T

he primary cause of gingival inflammation is bacterial

plaque. Other predisposing factors include calculus, faulty

restorations, complications associated with orthodontic
therapy, self-inflicted injuries, use of tobacco, and others. These will
be discussed in turn.

CALCULUS

Calculus consists of mineralized bacterial plaque that forms on the

surfaces of natural teeth and dental prostheses.

Supragingival and Subgingival Calculus

Supragingival calculus is located coronal to the gingival margin and

therefore is visible in the oral cavity. It is usually white or whitish
yellow in color, hard with claylike consistency, and easily detached
from the tooth surface. After removal, it may rapidly recur, especially
in the lingual area of the mandibular incisors. The color is
influenced by contact with such substances as tobacco and food
pigments. It may localize on a single tooth or group of teeth, or it
may be generalized throughout the mouth.
The two most common locations for supragingival calculus to
develop are the buccal surfaces of the maxillary molars (Figure
22-1) and the lingual surfaces of the mandibular anterior teeth
(Figure 22-2).32 Saliva from the parotid gland flows over the facial
surfaces of upper molars via the parotid duct, whereas the submandibular
duct and lingual duct empty onto the lingual surfaces of
the lower incisors from the submaxillary and sublingual glands,
respectively. In extreme cases, calculus may form a bridgelike structure
over the interdental papilla of adjacent teeth or cover the
occlusal surface of teeth lacking functional antagonists.
Subgingival calculus is located below the crest of the marginal
gingiva and therefore is not visible on routine clinical examination.
The location and extent of subgingival calculus may be evaluated
by careful tactile perception with a delicate dental instrument such
as an explorer. Clerehugh et al29 used a World Health Organization
#621 probe to detect and score subgingival calculus. Subsequently,
these teeth were extracted and visually scored for subgingival calculus.
An agreement of 80% was found between these two scoring
methods. Subgingival calculus is typically hard and dense and frequently
appears dark brown or greenish black in color (Figure 22-3)
and is firmly attached to the tooth surface. Supragingival calculus
and subgingival calculus generally occur together, but one may be
present without the other. Microscopic studies demonstrate that
deposits of subgingival calculus usually extend nearly to the base
of periodontal pockets in chronic periodontitis but do not reach
the junctional epithelium.
When the gingival tissues recede, subgingival calculus becomes
exposed and is therefore reclassified as supragingival (Figure 22-4).
Thus supragingival calculus can be composed of both supragingival
calculus and previous subgingival calculus. A reduction in gingival
inflammation and probing depths with a gain in clinical attachment
can be observed after the removal of subgingival plaque and calculus
(Figure 22-5) (see Chapter 45).

Prevalence

Anerud and co-workers4 observed the periodontal status of a group

of Sri Lankan tea laborers and a group of Norwegian academicians
for a 15-year period. The Norwegian population had ready access
to preventive dental care throughout their lives, whereas the Sri
Lankan tea laborers did not. The formation of supragingival calculus

was observed early in life in the Sri Lankan individuals, probably

shortly after the teeth erupted. The first areas to exhibit
calculus deposits were the facial aspects of maxillary molars and the
lingual surfaces of mandibular incisors. Deposition of supragingival
calculus continued as individuals aged, reaching a maximal calculus
score around 25 to 30 years of age. At this time, most of the teeth
were covered by calculus, although the facial surfaces had less calculus
than the lingual or palatal surfaces. Calculus accumulation
appeared to be symmetric, and by age 45 only a few teeth, typically
the premolars, were without calculus. Subgingival calculus appeared
first either independently or on the interproximal aspects of areas
where supragingival calculus already existed.4 By age 30, all surfaces
of all teeth had subgingival calculus without any pattern of
predilection.
The Norwegian academicians received oral hygiene instructions
and frequent preventive dental care throughout their lives. The
Norwegians exhibited a marked reduction in the accumulation of
calculus as compared with the Sri Lankan group. However, despite
the fact that 80% of teenagers formed supragingival calculus on the
facial surfaces of the upper molars and the lingual surfaces of lower
incisors, no additional calculus formation occurred on other teeth,
nor did it increase with age.4
Both supragingival calculus and subgingival calculus may be
seen on radiographs (see Chapter 31). Highly calcified interproximal
calculus deposits are readily detectable as radiopaque projections
that protrude into the interdental spaces in Figure 22-6.
However, the sensitivity level of detecting calculus by radiographs
is inconsistent.23 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.

Composition
Inorganic Content. Supragingival calculus consists of inorganic
(70% to 90%50) and organic components. The major inorganic

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.169
The percentage of inorganic constituents in calculus is similar to
that in other calcified tissues of the body. The principal inorganic
components have been reported as approximately 39% calcium,
19% phosphorus, 2% carbon dioxide, and 1% magnesium and trace
amounts of sodium, zinc, strontium, bromine, copper, manganese,
tungsten, gold, aluminum, silicon, iron, and fluorine. 107
At least two-thirds of the inorganic component is crystalline in
structure.85 The four main crystal forms and their approximate
percentages are as follows: hydroxyapatite 58%, magnesium whitlockite
21%, octacalcium phosphate 12%, and brushite 9%.
Generally, two or more crystal forms are typically found in a
sample of calculus. Hydroxyapatite and octacalcium phosphate are
detected most frequently (i.e., in 97% to 100% of all supragingival
calculus) and constitute the bulk of the specimen. Brushite is more
common in the mandibular anterior region and magnesium whitlockite
in the posterior areas. The incidence of the four crystal forms
varies with the age of the deposit.15
Organic Content. The organic component of calculus consists
of a mixture of protein-polysaccharide complexes, desquamated
epithelial cells, leukocytes, and various types of microorganisms. 94
Figure 22-6 A bitewing radiograph illustrating subgingival calculus
deposits that are depicted as interproximal spurs (arrows).
Figure 22-7 Calculus attached to pellicle on enamel surface and cementum.

An enamel void (E) has been created in the preparation of the specimen.
CA, Calculus; P, pellicle; C, cementum.
For more information on organic content, please visit the
companion website at
www.expertconsult.com.

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.136,158 The ratio of calcium to
phosphate is higher subgingivally, and the sodium content increases
with the depth of periodontal pockets.89 These altered compositions
may be attributed to the origin of subgingival calculus being
plasma, whereas supragingival calculus is partially composed of
saliva constituents. Salivary proteins present in supragingival calculus
are not found subgingivally.10 Dental calculus, salivary duct
calculus, and calcified dental tissues are similar in inorganic
composition.

Attachment to the Tooth Surface

Differences in the manner in which calculus is attached to the tooth

surface affect the relative ease or difficulty encountered in its
removal. Four modes of attachment have been described. 81,138,145,173
Attachment by means of an organic pellicle on cementum is
depicted in Figure 22-7, and attachment on enamel is shown in
Figure 22-8. Mechanical locking into surface irregularities, such as
caries lesions or resorption lacunae, is illustrated in Figure 22-9.
The fourth mode of attachment consists of close adaptation of the
undersurface of calculus to depressions or gently sloping mounds
of the unaltered cementum surface,154 as shown in Figure 22-10,
and penetration of bacterial calculus into cementum, as shown in
Figures 22-11 and 22-12.

Formation
Calculus is mineralized dental plaque. The soft plaque is hardened
by the precipitation of mineral salts, which usually starts between
the first and fourteenth days of plaque formation. Calcification has
been reported to occur in as little as 4 to 8 hours. 159 Calcifying
plaques may become 50% mineralized in 2 days and 60% to 90%
mineralized in 12 days.106,139,149 All plaque does not necessarily
undergo calcification. Early plaque contains a small amount of
inorganic material, which increases as the plaque develops into
calculus. Plaque that does not develop into calculus reaches a
plateau of maximal mineral content within 2 days.140 Microorganisms
are not always essential in calculus formation because calculus
occurs readily in germ-free rodents.57
Saliva is the source of mineralization for supragingival calculus,
whereas the serum transudate called gingival crevicular fluid furnishes
the minerals for subgingival calculus.69,156 The calcium
concentration/content in plaque is 2 to 20 times that found in
saliva.15 Early plaque of heavy calculus formers contains more