Log in Register

Login to your account

Username *
Password *
Remember Me

Create an account

Fields marked with an asterisk (*) are required.
Name *
Username *
Password *
Verify password *
Email *
Verify email *
Captcha *

Captcha Image Reload image challenge


Periodontics

Authors: Dr. Sohini Banerjee

Abstract

Dental calculus consists of mineralized bacterial plaque that form on the surfaces of natural teeth and dental prostheses. Although the primary cause of gingival inflammation is bacterial plaque, dental calculus act as a major predisposing factor. This case report will highlight a case of female patient with chronic generalised periodontitis having a giant calculus like deposits within the oral cavity.

Key words: Dental calculus, chronic periodontitis, giant calculus

Introduction:

Dental calculus consists of mineralized bacterial plaque that form on the surfaces of natural teeth and dental prostheses.1-4Although the primary cause of gingival inflammation is bacterial plaque, dental calculus act as a major predisposing factors of gingival and periodontal diseases. It may be of two types namely supragingival (located coronal to gingival margin), subgingival (located below the gingival margin).1-3 However, the two most common locations for supragingival calculus are the buccal surfaces of maxillary molars and the lingual surfaces of mandibular anterior teeth.3 The term ‘calculus’, basically implies accidental or incidental mineral build-ups within the human bodies like kidney stones and minerals on teeth.4,5 Supragingival calculus consists of both inorganic (70-90%) and organic components.4 The major inorganic portion consists of 76% calcium phosphate, Ca3(PO4)2; 3% calcium carbonate, CaCO3; and traces of magnesium phosphate, Mg3(PO4)2; and other metals.5 The major inorganic components are crystalline in nature namely hydroxyapatite(58%), magnesium whitlockite, octacalcium phosphate, brushite.4 The organic component of calculus consists of a mixture of protein-polysaccharide complexes, desquamated epithelial cells, leukocytes etc. However, the composition of subgingival calculus is similar to that of supragingival calculus with little difference such as same hydroxyapatite with less brushite and octacalcium phosphate.4

Fig.1. Intra-oral view of the patient Fig.2. Large calculus mass within the oral cavity
Fig.1. Intra-oral view of the patient Fig.2. Large calculus mass within the oral cavity

This case report will highlight a case of female patient with chronic generalised periodontitis having a giant calculus like deposits within the oral cavity.

Case Report:

A female patient aged 29 years reported to the department with chief complaint of bleeding from gums along with discomfort on lower anterior teeth region for last six months. On general examination, patient was found to be systematically healthy. On enquiring, she stated that she brushes twice daily with toothpaste and tooth brush. On examination, patient’s oral hygiene was found to be very poor with large deposits of calculus covering almost all of the crown surfaces of visible upper anterior teeth (Fig.1).Ulceration was noted on lower lip. On the lingual surfaces of lower anterior teeth a large deposit of calculus (measuring almost 5cm x7cm) was found to cover all of the tooth surfaces extending up to the floor of the mouth (Fig.2).The mass was found to be round to oval in shape having a yellowish coating over it. The gingiva was found to inflamed, edematous with tendency to bleed on provocation .The probing pocket depth was found to be around 3-5 mm all around the arch. The large mass was surgically excised with the help of chisel and mallet (Fig.3).The patient was then instructed to undergo through oral prophylaxis treatment. Patient was advised to follow up proper oral hygiene instructions and was put on maintenance therapy (Fig.4& Fig.5). The patient was reported to the department on follow-up visits after one month and was found to be doing well with proper maintenance of oral hygiene.

Discussion:
Fig.3. Calculus mass excised from the oral cavity Fig.4. Intra-oral lingual view after oral prophylaxis
Fig.3. Calculus mass excised from the oral cavity Fig.4. Intra-oral lingual view after oral prophylaxis

Dental calculus consists of mineralized bacterial plaque that forms on the surfaces of natural teeth and dental prostheses.1-4 The soft plaque is hardened by precipitation of mineral salts between 1st and 14th days of plaque formation.4 Fifty percent mineralization occurs in first 2 days and 60 to 90% in 12 days.4 Calcification entails the binding of calcium ions to the carbohydrate –protein complex of the organic matrix and the precipitation of crystalline calcium phosphate salts.4 Calcification of supragingival plaque and in attached component of subgingival plaque begin along the inner surface adjacent to the tooth. Separate foci of calculus usually coalesce to form large solid masses of calculus.4 However, saliva is the source of mineralization for supragingival calculus. Saliva from the parotid gland flows over the facial surfaces of upper molars through Stenson’s duct, whereas the orifices of Wharton’s duct and Bartholin’s duct empty onto lingual surfaces of the lower incisors from the submandibular and sublingual glands, results in formation of calculus in poor hygiene cases.1,4,5

In this case, female patient aged 29 years reported to the department with chief complaint of bleeding from gums along with discomfort on lower anterior teeth region for last six months. Patient’s oral hygiene was found to be poor. On the lingual surfaces of lower anterior teeth a large deposit of calculus (measuring almost 5cm x7cm) was found to cover all of the tooth surfaces extending up to the floor of the mouth. After surgical removal of the mass with chisel and mallet patient was undergone through oral prophylaxis treatment and was put on follow up visits. Although it was reported by the patient and her family members that she was brushing her tooth twice daily since her childhood, but it was not corroborating at all with her poor oral hygiene status. It might be possible that patient was not following proper oral hygiene methods to clean her teeth and oral cavity. The most surprising part is that the patient is completely un-aware about the situation of having a large mass within the oral cavity. Therefore, poor oral hygiene maintenance was a major causative factor of large calculus mass within the oral cavity. Moreover, the ductal opening of sublingual and submandibular salivary gland were near to the location of large calculus mass.1 Therefore, more precipitation and deposition of calcium and phosphate ion might also be a possible cause of this large mass of calculus along with poor oral hygiene status. Even, the qualitative nature of thick, viscous saliva of submandibular salivary glands might be an addition reason to this case.1,4

Fig.5. Intra-oral buccal view after oral prophylaxis
Fig.5. Intra-oral buccal view after oral prophylaxis

Conclusion:

Periodontal diseases are highly prevalent characterized by signs and symptoms of gingival inflammation and periodontal tissue destruction. Although, dental plaque is the primary cause of periodontal disease, dental calculus which is a mineralised bacterial plaque act as a major precipitating factor. Proper oral hygiene instructions along with oral hygiene maintenance is necessary to prevent the formation of large calculus mass within the oral cavity along with professional recall visits to the dental surgeons.

References:
  1. Bahadure RN, Thosar N, Jain ES. Unusual case of calculus in floor of the mouth: A Case Report. Int J Clin Pediatr Dent 2012; 5(3):223-225.
  2. Tan B, Sun W, Han N, Yang Z. Chronic Apical Periodontitis with Calculus-like Mineral Deposit on the Root Apex: A Case Report. OHDM, December, 2014;13(4):1100-1105.
  3. Dawes C. Recent research on calculus,N Zealand Dent J1998;94:60.
  4. Newman MG, Takei HH.; Klokkevold PR,Carranza FA, Odont, DR. The role of dental calculus and other predisposing factors. In: Hinrichs James E, editor. Carranza’s clinical periodontology. 10th ed. 2007. 170 p.
  5. Clayton YM, Fox EC. Investigations into the mycology of dental calculus in town-dwellers, agricultural workers and grazing animals. J Periodontol 1973 May;44(5):281-285.