harsukh educational charitable society international journal of...

Mangla C. Caculus Detection Tools.

53 HECS International Journal of Community Health and Medical Research |Vol. 4|Issue 3| July- Sept 2018

Harsukh Educational Charitable Society International Journal of Community Health and Medical Research

Journal home page: www.ijchmr.com doi: 10.21276/ijchmr

Official Publication of “Harsukh Educational Charitable Society” [Regd.]

Review Article

Calculus Detection Tools- A Review Chhaya Mangla M.D.S. (Periodontology), Former Senior Lecturer, Adesh Institute Of Dental Sciences And Research, Bathinda, Punjab. ABSTRACT Background: Bacterial plaque and calculus are accepted etiological agents in the initiation and progression of periodontal disease. Their accumulation and attachment are facilitated by a roughened root surface. The rough calculus surface may not, in itself, induce inflammation in the adjacent periodontal tissues, but may serve as an ideal substrate for subgingival microbial colonization. Many techniques have been used to identify and remove calculus deposits present on the root surface. The purpose of this review is to compile the various methods and their advantages for the detection and removal of calculus. Key words: Calculus, Diagnosis, Periodontal Disease, Scaling, Root Planning. Corresponding Author: Dr. Chhaya Mangla, , M.D.S. (Periodontology), Former Senior Lecturer, Adesh Institute Of Dental Sciences And Research, Bathinda, Punjab. This article may be cited as: Mangla C. Calculus Detection Tools- A Review. HECS Int J Comm Health Med Res 2018; 4(3):53-58.

NTRODUCTION Periodontal disease is a common, complex multifactorial disease characterized by the destruction of periodontal tissues and loss of connective tissue attachment. Bacterial plaque is the main etiological factor implicated in the

etiology of periodontal disease. So, the removal of this bacterial biofilm is a decisive factor in the prevention as well as the treatment of this disease.1A continuous exchange of ions is always happening on the tooth surface with a constant exchange of calcium and phosphate ions. This leads to formation of calculus which in turn can aggravate the disease process.2,3,4 Nevertheless, periodontal destruction is clearly related to the very presence of calculus, which may extend the range ofdamage associated with plaque microorganisms.3,5,6Current subgingival root debridement techniques involve the systematic treatment of all diseased root surfaces by hand, sonic, and/or ultrasonic instruments. This step is followed by tactile perception with a periodontal probe, explorer, or curette, until the root surface feels smooth and clean. The drawback of traditional tactile perception of the subgingival environment is that the clinician may lack visibility and accessibility before and after treatment, leading to residual calculus and/or the undesirable removal of cementum. The location and inflammatory status of the gingiva also impact the detection and subsequent removal of deep-seated calculus.7 The proper evaluation of a smooth and clean root surface is essential to enable a thorough and substance sparing debridement.8 Clinicians are often uncertain about the nature of the subgingival root surface

while performing periodontal instrumentation. The aim of this article is to provide a review of tools and devices based on currently available clinical and experimental data. Calculus :

Calculus is a porous substance that can adsorb a variety of toxic products and retain significant levels of endotoxin, which itself can damage tissue.9 These toxins are located on, not within, periodontally diseased root surfaces.Calculus can be defined as a hard concretion that forms on teeth or dental prostheses through calcification of bacterial plaque.Depending upon its location calculus can be classified as either subgingival or supragingival. Various studies carried out to reveal the presence of calculus have shown that calculus is present in 70-100% cases. These studies do not discriminate between supra and subgingival calculus but they indicate high prevalence of calculus in all studied populations. Calculus is primarily composed of calcium phosphate salts covered by an unmineralized bacterial layer. Inorganic content of calculus matches that of bone, dentine and cementum. It mainly consists of dicalcium phosphate dehydrate, octacalcium phosphate, substituted hydroxyapatite and magnesium substituted Tricalcium phosphate (whitlockite). Structure of calculus largely resembles that of dentine, which is porous in nature. Hence it can provide a safe-house for bacteria.10

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Role of calculus in etiology of periodontal disease: Periodontal inflammation precedes formation of calculus. A considerable increase in gingival crevicular fluid (GCF) flow is necessary for formation of subgingival calculus. Mineral content of supra and subgingival calculus is derived from saliva and GCF respectively. Unmineralized layer of bacteria is always present on surface of calculus, which makes it difficult to determine whether calculus or the bacterial plaque is responsible for initiation of disease.11Early studies in experimental animals reported that autoclaved calculus does not cause a pronounced inflammation or abscess formation in the connective tissues12 and also provided evidence that a normal epithelial attachment can be formed on the calculus surface which has been treated with chlorhexidine.13 These studies clearly exclude the possibility of dental calculus as a primary cause of periodontal diseases. The effect of calculus seems to be secondary by providing an ideal surface configuration conducive to further plaque accumulation and subsequent mineralization. Calculus deposits may have developed in areas with difficult access for the oral hygiene or may jeopardize proper oral hygiene practices due to the size of the deposits. Calculus may also amplify the effects of bacterial plaque by keeping the bacterial deposits in close contact with the tissue surface, thereby influencing both the bacterial ecology and the tissue response.14 The non-mineralised plaque on the calculus surface is the primary irritant, but the underlying calcified portion may be a significant contributing factor. It provides a fixed nidus for the continued accumulation of plaque and retains it close to gingiva. Schroeder (1969) concluded, “Initial damage to the gingival margin is presumably due to immunological (antigen) and/or enzymatic effects caused by microorganisms of the plaque. This process is enhanced by the formation of supra and subgingival calculus, which provides further retention and thus promotes new plaque accumulation. Calculus itself does not cause pocket formation but in turn favours and promotes the chronicity of inflammation and thus contributes towards making it progressively worse.15 Several animal and clinical studies have shown that the diligent and complete removal of the subgingival plaque on the top of the subgingival calculus will result in the healing of periodontal lesions and maintenance of healthy gingival and periodontal tissues. These studies have clearly elucidated the role of subgingival calculus as plaque-retentive factor.8 Success of phase I therapy in halting the disease process and advent of toothpastes containing anti-calculus agents have renewed the interest in role of calculus in disease process.15 Tools to detect calculus: Clinicians are often uncertain about the nature of a subgingival root surface while performing periodontal instrumentation. The correct evaluation of a cleaned surface is key to enable thorough and substance- sparing debridement. To support the clinician‘ s decision to either stop or continue therapy, the past few years have witnessed the development of several calculus-detection techniques based on different technologies.9

1. Conventional method: • The supragingival calculus can be directly observed and

amount measured with a calibrated probe.

• For the detection of subgingival calculus, each tooth surface is carefully checked to the level of gingival attachment with a sharp no. 17 or no. 3A explorer. Warm air may be used to deflect the gingiva and aid in visualization of calculus.( Fig. 1)

• Although radiographs may sometimes reveal heavy calculus deposits interproximally and even on facial and lingual surfaces, it cannot be used reliably for the thorough detection of calculus.Highly calcified proximal calculus deposits are readily detectable as radio-opaque projections that protrude into the interdental space. However, the sensitivity level of calculus detection by radiographs is low.(Fig 2)

• The location of calculus does not indicate the bottom of the periodontal pocket because the most apical plaque is not sufficiently calcified to be visible on radiographs.

• Use of compressed air –Small amounts of calculus may be invisible when they are wet with saliva. With light & drying with air, small deposits usually can be seen.16

• However, the traditional tactile perception of the subgingival root surface without the visual accessibility lacks sensitivity, specificity and reproducibility. Thus, the subgingival debridement may lead to varying degrees of residual calculus, removal of root cementum or both.17,18 In order to overcome these shortcomings, a number of different technologies have been incorporated into dental devices for the purpose of identifying and selectively removing the dental calculus.

Fig 1. Conventional method with explorer

Fig 2. Radiographic view of calculus

2. Advance tools :

Current technologies for calculus detection comprise detection-only systems as well as combined calculus detection and calculus-removal systems8 (Table 1).



Table 1. Calculus detection technology

A) Calculus detection only

Fibreoptic endoscopy: The fiberoptic endoscopy based technology for calculus detection is currently being used in only one device, Perioscopy (Perioscopy Inc., Oakland, CA, USA). Perioscopy is a minimally invasive miniature periodontal endoscope and is inserted into the periodontal pocket for subgingival visualization of the root surface at magnifications of 24–48x.This system consists of a 10,000-pixel fiberoptic bundle with 1mm diameter surrounded by multiple illumination fibers, a light source, an irrigation system and a display monitor with liquid crystal.(Fig 3) This automated system aids in the visualization of the subgingival root surface, tooth structure and residual calculus in real time. (Fig 4) Also, the magnified images (ranging from x24 X to x46) can be viewed on the monitor in real time and images as well as videos can be saved in computer files. In addition, this endoscope-based system may help in identifying and locating the residual calculus spots during instrumentation. One common problem reported in studies comparing the endoscopic technique with the conventional explorer is the additional training period of at least 8hr to learn the procedure and subsequent practical experience up to 4 weeks.The endoscope may help to identify and locate calculus spots during instrumentation of residual calculus at the time of, or after, scaling.9(fig 5)

Fig 3. Perioscopy system, dental endoscope

Fig 4. Perioscope instrumentation permits deep subgingival visualization in a periodontal pocket

Fig 5. An endoscopic view of residual burnished calculus

Spectro- optical technology The spectro-optical technology to detect calculus is currently being used in one device, DetecTar (Dentsply Professional, York, PA, USA). This automated system consists of a light-emitting diode, an optical fiber, computer and this device available as a portable cordless handpiece with a curved periodontal probe that has millimeter markings to measure pocket depths.( Fig 6,7) When the subgingival calculus is irradiated by red light, it results in the production of a characteristic spectral signature caused by absorption, reflection and diffraction.( Fig. 8) These spectral signals are sensed by an optical fiber and converted into an electrical signal that is analyzed by a computer device. This device aids in the scanning of the subgingival root surface without any tactile pressure. As soon as calculus is detected, the operator receives the information by audible and luminous signals.9



Fig.6. Detec Tarsystem

Fig 7. Detec Tar probe

Fig 8. Light signal upon detection by Detec Tar probe

Autofluorescence based system Several in vitro studies have shown that oral microorganisms and their metabolites like porphyrins,metalloporphyrins and other chromatophores contain the fluorophores that are emitted from the dental calculus andcarious lesions.19,20,21 This ability of calculus to emit fluorescent light following irradiation with light of a certain wavelength enables the detection of calculus. Based on this autoflurescent property of calculus, a newer diagnostic instrument has been developed, the Diagnodent (KaVo, Biberach, Germany). The device was initially launched for caries diagnosis. Later, the device was modified to enable calculus detection.8 Diagnodent is able to measure wide range of fluorescence intensities, transformed and shown on a digital display as relative calculus-detection values from 0-99.The emitted fluorescent light returning from the tooth tissue is captured by surrounding optical fibers and transmitted to an integrated photo diode, which serves as the fluorescence detector.Several distinct fluorescence bands between 570 and 730 nm were identified on calculus specimens, which could be elicited with light of wavelength 400–420 nm, but could

not be found on clean root surfaces.Readings corresponding to the calculus are indicated by a beep with an increasing sound frequency as the display value increases. According to the manufacturer:

l Values of >40 indicate mineralized deposits l Values of between 5 and 40 indicate very small calcified

plaque sites or residual calculus l Values of <5 indicate a clean root surface.

Values indicating calculus are indicated by a beep with an increasing audiotone frequency as the display value increases. The autofluorescence-based device for calculus detection has been evaluated only in in vitro studies so far, with any patient-derived clinical evidence lacking.When used in vitro, the autofluorescence-based system could differentiate between calculus and cementum with great reproducibility. In a preclinical situation, a superior effect of the system compared with manual use of an explorer could be shown only on molars. The diagnostic value of the auto-fluorescence-based system needs to be assessed in the clinical setting, and its effect on treatment outcomes determined.9

Fig 9. Calculus detection by Diagnodent pen

B) Combined calculus-detection and calculus-removal

systems:

Although detection-only systems demonstrated high sensitivities and specificities for the detection of calculus, the superior clinical outcomes following periodontal therapy has not been thoroughly investigated. A major disadvantage of the stand-alone diagnostic devices lies in the need to alternate between detection and debridement. In transition from a diagnosis device to a debridement instrument, information regarding the area the residual calculus is located may be lost and subsequently lead to over or under-instrumentation. The combined detection and treatment device aims to overcome this problem.8

Ultrasonic technology: Ultrasonic calculus-detection technology is based on a conventional piezo-driven ultrasonic scaler and is similar to the way that one might tap on the rim of a glass with a spoon to identify cracks acoustically. An insert at a conventional dental ultrasound scaler receives short, weak impulses with a frequency of about 50 Hz, which make the insert’s distal tip oscillate at a frequency that is dependent upon the surface characteristics. The oscillations are conducted into the piezo-ceramic discs, which



transform the oscillations into voltage. The voltage level represents the intensity of the tip oscillation, while the frequency stays the same. The overall signal, consisting of both the impulse stimulus and the impulse response, is evaluated using a computerized system, thereby generating information about a given surface characteristic. The ultrasonic device currently available (PerioscanTM Sirona, Bensheim, Germany) (Fig.10) provides a detection mode to discriminate between calculus deposits and clean roots, along with a treatment mode that allows conventional ultrasonic treatment at different power levels. When the ultrasonic tip touches the tooth surface, the detection results are indicated by a light signal integrated both in the handpiece and in a display of the table unit (green indicates cementum and blue indicates calculus)( Fig. 11,12). When calculus is detected, an additional acoustic signal sounds. The detection mode is only activated when no scaling treatment is performed. The detection and treatment modes can be used successively on the surface of the same tooth. If calculus deposits are found, the root surface can be treated with a higher power setting, whereas in the absence of calculus (thus requiring the systematic removal only of biofilm), instrumentation can be performed at a lower power setting.9

Fig. 10.Ultrasound based calculus detection technology.

Fig.11 Green light –presence of cementum

Fig.12. Blue light- presence of calculus

Laser based technology:

LASER is an acronym for Light Amplification by Stimulated Emission of Radiation. Maiman introduced the first laser device in 1960. The advantage of laser use is that it can concentrate light energy at a single point to target the tissues. In 1965, Kinersly et al. reported the first use of ruby lasers for calculus removal from the tooth surface. Since then, numerous types of lasers have been used in the field of dentistry.22Which laser is used depends on the frequency at which the laser can cut hard or soft tissues. The Food and Drug Administration (USA) approved the use of the Nd:YAG laser for soft-tissue surgeries in 1990 and for hard tissues in 1999. This laser can also be used for partial calculus removal from the root surface.23 However, the laser ablates the hard tissues as it removes calculus, which has hindered its use in this capacity. Studies have also shown that calculus removal by Nd:YAG laser is insufficient as compared to that achieved by hand instrumentation.24The Er:YAG laser has undergone extensive study since its introduction by Zharikov in 1974. This laser is largely absorbed in water, which causes less damage to the hard tissues, due to the reduced amount of heat production. Studies to assess the efficacy of lasers in calculus removal have shown comparable results with hand and ultrasonic instruments). Er:YAG lasers cause comparable loss of root substance compared to hand instruments. However, recent studies have shown that dental tissues are not removed along with calculus.7 Lasers have been demonstrated to cause deep ablation of the cementum (approximately 40–136 lm)23. The efficacy of lasers in calculus removal has been shown to be inferior compared to ultrasonic instruments, and clinicians continue to debate the use of lasers in non-surgical periodontal therapy. Keylaser3TMcombines a 655-nm InGaAsP diode for detection of calculus and a 2940-nm Er:YAG laser for treatment. A scale of 0–99 is used for detection of calculus, with values exceeding 40 indicating the definite presence of mineralized deposits. (Fig. 13)The Er:YAG laser becomes activated when it reaches a certain threshold and is switched off as soon as the value falls below the threshold. Studies assessing the efficacy of the Keylaser3TM have shown that it produces a tooth surface that is comparable to those produced by hand and ultrasonic instrumentation.25,26 The major concern with laser use is its high cost.

Fig.13. Keylaser 3



CONCLUSION A number of different technologies have been incorporated into dental devices for the purpose of identifying and selectively removing dental calculus. Some of these new approaches for calculus removal show promising results under optimum conditions. Despite promising laboratory research results, the new technology-assisted periodontal treatments have yet to show clinical superiority in comparison with conventional scaling.Clinical studies are necessary to assess if the use of these devices can improve long-term treatment outcome, with consequences of smaller residual probing depth, a reduced need for periodontal surgery and less hypersensitivity after treatmen REFERENCES 1. Neto CAF, Cavalcanti Fatturi Parolo C, Kuchenbecker

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Source of support: Nil Conflict of interest: None declared

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