Calculus and its role in the development of periodontal diseases – Deborah Lyle

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  Posted by: The Probe      16th November 2019

If dental plaque is not mechanically removed, over time it can calcify becoming calculus (tartar). Primarily composed of calcium phosphate, much like bone, but also highly adhesive, making it not unlike cement; once calculus has formed brushing and string floss are unable to clear it from the teeth. Why exactly plaque periodically undergoes mineralisation is not currently completely understood, but dental calculus is highly prevalent and its effects are not to be underestimated

Calculus is so tough and long lasting that it has even been used to learn about the dietary habits of ancient people, as well as their medicinal and tobacco usage. Microfossils from what people have eaten, drunk or breathed can all become trapped in developing calculus. Sequenceable DNA can be extracted from dental calculus that is centuries old![i],[ii]

Calculus can form on any surface where plaque goes undisturbed for long enough to mineralise, teeth and prostheses alike. Calculus can be classified by its location relative to the gum: supragingival and subgingivial calculus. Where the calculus has formed affects it’s composition and properties.

Supragingival calculus is typically whitish yellow in colour, contains more brushite, octa calcium phosphate, saliva proteins and is comparatively easy to remove from the tooth surface. It terms of consistency it is hard and clay-like. For obvious reasons, it is visible during a routine dental examination.

Subgingival calculus forms on the surface of the tooth below the free margin of the gingiva, and cannot be observed from a simple visual inspection. It takes on a brown or greenish black colour, and is more firmly attached to the tooth surface than its supragingival counterpart. It contains more sodium (increasingly so with pocket depth) and more magnesium whitelockite; salivary proteins can be expected to be absent. It is hard and flint-like, or similar to glass.[iii]

Role in periodontal disease

As calculus is both a product of plaque and is also covered in a layer of it, it is difficult to truly isolate its distinct effects. As an active bacterial colony plaque may be the greater threat, but the distinction is a more academic than practical matter.

Calculus has been historically believed to cause inflammation in nearby periodontal tissue, however, more recent research indicates it may not be directly responsible for this – instead its rough surface provide a perfect foundation for subgingival microbial colonisation. Furthermore it can adversely affect the gums by harbouring plaque, preserve reservoirs of toxic bacterial components and products, acting as an irritant to periodontal tissue, deforming and enlarging the periodontal pocket wall, and inhibiting the action of white blood cells.3

Periodontitis is unfortunately a very common ailment, with the severe form affecting 10-15% of adults, and the more moderate presentation affecting around half the population.[iv]

Where deep pockets have formed complete removal of plaque and calculus is challenging. The deeper the pocket, the greater the quantity of residual calculus is likely to remain.[v] As with most things, early intervention is preferable.


Wider health implications

Research indicates that dental calculus is associated with death from heart infarction. A long-term study begun in 1985, has found that a high calculus index score correlated with increased risk of premature death due to heart infarction.[vi] Previous research indicates that the mechanism for this is bacteraemia, bacterial infection of the blood, which can cause infective endocarditis. Individuals with calculus index scores of 2 or more, were found to be at four times the risk of developing bacteraemia than those with lower scores.[vii] Heart disease remains the leading cause of death globally, if calculus is even a small part of that, then ensuring patient’s remain as calculus free as possible could save lives.[viii]

Similarly, dental plaque has been associated with an increased risk of dying from cancer. Again the proposed mechanism is that poor oral hygiene (as evidenced through plaque and calculus accumulation) facilitates oral infections, which may play a role in cancer development.[ix] Correlation does not necessarily equal causation, but given the potential severity of the outcome and the relatively minor resources required to treat and prevent calculus accumulation, it seems a wise investment.

Diabetes is a known risk factor for periodontitis, potentially tripling the likelihood of developing the latter (particularly when blood sugar levels are poorly controlled). However, more recent research indicates that this relationship may be bidirectional, with periodontitis adversely affecting glycaemic control. Periodontal therapy in patients with diabetes has been associated with improved glycaemic control (HbA1c reductions of about 0.4%). Treating periodontal inflammation may therefore, be a clinically relevant means of helping to manage diabetes.4



While patients cannot remove calculus themselves, by maintaining a good oral health regimen they can keep plaque from accumulating and remove it before it has the chance to calcify.

The Whitening Professional Water Flosser from Waterpik® is an effective adjunct to manual tooth brushing. Gentle water pulsation can effectively and painlessly clean difficult to reach interproximal surfaces, removing 99.9% of plaque biofilm from treated areas.[x] The Whitening Professional mixes water with a gentle stain removal agent, helping to motivate patients into maintaining good oral health with a naturally brighter smile.

Calculus can play a key role in the development of periodontitis, and may affect the pathogenesis of other serious – potentially life-threatening – diseases. Yet it is preventable and with good oral hygiene instruction and sound recommendations, patients can inhibit the formation of calculus and avert any health impacts it may bring with it.


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[i] Warinner C., Speller C., Collins M. A new era in paleomicrobiology: prospects for ancient dental calculus as a long-term record of the human oral microbiome. Philosophical Transactions of the Royal Society B: Biological Sciences. 2015; 370(1660): 20130376. Accessed February 21, 2019.

[ii] Jersie-Christensen R., Lanigan L., Lyon D., Mackie M., Belstrøm D., Kelstrup C., Fotakis A., Willerslev E., Lynnerup N., Jensen L., Cappellini E., Olsen J. Quantitative metaproteomics of medieval dental calculus reveals individual oral health status. Nature Communications. 2018; 9: 4744. Accessed February 21, 2019.

[iii] Aghanashini S., Puvvalla B., Mundinamane D., Apoorva S., Bhat S., Lalwani M A comprehensive review on dental calculus. Journal of Health Sciences & Research. 2016; 7(2): 42-50. February 21, 2019.

[iv] Preshaw P., Alba A., Herrera D., Jepsen S., Konstantinidis A., Makrilakis K., Taylor R. Periodontitis and diabetes: a two-way relationship. Diabetologia. 2012; 55(1): 21-31. Accessed February 21, 2019.

[v] Lai P., Walters J. Resolution of localized chronic periodontitis associated with longstanding calculus deposits. Case Reports in Dentistry. 2014; 2014; 391503. Accessed February 21, 2019.

[vi] Söder B., Meurman J., Söder P. Dental calculus is associated with death from heart infarction. BioMed Research International. 2014; 2014: 569675. Accessed February 21, 2019.

[vii] Lockhart P., Brennan M., Thornhill M., Michalowicz B., Noll J., Bahrani-Mougeot F., Sasser H. Poor oral hygiene as a risk factor for infective endocarditis-related bacteremia. Journal of the American Dental Association. 2009; 140(10): 1238-1244. Accessed February 21, 2019.

[viii] World Health Organization. The top 10 causes of death. WHO. 2018. Accessed February 21, 2019.

[ix] Söder B., Yakob M., Meurman J., Andersson L., Söder P. The association of dental plaque with cancer mortality in Sweden. A longitudinal study. BMJ Open. 2012; 2: e001083. Accessed February 21, 2019.

[x] Gorur A., Lyle, D., Schaudinn C., Costerton J. Biofilm removal with a dental water jet. Compend Contin Ed Dent. 2009; 30(Special Iss 1):1–6. Accessed February 21, 2019.



 Deborah M. Lyle, RDH, MS

Deborah received her Bachelor of Science degree in Dental Hygiene and Psychology from the University of Bridgeport and her Master of Science degree from the University of Missouri – Kansas City.  She has 18 years clinical experience in dental hygiene in the United States and Saudi Arabia with an emphasis in periodontal therapy.  Along with her clinical experience, Deborah has been a full time faculty member at the University of Medicine & Dentistry of New Jersey, Forsyth School for Dental Hygienists and Western Kentucky University.  She has contributed to Dr. Esther M. Wilkins’ 7th, 8th, 9th and 10th editions of Clinical Practice of the Dental Hygienist and the 2nd and 3rd edition of Dental Hygiene Theory and Practice by Darby & Walsh.  She has written numerous evidence-based articles on the incorporation of pharmacotherapeutics into practice, risk factors, diabetes, systemic disease and therapeutic devices.  Deborah has presented numerous continuing education programs to dental and dental hygiene practitioners and students and is an editorial board member for the Journal of Dental Hygiene, Modern Hygienist, RDH, and Journal of Practical Hygiene and conducted several studies that have been published in peer-reviewed journals.  Currently, Deborah is the Director of Professional and Clinical Affairs for Waterpik, Inc.

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