontal probe placed against the lingual surface of then the instrument tip is inserted to the pocket depth.
the anterior tooth that will be scored with the probe and In a vertical direction light exploratory strokes are acti-
placed at the most inferior border of any calculus present. vated. On contact with the calculus, the tip of probe is
When the different colors at the probe end represent units, advanced more apically till the termination of calculus is
the amount of calculus present can be measured: felt on root surface. Generally, 0.2 to 1.0 mm is the distance
• U – No calculus appreciated between apical edge of calculus and bottom
• U – 1 mm of calculus of the pocket. Proximal surfaces when explored with an
• U – 2 mm of calculus instrument tip, it should be extended at least halfway
• U – 3 mm of calculus across the surface past the contact area.
• U – 4 mm of calculus
Radiographs
Marginal Line Calculus Index (MLC-I)
Interproximal calculus, a highly calcified deposit, can
(Muhlanann and Villa, 1967)
readily be detected as radiopaque projections protruding
• No calculus into the interdental space. The apical location of plaque is
• Calculus observable, but less than 0.5 mm in width not sufficiently calcified to be visible on radiograph, so the
and/or thickness calculus location does not indicate bottom of periodon-
• Calculus not exceeding 1 mm in width and/or tal pocket. Hence, conventional oral radiography was
thickness a poor diagnostic method for the detection of calculus
• Calculus exceeding 1 mm in width and/or thickness. (Buchanan et al, 1987).

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ADVANCE DIAGNOSTIC AIDS implant surface modifications subsequent to the application

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caries in young adult males. Suom Hammaslaak Toim
CONCLUSION 1970;66(6):301-364.
15. Alexander AG. A study of the distribution of supra and
While the bacterial plaque that coats the teeth is the subgingival calculus, bacterial plaque and gingival inflam-
chief causative factor in the initiation and progression of mation in the mouths of 400 individuals. J Periodontol 1971
periodontal disease, the removal of subgingival plaque Jan;42(1):21-28.
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17. Lennnon, MA.; Clerehugh, V. The identification of teenage
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