Journal

of
Dentistry
Journal of Dentistry 28 (2000) 93102
www.elsevier.com/locate/jdent
Review

Subgingival calculus: where are we now? A comparative review

E.A. Roberts-Harry*, V. Clerehugh
Department of Periodontology, Leeds Dental Institute, Clarendon Way, Leeds LS2 9LU, UK
Received 4 January 1999; accepted 15 July 1999

Abstract
Objective: To critically analyse the formation, composition, ethnic variations and pathogenic potential of subgingival calculus in compar-
ison with supragingival calculus.
Data sources: Using CD-ROM and index medicus, scientific papers relating to subgingival calculus or subgingival and supragingival
calculus written in the English language since 1960 were considered, with the emphasis on more recent articles.
Study selection: Studies were selected for their relevance and contemporary nature re:composition and formation of dental calculus and
comparisons of ethnic groups with regard to dental calculus, especially subgingival calculus. Some similar studies were not included.
Data extraction: Abstracts of studies were kept brief unless particularly important to the review. Population, methodology, statistics and
accurate conclusions were used as important guides to the quality and validity of studies.
Data synthesis: Similarities and differences between supragingival and subgingival calculus in composition and formation were shown.
Different morphological types of subgingival calculus were demonstrated. There was evidence for an association between calculus formation
and ethnicity with regard to supragingival and subgingival calculus, and an association between subgingival calculus composition and
ethnicity was indicated.
Conclusions: An association between ethnicity and subgingival calculus formation and composition was found. Further research into the
reasons for these ethnic differences in dental calculus and the role of the mineral constituents especially of subgingival calculus would be
valuable. q 2000 Elsevier Science Ltd. All rights reserved.
Keywords: Subgingival calculus; Supragingival calculus; Composition; Formation; Ethnicity

Contents
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
2. Definition and detection of subgingival calculus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
3. Composition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
3.1. Crystal types . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
3.2. Elemental composition and crystallization studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
4. Formation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
4.1. Influence of plaque bacteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
4.2. Pathogenic potential of calculus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
4.3. Influence of race . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
5. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100

1. Introduction has been conducted on subgingival calculus. It is undoubt-

It is a mystery as we approach the millennium and in this
present era of technological wizardry that so little research
* Corresponding author. Tel.: 1 44-113-2336-190; fax: 1 44-113-
2336-165.
E-mail address: a.r.calvert@leeds.ac.uk (E.A. Roberts-Harry)
0300-5712/00/$ - see front matter q 2000 Elsevier Science Ltd. All rights reserved.
PII: S0300-571 2(99)00056-1
edly largely responsible for the chronicity and progression
of periodontal disease [1,2] although its role in periodontal
tissue breakdown is still far from understood. It is 40 years
since the introduction of the electron microscope when it
emerged that dental plaque was the major aetiological factor
in the initiation of the disease and that supra- and sub-
gingival calculus was mineralised plaque covered by an
94 E.A. Roberts-Harry, V. Clerehugh / Journal of Dentistry 28 (2000) 93102

unmineralized bacterial layer [38]. Since that time and with
advancing knowledge of the effects of plaque, comparatively
few papers have been published on dental calculus and subgin-
gival calculus in particular. This is despite knowing that supra-
gingival calculus makes good oral hygiene more difficult to
achieve, thereby accelerating plaque formation, and that there
is no doubt as to the importance of subgingival calculus. Cler-
ehugh and Lennon [9] in a 2-year longitudinal study of early
periodontitis in adolescents showed that the presence of
subgingival calculus was, in fact, the factor most strongly
associated with subsequent loss of attachment. This was
reiterated in the 5-year results of this study [10].
Greene [11] found greater quantities of supragingival
calculus and higher levels of periodontal disease in Asian
populations compared with Caucasians. Several authors
have since shown a higher prevalence of subgingival calcu-
lus and periodontitis in Indo-Pakistani and West Indian
subjects [9,10,1215]. Moreover, Ong [16] in a study of
an Asian population in Singapore, showed that tooth loss
due to periodontal problems was more conspicuous in an
Indian ethnic group compared to both Chinese and Malay
groups. However, the reasons for these differences have not
been addressed and the role of subgingival calculus in the
pathogenicity of the periodontal diseases needs clarification.
The aim of this review is to critically analyse the forma-
tion, composition, ethnic variation and pathogenic potential
of subgingival calculus and to highlight the important differ-
ences in comparison with supragingival calculus.
2. Definition and detection of subgingival calculus
Dental calculus is defined as the calcified or calcifying
deposits that are found attached to the surfaces of teeth and
other solid structures in the oral cavity [17]. It is broadly
classified into two categories according to the location:
1. Supragingival calculus is located coronally or above the
gingival margin.
2. Subgingival calculus is located apically or below the
gingival margin in the gingival sulcus or periodontal
pocket.
Table 1 compares the characteristics of supragingival and
subgingival calculus.
To distinguish subgingival calculus from supragingival
calculus is not always easy at the region of the gingival
margin. In general, subgingival deposits are more brown
to black, hard and tenaciously adherent to the tooth surface.
The colour arises from a combination of haemorrhagic
elements from the gingival crevicular fluid and black
pigmentation from the calcified anaerobic rods as compared
to the yellow/white accretions of supragingival deposits
exposed to the saliva. However, supragingival deposits
may stain brown from, for example, food pigment or
tobacco. Subgingival deposits are more prevalent on the
interproximal and lingual than on the buccal tooth surfaces
and are distributed seemingly randomly on the teeth around
the mouth [17] while supragingival deposits are mostly
found opposite openings of the major salivary ducts.
Subgingival calculus deposits can sometimes be detected
visually by blowing air down the gingival crevice; the
deposits may also be visible on radiographs although this
is not always reliable [18]. The best method of detection,
short of surgically reflecting a flap, is probing down the
tooth surface and feeling for the rough nature of the deposits
and this has been made easier in recent years with the advent

Table 1
Characteristics of supragingival and subgingival calculus

Supragingival Subgingival
Location Coronal to gingival margin Apical to gingival margin
Colour Yellow/White Brown/Black
Distribution Adjacent to salivary duct openings Randomly around mouth
Composition Concentration of Ca, Mg, F, Sr & Zn lower and of Concentration of Ca, Mg & F higher and of carbonate
carbonate & Mn higher than subgingival calculus. lower than supragingival calculus. More irregular
More regular distribution of F distribution of F
Mineral content & source Averages 37% from saliva by volume Averages 58% from gingival crevicular fluid by volume
Crystal type & size Mostly OCP & HAP, some DCPD. Small needle- Mostly WHT, no DCPD. Small crystals only
shaped & large ribbon-like
Formation Heterogeneous nucleation & crystal growth. More Heterogeneous nucleation & crystal growth. More
variable (heterogeneous) calcification uniform (homogeneous) calcification
Microorganisms Dominated by microorganisms; some non-calcified Very few non-calcified microorganisms. Less
areas. More filamentous organisms; faster growth filamentous organisms; slower growth
Influence of race Greater prevalence & quantities in Asian populations Greater prevalence & quantities in Asian populations
associated with more extensive attachment loss. Lower
levels of sodium and magnesium in more apical
subgingival calculus in Indo-Pakistanis than in
Caucasians
Morphology Undifferentiated Several types identified: spiny, crusty, nodular; ledge/
ring; individual islands; smooth veneers; finger/fernlike;
supra- on subgingival
Pathogenic potential Little evident Associated with periodontal disease
 E.A. Roberts-Harry, V. Clerehugh / Journal of Dentistry 28 (2000) 93102
of the WHO 621 probe used with the CPITN/BPE systems
[19].
3. Composition
Mature dental calculus is a highly mineralised deposit
with an inorganic content resembling bone, dentine and
cementum [20]. Supragingival calculus comprises 70
80% inorganic salts of which about two-thirds are in crystal-
line form [20]. Calcium (Ca) and phosphorus (P) are the
major elements present with a Ca:P weight ratio ranging
from 1.66 to more than 2 [2024]. Small amounts of magne-
sium, sodium, carbonate and fluoride may be present as well
as traces of other elements [25]. The concentration of
calcium, magnesium and fluoride is greater in subgingival
calculus reflecting higher concentrations of these ions in the
gingival crevicular fluid than in saliva [20]. An organic
matrix of protein, lipid and carbohydrate constitutes the
remaining 1520% of the dry weight in supragingival calcu-
lus, probably less in subgingival calculus.
Early studies of the structure of dental calculus were
hampered by the high amounts of inorganic constituents,
which made thin sectioning of samples difficult, until the
advent of the electron microscope and the ability to prepare
ultrathin sections [4,26]. These thin, undecalcified sections
have shown that dental calculus is dominated by small,
needle-shaped, inorganic crystals of apatite. Some of the crys-
tals appear as platelets or rods and are generally randomly
orientated. The outline of calcified micro-organisms can
often be seen. Most significantly, the surface of calculus is
always covered by a layer of unmineralized plaque [4,5,26].
3.1. Crystal types
Four crystal types of calcium phosphate have been
reported in differing proportions in subgingival and supra-
gingival calculus:
1. DCPD, brushite or dicalcium phosphate dihydrate,
CaHPO42H20.
2. OCP, octacalcium phosphate, Ca8H2(PO4)65H2O.
3. WHT, magnesium containing whitlockite, beta-TCP,
(Ca,Mg)3(PO4)2.
4. HAP, carbonate-containing hydroxyapatite (approxi-
mately (CaM)10(CO3,HPO4,PO4)6(OH,X)2, where M are
other cations capable of substituting for the Ca 21, e.g.
Sr 21, Pb 21, K 1, Na 1, etc.; X Cl or F). Carbonate can
also substitute for the hydroxyl ion, OH 2.
Schroeder [27] has shown that in a longitudinal study of
developing calculus, DCPD appears first, then OCP, and
then as the calculus matures, WHT and HAP. However,
Kani et al. [28] proposed that in supragingival calculus
OCP formed first in the calcifying plaque, then gradually
hydrolysed and transformed into HAP at the pH of saliva. In
conditions of low pH and high Ca:P ratio, DCPD is formed
initially and is transformed into HAP or WHT at an early
95
stage of calcification driven by the rise of pH due to ammo-
nia produced in dental plaque. Under an anaerobic alkaline
condition and presence of magnesium, zinc and carbonate
ions in tissue liquid, a large amount of WHT is formed and
gradually develops as a stable state, which would account
for it being the main component in subgingival calculus. A
study to determine the distribution and concentration of
mineral in supragingival and subgingival calculus was
carried out by Friskopp and Isacsson [29]. Distribution of
mineral was found to vary considerably within the speci-
mens and between different specimens. While supragingival
calculus appeared heterogeneous with some areas non-calci-
fied and an average mineral content of 37% by volume,
subgingival calculus, in contrast, appeared homogeneously
calcified, with an average mineral content of 58%. There
were no differences in mineral content between surface
areas and portions close to the tooth and it was concluded
that once the calculus is formed no changes occur in the
mineral content, i.e. no maturation occurs with age, and
that local variations in mineral content within the calculus
might be explained by periodic differences in the fluid envir-
onment of the microbial plaque.
Sundberg and Friskopp [30] also found that the inorganic
constituents of subgingival calculus differ from supragingi-
val calculus. While the bulk crystals of WHT are the pre-
dominant component of subgingival calculus, supragingival
calculus has the platelet-shaped crystals of OCP and the
needle-shaped crystals of HAP.
3.2. Elemental composition and crystallization studies
The role of the various elements which form calculus
have not been fully investigated. It may be helpful to
know why one element is favoured over another in subgin-
gival and supragingival calculus formation and its effect.
For example, Okumura et al. [31] showed that concentra-
tions of fluoride were highest at the outer surface of dental
calculus and, then fell to a plateau for the interior of the
calculus, rising again as the tooth surface was approached.
This may reflect the rate of calculus formation. Subgingival
calculus tended to show more irregular profiles than the
smoother fluoride distribution seen in supragingival calcu-
lus although total fluoride, average fluoride, and maximum
fluoride concentrations were not significantly different in
either. In addition, no significant differences were observed
between males and females.
The difference in environmental pH and microflora may
also influence fluoride profiles in both subgingival and
supragingival calculus. Furthermore, the level of fluoride
in plaque overlying the calculus may be very relevant.
Reports of fluoride concentration in plaque have been very
variable; from 55 ppm in one study [32] to 1.47 ppm in
another [33].
Hidaka et al. [34] studied the distribution of silicon in
human supragingival calculus using an electron-probe
microanalyser and found localised areas of silicon on the
96 E.A. Roberts-Harry, V. Clerehugh / Journal of Dentistry 28 (2000) 93102
oral surface of the calculus. These areas contained either
silicon alone or silicon together with magnesium, alumi-
nium, potassium, calcium, and iron, which implies that the
areas may be opal or mica. As the silicic acid, silica, kaolin
and talc stimulated and mica inhibited the in vitro calcium
phosphate precipitation, this may indicate a regulatory role
of the silicon-rich areas in the formation of supragingival
and possibly also subgingival calculus.
Studies of the crystal types in subgingival deposits using
various methods of analysis [24,30,35] have also revealed
information regarding elemental composition. Little and
Hazen [24] reported a higher Ca:P ratio and greater sodium
content, that is, a consistently higher mineral content in
calculus formed deep within periodontal pockets, in
comparison with the more superficial subgingival deposits.
This suggested that the composition of the fluid from which
the marginal and deep subgingival calculus deposits were
formed, differed, because the composition of calcium phos-
phate precipitates as well as calcified tissue have been
shown to vary with the composition of the fluid. The high
Ca:P ratio seen in deep subgingival calculus is, in fact,
similar to that found in bone and dentine which reflect
serum composition. This in turn suggested that the fluid
supplying the constituents of deep subgingival calculus
was the serum transudate associated with the inflammatory
reaction in the periodontal pocket, unlike saliva in which
supragingival calculus bathes. The marginal subgingival
calculus showing a variable Ca:P ratio is presumably influ-
enced from fluid in the oral cavity and from the periodontal
pocket. Little and Hazen [24] also found that the composi-
tion of deep subgingival calculus tended to be related to the
location in the mouth; marginal subgingival calculus from
the upper molar region consistently showed a lower mineral
content than that from the lower lingual areas when subgin-
gival calculus was present in both areas in a subject.
Gron et al. [35] revealed that the magnesium and fluoride
contents were significantly higher and the carbonate content
significantly lower in subgingival than supragingival calcu-
lus and that WHT occurred with greatest frequency and
abundance in the subgingival calculus. They also observed
OCP in both supra- and subgingival deposits but no detect-
able DCPD in the subgingival deposits. Friskopp [36]
described the appearance of supra- and subgingival calculus
using light microscopy and transmission electron micro-
scopy (TEM). Light microscopy showed supragingival
calculus to be heterogeneous in nature, i.e. islets of calcified
material within the covering plaque and non-calcified areas
within the calculus. Subgingival calculus, however, was
homogeneous i.e. no calcified material in the covering
plaque and only calcified material within the calculus itself.
Under TEM, supragingival calculus was dominated by
micro-organisms, small needle-shaped and large ribbon-
like crystals, while subgingival calculus showed crystals
of small size only. A very few non-calcified micro-organ-
isms were seen within the calculus. This was later confirmed
by Sundberg and Friskopp [30] who noted that subgingival
samples seemed to be better crystallised than the supragin-
gival ones.
More recently, Kodaka and Miake [37] compared the
innermost, middle and outermost layers of ledge-type and
spiny deposits of subgingival calculus. They found the spiny
deposits to be almost entirely of the hexahedral WHT type,
with HAP type in the outermost and innermost layers, and
no OCP present. In contrast, the ledge-type deposits
included the grain-shaped HAP, plate-shaped OCPHAP,
and the WHT types everywhere other than the outermost
layer.
Grain-shaped HAP crystals are formed by the intra- and
extra-cellular calcification in dental calculus [4,27,38,39].
The well aligned ribbon-shaped OCP crystals, however, are
probably formed by the filamentous micro-organisms, and
this would account for the formation of the ledge type
deposits found in the subgingival calculus exposed to the
oral cavity and hence, saliva [40]. The deeper subgingival
spiny deposits, not exposed directly to saliva, appear to have
the rod-shaped micro-organisms as the cores of the bacillus-
shaped deposits, which are composed of WHT crystals.
These differences in the crystal formations may be related
to differences in pH value and magnesium sources between
saliva which has a low pH and small magnesium content
[41], and gingival fluid which has a high pH [42] and an
almost six times larger magnesium content [43]. In addition,
Schroeder and Bambauer [44] amongst others found that
OCP crystals are formed in lower pH than WHT crystals,
and WHT crystals favour a higher magnesium content for
their formation.
Knuuttila et al. [45] compared the concentrations of Ca,
Mg, Mn, Sr and Zn in supra- and subgingival calculus,
which had been collected from mandibular anterior teeth,
using atomic absorption spectrophotometry for the analysis.
They found highly significant P , 0:001 greater Zn and Sr
concentrations in the subgingival samples. The mean value
of Zn was 5.4 times higher in the subgingival calculus than
in the supragingival calculus. The concentration of Mn,
however, was significantly higher P , 0:01 in supragingi-
val calculus. The difference in the concentration of Mg in
supra- and subgingival calculus was highly significant
P , 0:001 only when samples from the same person were
compared. Finally, the concentration of Ca was very similar
in both types of calculus and individual variations were very
small.
Lundberg et al. [46] had presented data on copper content
of subgingival and supragingival calculus based on radio-
chemical assays and found a high variation.
Knuuttila et al. [47] studied copper content in human
subgingival calculus in relation to other elements, especially
Ca and Mg ions in the mineralization of calculus. Using an
atomic absorption spectrophotometer they determined the
assays of Ca, Mg, Fe, Cu, Pb and Zn contents. Fluoride
was also tested for using an ion-selective electrode. As in
Lundbergs study the Cu content varied and was in agree-
ment with its different concentrations in human dental
 E.A. Roberts-Harry, V. Clerehugh / Journal of Dentistry 28 (2000) 93102
plaque. However, the Cu content had a significant positive
correlation with Zn and a negative correlation with Ca. The
positive correlation between Cu and Zn has also been
demonstrated in human cancellous bone [48], possibly indi-
cating a similar mineral type and location in the inorganic
phase of bone and dental calculus formation. The inverse
relation between the Cu and Ca contents may be associated
with the cytotoxic effects of Cu on micro-organisms and/or
leucocytes, thus interfering with the role of micro-organ-
isms in dental calculus formation.
At a macroscopic level, Everett and Potter [49] divided
submarginal (subgingival) calculus deposits into six types
based on its appearance on extracted teeth under a magnify-
ing glass (3 ), and under a dissecting microscope. 1132
teeth from 396 patients suffering from advanced, chronic
destructive periodontal disease were looked at and categor-
ized as follows:
1. Crusty, spiny or nodular deposits n 706:
2. Ledge or ring formation n 664:
3. Thin, smooth veneers n 75:
4. Finger- and fern-like formations n 216:
5. Individual calculus islands or spots n 52:
6. Supramarginal upon submarginal deposits n 6:
The total number of cases categorised exceeds the number
of teeth examined because in some cases more than one type
of deposit was noted on a tooth. As can be seen, the common
ones were crusty, spiny or nodular deposits (62%) and ledge
or ring-like formations (59%). Little and Hazen [24] also
regarded the ledge formations as subgingival deposits, but it
may be more appropriate to consider them transitional
between supra- and deep subgingival types. They are
exposed to the oral environment, like supragingival calcu-
lus, as well as to the pocket environment. A recent study by
Roberts-Harry et al. compared the morphology of subgingi-
val calculus in an Indo-Pakistani group and a white Cauca-
sian group [50,51]. Five of the morphological types of
subgingival calculus, typed according to Everett and Potter
[49] were identified: crusty/spiny/nodular; ledge/ring; thin
smooth veneers; individual islands or spots; supramarginal
on submarginal. The first three types were more commonly
found in the Indo-Pakistani group, while the individual
islands were more prevalent in the white Caucasian
subjects. Finger- and fern-like formations were not seen.
Supramarginal on submarginal calculus was only found in
the Indo-Pakistani group. It was concluded that there were
differences in the morphological types of subgingival calcu-
lus in the two ethnic groups [5052].
4. Formation
Many studies have investigated the formation of dental
calculus [3,6,53,54]. These show that calculus formation is
always preceded by plaque formation, and that plaque
accumulations are the organic matrix for the subsequent
97
mineralization of the deposit. Initially, small crystals appear
in the intermicrobial matrix frequently in close apposition to
the external aspects of the bacteria. Gradually, the matrix
between the micro-organisms becomes calcified and then
the bacteria become mineralized. The first evidence of calci-
fication may occur after only a few days [53]. Similarly,
Muhlemann and Schroeder [7] demonstrated that crystalline
formation in plaque begins as early as 38 h after prophy-
laxis, and well-calcified calculus is present in 12 days.
Furthermore, Schroeder [27] stated that by 12 days, 60
80% of the maximum inorganic content of calculus is
present. Several more recent studies have demonstrated
this tendency for early accumulation of calculus following
prophylaxis and scaling [55,56]. However, development of
a deposit with a crystal composition characteristic of old
calculus requires months or even years [44]. The present
understanding of the mineralization process revolves around
two basic concepts: nucleation of crystal seeds and growth
of crystals. Nucleation of calcium and phosphate is termed
either homogeneous or heterogeneous. Homogeneous,
spontaneous nucleation requires more energy and a much
greater concentration of Ca and P ions than heterogeneous
nucleation [57] and therefore, only occurs under in vitro
conditions. However, heterogeneous nucleation occurs
within the range of biological calcification processes [58].
Homogeneous nucleation starts with aggregation of ions or
molecules which are added to one another in stepwise fash-
ion, known as a bimolecular mechanism, rather than simul-
taneous agglomeration which involves random clustering of
large quantities of units [58]. Heterogeneous nucleation, in
turn, requires much more energy and a greater concentration
of Ca and P ions than crystal growth. In the presence of
a sufficient amount of substrate, crystal growth occurs
automatically.
Therefore, the conditions necessary for nucleation need
only be present intermittently in order for mineralization to
begin and/or be maintained. This theory of nucleation is
obviously complicated by the plethora of different ions
and inorganic and organic components present in the saliva
which also vary in concentration, and which may settle in
plaque. Presumably, the plaque forms the environment for
the heterogeneous nucleation of calcium phosphate crystals,
which occurs even with a transient supersaturation of the
ions. Other inorganic ions may be incorporated into the
crystal structure depending on such conditions as, for
example, their concentration, and pH of the plaque.
It is now generally agreed that the main source of inor-
ganic ions for supragingival calculus formation is the saliva.
Early theories of how calculus then formed favoured the
idea of the localised plaque having a higher pH than that
of saliva, either by carbon dioxide loss or by ammonia
formation leading to precipitation of phosphates and bicar-
bonates. Later theories included certain organic molecules
acting as templates for the precipitation of minerals [59], or
the breakdown of nucleation inhibitors by plaque [60,61].
While there is some evidence for the latter two theories,
98 E.A. Roberts-Harry, V. Clerehugh / Journal of Dentistry 28 (2000) 93102
most evidence shows that a local increase in pH is the main
reason for calculus formation.
Kleinberg and Jenkins [62] found the pH of resting plaque
in 85% of cases to be higher than that of the surrounding
saliva by 0.51 unit. Critchley et al. [63] thought that this
was probably due to proteolytic activity in which urea,
ammonia and amines are formed. More recently, Watanabe
et al. [64] made similar findings and further proposed that
protease activity in saliva is positively correlated with
calculus index. Jenkins [41] also noted that calculus tended
to form most readily in plaques with the highest pH value,
whilst Driessens and Verbeeck [60] indicated that local
increases in pH were associated with calculus formation.
The formation of subgingival calculus is similar to that of
supragingival calculus in that pocket secretions also appear
to meet the requirements for nucleation and crystal growth.
In theory, pocket secretions do not occur in healthy gingivae
and so it is an indication of the presence of inflammation
when they do occur, and with increasing inflammation there
is an increased amount of fluid secreted [65]. This inflam-
matory exudate contains calcium [66], phosphates and
proteins [67].
4.1. Influence of plaque bacteria
Friskopp and Hammarstrom [68] compared the morphol-
ogy of well developed sub- and supragingival calculus. Both
had a heterogeneous core covered by a soft, loose layer of
micro-organisms; that covering the supragingival calculus
was dominated by filamentous micro-organisms lying
approximately perpendicular to and in direct contact with
the underlying calculus, while the subgingival calculus was
covered by a mixture of cocci, rods and filaments with no
distinct pattern of orientation. They found the subgingival
calculus deposits to be rough and irregular compared to the
smooth crystalline surface of the supragingival calculus.
Moreover, they treated some of the specimens with sodium
hypochlorite which then lost their soft covering leaving
channels the same size as the filamentous organisms pene-
trating into the calculus. This appearance led them to
conclude that calcification starts between, and not within,
the filamentous organisms. This is in accordance with the
findings of Schroeder et al. [54]. Friskopp and Hammar-
strom [68] also thought it probable that the filamentous
organisms promote calcification by providing an intermicro-
bial environment suitable for calcification. This would
explain the fast growth of supragingival calculus, which is
dominated by filaments compared with the slower growth
rate of subgingival calculus, with fewer filamentous
organisms.
Kodaka et al. [69] found bacillus-shaped deposits
composed of hexahedrally based crystals in dental calculus.
Electron probe microanalysis always detected calcium,
phosphorous and magnesium, present in molar ratios resem-
bling magnesium-containing whitlockite, and the crystals
also gave the electron diffraction pattern of whitlockite.
The bacillus-shaped deposits happened to co-exist with
the intracellular calcifying micro-organisms. Oral micro-
organisms partially replaced by the hexahedrally based
crystals were also found. These deposits were never seen
in the surface layer of calculus exposed to the oral cavity,
but occurred in the innermost layers of supragingival calcu-
lus and in the outer layers of deep subgingival calculus.
4.2. Pathogenic potential of calculus
Brown et al. [70] compared the relative amounts of
various microbes in the subgingival plaque of two groups
of young adults who had generalized moderate to severe
periodontitis. The subjects were chosen for each group
depending on the relative presence or absence of subgingi-
val calculus, which was assessed using a modification of the
index suggested by Greene and Vermillion [71]. Subgingi-
val calculus was assessed with an explorer on four surfaces
of all teeth after drying them with compressed air. They
found that those subjects with little or no detectable subgin-
gival calculus harboured significantly greater proportions of
coccoid forms and Actinobacillus actinomycetemcomitans
than those with obvious amounts of subgingival calculus.
Moreover, the subjects with clearly detectable subgingival
calculus harboured greater proportions of motile rods, total
motile organisms, and black-pigmented anaerobic rods than
did the subjects with little or no subgingival calculus. These
findings were despite the fact that the range of probing depth
and percentage bone loss showed no significant differences
between the groups; Listgarten et al. [72] also failed to
correlate the proportions of coccoid cells, spirochaetes,
motile rods, and other cell types with increases in probing
depths from disease affected sites. Moreover, in previous
studies, Howell et al. [73] and Sidaway [74] isolated anae-
robic rods from mature subgingival calculus. These organ-
isms appear to be calcifiable, or at least intimately
associated with subgingival calculus deposits. In addition,
the attachment and colonization of black-pigmented anae-
robic rods appear to benefit from the presence of plaques
containing Actinomyces and Streptococcus species [75]
which, in turn, are associated with calculus formation.
However, other workers did not entirely agree with these
findings. Socransky et al. [76] demonstrated a negative
correlation between anaerobic rods and Actinomyces and
Streptococcus species in disease sites. Listgarten [77]
suggested that the presence of A. actinomycetemcomitans
may exert a controlling effect on other plaque-producing
and normally calcifiable bacteria by inhibiting the coloniza-
tion and viability of these bacteria. The findings of Brown et
al. [70] would support this hypothesis. They reported that
amongst young adult patients, those with no clinically detect-
able subgingival calculus harboured significantly greater
proportions (%) of coccoid forms and A. actinomycetemcomi-
tans than did patients with obvious amounts of subgingival
calculus. Furthermore, comparing the occurrence and levels of
A. actinomycetemcomitans, P. intermedia and P. gingivalis,
 E.A. Roberts-Harry, V. Clerehugh / Journal of Dentistry 28 (2000) 93102
Clerehugh et al. [14] found significantly more P. gingivalis
in diseased sites than in healthy sites in adolescents who had
already developed early loss of attachment, and who had a
greater prevalence and extent of subgingival calculus.
4.3. Influence of race
The influence of race has been identified with regard to
periodontal microflora [78], early onset of periodontal
diseases [7981], host response to periodontal bacteria
[82,83] and tooth loss due to periodontal reasons [16].
Greene [11] found no difference in the intensity of calculus
deposits between under-developed and highly civilized
populations with the exception of Indians who reveal a
very high degree of dental calculus in younger age groups.
Dutta [84] stated that higher levels of plaque and calculus in
persons of a lower socio-economic status may be attributed
to a variety of causes. More recently, in the UK, Booth and
Ashley [13] studied the oral health of a group of 1517 year
old British school children of different ethnic origin. They
found that ethnic origin had a significant influence on
plaque, gingivitis, pocketing, DMFT scores and subgingival
calculus. In their study, the overall prevalence of period-
ontitis was 11.2%; European, Afro-Caribbean and Asian
groups had prevalences of 3, 21 and 14%, respectively.
Furthermore, the mean number of sites per subject with
subgingival calculus was 3.8 in the European group but a
much greater 7.3 in the Afro-Caribbean and 7 in the Asian
group.
A greater loss of attachment has been found amongst
Asian subjects compared to Caucasian subjects. Clerehugh
et al. [14] found a significantly higher prevalence P ,
0:05 and extent P , 0:001 of attachment loss $ 1 mm
in Indo-Pakistani subjects compared with Caucasians in a
recently studied adolescent population. Significantly, more
subjects with loss of attachment had subgingival calculus
and significantly more of their sites were affected P ,
0:01: Indo-Pakistani subjects had a higher prevalence and
extent of subgingival calculus (non-significant trend) than
Caucasians. Ellwood et al. [15] in a similar study found a
significantly greater prevalence of P. gingivalis amongst an
Indo-Pakistani group compared to a Caucasian group P ,
0:001: Notably, this prevalence was higher for sites with
subgingival calculus, pockets . 3 mm and bleeding on
probing P , 0:01:
The elemental composition of subgingival calculus in an
Indo-Pakistani and a white Caucasian group have also been
compared [5052,85]. Roberts-Harry et al. [50,51,85] found
no differences within or between the two ethnic groups with
regard to Ca:P ratios, fluoride or carbonate content.
However, the Indo-Pakistani group showed significantly
lower levels of sodium in the more apical samples than in
the coronal samples P , 0:001; and had significantly
lower levels of sodium P , 0:001 and magnesium P ,
0:001 in the apical subgingival calculus than the Cauca-
sians. This may be related to greater levels of WHT in the
99
more apical subgingival calculus. However, these differ-
ences in the elemental composition of the subgingival calcu-
lus may influence its overall solubility and may contribute to
its greater accretion in the Indo-Pakistani subjects [52,85].
Selikowitz and Gjermo [86] conducted a survey of Viet-
namese refugees living in Norway since 1975. Periodontal
examinations took place three weeks after arrival in
Norway, and in general, high levels of plaque, gingivitis
and subgingival calculus deposits were seen. This could
be explained by the terrible plight of these people and
their having little time for or interest in oral hygiene.
However, other studies of Asian populations have also
shown a high prevalence of deposits and gingivitis
[87,88]. In a UK based study of adolescents from differing
ethnic backgrounds Macaulay et al. [89] also found that the
Asian children had more evidence of subgingival calculus
than the European children P , 0:001:
Christersson et al. [90] performed a study using 508
adults aged 2573 years of age. The subjects were exam-
ined to determine their levels of plaque and subgingival
calculus accumulation and to evaluate their correlations
with periodontal disease, race, age, and gender in an attempt
to identify risk indicators for plaque and calculus formation.
For plaque, a correlation was shown with all the above
variables, whereas subgingival calculus showed a correla-
tion with disease status and race only.
In a similar study in Sweden, Dahllof et al. [91] assessed
dental caries and periodontal health in 225 18- and 19-year-
old adolescents with different ethnic backgrounds. While
there was no difference in dental caries prevalence, there
was an increased prevalence of periodontal disease amongst
the immigrant adolescents compared to the Swedish control
group. Subgingival calculus was found among 5.3% of the
Swedish adolescents compared to 35.1% in the immigrant
group.
The renowned study by Anerud et al. [92] compared the
levels and progression of supra- and subgingival calculus
undisturbed by active professional intervention or home
care on 480 tea labourers in Sri Lanka, with a group of
565 healthy, well-educated Norwegian males who had regu-
lar calculus removal and an above average standard of
dental home care. This study took place over a period of
15 years. The two groups were different in race, culture,
education and socioeconomically as well as representing
the opposite extremes as recipients of general and dental
health care, and these conditions remained throughout the
study.
They found that in the Sri Lankan group, both supra- and
subgingival calculus formation started before 14 years of
age, and by 40 years of age all the subjects and almost all
teeth and tooth surfaces had calculus. Subgingival calculus
alone or in combination with supragingival calculus
occurred in almost 99% of the individuals. Only 1% of
individuals had supragingival calculus only. Those who
smoked tobacco and chewed betel, both of which were
common in the Sri Lankan group, had significantly higher
100 E.A. Roberts-Harry, V. Clerehugh / Journal of Dentistry 28 (2000) 93102
calculus scores than those who only had one of these habits,
and those who had neither habit had the lowest calculus scores.
Teeth with subgingival calculus consistently showed a signif-
icantly higher rate of loss of attachment than teeth that
remained calculus free. In contrast, in the Norwegian group,
supragingival calculus did not increase in frequency from
adolescence to the forties. Approximately 55% of the partici-
pants had one or more sites with supragingival calculus only,
and 36% had subgingival calculus only or both. Subgingival
calculus scores, although low, showed some increase with
longer times of exposure, but appeared to have no impact on
loss of attachment. Much of the attachment loss, which
occurred in this group was attributable to buccal recession of
the type associated with good oral hygiene and where calculus
deposits were minimal compared to the other surfaces.
Furthermore, there were no appreciable differences in the
levels of supra- and subgingival calculus in smokers and
non-smokers, a factor not borne out in other studies [93,94].
They showed that in the population in which calculus
formation occurred without interference or interruption,
subgingival calculus was associated with higher rates of
progression of the periodontal lesion. This conclusion is in
agreement with earlier findings [95,96] and more recent
studies have reinforced this [9,10,14,16]. The exact role of
subgingival calculus in the initiation and progression of the
periodontal lesion is, however, still under debate [2], mainly
because of the confounding effect of the live bacteria in the
plaque covering the surface of the subgingival calculus
[2,14,15,7278,97].
5. Conclusion
In conclusion, it is known that plaque formation always
precedes calculus formation, and that plaque accumulations
with their bacterial contents are the organic matrix for the
subsequent mineralization of the calculus deposit. It is
understood that the inorganic constituents of supragingival
calculus arise from saliva and that those of the subgingival
calculus are from the serum transudate that is present when
a periodontal pocket occurs, and that different morphologi-
cal types of subgingival calculus occur.
Subgingival calculus has been named a factor highly
associated with attachment loss in periodontitis. Moreover,
ethnicity has been shown to influence the formation and
composition of subgingival and supragingival calculus,
with subsequent effects in periodontal disease levels.
What is not known is exactly how these differences come
about. Further research is required into factors governing
the formation, composition and morphology of subgingival
calculus and its role in the pathogenesis of the periodontal
diseases.
References
[1] Lindhe J, Westfelt E, Nyman S, et al. Long-term effect of surgical/
non-surgical treatment of periodontal disease. Journal of Clinical
Periodontology 1984;11:44858.
[2] Mandel ID, Gaffar A. Calculus revisited: a review. Journal of Clinical
Periodontology 1986;13:24957.
[3] Mandel ID, Levy BM, Wasserman BH. Histochemistry of calculus
formation. Journal of Periodontology 1957;28:1327.
[4] Gonzales F, Sognnaes RF. Electron microscopy of dental calculus.
Science 1960;131:1568.
[5] Zander HA, Hazen SP, Scott DB. Mineralization of dental calculus.
Proceedings of the Society for Experimental Biology and Medicine
1960;103:25760.
[6] Turesky S, Renstrup G, Glickman I. Histologic and histochemical
observations regarding early calculus formation in children and
adults. Journal of Periodontology 1961;32:714.
[7] Muhlemann HR, Schroeder HE. Dynamics of supragingival calculus
formation. Advanced Oral Biology 1964;1:175203.
[8] Oshrain HI, Salkind A, Mandel ID. A method for collection of subgin-
gival plaque and calculus. Journal of Periodontology 1968;39:3225.
[9] Clerehugh V, Lennon MA. A two-year longitudinal study of early
periodontitis in 14- to 16-year-old schoolchildren. Community Dental
Health 1986;3:13541.
[10] Clerehugh V, Lennon MA, Worthington HV, et al. Site progression of
loss of attachment over 5 years in 14- to 19-year-old adolescents.
Journal of Clinical Periodontology 1995;22:1521.
[11] Greene JC. Periodontal disease in India: report of an epidemiological
study. Journal of Dental Research 1960;39:30212.
[12] Lennon MA, Davies RM. Prevalence and distribution of alveolar bone
loss in a population of 15-year-old schoolchildren. Journal of Clinical
Periodontology 1974;1:17582.
[13] Booth V, Ashley F. The oral health of a group of 1517 year old
British school children of different ethnic origin. Community Dental
Health 1989;6(3):195205.
[14] Clerehugh V, Seymour GJ, Bird PS, et al. The detection of Actino-
bacillus actinomycetemcomitans Porphyromonas gingivalis and
Prevotella intermedia using ELISA in an adolescent population
with early periodontitis. Journal of Clinical Periodontology
1997;24(1):5764.
[15] Ellwood R, Worthington HV, Cullinan MP, et al. Prevalence of
suspected periodontal pathogens identified using ELISA in adoles-
cents of differing ethnic origins. Journal of Clinical Periodontology
1997;24(3):1415.
[16] Ong G. Periodontal reasons for tooth loss in an Asian population.
Journal of Clinical Periodontology 1996;23:3079.
[17] Lindhe J. Textbook of clinical periodontology, 2. Munksgaard, 1990.
[18] Buchanan SA, Jenderseck MA, Granet MA, et al. Radiographic detec-
tion of dental calculus. Journal of Periodontology 1987;58(11):74751.
[19] Clerehugh V, Abdeia R, Hull PS. The effect of subgingival calculus
on the validity of clinical probing measurements. Journal of Dentistry
1996;24(5):32933.
[20] Mandel ID. Contemporary periodontics, Mosby: Genco, Goldman
and Walter Cohen, 1990. p. 13546, chap. 10.
[21] Leung SW, Jensen AT. Factors controlling the deposition of calculus.
International Dental Journal 1958;8:61326.
[22] Little MF, Casciani CA, Rowley J. Dental calculus composition. I.
Supragingival calculus: ash, calcium, phosphorus, sodium and
density. Journal of Dental Research 1963;42:7886.
[23] Schroeder HE. Inorganic content and histology of early calculus in
man. Helvetica Odontologica Acta 1963;7:1730.
[24] Little MF, Hazen SP. Dental calculus composition (2): subgingival
calculus, ash, calcium, phosphorus and sodium. Journal of Dental
Research 1964;43:64551.
[25] Theilade J, Schroeder HE. Recent results in dental calculus research.
International Dental Journal 1966;16:20521.
[26] Theilade J. The microscopic structure of dental calculus. Thesis,
University of Rochester, Rochester, NY, 1960.
[27] Schroeder HE. Formation and inhibition of dental calculus, Bern:
Hans Huber Publishers, 1969. p. 1212.
 E.A. Roberts-Harry, V. Clerehugh / Journal of Dentistry 28 (2000) 93102
[28] Kani T, Kani M, Moriwaki Y, et al. Microbeam X-ray diffraction
analysis of dental calculus. Journal of Dental Research
1983;62(2):925.
[29] Friskopp J, Isacsson GA. Quantitative microradiographic study of the
mineral content of supragingival and subgingival dental calculus.
Scandinavian Journal of Dental Research 1984;92(1):2532.
[30] Sundberg M, Friskopp J. Crystallography of supragingival and
subgingival human dental calculus. Scandinavian Journal of Dental
Research 1985;93:308.
[31] Okumura H, Nakagaki H, Kato K, et al. Distribution of fluoride in
human dental calculus. Caries Research 1993;27:2716.
[32] Birkeland JM, Jorkjendl L, von der Fehr FR. The influence of fluoride
rinses on the fluoride content of dental plaque in children. Caries
Research 1971;5:16979.
[33] Duckworth RM, Morgan SN, Murray AM. Fluoride in saliva and
plaque following use of fluoride-containing mouthwashes. Journal
of Dental Research 1987;66(12):17304.
[34] Hidaka S, Okamoto Y, Abe K. Possible regulatory roles of silicic acid,
silica and clay minerals in the formation of calcium phosphate preci-
pitates. Archives of Oral Biology 1993;38(5):40513.
[35] Gron P, Van Campen GJ, Lindstrom I. Human dental calculus, inor-
ganic chemical crystallographic composition. Archives of Oral Biol-
ogy 1967;12(7):82937.
[36] Friskopp J. Ultrastructure of nondecalcified supragingival and subgin-
gival calculus. Journal of Periodontology 1983;54:54250.
[37] Kodaka T, Miake K. Inorganic components and the fine structures of
marginal and deep subgingival calculus attached to human teeth.
Bulletin of Tokyo Dental College 1991;32(3):99110.
[38] Ruzika G. Structure of sub- and supra-gingival dental calculus in
human periodontitis: an electron microscopic study. Journal of Peri-
odontal Research 1984;19:31727.
[39] Schroeder HE. Crystal morphology and gross structures of mineraliz-
ing during calculus formation. Helvetica Odontologica Acta
1965;9:7386.
[40] Kodaka T, Ishida I. Observations of plate-like crystals in human
dental calculus. Bulletin of Tokyo Dental College 1984;25:1318.
[41] Jenkins GN. The physiology and biochemistry of the mouth, Oxford:
Blackwell, 1978.
[42] Kleinberg I, Hall G. pH and depth of gingival crevices in different
areas of the mouths of fasting humans. Journal of Periodontal
Research 1969;4:10917.
[43] Holma B, Granath L-E, Gustafson G. A model for the study of tooth
enamel by scanning electron microscopy. Odontologisk Revy
1970;21:111.
[44] Schroeder HE, Bambauer HU. Stages of calcium phosphate crystal-
lization during calculus formation. Archives of Oral Biology
1966;11:114.
[45] Knuuttila M, Lappalainen R, Kontturi-Nahri V. Concentrations of Ca,
Mg, Mn, Sr and Zn in supra- and sub-gingival calculus. Scandinavian
Journal of Dental Research 1979;87(3):1926.
[46] Lundberg M, Soremark R, Thilander H. Analysis of some elements in
supra- and sub-gingival calculus. Journal of Periodontal Research
1966;1:2459.
[47] Knuuttila M, Lappalainen R, Rajala AM, et al. Copper in human
subgingival calculus. Scandinavian Journal of Dental Research
1983;91:1303.
[48] Lappalainen R, Knuuttila M, Lammi S, et al. Zn and Cu in human
cancellous bone. Acta Orthopaedica Scandinavica 1982;53:515.
[49] Everett FG, Potter GR. Morphology of submarginal calculus. Journal
of Periodontology 1959;30:2731.
[50] Roberts-Harry EA, Clerehugh V, Shore RC, et al. Morphology and
elemental composition of subgingival calculus in two ethnic groups.
Journal of Clinical Periodontology 1997;24:857 abstract.
[51] Roberts-Harry EA. An investigation into the composition of subgin-
gival calculus in Asian and non-Asian groups. Thesis, University of
Leeds, 1996.
[52] Shore RC, Roberts-Harry EA, Clerehugh V, et al. The elemental
101
composition of subgingival calculus in two ethnic groups. Journal
of Dental Research 1997;76(5):1023 abstract.
[53] Theilade J. Electron microscopic study of calculus attachment to
smooth surfaces. Acta Odontologica Scandinavia 1964;22:379
87.
[54] Schroeder HE, Lenz H, Muhlemann HR. Microstructures and miner-
alization of early dental calculus. Helvetica Odontolologica Acta
1964;8:1.
[55] Klein FK, Dicks JL. Evaluation of accumulation of calculus in tube-
fed, mentally handicapped patients. Journal of the American Dental
Association 1984;108:3524.
[56] Dicks JL, Banning JS. Evaluation of calculus accumulation in tube-
fed, mentally handicapped patients: the effects of oral hygiene status.
Special Care Dentist 1991;11:1046.
[57] Sherman BS, Sobel AE. Differentiating between nucleation and crys-
tal growth in mineralizing tissues and macromolecules. Archives of
Oral Biology 1965;10:323.
[58] Glimcher MJ. Specificity of the molecular structure of organic
matrices in mineralization. In: Sognnaes RF, editor. Calcification in
biological systems, Washington, DC: American Association of
Advance Sciences, 1960. p. 421.
[59] Leach SA. Release and breakdown of sialic acid from human salinary
mucin and its role in the formation of dental plaque. Nature
1963;199:486.
[60] Driessens FCM, Verbeeck RMH. Possible pathways of mineralization
of dental plaque. In: ten Cate JM, editor. Recent advances in the study
of dental calculus, Oxford: IRL Press, 1989. p. 717.
[61] Moreno EC, Aoba T, Gaffar A. Physical chemistry of calculus forma-
tion, recent advances in the study of dental calculus, New York:
Oxford University Press, 1989. p. 129.
[62] Kleinberg I, Jenkins GN. The pH of dental plaques in the different
areas of the mouth before and after meals and their relationship to the
pH and rate of flow of resting saliva. Archives of Oral Biology
1964;9:493.
[63] Critchley P, Saxton CA, Kolendo AB. The histology and histochem-
istry of dental plaque. Caries Research 1968;2:115.
[64] Watanabe T, Toda K, Morishita M, et al. Correlations between sali-
vary protease and supragingival or subgingival calculus index. Jour-
nal of Dental Research 1982;61:104851.
[65] Loe H, Holm-Pedersen P. Absence and presence of fluid from normal
and inflamed gingivae. Periodontics 1965;3:171.
[66] Krasse B, Egelberg J. The relative proportions of sodium, potassium
and calcium in gingival pocket fluid. Acta Odontologica Scandinavica
1962;20:143.
[67] Weinstein E, Mandel ID. The fluid of the gingival sulcus. Periodontics
1964;2:147.
[68] Friskopp J, Hammarstrom L. A comparative, scanning electron
microscopic study of supragingival and subgingival calculus. Journal
of Periodontology 1980;51:55362.
[69] Kodaka T, Hirayama A, Miake K, et al. Bacillus-shaped deposits
composed of hexahedrally based crystals in human dental calculus.
Scanning Microscopy 1989;3(3):84354.
[70] Brown CM, Hancock EB, OLeary TJ, et al. A microbiological
comparison of young adults based on relative amounts of subgingival
calculus. Journal of Periodontology 1991;62(10):5917.
[71] Greene JC. The oral hygiene index: development and uses. Journal of
Periodontology 1967;38:62535.
[72] Listgarten MA, Levin S, Schifter CC, et al. Comparative differential
dark-field microscopy of subgingival bacteria from tooth surfaces
with recent evidence of recurring periodontitis and from nonaffected
surfaces. Journal of Periodontology 1984;55:398401.
[73] Howell A, Rizzo F, Paul F. Cultivable bacteria in developing and
mature human dental calculus. Archives of Oral Biology
1965;10:30713.
[74] Sidaway DA. A microbiological study of dental calculus. 1. The
microbial flora of mature calculus. Journal of Periodontal Research
1978;13:34959.
102 E.A. Roberts-Harry, V. Clerehugh / Journal of Dentistry 28 (2000) 93102
[75] Gibbons RJ. Adherent interactions which may affect microbial ecol-
ogy in the mouth. Journal of Dental Research 1984;63:37885.
[76] Socransky SS, Haffajee AD, Dzink JL, et al. Associations between
microbial species in subgingival plaque samples. Oral Microbiology
and Immunology 1988;3:17.
[77] Listgarten MA. Nature of periodontal disease: pathogenic mechan-
isms. Journal of Periodontal Research 1987;22:1728.
[78] Schenkein HA, Burmeister JA, Koertge TE, et al. The influence of
race and gender on periodontal microflora. Journal of Periodontology
1993;64:2926.
[79] Loe H, Brown LJ. Early onset periodontal disease in the United States
of America. Journal of Periodontology 1991;62:60816.
[80] Oliver RC, Brown LJ, Loe H. Variations in the prevalence and extent
of periodontitis. Journal of the American Dental Association
1991;122:438.
[81] Beck JD, Koch GG, Rozier RG, et al. Prevalence and risk indicators
for periodontal attachment loss in a population of older community-
dwelling blacks and whites. Journal of Periodontology 1991;61:521
8.
[82] Gunsolley JC, Tew JG, Gooss CM, et al. Effects of race and period-
ontal status on antibody reactive with Actinobacillus actinomycetem-
comitans strain Y4. Journal of Periodontal Research 1988;23:30812.
[83] Gunsolley JC, Tew JG, Conner T, et al. Relationship between race and
antibody reactice with periodontitis associated bacteria. Journal of
Periodontal Research 1991;26:5963.
[84] Dutta A. A study on prevalence of periodontal disease and dental
caries amongst the school going children in Calcutta. Journal of All
India Dental Association 1965;37:367.
[85] Roberts-Harry EA, Clerehugh V, Shore RC et al. Morphology and
elemental composition of subgingival calculus in two ethnic groups,
submitted for publication.
[86] Selikowitz H-S, Gjermo P. Periodontal conditions, remaining teeth
and oral hygiene habits in a group of Vietnamese refugees in Norway.
Journal of Clinical Periodontology 1985;12:4250.
[87] Anerud A, Loe H, Boysen H, et al. The natural history of periodontal
disease in man. Changes in the gingival health and oral hygiene before
40 years of age. Journal of Periodontal Research 1979;14:52640.
[88] Selikowitz H-S. The relationship between periodontal conditions and
perceptions of periodontal health among Pakistani immigrants in
Norway. Journal of Clinical Periodontology 1987;14:3404.
[89] Macaulay WR, Taylor GO, Lennon MA, et al. The suitability of three
periodontal indices for epidemiological studies conducted for plan-
ning purposes. Community Dental Health 1988;5:1139.
[90] Christersson LA, Grossi SG, Dunford RG, et al. Dental plaque and
calculus: risk indicalors for their formation. Journal of Dental
Research 1992;71(7):142530.
[91] Dahllof G, Bjorkman S, Lindvall K, et al. Oral health in adolescents
with immigrant background in Stockholm. Swedish Dental Journal
1991;15(4):197203.
[92] Anerud A, Loe H, Boysen H. The natural history and clinical course
of calculus formation in man. Journal of Clinical Periodontology
1991;18:16070.
[93] Linden GJ, Mullally BH. Cigarette smoking and periodontal destruc-
tion in young adults. Journal of Periodontology 1994;65:71823.
[94] Feldman RS, Bravacos JS, Rose CL. Association between smoking
different tobacco products and periodontal disease indexes. Journal of
Periodontology 1983;54:4817.
[95] Waerhaug J. The gingival pocket. Anatomy, pathology, deepening
and elimination. Odontologica Tidsskrift 1952;60:1.
[96] Lovdal A, Arno A, Waerhaug J. Incidence of clinical manifestations
of periodontal disease in light of oral hygiene and calculus formation.
Journal of the American Dental Association 1958;56:2133.
[97] Theilade J, Zander HA. Morphology of dental calculus. Journal of
Dental Research 1960;39:109 abstract.