Introduction 

Dental tartar, also known as calculus, is a hard calcified deposit that forms on the teeth and gums. When plaque is not removed by basic oral hygiene, such as flossing and brushing, it hardens within 24 to 72 hours to form tartar.¹ Bacteria present in our oral cavity use the sugar in the food to produce acids, which later form a thin layer of plaque.²

Orthodontics is a branch of dentistry that focuses on the prevention, diagnosis and treatment of misaligned teeth and gums with the help of dental appliances like braces, retainers and aligners. Poor oral hygiene of the patient who is undergoing orthodontic treatment may lead to dental issues, which in turn delay the treatment process.³

Accumulation of tartar around the orthodontic appliances leads to bad breath, gum diseases if not treated, and also acts as an obstacle for the dentist during the treatment. Apart from maintaining basic oral hygiene, cleaning the areas around the brackets with interdental brushes, using mouthwash twice daily, maintaining a good diet and regular check-ups with your dentist will prevent the formation of tartar.

The formation and impact of tartar on oral health

Plaque is formed when bacteria in the oral cavity react with saliva and food particles, creating a thin sticky film on the teeth, and when the plaque is not cleaned through oral hygiene measures, it hardens to form tartar, also known as calculus. Factors that contribute to tartar formation include poor oral care, inadequate brushing or flossing, and certain lifestyle behaviours like smoking and tobacco consumption.⁴ Plaque can be cleaned by regular care, whereas tartar can only be cleaned by a professional, like a dentist or a dental hygienist. Common areas where tartar is formed are on the lower teeth along the junction of gums and teeth, and in some severe cases, on the gums as well.

Tartar looks like a yellow, brown or black thick crust-like coating along the surface of the teeth. Prolonged duration of tartar will lead to bad breath, also known as halitosis. The gums tend to be swollen and red in colour, and may bleed during brushing. This can cause the gum lining to recede downward, causing pocket formations and mobility of the tooth.⁵ 

The rough surface of the tartar is a breeding ground for bacteria, and releases acids which erode the enamel surface. These acids also contribute to caries and cavity formation.

Challenges tartar poses for individuals with braces or other dental appliances

Orthodontic appliances like brackets, retainers, and aligners trap food particles, providing a suitable environment for the bacteria to live in. Difficulty in cleaning these food particles increases plaque accumulation, and if left with no proper care, leads to dental and gingival issues, disrupting the orthodontic treatment. Proper care includes flossing, the use of interdental brushes and regular check-ups with your dentist.

Tartar buildup can cause inflammation of the gums known as gingivitis. Symptoms of gingivitis include the gums presenting as red in colour, swollen, and bleeding while brushing.  With time, this can advance into Periodontitis, in which gums pull away from the teeth and gingival pockets are formed, the gum lining recedes, and teeth tend to be mobile.⁶

The presence of tartar is seen as a yellow or brown stain, and the area shows visible staining after the removal of brackets. The acidic byproduct present in the plaque causes enamel demineralisation and the formation of white spot lesions. After the completion of orthodontic treatment, these white spots are left behind, and the teeth are affected aesthetically.⁷

Plaque accumulation with time causes gingivitis, which can be seen as inflamed gums, tooth decay, cavities and periodontal problems like tooth mobility, bone loss, and delays the patient’s ongoing orthodontic treatment. 

Strategies for tartar prevention and management in orthodontic patients

• Enhanced Oral hygiene Practices 

The regular tooth brushing techniques may not help as there are fixed orthodontic appliances like brackets and retainers which trap food particles; hence, it is important that the patient brushes their teeth after every meal. It is important to use a soft-bristle toothbrush and ensure that the bristles reach the gum line of each tooth, and above and below the brackets.⁸ Charters' tooth brushing technique is considered the best technique for orthodontic patients. The bristles are kept at a 45-degree angle to the tooth and moved in a circular vibratory motion.⁹

Flossing is also as important as brushing, as it helps remove plaque and food particles between the teeth and the places that are hard to reach. Make sure that the flossing is done gently between the tooth and the orthodontic wires, as a hard pull may damage the braces.

• Use of antimicrobial mouthwashes

Mouthwashes containing chemical agents, particularly chlorhexidine, are an important antimicrobial agent that will fight against bacteria present in the plaque and prevent further dental issues. It is a very good measure for orthodontic patients who have difficulty practising mechanical means alone.

Fluorides prevent the formation of stains, white spot lesions and tooth decay. Fluorides can be in the form of toothpastes, mouthwashes or varnishes that are used by dentists in the clinic as a preventive measure.¹⁰

• Professional dental cleanings and checkups 

During orthodontic treatment, dental check-ups every 6 months are important to maintain good oral hygiene. Scaling or cleaning should be done if necessary, as there might be plaque accumulated around the braces. Regular check-ups also prevent any other dental issues. With the help of ultrasonic scalers, dentists or dental hygienists remove the hard coating of tartar as well as brown black stains on the surface of the teeth.¹¹

• Dietary modifications

Sticky or sugary food should be avoided as it gets stuck in the braces and makes it difficult to clean, while sugary food causes plaque buildup. Frequent intake of water is necessary as it cleans food debris present and also prevents the formation of plaque.¹²

• Orthodontic-specific tools for tartar prevention

Other than toothbrushes, toothpaste and floss, there are other orthodontic-specific tools like interdental brushes, floss threaders and dental picks available. Unlike normal toothbrushes, interdental brushes are small and have easy access in areas around the brackets and wires, for orthodontic patients. Floss threaders are easier to use than the normal dental floss as they contain a looped plastic tool which easily assists in passing the dental floss through the orthodontic appliances. Dental picks are small plastic picks that come in different forms of shapes, sizes and colours and are easy to carry around. They are especially used around the orthodontic arch wires.¹³

Summary

Plaque accumulation is a common and significant concern for orthodontic patients, which leads to tartar formation, a hard, thick crust along the surface of the tooth and the gumline. In the early stages, it results in inflamed gums, and over time, the gum can recede, pockets are formed and different grades of tooth mobility. Tooth decay and cavities can be seen, and such issues may overall delay the orthodontic treatment. It is important to regularly maintain oral hygiene by brushing after every meal, flossing, using antimicrobial mouthwashes and orthodontic-specific tools like interdental brushes, dental picks and floss threaders. Patients should pay attention to diet, avoid sugary sticky food, increase water intake and frequent check-ups with the dentist. By following these preventive measures, patients can achieve healthier gums and a good orthodontic outcome.