See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/321442305

Dental calculus: The calcified biofilm and its role in disease development

Article  in  Periodontology 2000 · December 2017

DOI: 10.1111/prd.12151

CITATIONS READS

8 1,101

2 authors, including:

Aliye Akcalı
Queen Mary, University of London
41 PUBLICATIONS   204 CITATIONS   

SEE PROFILE

All content following this page was uploaded by Aliye Akcalı on 29 December 2017.

The user has requested enhancement of the downloaded file.

Periodontology 2000, Vol. 0, 2017, 1–8
Printed in Singapore. All rights reserved
Dental calculus: the calcified
biofilm and its role in disease
development
A L I Y E A K C A L I & N I K L A U S P. L A N G
Dental calculus as a testimony of
evolutionary biology
Mineralized biofilms, penetrated by crystals of vari-
ous calcium phosphates, develop above or below the
free gingival margin as moderately hard deposits that
are white/yellowish in color. They are superficially
covered with vital, nonmineralized biofilms (41). The
development of mineralized biofilm represents a
dynamic process that starts with the initiation of a
nonmineralized biofilm which eventually calcifies, at
which point it is termed dental calculus. The calcifica-
tion process follows various mechanisms of mineral-
ization (58). During these processes, bacterial biofilm
(encompassing bacterial species that may be identi-
fied in saliva) is entrapped within the mineralized
deposits. It is widely accepted that nonmineralized
biofilms consist of over 800 different taxa (20).
Viral and fungal taxa, as well as disease-associated
microorganisms of the respiratory tract, have been
identified both in ancient biofilms and in more
recently mineralized biofilms (56). As dental calculus
represents the first fossilized record of bacterial com-
munities associated with the human body (micro-
biome), it is an important source of information
related to the evolution of the human microbiome
(57).
Initiated by research on archaeological human and
animal samples (2), early studies of ancient dental
calculus were performed. Scanning electron micro-
scopy and the first observations and description of
in situ calcified oral microbes (5) revealed the broad
presence of well-preserved calcified microorganisms
in human calculus and allowed the extrapolation into
ancient oral microbiomes (6, 10). Intact bacterial
DNA within preserved calcified biofilm deposits was
first demonstrated in 2011 (34), and the extraction
© 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
PERIODONTOLOGY 2000
and selected sequencing of ancient oral microbial
DNA was reported in 2012 (4). Different metagenomic
sequencing strategies have recently been applied to
ancient dental calculus and described immense pos-
sibilities for dental calculus to reform ancient
biomedical research (56).
Modern investigations of the native human
microbiota have demonstrated that the human
microbiome plays a central role in health and
chronic disease, raising questions about changes in
microbial ecology, diversity and function throughout
the course of human evolution. Human dental
calculus has been shown to be abundant, nearly
ubiquitous and represents a long-term reservoir of
the ancient oral microbiome, preserving not only
microbial and host biomolecules, but also dietary
and environmental debris. The study of ancient
mineralized or fossilized biofilms may provide
insight into bacterial virulence factors, host defense
proteins and the development of diseases of civiliza-
tion that are faced today. The study of dental
calculus will help the development of a new era in
palaeomicrobiology.
Development and structure of
dental calculus
Dental calculus develops when nonmineralized bio-
films, extremely rich in oral bacteria (45), become
mineralized with calcium phosphate mineral salts.
These mineralized biofilms form both supragingivally
and subgingivally (41) (Fig. 1A,B). Nonmineralized
dental biofilm entraps particles from the oral cavity,
including large amounts of oral bacteria, human pro-
teins, viruses and food remnants, and preserves their
DNA (15) (Fig. 2).
1
Akcalı & Lang

The rate of calculus formation, and its composi-
tion, may differ depending on the intra-oral localiza-
tion. Dental calculus in close proximity to the
openings of the large salivary gland ducts contains
more calcium and phosphorus than does dental cal-
culus that develops at other intra-oral sites (13, 40)
(Fig. 3).
A
Histologically, supragingival and subgingival calcu-
lus are similar in terms of appearance and in the
sequence of events of the formation of the supragin-
gival and subgingival deposits, respectively (32).
Subgingival dental calculus has been demonstrated
to retain significant levels of endotoxin that may
influence tissue damage in controlled experi-
ments (58).
The presence of calcified masses with a spongy
appearance and containing empty spaces represent-
ing the former sites of entombed and degenerated
organisms was noted in morphological studies (23).
Moreover, the presence of tubular holes was
reported (44). These holes appeared to be the areas
of nonmineralized bacteria surrounded by a calci-
fied matrix. Areas were also noted where bacteria
were calcified but surrounded by a nonmineralized
space. A difference in the microbial profile of
supragingival and subgingival calculus was revealed

Fig. 3. Dental calculus in close proximity to the large sali-

vary gland ducts openings contains more calcium and
Fig. 1. (A, B) Supragingival and subgingival dental phosphorus than does dental calculus developing at the
calculus. other sites.

Fig. 2. Nonmineralized dental bio-

film entraps particles from the oral
cavity, including large amounts of
oral bacteria, human proteins,
viruses and food remnants.

2

(9). Filamentous organisms dominated supragingival
calculus and were oriented at right angles to the
surface of the teeth, whereas subgingival calculus
was covered by cocci, rods and filaments with no
distinct pattern of orientation. The mineralized
microorganisms in calculus are hardly capable of
any metabolic activity. Following the mineralization
process, dental calculus loses its microbial virulence.
Nevertheless, it now provides a surface onto which
newly developing biofilm is deposited with various
compositions (41).
The process of mineralization involves metabolic
activities of the bacterial colonies and strengthens
the attachment of nonmineralized biofilms to the
tooth surface. It thus maintains close proximity to
the gingival tissues, as dental biofilms always cover
the surface of the mineralized deposits (11) (Fig. 4).
From a clinical point of view, it must be noted that
dental calculus always harbors a living, nonmineral-
ized biofilm (depicted as the blue mass of biofilm in
Fig. 4), which jeopardizes the integrity of the dento-
gingival unit.
Fig. 4. Undecalcified ground section of a dog tooth stained
with toluidine blue and basic fuchsin, showing supragingi-
val calculus (CA) on enamel and dentin in close proximity
to the gingival margin. The calcified deposits are always
covered with a layer of nonmineralized biofilm (blue
mass), eliciting the host response in the gingiva. Data from
Bosshardt & Lang (3), with permission of Wiley/Blackwell.
Dental calculus
Formation rate of dental calculus
The formation rate of dental calculus varies greatly
between individuals, but is usually typical for a single
individual. The rate of calculus formation and the
amount of calculus formed depends on multiple fac-
tors, including diet, especially alkaline foods (15, 17)
and sugars (39), genetic variations in the salivary con-
tent (29) and other factors, such as age, race, gender,
presence of disease and the bacterial load of the sub-
ject (29, 58). To date, little is known about the rate at
which calculus is formed throughout life and whether
it is possible to dissolve calculus.
Studies focusing on the various factors influencing
calcification in heavy and light calculus formers iden-
tified two major factors: (i) a different biochemical
composition of saliva between heavy and light calcu-
lus formers during early plaque development; and (ii)
higher levels of calcium, three times higher levels of
phosphorus and lower levels of potassium in the sal-
iva of heavy calculus formers than in the saliva of light
calculus formers (24). On average, calculus formers
deposit daily calculus in the range of 0.10–0.15% dry
weight (43, 51).
The mineralization process of the biofilm appears
to be complete in 12 days, but half of the mineraliza-
tion occurs in the first 2 days (28, 40). Following min-
eralization, the roughened surface of the calculus
provides an ideal ground for the deposition of new
biofilm. Calcified and previously calcified biofilms
consist of four different types of calcium phosphate
crystals (14, 41):
 CaH (PO4) 9 2H2O = brushite
 Ca4H (PO4)3 9 2H2O = octacalcium phosphate
 Ca5(PO4)3(OH) = hydroxyapatite
 b-Ca3 (PO4)2 = whitlockite.
Supragingival calculus is clearly built up in layers
and shows high heterogeneity from one layer to
another. On average, the mineral content is 37%, but
ranges from 16% to 51%, with some exceptional layers
having a maximal density of minerals of up to 80% (8,
16). The predominant mineral in exterior layers is
octacalcium phosphate, while hydroxyapatite is dom-
inant in the inner layers of old calculus. Whitlockite is
only found in small proportions (47). Brushite is pre-
sent in recently calcified deposits (i.e. those not older
than 2 weeks) and appears to form the basis for
supragingival calculus formation.
Subgingival calculus appears more homogeneous
than supragingival calculus as it is built up in layers of
equally high mineral density. On average, the density
3
Akcalı & Lang
is 58%, ranging from 32% to 78%. Maximal values of
60–80% have also been identified (8, 16). The pre-
dominant mineral is whitlockite, although hydroxya-
patite has been found (47). Whitlockite contains small
proportions (3%) of magnesium (26).
In the presence of a relatively low plaque pH and a
concomitantly high calcium/phosphorus ratio in sal-
iva, brushite is formed and this may later develop into
hydroxyapatite and whitlockite. When supragingival
plaque mineralizes, octacalcium phosphate forms
and is gradually changed into hydroxyapatite. In the
presence of alkaline and anaerobic conditions and
concomitant presence of magnesium (or zinc and
carbon trioxide), large amounts of whitlockite are
formed in a stable form of mineralization.
As a mechanical effect of mineralization of biofilms
and spreading, the epithelium is displaced around
the gingival line and allows bacteria from living, non-
mineralized biofilms to move closer to the alveolar
bone (37) (Fig. 5).
The presence of calculus may limit the ability to
perform optimal oral hygiene practices (33) and
hence may increase the rate of biofilm deposition.
This, in turn, may reduce drainage from the crevicular
Fig. 5. Undecalcified ground section of a dog tooth stained
with toluidine blue and basic fuchsin, showing subgingival
calculus (CA) on a root surface. Uncalcified biofilm (light
blue) extends on top of the calcified deposits and apically
into the periodontal pocket. There is a calculus-free zone
between the apical termination of the calculus and the api-
cal extension of the periodontal pocket. Data from Bos-
shardt & Lang (3) with permission of Wiley/Blackwell.
4
area (25). Moreover, subgingival calculus may serve
as a secondary retentive site for toxic bacterial prod-
ucts (42).
Clinical relevance of dental
calculus
It has convincingly been demonstrated that a normal
dento-gingival junction could re-establish after
removal of the subgingival biofilm and calculus (53).
However, such complete removal of calculus on root
surfaces is difficult in daily practice (35).
Although strong associations between calculus
deposits and periodontitis have been demonstrated
in experimental (54, 55) and epidemiologic (22) stud-
ies, it should be noted that calculus is always covered
by an unmineralized layer of viable biofilm. It is a
matter of debate whether or not calculus may exert a
detrimental effect on the soft tissues owing to its
rough surface per se. However, it has clearly been
established that surface roughness alone does not ini-
tiate gingivitis (52).
Although there is a positive correlation between the
presence of calculus and the prevalence of gingivitis
(18, 21, 36, 38), no cause–effect relationship between
calculus and disease initiation and progression has
been established. Moreover, in monkeys, a normal
epithelial attachment, with the junctional epithelial
cells forming hemidesmosomes and a basement
membrane, on calculus was revealed if the calculus
surface was disinfected using chlorhexidine (19). Fur-
thermore, bacteria-free calculus can be formed by
salivary gland extracts of germ-free animals (7, 50). It
has also been shown that even in a sterile form, for
instance after autoclaving, dental calculus remains
sufficiently irritating to cause a granulomatous reac-
tion in guinea-pig skin. Moreover, it has been demon-
strated that autoclaved calculus may be encapsulated
in connective tissue without inducing marked inflam-
mation or abscess formation (1). These findings con-
firm that dental biofilm is more irritating to the
tissues than the calculus it covers (46).
Previously, there was a general consensus that a
correlation existed between the calculus index and
periodontal disease (12, 37, 49). However, recent
research has focused on either direct or indirect
effects of calculus on gingival inflammation. The rela-
tionship between inflammation of the pocket wall
and subgingival calculus could be an example of the
direct relationship (59). On the other hand, indirect
association was shown through increased salivary
levels of calcium in periodontal disease (48).

Supragingival and subgingival calculus progressing
in an apical direction or laterally is directly responsi-
ble for the pocked deepening and loss of attachment
(55), as a metabolically active biofilm always covers
subgingival calculus (Fig. 5). The clinical appearance
of the periodontal tissues may be affected by subgin-
gival dental calculus because it provides a rough
surface for retention and establishment of microor-
ganisms and hence indirectly impairs sufficient
removal of biofilm, the cause of periodontal disease.
Subgingival calculus is also a by-product, which owes
its secondary development to the presence of
microorganisms and exudative inflammatory prod-
ucts (41). However, deposition of calculus may differ
in interproximal areas because of the presence of the
col, which is thinly covered by nonkeratinized junc-
tional epithelium and enables accumulation of
subgingival calculus during the early phases of the
inflammation.
Well-controlled animal (30) and clinical (27, 31)
studies have shown that the removal of subgingival
plaque on the surface of the subgingival calculus
resulted in healing of periodontal lesions and the
maintenance of healthy gingival and periodontal tis-
sues, provided that the removal was meticulous and
performed on a regular basis. One of these studies
(27) clearly demonstrated that the microbial compo-
sition and clinical parameters following the diligent
and complete removal of subgingival biofilm by
chipping off gross amounts of calculus were almost
identical to those obtained with routine removal of
subgingival calculus by root surface instrumentation.
Again, it should be noted that meticulous supragin-
gival biofilm control guaranteed depletion of the
supragingival bacterial reservoir required for subgin-
gival recolonization.
These studies have clearly elucidated the role of
subgingival calculus as a plaque-retaining factor.
Moreover, the studies have documented that biofilm
removal is a more important therapeutic approach
than the deliberate removal of the subgingival cal-
culus believed to contain large amounts of endo-
toxin. Hence, the overt and intensive removal of
subgingival calcified biofilms should not be per-
formed in combination with extensive removal of
cementum for the purpose of eliminating contami-
nated hard structures.
Conclusion
The significance of dental calculus in the initiation
and progression of periodontitis has been
Dental calculus
demonstrated by the clear associations between the
presence of calculus and periodontitis. Although den-
tal calculus is always covered with viable bacterial
biofilm, it is difficult to distinguish between the
effects of calculus or biofilm per se on the periodon-
tium. Dental calculus is an ideal breeding environ-
ment for bacterial biofilm and growth and it is
accepted as an important secondary etiological factor
in the development and progression of periodontitis.
Based on the knowledge to date, still the most impor-
tant objective of periodontal therapy is the elimina-
tion of microbial etiological factors, namely the
removal of supragingival and subgingival bacterial
biofilms and, consequently, also dental calculus.
References
1. Allen DL, Kerr DA. Tissue response in the guinea pig to ster-
ile and non-sterile calculus. J Periodontol 1965: 36: 121–126.
2. Armitage PL. The extraction and identification of opal phy-
toliths from the teeth of ungulates. J Archaeol Sci 1975: 2:
187–197.
3. Bosshardt DD, Lang NP. Dental calculus. In: Lang NP,
Lindhe J, editors. Clinical periodontology & implant den-
tistry, 6th edn (Chapter 9). Oxford, UK: Wiley Blackwell,
2015: 183–189.
4. De La Fuente C, Flores S, Moraga M. DNA from human
ancient bacteria: a novel source of genetic evidence from
archaeological dental calculus. Archaeometry 2012: 55: 767–
778.
5. Dobney K, Brothwell D. A scanning electron microscope
study of archaeological dental calculus. In: Olsen SL, edi-
tors. Scanning electron microscopy in archaeology. British
archaeological reports international series. Oxford: Archaeo-
press, 1988: 372–385.
6. Dobney K. Study of the dental calculus. In: Lilley JM, Stroud
G, Brothwell DR, Williamson MH, editors.The Jewish burial
ground at Jewbury. York, UK: York Archaeological Trust,
Council for British Archaeology, 1994: 507–521.
7. Draus F, Leung SW, Miklos F. Modified apparatus for the
formation of synthetic calculus. J Dent Res 1960: 39: 857.
8. Friskopp J, Isacsson G. Mineral content of supragingival
and subgingival dental calculus. A quantitative microradio-
graphic study. Scand J Dent Res 1984: 92: 417–423.
9. Friskopp J, Hammarstro € m L. An enzyme histochemical
study of dental plaque and calculus. Acta Odontol Scand
1982: 40: 459–466.
10. Hansen PH, Meldgaard J, Nordqvist J, editors. The Green-
land mummies. Washington, DC: Smithsonian Institution
Press, 1991.
11. Hazen SP. Supragingival dental calculus. Periodontol 2000
1995: 58: 125–136.
12. Jenkins GN. The biochemistry of plaque and caries with
special reference to fluoride. In: Marthaler TM, editor.
Metabolism and cariogenicity of dental plaque. Switzerland:
Zyma Nyon, 1974.
13. Jenkins GN. The chemistry of plaque. Ann N Y Acad Sci
1965: 131: 786–794.
5
Akcalı & Lang
14. Jepsen S, Deschner J, Braun A, Schwarz F, Eberhard J. Cal-
culus removal and the prevention of its formation. Peri-
odontol 2000 2011: 55: 167–188.
15. Jin Y, Yip HK. Supragingival calculus: formation and
control. Crit Rev Oral Biol Med 2002: 13: 426–441.
16. Kani T, Kani M, Moriwaki Y, Doi Y. Microbeam X-ray diffrac-
tion analysis of dental calculus. J Dent Res 1983: 62: 92–95.
17. Lieverse AR. Diet and the aetiology of dental calculus. Int J
Osteoarchaeol 1999: 9: 219–232.
18. Lilienthal B, Amerena V, Gregory G. An epidemiological
study of chronic periodontal disease. Arch Oral Biol 1965:
10: 553–566.
19. Listgarten MA, Ellegaard B. Electron microscopic evidence
of a cellular attachment between junctional epithelium and
dental calculus. J Periodontal Res 1973: 8: 143–150.
20. Liu B, Faller LL, Klitgord N, Mazumdar V, Ghodsi M, Som-
mer DD, Gibbons TR, Treangen TJ, Chang YC, Li S, Stine
OC, Hasturk H, Kasif S, Segre  D, Pop M, Amar S. Deep
sequencing of the oral microbiome reveals signatures of
periodontal disease. PLoS One 2012: 7: e37919.
21. Lo€ e H. Prevention and control of periodontal disease at the
community level: is it feasible? The scientific basis of peri-
odontal disease prevention. N Z Dent J 1984: 80: 108–111.
22. Lo€ vdal A, Arno
€ A, Wærhaug J. Incidence of clinical manifes-
tations of periodontal disease in light of oral hygiene and
calculus formation. J Am Dent Assoc 1958: 56: 21–33.
23. Lustmann J, Lewin-Epstein J, Shteyer A. Scanning electron
microscopy of dental calculus. Calcif Tissue Res 1976: 21:
47–55.
24. Mandel I. Biochemical aspects of calculus formation. J Peri-
odontal Res 1969: 4: 7–8.
25. Mandel ID. Biochemical aspects of calculus formation. I.
Comparative studies of plaque in heavy and light calculus
formers. J Periodontal Res 1974: 9: 10–17.
26. McDougall WA. Analytical transmission electron micro-
scopy of the distribution of elements in human supra-gingi-
val dental calculus. Arch Oral Biol 1985: 30: 603–608.
27. Mombelli A, Nyman S, Bra €gger N, Wennstro € m J, Lang NP.
Clinical and microbiological changes associated with an
altered subgingival environment induced by periodontal
pocket reduction. J Clin Periodontol 1995: 22: 780–787.
28. Mu € hlemann H, Schroeder H. Dynamics of supragingival
calculus formation. Adv Oral Biol 1964: 1: 175–203.
29. Nancollas GH, Johnsson MA. Calculus formation and inhi-
bition. Adv Dent Res 1994: 8: 307–311.
30. Nyman S, Sarhed G, Ericsson I, Gottlow J, Karring T. Role of
“diseased” root cementum in healing following treatment
of periodontal disease. An experimental study in the dog.
J Periodontal Res 1986: 21: 496–503.
31. Nyman S, Westfelt E, Sarhed G, Karring T. Role of “diseased”
root cementum in healing following treatment of periodontal
disease. A clinical study. J Clin Periodontol 1988: 15: 464–468.
32. Oshrain H, Salkind A, Mandel ID. An histologic comparison
of supra and subgingival plaque and calculus. J Periodontol
1971: 42: 31–33.
33. Pradeep AR, Agarwal E, Arjun Raju P, Rao MS, Faizuddin M.
Study of orthophosphate, pyrophosphate, and pyrophos-
phatase in saliva with reference to calculus formation and
inhibition. J Periodontol 2011: 82: 445–451.
34. Preus HR, Marvik OJ, Selvig KA, Bennike P. Ancient bacte-
rial DNA (aDNA) in dental calculus from archaeological
human remains. J Archaeol Sci 2011: 38: 1827–1831.
6
35. Rabbani GM, Ash MM Jr, Caffesse RG. The effectiveness of
subgingival scaling and root planing in calculus removal.
J Periodontol 1981: 52: 119–123.
36. Ramfjord SP, Emslie RD, Greene JC, Held AJ, Wærhaug J.
Epidemiological studies of periodontal diseases. Am J Pub-
lic Health Nations Health 1968: 58: 1713–1722.
37. Riethe P. Oral hygiene for the prevention of dental
caries and periodontal diseases 1. Quintessenz J 1974: 4:
35–37.
38. Scha €tzle M, Lo
€ e H, Lang NP, Bu€ rgin W, Anerud A, Boysen
H. The clinical course of chronic periodontitis. J Clin Peri-
odontol 2004: 31: 1122–1127.
39. Scheie AA. Mechanisms of dental plaque formation. Adv
Dent Res 1994: 8: 246–253.
40. Schroeder H. Inorganic content and histology of early den-
tal calculus in man. Helv Odontol Acta 1963: 7: 17.
41. Schroeder HE. Formation and inhibition of dental calculus.
Berne: Hans Huber, 1969.
42. Schwartz SR, Massler M, LeBeau LJ. Gingival reactions to
different types of tooth accumulated materials. J Periodon-
tol 1971: 42: 144–151.
43. Sharawy AM, Sabharwal K, Socransky SS, Lobene RR. A
quantitative study of plaque and calculus formation in nor-
mal and periodontally involved mouths. J Periodontol 1966:
37: 495–501.
44. Shirato M, Kamishikiryo K, Itoh A, Kado H, Maeda Y, Seki-
guchi T, Fukui K, Takezawa T. Observations of the surface
of dental calculus using scanning electron microscopy.
J Nihon Univ Sch Dent 1981: 23: 179–187.
45. Socransky SS, Haffajee AD. Dental biofilms: difficult thera-
peutic targets. Periodontol 2000 2002: 28: 12–55.
46. Socransky SS. Relationship of bacteria to the etiology of
periodontal disease. J Dent Res 1970: 49: 203–222.
47. Sundberg JR, Friskopp J. Crystallography of supragingival
and subgingival human dental calculus. Scand J Dent Res
1985: 93: 30–38.
48. Sutej I, Peros K, Benutic A, Capak K, Basic K, Rosin-Grget K.
Salivary calcium concentration and periodontal health of
young adults in relation to tobacco smoking. Oral Health
Prev Dent 2012: 10: 397–403.
49. ten Cate JM. Research on dental calculus: why? In: ten Cate
JM, editor. Recent advances in the study of dental calculus.
Oxford: Oxford University Press, IRL Press, 1988: 1–4.
50. Theilade J. Electron microscopic study of calculus attach-
ment to smooth surfaces. Acta Odontol Scand 1964: 22:
379–387.
51. Turesky S, Renstrup G, Glickman I. Effects of changing the
salivary environment on progress of calculus formation.
J Periodontol 1962: 33: 45.
52. Wærhaug J. Effect of rough surfaces upon gingival tissues.
J Dent Res 1956: 35: 323–325.
53. Wærhaug J. Healing of the dento-epithelial junction follow-
ing subgingival plaque control. I. As observed in human
biopsy material. J Periodontol 1978: 49: 1–8.
54. Wærhaug J. Microscopic demonstration of tissue reaction
incident to removal of dental calculus. J Periodontol 1955:
26: 26–29.
55. Wærhaug J. The gingival pocket. Odontol Tidskr 1952: 60:
1–186.
56. Warinner C, Rodrigues JF, Vyas R, Trachsel C, Shved N,
Grossmann J, Radini A, Hancock Y, Tito RY, Fiddyment S,
Speller C, Hendy J, Charlton S, Luder HU, Salazar-Garcıa

DC, Eppler E, Seiler R, Hansen LH, Castruita JA, Barkow-
Oesterreicher S, Teoh KY, Kelstrup CD, Olsen JV, Nanni P,
Kawai T, Willerslev E, von Mering C, Lewis CM Jr, Collins
MJ, Gilbert MT, Ru € hli F, Cappellini E. Pathogens and host
immunity in the ancient human oral cavity. Nat Genet 2014:
46: 336–344.
57. Weyrich LS, Dobney K, Cooper A. Ancient DNA analysis of
dental calculus. J Hum Evol 2015: 79: 119–124.
View publication stats
Dental calculus
58. White DJ. Dental calculus: recent insights into occurrence,
formation, prevention, removal and oral health effects of
supragingival and subgingival deposits. Eur J Oral Sci 1997:
105: 508–522.
59. Wilson TG, Harrel SK, Nunn ME, Francis B, Webb K. The
relationship between the presence of tooth-borne subgingi-
val deposits and inflammation found with a dental endo-
scope. J Periodontol 2008: 79: 2029–2035.
7