CHAPTER 7

The Role of Dental Calculus and Other Local

Predisposing Factors
James E. Hinrichs and Vivek Thumbigere Math

CHAPTER OUTLINE
Calculus
Other Predisposing Factors

The primary cause of gingival inflammation is bacterial plaque. in color (Figure 7-3), and it is firmly attached to the tooth surface.
Other predisposing factors include calculus, faulty restorations, Supragingival calculus and subgingival calculus generally occur
complications associated with orthodontic therapy, self-inflicted together, but one may be present without the other. Microscopic
injuries, and the use of tobacco, in addition to several others. These studies demonstrate that deposits of subgingival calculus usually
will be discussed in turn. extend nearly to the base of periodontal pockets in individuals with
chronic periodontitis but do not reach the junctional epithelium.
Calculus When the gingival tissues recede, subgingival calculus becomes
Calculus consists of mineralized bacterial plaque that forms on the exposed and is therefore reclassified as supragingival (Figure 7-4,
surfaces of natural teeth and dental prostheses. A). Thus, supragingival calculus can be composed of both supra-
gingival calculus and previous subgingival calculus. A reduction in
Supragingival and Subgingival Calculus gingival inflammation and probing depths with a gain in clinical
Supragingival calculus is located coronal to the gingival margin attachment can be observed after the removal of subgingival plaque
and therefore is visible in the oral cavity. It is usually white or and calculus (Figure 7-4, B; see Chapter 46).
whitish yellow in color; hard, with a claylike consistency; and
easily detached from the tooth surface. After removal, it may Prevalence
rapidly recur, especially in the lingual area of the mandibular inci- Anerud and colleagues4 observed the periodontal status of a group
sors. The color is influenced by contact with such substances as of Sri Lankan tea laborers and a group of Norwegian academicians
tobacco and food pigments. It may localize on a single tooth or for a 15-year period. The Norwegian population had ready access
group of teeth, or it may be generalized throughout the mouth. to preventive dental care throughout their lives, whereas the Sri
The two most common locations for the development of supra- Lankan tea laborers did not. The formation of supragingival calcu-
gingival calculus are the buccal surfaces of the maxillary molars lus was observed early in life in the Sri Lankan individuals, prob-
(Figure 7-1) and the lingual surfaces of the mandibular anterior ably shortly after the teeth erupted. The first areas to exhibit
teeth (Figure 7-2).34 Saliva from the parotid gland flows over the calculus deposits were the facial aspects of maxillary molars and
facial surfaces of the upper molars via the parotid duct, whereas the lingual surfaces of mandibular incisors. The deposition of
the submandibular duct and the lingual duct empty onto the supragingival calculus continued as individuals aged, and it reached
lingual surfaces of the lower incisors from the submaxillary and a maximal calculus score when the affected individuals were
sublingual glands, respectively. In extreme cases, calculus may around 25 to 30 years old. At this time, most of the teeth were
form a bridgelike structure over the interdental papilla of adjacent covered by calculus, although the facial surfaces had less calculus
teeth or cover the occlusal surface of teeth that are lacking func- than the lingual or palatal surfaces. Calculus accumulation appeared
tional antagonists. to be symmetric, and, by the age of 45 years, these individuals had
Subgingival calculus is located below the crest of the marginal only a few teeth (typically the premolars) without calculus. Sub-
gingiva and therefore is not visible on routine clinical examination. gingival calculus appeared first either independently or on the
The location and extent of subgingival calculus may be evaluated interproximal aspects of areas where supragingival calculus already
by careful tactile perception with a delicate dental instrument such existed.4 By the age of 30 years, all surfaces of all teeth had sub-
as an explorer. Clerehugh and colleagues31 used a World Health gingival calculus without any pattern of predilection.
Organization no. 621 probe to detect and score subgingival calcu- The Norwegian academicians received oral hygiene instruc-
lus. Subsequently, these teeth were extracted and visually scored tions and frequent preventive dental care throughout their lives.
for subgingival calculus. An agreement of 80% was found between The Norwegians exhibited a marked reduction in the accumulation
these two scoring methods. Subgingival calculus is typically hard of calculus as compared with the Sri Lankan group. However,
and dense; it frequently appears to be dark brown or greenish black despite the fact that 80% of teenagers formed supragingival

116
 CHAPTER 7 The Role of Dental Calculus and Other Local Predisposing Factors 117

Figure 7-1 Supragingival calculus is depicted on the buccal sur-

faces of maxillary molars adjacent to the orifice for the parotid A
duct.

B
Figure 7-4 A, A 31-year-old white man with extensive supragin-
Figure 7-2suEpxrtaegnisnigvieval calculus is present on the gival and subgingival calculus deposits throughout his dentition is
lingual surfaces of the lower anterior teeth. shown. B, One year after receiving thorough scaling and root
planing to remove supragingival and subgingival calculus deposits,
followed by restorative care. Note the substantial reduction in
gingival inflammation.

ganic proportions of calculus have been reported as approximately

76% calcium phosphate, (Ca3[PO4]2); 3% calcium carbonate
(CaCO3); and traces of magnesium phosphate (Mg3[PO4]2) and
other metals.176 The percentage of inorganic constituents in calcu-
lus is similar to that of other calcified tissues of the body. The
principal inorganic components have been reported as approxi-
mately 39% calcium, 19% phosphorus, 2% carbon dioxide, and 1%
magnesium as well as trace amounts of sodium, zinc, strontium,
bromine, copper, manganese, tungsten, gold, aluminum, silicon,
iron, and fluorine.113
At least two thirds of the inorganic component is crystalline in
Figure 7-3piDgamrkented deposits of subgingival calculus are structure.89 The four main crystal forms and their approximate
shown on the distal root of an extracted lower molar. percentages are as follows: hydroxyapatite, 58%; magnesium whit-
lockite, 21%; octacalcium phosphate, 12%; and brushite, 9%.
calculus on the facial surfaces of the upper molars and the lingual Two or more crystal forms are typically found in a sample of
surfaces of lower incisors, no additional calculus formation calculus. Hydroxyapatite and octacalcium phosphate are detected
occurred on other teeth, and its presence did not increase with the most frequently (i.e., in 97% to 100% of all supragingival calculus)
individuals age.4 and constitute the bulk of the specimen. Brushite is more common
Both supragingival calculus and subgingival calculus may be in the mandibular anterior region, and magnesium whitlockite is
seen on radiographs (see Chapter 32). Highly calcified interproxi- found in the posterior areas. The incidence of the four crystal forms
mal calculus deposits are readily detectable as radiopaque projec- varies with the age of the deposit.16
tions that protrude into the interdental spaces (Figure 7-5). However,
the sensitivity level of detecting calculus by radiographs is incon- Organic Content. The organic component of calculus con-
sistent.24 The location of calculus does not indicate the bottom of sists of a mixture of proteinpolysaccharide complexes, desqua-
the periodontal pocket, because the most apical plaque is not suf- mated epithelial cells, leukocytes, and various types of
ficiently calcified to be visible on radiographs. microorganisms.99
Between 1.9% and 9.1% of the organic component is
Composition carbohydrate, which consists of galactose, glucose, rhamnose,
Inorganic Content. Supragingival calculus consists of inor- mannose, glucuronic acid, galactosamine, and sometimes arabi-
ganic (70% to 90%52) and organic components. The major inor- nose, galacturonic acid, and glucosamine.92,98,161 All of these organic
118 PART 1 Biologic Basis of Periodontology

Figure 7-6atC
taaclhcuedlutso the pellicle on the enamel surface
and the cementum. An enamel void (E) has been created during
the preparation of the specimen. C, Cementum; CA, calculus;
P, pellicle.

Figure 7-5 bAitewing radiograph illustrating subgingival calculus

deposits that are depicted as interproximal spurs (arrows).

E
components are present in salivary glycoprotein, with the excep-
tion of arabinose and rhamnose. Salivary proteins account for 5.9% CA
to 8.2% of the organic component of calculus and include most
amino acids. Lipids account for 0.2% of the organic content in the P
D
form of neutral fats, free fatty acids, cholesterol, cholesterol esters,
and phospholipids.93
The composition of subgingival calculus is similar to that of
supragingival calculus, with some differences. It has the same
hydroxyapatite content, more magnesium whitlockite, and less
brushite and octacalcium phosphate.142,165 The ratio of calcium to
CEJ
phosphate is higher subgingivally, and the sodium content increases
with the depth of periodontal pockets.94 These altered compositions
may be attributed to the origin of subgingival calculus being
plasma, whereas supragingival calculus is partially composed of C
saliva constituents. Salivary proteins present in supragingival cal-
culus are not found subgingivally.11 Dental calculus, salivary duct Figure 7-7 Non-decalcified specimen with calculus (CA) attached
calculus, and calcified dental tissues are similar in inorganic to enamel (E) surface just coronal to the cementoenamel junction
composition. (CEJ). Note plaque (P) on the surface of the calculus; dentin (D)
and cementum (C) are also identified. (Courtesy Dr. Michael Rohrer,
Attachment to the Tooth Surface Minneapolis, MN.)
Differences in the manner in which calculus is attached to the tooth
surface affect the relative ease or difficulty encountered during its
removal. Four modes of attachment have been described.85,145,152,181 Formation
Attachment by means of an organic pellicle on cementum is Calculus is mineralized dental plaque. The soft plaque is hardened
depicted in Figure 7-6, and attachment on enamel is shown in by the precipitation of mineral salts, which usually starts between
Figure 7-7. Mechanical locking into surface irregularities, such as the first and fourteenth days of plaque formation. Calcification has
caries lesions or resorption lacunae, is illustrated in Figure 7-8. The been reported to occur within as little as 4 to 8 hours.166 Calcifying
fourth mode of attachment consists of the close adaptation of the plaques may become 50% mineralized in 2 days and 60% to 90%
undersurface of calculus to depressions or gently sloping mounds mineralized in 12 days.112,146,156 All plaque does not necessarily
of the unaltered cementum surface,161 as shown in Figure 7-9, and undergo calcification. Early plaque contains a small amount of
the penetration of bacterial calculus into cementum, as shown in inorganic material, which increases as the plaque develops into
Figures 7-10 and 7-11. calculus. Plaque that does not develop into calculus reaches a
 CHAPTER 7 The Role of Dental Calculus and Other Local Predisposing Factors 119

Figure 7-8 Calculus (CA) attached to a cemental resorption area Figure 7-11anPdlaqcu
aleculus on the tooth surface. Note the
(CR) with cementum (C) adjacent to dentin (D). spherical areas of focal calcification (FC) and the perpendicular
alignment of the filamentous (F) organisms along the inner surface
of plaque and cocci (C) on the outer surface.

plateau of maximal mineral content within 2 days.147 Microorgan-

isms are not always essential in calculus formation, because calcu-
lus occurs readily in germ-free rodents.59
Saliva is the source of mineralization for supragingival calcu-
lus, whereas the serum transudate called gingival crevicular fluid
furnishes the minerals for subgingival calculus.71,163 The calcium
concentration/content in plaque is 2 to 20 times that found in
saliva.16 Early plaque of heavy calculus formers contains more
calcium, three times more phosphorus, and less potassium than that
of noncalculus formers, thereby suggesting that phosphorus may
be more critical than calcium for plaque mineralization.99 Calcifica-
tion entails the binding of calcium ions to the carbohydrateprotein
Figure 7-9 Undersurface of subgingival calculus (C) previously complexes of the organic matrix and the precipitation of crystalline
attached to the cementum surface (S). Note the impression of calcium phosphate salts.97 Crystals form initially in the intercellular
cementum mounds in the calculus (arrows). (Courtesy Dr. John Sot- matrix and on the bacterial surfaces and finally within the
tosanti, La Jolla, CA.) bacteria.53,182
The calcification of supragingival plaque and in the attached
component of subgingival plaque begins along the inner surface
adjacent to the tooth. Separate foci of calcification increase in size
and coalesce to form solid masses of calculus (see Figure 7-11).
Calcification may be accompanied by alterations in the bacterial
content and staining qualities of the plaque. As calcification pro-
gresses, the number of filamentous bacteria increases, and the foci
of calcification change from basophilic to eosinophilic. There is a
reduction in the staining intensity of groups that exhibit a positive
periodic acidSchiff reaction.
Sulfhydryl and amino groups are also reduced and instead stain
with toluidine blue, which is initially orthochromatic but which
becomes metachromatic and disappears.172 Calculus is formed in
layers, which are often separated by a thin cuticle that becomes
embedded in the calculus as calcification progresses.101
The initiation of calcification and the rate of calculus accumula-
Figure 7-10 Subgingival calculus (C) embedded beneath the tion vary among individuals, among tooth variety in the same
cementum surface (arrows) and penetrating to the dentin (D), dentition, and at different times in the same person.113,168 On the
thereby making removal difficult. (Courtesy Dr. John Sottosanti, La basis of these differences, persons may be classified as heavy,
Jolla, CA.) moderate, or slight calculus formers or as noncalculus formers. The
120 PART 1 Biologic Basis of Periodontology

average daily increment in calculus formers is from 0.10% to

0.15% of dry weight calculus.156,168 Calculus formation continues
until it reaches a maximum, after which it may be reduced in
amount. The time required to reach the maximal level has been
reported to be between 10 weeks32 and 6 months.170
The decline from maximal calculus accumulation, which is
referred to as the reversal phenomenon, may be explained by the
vulnerability of bulky calculus to mechanical wear from food and
from the cheeks, lips, and tongue.

Theories Regarding the Mineralization of Calculus.

The theoretical mechanisms by which plaque becomes mineralized
can be stratified into two categories.114
1p.reMcipiniteartaioln results from a local rise in the degree of
saturation of calcium and phosphate ions, which may be brought
about in the following several ways:
A rise in the pH of the saliva causes the precipitation of
calcium phosphate salts by lowering the precipitation con-
stant. The pH may be elevated by the loss of carbon dioxide
and the formation of ammonia by dental plaque bacteria or
by protein degradation during stagnation.15,66 Figure 7-12ulCuaslc (CA) penetrates the tooth surface and is
Colloidal proteins in saliva bind calcium and phosphate ions embedded within the cementum (C). Note the plaque (P) attached
and maintain a supersaturated solution with respect to to the calculus.
calcium phosphate salts. With the stagnation of saliva, col-
loids settle out, and the supersaturated state is no longer main-
tained, thereby leading to the precipitation of calcium
phosphate salts.130,149 Etiologic Significance
Phosphatase liberated from dental plaque, desquamated epi- Distinguishing between the effects of calculus and plaque on the
thelial cells, or bacteria precipitates calcium phosphate by gingiva is difficult, because calculus is always covered with a
hydrolyzing organic phosphates in saliva, thereby increasing nonmineralized layer of plaque.147 A positive correlation between
the concentration of free phosphate ions.175 Esterase is another the presence of calculus and the prevalence of gingivitis exists,132
enzyme that is present in the cocci and filamentous organisms, but this correlation is not as great as that between plaque and gin-
leukocytes, macrophages, and desquamated epithelial cells of givitis.55 The initiation of periodontal disease in young people is
dental plaque.9 Esterase may initiate calcification by hydro- closely related to plaque accumulation, whereas calculus accumu-
lyzing fatty esters into free fatty acids. The fatty acids form lation is more prevalent in chronic periodontitis found in older
soaps with calcium and magnesium that are later converted adults.55,90
into the less-soluble calcium phosphate salts. The incidence of calculus, gingivitis, and periodontal disease
2ag.eSnetsediinndguce small foci of calcification that enlarge increases with age. It is extremely rare to find periodontal
and coalesce to form a calcified mass.115 This concept has been pockets in adults without at least some subgingival calculus being
referred to as the epitactic concept or, more appropriately, as present, although the subgingival calculus may be of microscopic
heterogeneous nucleation. The seeding agents in calculus for- proportions.
mation are not known, but it is suspected that the intercellular Calculus does not contribute directly to gingival inflammation,
matrix of plaque plays an active role.100,112,182 The carbohydrate but it provides a fixed nidus for the continued accumulation of
protein complexes may initiate calcification by removing plaque and its retention in close proximity to the gingiva (Figure
calcium from the saliva (chelation) and binding with it to form 7-12). Subgingival calculus is likely to be the product rather than
nuclei that induce the subsequent deposition of minerals.97,171 the cause of periodontal pockets. Plaque initiates gingival inflam-
mation, which leads to pocket formation, and the pocket in turn
Role of Microorganisms in the Mineralization of provides a sheltered area for plaque and bacterial accumulation.
Calculus. Mineralization of plaque generally starts extracellu- The increased flow of gingival fluid associated with gingival
larly around both gram-positive and gram-negative organisms, but inflammation provides the minerals that mineralize the continually
it may also start intracellularly.87 Filamentous organisms, diphthe- accumulating plaque that results in the formation of subgingival
roids, and Bacterionema and Veillonella species have the ability to calculus (Figure 7-13). Over a 6-year period, Albandar and col-
form intracellular apatite crystals (see Figure 7-11). Mineralization leagues observed 156 teenagers with aggressive periodontitis.2
spreads until the matrix and the bacteria are calcified.53,183 They noted that areas with detectable subgingival calculus at the
Bacterial plaque may actively participate in the mineralization initiation of the study were much more likely to experience a loss
of calculus by forming phosphatases, which changes the pH of the of periodontal attachment than sites that did not initially exhibit
plaque and induces mineralization,40,97 but the prevalent opinion is subgingival calculus.
that these bacteria are only passively involved53,137,175 and are Although the bacterial plaque that coats the teeth is the main
simply calcified with other plaque components. The occurrence of etiologic factor in the development of periodontal disease, the
calculus-like deposits in germ-free animals supports this opinion.59 removal of subgingival plaque and calculus constitute the corner-
However, other experiments suggest that transmissible factors are stone of periodontal therapy. Calculus plays an important role in
involved in calculus formation and that penicillin in the diets of maintaining and accentuating periodontal disease by keeping
some of these animals reduces calculus formation.10 plaque in close contact with the gingival tissue and by creating
 CHAPTER 7 The Role of Dental Calculus and Other Local Predisposing Factors 121

A B
Figure 7-13elSeccatrnonninm
g icroscope view of an extracted Figure 7-15 A, Radiograph of an amalgam overhang on the distal
human tooth showing a cross-section of subgingival calculus (C) surface of the maxillary second molar that is a source of plaque
separated (arrows) from the cemental surface during processing of retention and gingival irritation. B, Radiograph that depicts the
the specimen. Note the bacteria (B) attached to the calculus and the removal of excessive amalgam.
cemental surfaces. (Courtesy Dr. John Sottosanti, La Jolla, CA.)

coffee, tea, certain mouthrinses, and pigments in foods can con-

tribute to stain formation.95,162

Other Predisposing Factors

Iatrogenic Factors
Deficiencies in the quality of dental restorations or prostheses are
contributing factors to gingival inflammation and periodontal
destruction. Inadequate dental procedures that contribute to the
deterioration of the periodontal tissues are referred to as iatrogenic
factors. Iatrogenic endodontic complications that can adversely
affect the periodontium include root perforations, vertical root
Figure 7-14oT
bacco stains on the apical third of the clinical crown fractures, and endodontic failures that may necessitate tooth
caused by cigarette smoking. extraction.180,181
Characteristics of dental restorations and removable partial den-
tures that are important to the maintenance of periodontal health
include the location of the gingival margin for the restoration, the
areas where plaque removal is impossible. Therefore, the clinician space between the margin of the restoration and the unprepared
must not only possess the clinical skill to remove the plaque and tooth, the contour of the restorations, the occlusion, the materials
calculus, but he or she must also be very conscientious about per- used in the restoration, the restorative procedure itself, and the
forming this task. design of the removable partial denture. These characteristics are
described in this chapter as they relate to the etiology of periodontal
Materia Alba, Food Debris, and Dental Stains disease. A more comprehensive review with special emphasis on
Materia alba is an accumulation of microorganisms, desquamated the interrelationship between restorative procedures and the peri-
epithelial cells, leukocytes, and a mixture of salivary proteins and odontal status is presented in Chapter 67.
lipids, with few or no food particles; it lacks the regular internal
pattern observed in plaque.148 It is a yellow or grayish-white, soft, Margins of Restorations. Overhanging margins of dental
sticky deposit, and it is somewhat less adherent than dental plaque. restorations contribute to the development of periodontal disease
The irritating effect of materia alba on the gingiva is caused by by (1) changing the ecologic balance of the gingival sulcus to an
bacteria and their products. area that favors the growth of disease-associated organisms (pre-
Most food debris is rapidly liquefied by bacterial enzymes and dominantly gram-negative anaerobic species) at the expense of the
cleared from the oral cavity by salivary flow and the mechanical health-associated organisms (predominantly gram-positive faculta-
action of the tongue, cheeks, and lips. The rate of clearance from tive species)88 and (2) inhibiting the patients access to remove
the oral cavity varies with the type of food and the individual. accumulated plaque.
Aqueous solutions are typically cleared within 15 minutes, whereas The frequency of overhanging margins on proximal restorations
sticky foods may adhere for more than 1 hour.88,169 Dental plaque has varied in different studies from 16.5% to 75%.18,51,70,121 A highly
is not a derivative of food debris, and food debris is not an impor- significant statistical relationship has been reported between mar-
tant cause of gingivitis.39,75 ginal defects and reduced bone height.18,60,70 The removal of over-
Pigmented deposits on the tooth surface are called dental stains. hangs allows for the more effective control of plaque, thereby
Stains are primarily an aesthetic problem and do not cause inflam- resulting in a reduction of gingival inflammation and a small
mation of the gingiva. The use of tobacco products (Figure 7-14), increase in radiographic alveolar bone support54,63,159 (Figure 7-15).