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JDC CLINICAL ARTICLE

Role of Anatomic and Salivary Factors in Dental Calculus


Formation in Primary and Mixed Dentition Stages

Hossein Afshar, DDS, MS 1 Mehdi Ghandehari, DDS, MS 2


Afshin Khorsand, DDS, MS 3 Ghassem Ansari, DDS, MS 4
Azam Nahvi, DDS, MS 5 Zahra Baniameri, DDS, MS 6

ABSTRACT
Purpose: Clinical experience shows that formation of calculus is a very rare phenome-
non in primary teeth, but it increases as the permanent teeth erupt. The purpose of
this study was to assess the relationship between dental calculus, dental anatomy, and
salivary factors in primary and mixed dentition stages.
Methods: A cross-sectional study was carried out to determine the buccolingual di-
mensions of the most concave and the most convex surfaces of the lingual aspect of
mandibular central incisor crowns in a sample group of 120 three- to five-old children
and 120 eight- to 10-year old children. Saliva samples were collected from 20 in
each group. Data were analyzed using t tests.
Results: Significant differences were found between the ratio of the buccolingual di-
mensions of the most convex to the most concave areas of the lingual surfaces in
primary and permanent incisors (P=0.028). Saliva analysis revealed significant dif-
ferences in total protein (P=0.002), sodium (P=0.037), bicarbonate (P=0.003), and
ammonia (P=0.025) between the two age groups.
Conclusions: Anatomic and salivary factors may be important reasons for the differ-
ences in calculus formation. (J Dent Child 2016;83(1):3-8)
Received September 19, 2014; Last Revision February 18, 2015; Revision April
6, 2015.
KEYWORDS: DENTAL CALCULUS, PRIMARY TEETH, SALIVARY

S
upra- and subgingival plaque accumulation has tion of calculus are different, depending on the popula-
been reported in a large number of adults. Calculus tion group, dietary habits, oral hygiene, age, and systemic
is mineralized dental plaque primarily caused by diseases.1 In communities receiving regular dental care,
the deposition of calcium phosphate mineral salts be- supragingival calculus is usually limited to tooth sur-
tween or inside microorganisms.1 The amount and loca- faces adjacent to the openings of salivary gland ducts.1
The presence of supragingival plaque and calculus can be
directly observed and the amount measured with a cali-
Drs. 1Afshar and 2Ghandehari are associate professors, Department of brated probe.2
Pediatric Dentistry, and 3Dr. Khorsand is an associate professor, Depart- Lingual surfaces of mandibular incisors are the most
ment of Periodontics, all at Tehran University of Medical Sciences;
and 4Dr. Ansari is a professor, Department of Pediatric Dentistry, common location for dental calculus, followed by the
Shahid Beheshti University of Medical Sciences, all in Tehran, Iran. buccal surfaces of maxillary molars.3 High salivary flow
5
Dr. Nahvi is an assistant professor, Department of Pediatric Dentis- rate in these areas is responsible for deposition of calcium
try, Mazandaran University of Medical Sciences, Sari, Mazandaran,
Iran. 6Dr. Baniameri is a pediatric dentist at the Taleghani Hospital, phosphate.4 On the other hand, it has been shown that
Gonbad, Golestan, Iran. pH changes also play a role in the formation of dental
Correspond with Dr. Baniameri at yaldabaniameri@yahoo.com.

Journal of Dentistry for Children-83:1, 2016 Calculus in primary and mixed dentitions Afshar et al. 3
calculus. At a higher pH, colloidal proteins in saliva three-to five-year-old and eight- to 10-year-old children
bond to calcium and phosphorus ions and form super- to participate, obtain informed consent and distribute
saturated solutions of calcium phosphate salts, leading to questionnaires on demographic and health information
their depositions.5 This pH increase is explained by the of their children. Children were excluded if they had
loss of carbon dioxide and formation of ammonia by any systemic disease according to parental reports on the
dental plaque bacteria or spoiled protein causing the questionnaires. Participants were also excluded if during
deposition of calcium phosphate salts through the re- the dental examination they had a history of trauma,
duction of permanent deposition coefficient.5 Plaque pH restoration, poor oral hygiene, or developmental defects
increases by the reduction of sucrose concentration in of mandibular incisors. In the case of any exclusion, the
the oral cavity due to high salivary flow and accessibil- next child on the list was called.
ity of salivary urea.4 Earlier studies have shown that pri- Examination of the children took place from 9 to
mary plaque contains higher levels of calcium and phos- 11 a.m based on circadian variation before the first
phorous, with a lower level of potassium in high calculus daily break of school time in the month of October. Oral
patients.6 examinations were carried out by the aforementioned
Clinical experience shows that the formation of calcu- examiner in a well-lit room while the child was sitting
lus is rare in the primary dentition; however, it increases in an office chair facing a window. The lingual surface
with age and eruption of permanent teeth, particularly of mandibular incisors were examined with a dental
the mandibular incisors.7-9 Dental calculus has been re- mirror for calculus formation after drying with a sterile
ported in nine percent of four- to six-year-olds, 18 percent gauze. Calculus was scored using the Calculus Surface
of seven- to nine-year-olds, and 33 to 43 percent of 10- Index.11 The oral hygiene of the participants was good.
to 15-year-olds, with a higher prevalence and severity in All predisposing factors on calculus formation were
children with cystic fibrosis (77 percent in seven- to nine- evaluated and recorded, including tongue-thrusting,
year-olds and 90 percent in 10- to 15-year-olds).10 This crowding, interdental spaces, and the presence of black
disease is related to high prevalence of dental calculus stain.
because of high concentrations of some salivary factors The buccolingual dimensions of the most convex and
such as total proteins, phosphate and sodium. concave areas of the lingual surfaces (cingulum area) of
The causes of dental calculus and their differences in the mandibular central incisors were measured in a per-
primary and mixed dentition stages have been identi- pendicular path to the long axis of the teeth using a
fied.9 Thus, the purpose of this study was to assess the caliper, with 0.1 mm readability (Reico dent, Berlin,
influence of anatomical differences between primary and Germany), which was moved in a 90-degree angle to
permanent mandibular incisors and salivary composition long axis of the teeth to calculate the minimum and
in the formation of calculus in children. maximum measures. It should be mentioned that, in
teeth with calculus, its location did not usually interfere
with the measurement. In those that did, the calculus
METHODS was removed using a sterile hand scaler.
The study protocol was approved by the ethics committee All measurements were carried out by one examiner.
of Tehran University of Medical Sciences, Tehran, Iran. Written informed consent was obtained from parents.
This clinical evaluation was designed to assess potential Saliva samples were obtained from members of both
reasons for the difference in the prevalence of dental cal- age groups, who were asked not to eat anything for two
culus in primary and mixed dentition stages. The mini- hours prior to sampling. Each child was requested to
mum number of children was calculated as 120 in each chew a piece of tasteless gum for five minutes and then
group, based on the findings of a pilot study on 20 cases, spit into disposable containers (Rabet Amin Beinolmelal,
with α equals 0.05, β equals 0.2, standard deviation Tehran, Iran). Salivary flow rate was calculated using
equals 0.05, and a difference between dental calculus per- the following equation:12
cent in the two age groups of 0.2. Biologic criteria were
ml Volume of saliva collected (within 5 min)
examined in order to calculate the number of children
as 20 in each group.
Salivary flow rate ( )
min
=
5 (min)
Tehran is divided into several geographic areas known
as districts. The study area was district six, which in- Collected saliva samples were transferred to disposable
cluded a middle class community located in the center screw-top Falcon tubes (Jet Biofil, Guangzhou, China)
of the city. Kindergarten and elementary schoolchildren using disposable sterile syringes to prevent external con-
lists were obtained from the district’s education depart- tamination and possible changes in the composition of
ment. Children were selected randomly by using a saliva. Samples were then kept in ice bags and transferred
table of random numbers from eight kindergarten lists to the laboratory within two hours for biochemical
and five primary school lists. The school staff was trained analysis. A digital pH-meter (Scientific Instrument,
by one of the researchers on how to approach parents of Chandler’s Ford, UK) was used for pH measurements.

4 Afshar et al. Calculus in primary and mixed dentitions Journal of Dentistry for Children-83:1, 2016
The buffering capacity of saliva was measured using spe- DISCUSSION
cific amounts of 0.1 N of hydrochloric acid with se- A limited number of studies have discussed the differ-
quential measurements of the pH for 15 minutes for ences in the prevalence of calculus formation between
each sample. primary and permanent dentitions. Earlier reports have
Calcium and phosphate levels were measured, along focused on the differences in the prevalence of calculus
with total protein, glycosylated amylase, ammonium, formation at various ages.6,9,13,14 This study focuses on the
sIgA, and bicarbonate, using spectrophotometry (model prevalence of calculus formation and its relation to the
no. 35, Bacharach Coleman Instruments, Pittsburgh, anatomy of teeth and biological indices. Our findings are
Pa., USA) with specific kits Flame photometry (Screen in agreement with previous studies about dental calculus
Lyte, Florence, Italy), using a special kit for the mea- prevalence.6,9,13,14
surement of salivary sodium and potassium. The difference between the ratio of the buccolingual
Data were analyzed using chi-square and t-tests, and dimensions in the most convex to the most concave areas
SPSS 11.5 software (IBM Corp., Chicago, Ill., USA), of the lingual surfaces of primary and permanent man-
with a significance level of <0.05. dibular central incisors was statistically significant. This
indicates that the lingual surfaces of primary central in-
cisors are significantly flatter than the corresponding
RESULTS surfaces in permanent central incisors (Table 2). Calculus
A total of 240 three- to five-year-old and eight- to 10- deposition is seen less frequently in flat surfaces com-
year-old children (120 in each group) participated. Sex pared to the concave areas, probably because materia
distribution was similar. The prevalence of calculus was alba deposition, which may turn into calculus with time,
zero in three- to five-year-olds and 14 percent in eight- is less on flat surfaces (Table 3). Thus, such morphological
to 10-year-old children (nine males and eight females; difference may be considered an important contributing
Table 1). The mean buccolingual dimensions of the local factor for explaining the differences in the preval-
most concave and convex areas of the lingual surfaces of ence of calculus formation between primary and perma-
mandibular central incisors were 1.9 and 2.0 mm in pri- nent mandibular central incisors. The mean buccolingual
mary teeth, respectively, and 2.9 and 3.8 mm in perma- dimensions of the most convex areas of the lingual
nent teeth, respectively (Table 2). surfaces of permanent mandibular central incisors were
Existing calculus in the permanent mandibular cen- significantly greater in the calculus group than those
tral incisors of 17 children provided the chance for without calculus. Moreover, significant differences were
comparing buccolingual measures of the teeth with and also found between the most convex and the most con-
without calculus. cave areas, indicating a flat lingual surface in the group
In the mixed dentition stage, the mean buccolingual without calculus (Table 3).
dimensions of the most concave and convex areas of the
lingual surfaces of permanent mandibular central inci- Table 1. Prevalence of dental calculus in primary
sors were 2.1 to 2.0 mm and 4.1 to 3.7 mm in subjects and permanent incisors
with and without calculus, respectively, with a respective
Mandibular Dental calculus No. of
ratio of 1.9 to 1.8 (Table 3). This comparison was not incisors prevalence children
possible in primary teeth due to the absence of calculus. (number of
The effects of tongue-thrusting, crowding, interdental children/percent)
spaces, and black stain on the dental calculus prevalence
Primary 0 (0) 120
were not statistically significant.
Permanent 17 (14) 120
Biological indices were evaluated in 20 three- to
P-value (P<.05) <0.001 –
five-year-old and 20 eight- to 10-year-old children,
with the differences only being identified
in the salivary levels of bicarbonate, total
protein, sodium, and ammonium (Table 4). Table 2. Mean measurements of the lingual surface of the
A clear difference was noted in the mandibular central incisors (in mm)
color of saliva, with a more yellowish ap- Mandibular Mean buccolingual Mean buccolingual Ratio of No. of
pearance observed in the older group. central dimensions of the dimensions of the 2/1±(SD) children
However, the difference in the buffering incisor most concave area most convex area of
of the lingual the lingual surface
capacity of saliva among the two age surface (1)±(SD) (2) ±(SD)
groups was not significant.
Primary 1.9±0.42 2.9±0.47 1.5±0.14 120
Permanent 2±0.33 3.8±0.69 1.9±0.23 120
P-value (P<.05) 0.004 <0.001 0.028 –

Journal of Dentistry for Children-83:1, 2016 Calculus in primary and mixed dentitions Afshar et al. 5
Another factor to be considered in calculus formation observation. Saliva was yellower in the older group,
is that the enamel in permanent teeth is more mineral- which may be due to the higher levels of ammonium.
ized and, consequently, smoother than that of primary Sodium, bicarbonate, and ammonium are also assumed
teeth.15 The smoother the surface, the lower the deposi- to have an impact on calculus formation.16,17,20 A further
tion of calculus, indicating a greater effect of morpho- critical point to be noted is the buffering capacity of
logical differences. saliva, which was not found to be significantly different
When salivary components were compared, differ- between the two groups. This buffering capacity is
ences between the three- to five-year-old children and known to be influenced by sodium and bicarbonate in
eight- to 10-year-old children were statistically significant particular.18,19 The reduction in bicarbonate levels and
only in total protein, sodium, ammonium, and bicar- increase in sodium levels would lead to a neutralized
bonate levels (Table 4). Several authors have reported L state without any change in the buffering capacity,
that changes in the levels of sodium, bicarbonate, and despite a high salivary flow rate.
ammonium were associated with an increase in the sal- Considering the multifactorial nature of calculus
ivary flow rate.16-19 The difference in the color of saliva formation, changes in one or more causative factors
was noticeable between the two age groups in clinical may not be regarded as the only reason for the presence
or absence of calculus. Histatin, cystatin, and
particularly proline-rich proteins and statherin
Table 3. Mean buccolingual dimensions of the lingual surface play important roles in the regulation of cal-
of permanent mandibular central incisors (in mm) culus formation via inhibition of hydroxyapetite
with and without calculus crystals growth. 21-24 Complex etiologic factors
Mean buccolingual Mean buccolingual Ratio No. and their interactions may be responsible for the
dimensions of the dimensions of the of of existing variability of calculus status.
most concave area most convex area 2/1±(SD) children Listgarten25 reported that calculus-free areas
of the lingual of the lingual
surface (1)±(SD) surface (2)±(SD)
have a significantly higher colonization rate of
Aggregatibacter actinomycetem comitans (Aa),
Subjects with 2.10±0.24 4.10±0.49 1.90±0.09 17 with a lower colonization rate of anaerobic rods
calculus with black pigments. Thus, Aa plays an inhibi-
Subjects without
2.00±0.34 3.70±0.70 1.80±0.33 103 tory role in the colonization of calcifiable bac-
calculus teria. 25 It is also demonstrated that penicillin
P-value (P<.05) 0.1 0.02 0.037 _ could have a preventive role in the calculus
formation if it is present in the dietary regimen
of some animals. 5 Moreover, the use of anti-
biotics is known to decrease the amount of
Table 4. Mean biological indices dental plaque and calculus in patients with
cystic fibrosis.26 In contrast, it has been argued
Biological indices 3- to 5-year-old 8- to 10-year-old P-value
children ±(SD) children ±(SD) (P<.05) that the presence of microorganisms is not
always necessary for calculus formation, as it
Salivary flow rate (ml/min) 0.50±0.15 0.59±0.27 0.227 forms quickly in germ-free animals. 6 These
Level of sIgA (mg/dl) 75.37±29.77 78.05±33.09 0.79
results raise an interesting hypothesis: the type
of colonizing bacteria may be different as the
Total protein concentration
(mg/dl)
120.00±55.06 186.00±67.85 0.002 child grows. Microorganisms involved in calculus
Sodium concentration formation could have greater colonization
14.32±12.41 21.63±8.69 0.037
(meq/l) capacity in the latter group. Further studies are
Potassium concentration
7.00±3.77 7.80±2.14 0.404 required to measure the different bacteria be-
(meq/l)
tween primary and permanent teeth.
Phosphate concentration
11.94±2.93 12.82±4.47 0.467
(mg/dl)
Calcium concentration
0.87±0.65 1.11±0.35 0.161
(mg/dl) CONCLUSION
Glycosylated amylase
120367.50±49266.64 153430.00±71667.12 0.097 Based on the findings of this study, the following
concentration (U/L)
conclusion can be made:
Bicarbonate concentration
(mmol/l)
36.10±2.70 33.27±2.98 0.003 Anatomic and salivary factors may be
Ammonium concentration important reasons for the differences in
15422.50±264.00 20259.00±598.00 0.025
(µg/dl) calculus formation in primary and perma-
Level of pH 7.78±0.63 7.73±0.78 0.89 nent dentition stages.
No. of children 20 20 _

6 Afshar et al. Calculus in primary and mixed dentitions Journal of Dentistry for Children-83:1, 2016
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8 Afshar et al. Calculus in primary and mixed dentitions Journal of Dentistry for Children-83:1, 2016
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