In dentistry

Dentistry

Dentistry is the branch of medicine that is involved in the study, diagnosis, prevention, and treatment of diseases, disorders and conditions of the oral cavity, maxillofacial area and the adjacent and associated structures and their impact on the human body. Dentistry is widely considered...

, calculus or tartar is a form of hardened dental plaque

Dental plaque

Dental plaque is a biofilm, usually a pale yellow, that develops naturally on the teeth. Like any biofilm, dental plaque is formed by colonizing bacteria trying to attach themselves to a smooth surface...

. It is caused by the continual accumulation of minerals from saliva on plaque on the teeth. Its rough surface provides an ideal medium for further plaque formation, threatening the health of the gingiva

Gingiva

The gingiva , or gums, consists of the mucosal tissue that lies over the mandible and maxilla inside the mouth.-General description:...

.

Brushing and flossing can remove plaque from which calculus forms; however, once formed, it is too hard and firmly attached to be removed with a toothbrush. Calculus buildup can be professionally removed with ultrasonic tools and specialized sharp instruments

Periodontal scaler

Periodontal scalers are dental instruments used primarily in the prophylactic and periodontal care of human teeth. The working ends come in a variety of shapes and sizes, but they are always narrow at the tip, so as to allow for access to narrow embrasure spaces between teeth...

 during a dental visit.

Etymology

Calcis, in Greek

Greek language

Greek is an independent branch of the Indo-European family of languages. Native to the southern Balkans, it has the longest documented history of any Indo-European language, spanning 34 centuries of written records. Its writing system has been the Greek alphabet for the majority of its history;...

, was a term used for various kinds of stones, coming from the term for limestone. This spun off many modern words, including "calculate" (use stones for mathematical purposes), and "calculus", which came to be used, in the 18th century, for accidental or incidental mineral buildups in human and animal bodies, like kidney stones and minerals on teethhttp://www.etymonline.com/index.php?term=calculus&allowed_in_frame=0.

Tartar, on the other hand, originates in Greek as well, but as the term for the white encrustation inside casks, aka potassium bitartrate

Potassium bitartrate

Potassium hydrogen tartrate, also known as Potassium bitartrate, has formula KC4H5O6, is a byproduct of winemaking. In cooking it is known as cream of tartar. It is the potassium acid salt of tartaric acid, a carboxylic acid.-Occurrence:...

 commonly known as cream of tartar. This came to be a term used for calcium phosphate

Calcium phosphate

Calcium phosphate is the name given to a family of minerals containing calcium ions together with orthophosphates , metaphosphates or pyrophosphates and occasionally hydrogen or hydroxide ions ....

 on teeth in the early 19th centuryhttp://www.etymonline.com/index.php?term=tartar&allowed_in_frame=0.

Clinical significance

Plaque

Dental plaque

Dental plaque is a biofilm, usually a pale yellow, that develops naturally on the teeth. Like any biofilm, dental plaque is formed by colonizing bacteria trying to attach themselves to a smooth surface...

 accumulation causes the gingiva

Gingiva

The gingiva , or gums, consists of the mucosal tissue that lies over the mandible and maxilla inside the mouth.-General description:...

 to become irritated and inflamed, and this is referred to as gingivitis

Gingivitis

Gingivitis is a term used to describe non-destructive periodontal disease. The most common form of gingivitis is in response to bacterial biofilms adherent to tooth surfaces, termed plaque-induced gingivitis, and is the most common form of periodontal disease...

. When the gingiva become so irritated that there is a loss of the connective tissue

Connective tissue

"Connective tissue" is a fibrous tissue. It is one of the four traditional classes of tissues . Connective Tissue is found throughout the body.In fact the whole framework of the skeleton and the different specialized connective tissues from the crown of the head to the toes determine the form of...

 fibers

Gingival fibers

The gingival fibers are the connective tissue fibers that inhabit the gingival tissue adjacent to teeth and help hold the tissue firmly against the teeth...

 that attach the gums to the teeth and bone that surrounds the tooth, this is known as periodontitis. Because dental plaque is the sole cause of periodontitis, it is referred to as the primary aetiology. Plaque that remains in the oral cavity long enough will eventually calcify and become calculus. Calculus is detrimental to gingival health because it serves as a trap for increased plaque formation and retention; thus, calculus, along with everything else that causes a localized build-up of plaque, is referred to as a secondary etiology of periodontitis.

Calculus can form both along the gumline, where it is referred to as supragingival ("above the gum"), and within the narrow sulcus

Gingival sulcus

The gingival sulcus is an area of potential space between a tooth and the surrounding gingival tissue and is lined by sulcular epithelium. The depth of the sulcus is bounded by two entities: apically by the gingival fibers of the connective tissue attachment and coronally by the free gingival...

 that exists between the teeth and the gingiva, where it is referred to as subgingival ("below the gum"). Calculus formation can result in a number of clinical manifestations, including bad breath

Halitosis

Halitosis is a term used to describe noticeably unpleasant odors exhaled in breathing. Halitosis is estimated to be the third most frequent reason for seeking dental aid, following tooth decay and periodontal disease.- General :...

, receding gums

Receding gums

Receding gums refers to exposure in the roots of the teeth caused by a loss of gum tissue and/or retraction of the gingival margin from the crown of the teeth. Gum recession is a common problem in adults over the age of 40, but it may also occur starting from the teens...

 and chronic

Chronic (medicine)

A chronic disease is a disease or other human health condition that is persistent or long-lasting in nature. The term chronic is usually applied when the course of the disease lasts for more than three months. Common chronic diseases include asthma, cancer, diabetes and HIV/AIDS.In medicine, the...

ally inflamed gingiva.

When plaque is supragingival, the bacterial content consists mostly of aerobic bacteria and yeast

Yeast

Yeasts are eukaryotic micro-organisms classified in the kingdom Fungi, with 1,500 species currently described estimated to be only 1% of all fungal species. Most reproduce asexually by mitosis, and many do so by an asymmetric division process called budding...

, or those bacteria which utilize and can survive in an environment containing oxygen

Oxygen

Oxygen is the element with atomic number 8 and represented by the symbol O. Its name derives from the Greek roots ὀξύς and -γενής , because at the time of naming, it was mistakenly thought that all acids required oxygen in their composition...

. Subgingival plaque, however, is composed mainly of anaerobic bacteria, or those bacteria which cannot exist in an environment containing oxygen. Anaerobic bacteria are especially dangerous to the gingiva and the gingival fibers

Gingival fibers

The gingival fibers are the connective tissue fibers that inhabit the gingival tissue adjacent to teeth and help hold the tissue firmly against the teeth...

 that attach the teeth to the gums, leading to periodontitis. Calculus tartar paste is commonly exhibited by humans. Almost all individuals with periodontitis exhibit considerable subgingival calculus deposits. These anaerobic bacteria have been linked to cardiovascular disease and mothers giving birth to pre-term low weight babies, but there is no conclusive evidence yet that periodontitis is a significant risk factor for either of these two conditions.

Prevention

The best way to prevent the build up of calculus is through twice daily toothbrushing and flossing

Dental floss

Dental floss is made of either a bundle of thin nylon filaments or a plastic ribbon used to remove food and dental plaque from teeth. The floss is gently inserted between the teeth and scraped along the teeth sides, especially close to the gums. Dental floss may be flavored or unflavored, and...

 and regular cleaning visits based on a schedule recommended by the dental health care provider. Calculus accumulates more easily in some individuals, requiring more frequent brushing and dental visits. There are also some external factors that facilitate the accumulation of calculus, including smoking

Smoking

Smoking is a practice in which a substance, most commonly tobacco or cannabis, is burned and the smoke is tasted or inhaled. This is primarily practised as a route of administration for recreational drug use, as combustion releases the active substances in drugs such as nicotine and makes them...

 and diabetes

Diabetes mellitus

Diabetes mellitus, often simply referred to as diabetes, is a group of metabolic diseases in which a person has high blood sugar, either because the body does not produce enough insulin, or because cells do not respond to the insulin that is produced...

. While toothpaste

Toothpaste

Toothpaste is a paste or gel dentifrice used with a toothbrush as an accessory to clean and maintain the aesthetics and health of teeth. Toothpaste is used to promote oral hygiene: it serves as an abrasive that aids in removing the dental plaque and food from the teeth, assists in suppressing...

 with an additive ingredient of zinc citrate has been shown to produce a statistically significant

Statistical significance

In statistics, a result is called statistically significant if it is unlikely to have occurred by chance. The phrase test of significance was coined by Ronald Fisher....

 reduction in plaque accumulation, it is of such a small degree that its clinical importance is questionable.

Sub-gingival calculus formation and chemical dissolution

Sub-gingival calculus (tartar) is composed almost entirely of two components: fossilized anaerobic bacteria whose biologic composition has been replaced by calcium phosphate

Calcium phosphate

Calcium phosphate is the name given to a family of minerals containing calcium ions together with orthophosphates , metaphosphates or pyrophosphates and occasionally hydrogen or hydroxide ions ....

 salts, and calcium phosphate salts that have joined the fossilized bacteria in calculus formations. The initial attachment mechanism and the development of mature calculus formations are based on electrical charge. Unlike calcium phosphate, the primary component of teeth, calcium phosphate salts exist as electrically unstable ions. The following minerals are detectable in calculus by X-ray diffraction: brushite

Brushite

Brushite is a mineral with the chemical formula . It is believed to be a precursor of apatite and is found in guano-rich caves, formed by the interaction of guano with calcite and clay at a low pH. Brushite was first described in 1865 and named for the American mineralogist George Jarvis Brush...

, octacalcium phosphate

Octacalcium phosphate

Octacalcium phosphate is a calcium phosphate with a formula Ca8H26.5H2O. OCP may be a precursor in creation of the tooth enamel, dentine and bones in living organisms....

, magnesium-containing whitlockite

Whitlockite

Whitlockite is a mineral, an unusual form of calcium phosphate. Its formula is Ca96PO3OH. It is a relatively rare mineral but is found in granitic pegmatites, phosphate rock deposits, guano caves and in chondrite meteorites...

, and carbonate-containing hydroxyapatite.

The reason fossilized bacteria are initially attracted to one part of the subgingival tooth surface over another is not fully understood; once the first layer is attached, ionized calculus components are naturally attracted to the same places due to electrical charge. The fossilized bacteria pile on top of one another, in a rather haphazard manner. All the while, free-floating ionic components fill in the gaps left by the fossilized bacteria. The resultant hardened structure can be compared to concrete; with the fossilized bacteria playing the role of aggregate, and the smaller calcium phosphate salts being the cement. The once purely electrical association of fossilized bacteria then becomes mechanical, with the introduction of free-floating calcium phosphate salts. The “hardened” calculus formations are at the heart of periodontal disease and treatment.