Calculus deposits that adhere subgingivally, that is, below the gingival margin (the gum line) to the surfaces of the tooth roots, are called calculi. They mechanically irritate the soft tissues of the periodontium (the tooth-supporting apparatus) and promote the adhesion of microorganisms, whose toxins (bacterial poisons) can trigger the development of periodontitis (inflammation of the tooth-supporting apparatus). Consequently, the removal of tartar from under the gum line is an essential prerequisite for the treatment and prevention of periodontitis. Tartar refers to firmly adhering deposits hardened by the storage of minerals. They can no longer be removed with a toothbrush and other aids for daily oral hygiene. Mineralized deposits that adhere along or above the gingival margin to the tooth neck and crown are called supragingival calculus. This arises from biofilm (plaque, bacterial plaque), which is not removed by a toothbrush and other aids, and into which minerals from saliva are deposited. The mineral content is about 40%. The minerals in subgingival tartar – the so-called calculus – which is firmly attached to the root surface in the gingival pocket, originate from the exudate (secretions) of the gingival pocket. Here, the mineral content is significantly higher at 60% and calculus adheres to the tooth root much more firmly than supragingival calculus. They prevent the gingival margin and pocket epithelium from attaching to the root surface and thus promote further penetration of the biofilm into the gingival pockets. As the depth of the gingival pockets increases, more anaerobic (without oxygen) microorganisms thrive there. These produce toxins (bacterial poisons) which lead to gingivitis (inflammation of the gums) and, in the further course, to periodontitis – an inflammatory process which, in addition to inflammation of the connective tissue parts of the periodontium, is accompanied by destruction of the alveolar bone (the bone surrounding the tooth root). Attachment loss (loss of attachment) is the result.
Indications (areas of application)
Thus, calculus removal is a mechanical infection control procedure with the goal of eliminating periodontal biofilm (microorganisms in the gingival pocket) and thus preventing or reversing the development of periodontitis. If attachment loss has already occurred, i.e., loss of alveolar bone and periodontal ligament (connective tissue fibrous apparatus between the tooth surface and bone), attachment gain after elimination of the inflammatory process is the goal of calculus removal.
- Periodontitis with supra-alveolar (ending above the bony tooth compartment) gingival pockets.
- Pockets with probing depths less than 6 mm.
- Single pockets on single-rooted teeth with probing depths greater than 6 mm.
Contraindications
- Intraalveolar pockets (extending into the bony tooth socket) that can only be curetted (scraped out) under visual control
- Endocarditis risk (risk of inflammation of the inner lining of the heart).
- Immunosuppression (process that suppresses immunological processes).
- Blood clotting disorders
- Other systemic diseases that prohibit surgical intervention.
Before the procedure
The removal of calculus can only be successful if after cleaning can prevent the re-accumulation of mineralized plaque. For this purpose, the patient must be instructed in advance to improve his or her oral hygiene technique, which must be permanently changed and optimized. Regular appointments for professional tooth cleaning (PZR) support him in this. However, the focus is inevitably on the daily routine at home. X-rays can be used to assess the extent to which periodontal inflammation (of the periodontium) has already led to the loss of alveolar bone (bony alveolus: surrounds the root of the tooth). The PSI (Periodontal Screening Index) survey is used to assess the state of inflammation and the depth of gingival pockets.
The procedures
The removal of biofilm and supra- and subgingival calculus is called scaling. Any remaining tartar particles and roughness are then leveled in a procedure called root planing.The aim of surface treatment is to achieve a root surface that is as smooth as possible and offers new mineral deposits, the biofilm and the toxins it produces fewer retention opportunities (hold). At the same time, deep pockets and anatomical features of the roots make it difficult to access all root surfaces in any procedure. In addition, scaling and root planing must be performed without direct vision in non-surgical periodontal treatment. Full mouth scaling involves complete treatment within 24 hours without antiseptic (germicidal agent) or tongue cleaning. The success of scaling is less dependent on the procedure used, but rather on the care and systematic approach with which each surface of each tooth is treated. I. Hand scaling
For the conventional removal of hard plaque by hand, special hand instruments are used and resharpened for each use. Scalers have a cross-sectionally triangular, tapered cutting edge and are generally used for supragingival calculus. The spoon-shaped working ends of curettes provide a larger contact surface and are used for subgingival root work. While the working end of universal curettes is sharpened on both sides, the cutting edges of Gracey curettes have only one sharpened side each, which is intended for contact with the root surface. These instruments are specially designed for specific tooth surfaces with appropriate angulations at the working ends and shank. The working ends of scalers and curettes must be applied to the tooth surface at a defined angle, which is between 60° and 80° depending on the instrument. The working end, which is inserted into the gingival pocket and correctly applied, is pulled off from apical to coronal (from the root to the tooth crown) while maintaining the contact pressure. The processed paths must overlap slightly. All root surfaces are systematically cleaned in sequence. II. ultrasonic scaling
Ultrasonic scaling is performed using high-frequency oscillating working tips in the range of 20 to 40 kHz. The instrument tips are usually made of metal, but carbon tips are also used in the Vector method. The oscillating approach removes the mineral deposits by hammering movements against the tooth surface. All instruments oscillate along the instrument axis. The amplitudes of the deflection are very low, ranging from 12 to 80 μm. The working tips are designed to direct water, saline or disinfectant solutions into the gingival pocket – primarily to prevent thermal damage to the hard and soft tissues by frictional heat, with simultaneous pocket rinsing being a very welcome side effect perfected by the possibility of disinfectant additives. As with hand scaling, placing the working tip at the correct angle to the tooth surface is important to prevent damage to the tooth structure. However, in ultrasonic scaling, the working tip is guided along the tooth surface at an angle of only 0° to 10° under a minimum contact pressure of 3 N in a continuous movement. Unlike hand instruments, ultrasonic tips are only in contact with the tooth in a punctiform manner, which results in a different working pattern: the tooth surfaces are not scaled in longitudinal paths, but are covered in a grid-like manner with movements in longitudinal and transverse directions. III. laser scaling
When using dental lasers, it is first of all mandatory to wear the protective goggles specific to the application in question in order to prevent eye damage to patients and the treatment team. The high technical effort and specialized further training mean that the use of lasers by dentists is generally the exception rather than the rule. In addition, tartar and calculus cannot yet be specifically removed under practice conditions with most current laser systems. However, results with lasers in the 3 μm range, such as the Er:YAG laser, are promising, even though the root surfaces remain quite rough. Nevertheless, the attachment gain is comparable to the result of conventional scaling with hand instruments or ultrasound.
After the procedure
Immediately following mechanical removal of the calculus is chemical pocket decontamination. This is usually performed with a CHX rinse (chlorhexidine digluconate).A long-term depot can be placed in selected pockets with an antibacterial chip that releases the same active ingredient over a period of about ten days. The procedure is followed by supportive periodontal therapy (UPT) with its recalls (progress checks), the intervals of which are usually three to six months. The PSI (Periodontal Screening Index) survey contributes to the assessment of pocket depths and inflammation status, and professional tooth cleaning (PZR) and refresher training on oral hygiene techniques serve to stabilize long-term results.