Dental Calculus

Dental calculus (tartar) is calcified dental plaque that forms on teeth and prostheses when plaque minerals from saliva or gingival crevicular fluid precipitate as calcium phosphate crystals. It acts as a plaque retaining surface, cannot be removed by brushing or flossing, and contributes to gingivitis and periodontitis.

• Supragingival calculus: forms above the gum margin, is cream or yellow and hard, derived from saliva, and forms most at the lingual surfaces of lower incisors and the buccal surfaces of upper molars (opposite the salivary duct openings).
• Subgingival calculus: forms within periodontal pockets, is dark brown or black, harder and more firmly attached, and derived from blood breakdown and gingival fluid.
• Mineralisation begins within 24 to 72 hours of plaque formation and matures in 1 to 12 weeks; the rate varies between people (heavy formers).
• Risk factors: poor plaque control, high salivary calcium and pH, dehydration, smoking, tobacco chewing and betel nut use, crowding, mouth breathing, diabetes, and certain medicines.

• Hard yellow, brown or black deposits on teeth, often with rough surfaces felt by the tongue.
• Bad breath, bleeding or swollen gums, gum recession in advanced disease, deep pockets, and loose teeth; painless in most cases.
• Staining of the deposit from tea, coffee, tobacco, betel nut and chlorhexidine.
• Associated signs: gingival inflammation, periodontal pockets, bone loss on radiographs, halitosis and sometimes periodontal abscess.

• Clinical inspection and probing: calculus is detected by probing (a ledge with a fine explorer) and by the roughness of the root surface; air drying the tooth shows the supragingival deposits.
• Radiographs: bitewings show interproximal calculus and bone levels; periapical or panoramic radiographs when pockets are 5 mm or more.
• Periodontal examination: pocket depths, bleeding on probing, attachment loss, and mobility; basic periodontal examination scores each sextant to decide on referral (a pocket of 6 mm or more, or code 4, warrants a full periodontal assessment).
• Check diabetes (HbA1c), smoking, and medicines.
• Differentials: stain, food impaction, materia alba, enamel hypoplasia, root caries, and fluorosis.

Professional removal (the only effective treatment)

• Scaling with ultrasonic instruments (piezoelectric or magnetostrictive) and hand scalers, followed by polishing with a rubber cup and fine paste; subgingival calculus needs root surface debridement with curettes under local anaesthetic, using lidocaine 2 percent with adrenaline 1 in 80 000 (1.8 mL per quadrant) or topical lidocaine prilocaine gel in the pocket.
• Perform in sessions by quadrant or half mouth; reassess pockets and bleeding 4 to 8 weeks later; repeat debridement for residual pockets of 4 mm or more.

Home care after scaling

• Brush twice daily for 2 minutes with fluoride toothpaste 1350 to 1500 ppm; clean between teeth every day with interdental brushes or floss; use an electric toothbrush.
• Anti-tartar toothpaste (pyrophosphates, zinc citrate, or zinc oxide) reduces new calculus by 20 to 30 percent but does not remove existing calculus.
• Chlorhexidine 0.2 percent mouthwash 10 mL twice daily for up to 2 weeks after scaling if hygiene is difficult.
• Sensitivity after scaling: desensitising toothpaste (potassium nitrate 5 percent) and avoid cold and acidic foods for 2 to 4 weeks.
• Analgesia if needed: paracetamol 1 g or ibuprofen 400 mg.

Risk factor control

• Stop smoking and tobacco chewing; optimise diabetes control; treat dry mouth; stay hydrated.
• Maintenance scaling every 3 to 6 months for heavy formers or for periodontitis; every 6 to 12 months in others.

Antibiotics and medical conditions

• Antibiotics are not required for routine scaling; give them only for acute periodontal abscess with spreading infection (amoxicillin 500 mg orally three times daily for 5 days, with metronidazole 400 mg three times daily for 5 days if severe).
• Antibiotic prophylaxis before scaling is no longer advised for most patients with heart valve disease, but is considered for patients at the highest risk of infective endocarditis (for example previous endocarditis, prosthetic valves) after specialist cardiology input.
• Anticoagulants (warfarin with an INR below 4, direct oral anticoagulants) usually continue; use local haemostatic measures; consider tranexamic acid 5 percent mouthwash 10 mL four times daily for 2 days in patients with bleeding problems.

Referral

• Dental or periodontal referral for pockets of 5 mm or more, furcation involvement, tooth mobility, recurrent abscess, rapidly progressive bone loss, or young patients with severe disease.