Introduction

Tartar or Calculus consists of mineralised bacterial plaque which forms on the surfaces of natural teeth and dental prostheses. When the plaque is allowed to sit on tooth surfaces for a longer period, the oral bacteria act as agents to degrade calcium and phosphate from saliva and gingival fluids. This leads to the formation of insoluble mineral crystals that coalesce to form a calcified mass, which adheres to tooth surfaces. It also contributes to halitosis (bad breath) and unpleasant appearance (usually yellowish or brown), thus affecting the confidence of the individual. Esthetic/cosmetic dentistry has evolved by offering different cost-effective treatments to accommodate the demand and improve the oral health of the population.

What is tartar?

Dental plaque/biofilm is clinically defined as a structured, resilient, yellow-greyish substance that adheres to intraoral hard substances¹. It is porous and difficult to remove by rinsing or the use of sprays. It is mainly composed of microorganisms, a mix of salivary enzymes and an intercellular matrix derived from gingival crevicular fluids, saliva and bacterial products. The soft plaque is hardened by the precipitation of mineral salts, which occurs within 2 weeks of plaque formation, followed by calcification in some cases. There are two types of calculus based on their location on the teeth - subgingival and supragingival calculus. Subgingival calculus is located below the crest of the gingival margin and is not visible on routine oral examination, but can be evaluated by careful tactile perception with a dental instrument such as a probe. It is typically hard in consistency and appears dark brown or greenish-black in colour.  When the gingival tissues recede, the subgingival calculus is reclassified as supragingival calculus and is found on the buccal surfaces of upper molars and lower anterior teeth. It is usually white or yellowish and is visible in the oral cavity.¹

Predisposing factors

There are various factors contributing to the buildup of tartar, such as:

• Poor oral hygiene: Improper tooth brushing practices can result in the buildup of plaque
• Diet: Consuming a diet rich in sugars and starchy foods can act as a substrate for pathogenic bacteria in the mouth.
• Smoking: Smokers have a higher prevalence of subgingival calculus due to reduced production of saliva, which interferes with the cleansing action of saliva and noticeable calculus on teeth due to tobacco stains
• Dry mouth (Xerostomia): People who are predisposed to dry mouth due to medications (antimuscarinics, antihistamines, tricyclic antidepressants, and some diuretics). It can also be caused by irradiation of the head and neck region, dehydration, anxiety, or Sjögren's syndrome
• Tooth-related reasons: Open contact with dental restorations, ill-fitted appliances, and malocclusion (misaligned teeth) can make tooth brushing difficult, thus accumulating dental plaque and tartar

How tartar leads to discolouration

There are mainly two types of tooth discolouration - extrinsic (superficial) and intrinsic (deep discolouration), which occur due to various factors. One reason is dietary habits such as coffee, tea, wine, and carbonated drinks, which contain chromogens that stick to the enamel. It can usually be removed by proper oral hygiene practices. Smoking and/or chewing tobacco also lead to tough stains from nicotine on tooth surfaces. Removal of these types of stains typically requires professional cleaning. Poor oral hygiene, which leads to the buildup of plaque and tartar, can lead to tooth discolouration (trap stains) and bad breath. It is important to note that the accumulation of calculus does not entirely reflect on their attitude towards oral health. There are several factors which prohibit an individual from performing these tasks, such as disabilities, lack of knowledge of good toothbrushing habits, and age, which are beyond their control. Apart from these factors, the intrinsic stains are caused by certain medications such as tetracycline (taken during tooth development in infants/children), conditions like fluorosis (excessive fluoride intake over a long period, characterised by whitish or brownish streaks on tooth surfaces), and enamel erosion.

Health implications of tartar 

Tartar adversely affects the gums by harbouring toxic bacterial components and products, which irritate periodontal tissue, deforming and enlarging the periodontal pocket wall, and inhibiting the action of immune cells. The process of gum inflammation (gingivitis) can slowly progress to periodontal infection, which is known as periodontitis, and there are different grades and stages of disease based on certain measures (assessed using CPI/CPITN index). Studies show that periodontitis was identified as a modifiable risk factor for several systemic diseases, such as heart disease, diabetes, etc.⁶ This highlights the significance of periodontal therapy and creates a treatment plan based on the severity to reduce the chances of re-infection. 

The importance of cosmetic dentistry in addressing tartar staining

Teeth cleaning and tartar removal 

• Professional cleaning (scaling and root planing): Different treatment modalities have been identified to treat gingival and periodontal inflammation. The most common treatment is scaling and root planing (SRP), especially for plaque-induced gingivitis. SRP is performed using manual or ultrasonic scalers to remove plaque and calculus from the tooth surface (crown and root). There are other ultrasonic instruments, such as Vector (Its efficiency of removal of subgingival deposits relies mainly on the abrasive fluid that is being used) and PerioScan (a combination of detection and removal mechanism is advantageous since calculus is removed just by switching the mode from detection to removal). LASER (abbreviation for Light Amplification By Stimulated Emission of Radiation) uses lasers selected according to their variety of wavelengths for soft and hard tissue procedures, and detects calculus through a non-contact and minimally invasive technology^7,11
• Importance of regular dental visits: It is recommended to visit the dentist once every 6 months for checkups and professional cleaning to prevent the accumulation of plaque

Whitening treatments 

These treatments are used to remove dental stains such as:

1. In-office whitening procedures: The process uses bleaching agents (hydrogen peroxide or carbamide peroxide) with UV light that acts as a catalyst to break down the peroxide, becoming a faster, safer and more effective whitening solution
2. At-home whitening options recommended by dentists: Several whitening kits are available on the market. However, some clinics offer custom-made moulds of the teeth with whitening agents that can be applied over the teeth surfaces to remove stains at home

Veneers and bonding 

For deep stains which are difficult to remove using bleaching treatments, porcelain or ceramic veneers can be used to improve the appearance of the teeth and restore the self-confidence of the individual. 

Bonding treatment uses tooth-coloured composite resin and is chemically bonded over areas of heavy tooth stains.

Preventing tartar build-up and staining

Despite multiple treatment options for stain and tartar removal, it is important that the individual incorporates good oral hygiene practices such as:

• Proper brushing and flossing techniques
• Regular dental check-ups and cleanings
• Dietary considerations to minimise staining 
• Using fluoride and antibacterial mouthwash to prevent tartar buildup

Summary

Calculus/Tartar is formed by the mineralisation of dental plaque, causing stains and an unpleasant appearance. Proper interventions such as regular toothbrushing and dental visits, are crucial to reduce periodontal infection. There are several options in cosmetic dentistry for managing and reversing tartar staining. Professional treatments such as in-office, veneer and bonding, and also at-home whitening treatment are used to achieve optimal smile aesthetics.