62. Etiology - Local Calculus, Tooth Anatomy, Mouthbreathing

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  1. Calculus formation
  2. Calculus composition
  3. review articles on calculus
  4. calculus attachment to root surfaces
  5. palatogingival groove
  6. root surface area factors
  7. bifurcational ridges
  8. cervical enamel projections
  9. open interdental contacts
  10. food impaction
  11. the effect of mouth breathing on the periodontium
  12. review of local factors that effect the periodontium

Discussion Topics

Discuss the impact of the following on periodontal disease and gingival inflammation.

Calculus Structure

What is calculus?

Are supragingival and subgingival calculus similar in how they form? Their composition?

  1. Friskopp J: Ultrastructure of nondecalcified supragingival and subgingival calculus. J. Periodontol. 54:542-550, 1983.

  2. Carranza FA: Glickman's Clinical Periodontology. 7th ed., Chap. 26, pp. 387-399, W.B. Saunders Co., Phila, 1990.

  3. Jin Y, Yip H-K: Supragingival calculus: Formation and control. Crit Rev Oral Biol Med 2002; 13: 426-441 (Review)

  1. Anerud A, Loe H, Boysen H: The natural history and clinical course of calculusformation in man. J. Clin. Periodontol. 18:160-170, 1991.

  2. Tan BT, Mordan NJ, Embleton J, Pratten J, Galgut PN.Study of bacterial viability within human supragingival dental calculus.J Periodontol. 2004 Jan;75(1):23-9

  3. Davies RM, Ellwood RP, Volpe AR, Petrone ME. Supragingival calculus and periodontal disease. Periodontol 2000. 1997 Oct;15:74-83. Review.

  4. Mandel I, Goffar A: Calculus revisited. A review. J Clin Periodontol 13:249, 1986.

  5. Richardson AC, Chadroff B, Bowers GM : The apical location of calculus within the intrabony defect. J. Periodontol. 61:118-122, 1990.

  6. White DJ: Dental calculus: recent insights into occurrence, formation, prevention, removal and oral health effects of supragingival and subgingival deposits. Eur J Oral Science1997; 105: 508-522

  7. Roberts-Harry EA, Clerehugh V: Subgingival calculus: where are we now? A comparative review. J Dent 2000; 28: 93-102


Calculus Attachment

  1. Zander HA: The attachment of calculus to root surfaces. J Periodontol 24:16-19,1953.

  2. Kopczyk RA, Conroy CW: The attachment of calculus to root planed surfaces

  3. Periodontics 6:78-83, 1968.

  4. Moskow BS: Calculus attachment in cemental separations. J Periodontol 40:125-130,

  5. 1969.

  6. Canis MF, Kramer GM, Pameijer CM: Calculus attachment - review of the literature and

  7. new findings. J. Periodontol. 50:406-415, 1979.

Tooth Anatomy

  1. Everett FG, Kramer GM: The disto-lingual groove in the maxillary lateral incisor: A periodontal hazard. J. Periodontol. 43:352-361, 1972.

  2. Withers JA, Brunsvold MA, Killoy WJ, & Robe AJ: The relationship of palato-gingival grooves to localized periodontal disease. J Periodontol 52:41-44, 1981.

  3. Kogon SL : The prevalence, location, and conformation of palatoradicular grooves in maxillary incisors. J. Periodontol. 57:231- , 1986.

  4. Hou GL, Tsai CC. Relationship between palato-radicular grooves and localized periodontitis. J Clin Periodontol. 20:678-82, 1993

  5. Leknes K, Lie T, Selvig K: Root grooves: A risk factor in periodontal attachment loss. J Periodontol 1994;65: 859-863

  6. Gher ME, Vernino AR: Root anatomy: a local factor in inflammatory periodontal disease. Int. J. Perio. Restor. Dent. 1(5):53-, 1981.

  7. Gher MW Jr, Dunlap RW. Linear variation of the root surface area of the maxillary first molar. J Periodontol. 1985 Jan;56(1):39-43.

  8. Dunlap RM, Gher ME. Root surface measurements of the mandibular first molar. Periodontol. 1985 Apr;56(4):234-8.

  9. Booker BW, Loughlin DM : A morphologic study of the mesial root surface of the adolescent maxillary first bicuspid. J. Periodontol. 56: 666- ,1985.

  10. Ferreira Z, Pilatti G, Lamira A: Treatment of a palato-gingival groove related periodontal bone defect. Quintess Intern 2000; 31: 342-345

  11. Everett Fg, Jump Eb, Holder Td, Williams Gc. The intermediate bifurcational ridge: a study of the morphology of the bifurcation of the lower first molar.. J Dent Res. 1958 Feb;37(1):162-9

  12. Bernard S. Moskow, Pedro Martinez Canut Studies on root enamel(2) Enamel pearls. A review of their morphology, localization, nomenclature, occurrence, classification, histogenesis and incidence, , J Clin Periodontol 1990; 17:275-281.

  13. Masters, DH & Hoskins, SW: Projection of cervical enamel into molar furcations. J. Periodontol. 1964: 35: 49-53

  14. RH Swan and WC Hurt. Cervical enamel projections as an etiologic factor in furcation involvement J Am Dent Assoc, Vol 93, No 2, 342-345. 1976

Tooth Contacts/Food Impaction

  1. Hirschfeld I: Food impaction. J.A.D.A. 17:1504-1528, 1930.

  2. Larato DC: Relationship of food impaction to interproximal intrabony lesions. J. Periodontol. 42:237-238, 1971.

  3. Kepic TJ, O'Leary TJ: Role of marginal ridge relationships as an etiologic factor in periodontal disease. J. Periodontol. 49:570- , 1978.

  4. Hancock EB, Mayo CV, Schwab RR, Wirthlin R : Influence of interdental contacts on periodontal status. J. Periodontol. 51:445-449, 1980.

  5. Jernberg GR, Bakdash MB, Keenan KM. Relationship between proximal tooth open contacts and periodontal disease. J Periodontol 1983; 54:529-533.

Miscellaneous Local Factors - Mouthbreathing

  1. Wagaiyu EG, Ashley FP. Mouthbreathing, lip seal and upper lip coverage and their relationship with gingival inflammation in 11-14 year-old schoolchildren. J Clin Periodontol.18:698-702, 1991

  2. D. C. Matthews, M. Tabesh: Detection of localized tooth-related factors that predispose to periodontal infections, Periodontol 2000 2004; 34: 136-50

What is calculus?

Are supragingival and subgingival calculus similar in how they form? Their composition?

How does calculus form?

How is calculus formation controlled?

Friskopp, 1983                       ARTICLE

P: To study the ultra-structure of non-decalcified supragingival (supra-g) and subgingival (sub-g) calculus.

M & M: 10 teeth w/ supra-g and sub-g calculus were extracted from patients with advanced periodontal disease. The calculus was dissected from the teeth with a scalpel and then dehydrated in a graded series of ethanol and embedded in epoxy resin. The specimens were then sectioned and prepared for LM and TEM.

R/DISC: LM exam demonstrated that the supra-g calculus was heterogeneous with islets of calcified material within the covering plaque and with non-calcified areas within the calculus. TEM revealed supra-g calculus was heterogeneous, dominated by microbes, small needle-shaped crystals and large ribbon-like crystals, and non-calcified microbes were surrounded with densely packed small crystals. LM of sub-g calculus was homogeneous; TEM revealed crystals of small size only, very few calcified microorganisms and only calcified material within the calculus itself & not on the covering plaque.

The bacterial cell wall seemed to be the structure that was last calcified, both supra-g and sub-g. The morphology of supra-g plaque was dominated by filamentous microorganisms, while sub-g plaque contained various forms of microorganisms with no dominating form.

Carranza, 1990                       NO ARTICLE

The primary effect of calculus is not, as was originally thought, due to mechanical irritation, but is related to it always being covered by bacteria. Supra-g calc is called salivary calc since saliva is the major source of minerals, whereas sub-g calc is called serum calc because GCF is the main source of mineral.

Prevalence: Supra-g C (86-100%) for people < 40 yo. Sub-g is (40-100%) for > 40 yo.

Composition:

Inorganic content: accounts for 70-90% of supra-g. It consists of 76% calcium phosphate, 3.1% Calcium carbonate, and traces of other metal. At least 2/3 of inorganic content is crystalline in structure. The 4 main crystal forms are hydroxyapatite (58%); magnesium whitlockite (MW) (12%), octacalcium phosphate (OCP) (21%) and brushite (9%). Generally two or more crystal forms occur in a calculus sample with HA and OCP being the most common (97%). Brushite is more common in the mand ant region and MW in the post areas.

Organic content: Mixture of protein-polysaccharide complexes, desquamated epith, leukocytes, and various types of microorganisms.

Sub-g calc has the same HA, more MW and less brushite and OCP. Calcium/phosphate ratio is higher sub-g and the sodium content incr w/ the depth of the perio pkts.

Formation: Calculus is attached dental plq that has undergone mineralization, which usually starts b/w the 1st and 14 day. Plq is 50% mineralized in 2 days. Not all plqs become calcified. Microorganisms are not always necessary for calc formation since it occurs in germ-free rats.

Calcification entails the binding of calcium to the carbohydrate-protein complexes and the precipitation of crystalline phosphate salts. Crystals form initially in the intercellular matrix and on the bacterial surfaces and finally w/in the bacteria.

Calcification begins along the inner surface of the sub-g plq (and in the attached component of sub-g plq) adjacent to the tth in separate foci that incr in size and coalesce to form solid masses of calc. Calc is formed in layers separated by a thin cuticles.

C formation continues until it reaches a max (2-6 mos), from which it may be reduced in amount.

Mineralization theories:

  1. Mineral precipitation results from a local rise in the degree of saturation of Ca & phosphate.

  2. Seeding agents induce small foci of calcification, which enlarge and coalesce to form a calcified mass (also called heterogenous nucleation).

BL: The principal irritating factor in calculus is surface plaque rather than its calcified interior. Calculus is a sig pathogenic factor in periodontal disease.

Jin, 2002(Review)                       ARTICLE

R: Dental calculus is composed of inorganic components and an organic matrix. Brushite, dicalcium phosphate dihydrate, octacalcium phosphate, hydroxyapatite, and whitlockite comprise the mineral part of dental calculus. Salivary proteins adsorb on the tooth surface to form an acquired pellicle. It is followed by the adherence of various oral micro-organisms. Fimbriae, flagella, and other surface proteins allow for microbial adherence. Co-aggregation and co-adhesion enable some micro-organisms, which are incapable of adhering, to adhere to the pellicle-coated tooth surface. Once organisms attach to the tooth surface, new genes could be expressed so that mature dental plaque can form and biofilm bacteria assume increased resistance to antimicrobial agents. Supersaturation of saliva and plaque fluid with calcium phosphates is the driving force for plaque mineralization. Both salivary flow rate and plaque pH appear to influence the saturation degree of calcium phosphates. Acidic phospholipids and specific protolipids present in cell membranes play a key role in microbial mineralization.

Anerud 1991                       ARTICLE

P: To describe relationship between time and risk of calculus formation and the levels and patterns of calculus within the dentition, to explore stability and change in calculus status, to describe the relationship between calculus formation and certain oral habits, and to examine the effect of calculus formation on attachment loss.

M+M: Longitudinal study looking at Sri Lankan and Norwegian populations differing in geography, race, culture, education, and socioeconomics. Norwegian group (from 1969-1988):565 healthy male high school, university students and junior faculty in non-medical, non-dental programs between 16 and 30 years of age, who had exposure to dental care throughout life. Sri Lankan tea workers group (1970-1985): 480 males between 14 and 30+ years of age who had never been exposed to any program of dental professional or self -care. Norwegian group was first examined in 1970, with subsequent examinations in 1971, 1973, 1975, 1981 and 1988. Sri Lankan group was first examined in 1970 with subsequent examinations in 1971, 1973, 1977, 1982 and 1985. At each exam, mesial and buccal surfaces of all teeth (except 3d molars) scored for calculus by same examiner using Loe (1967) parameters. No preventative or therapeutic measures during the scoring sessions.

R: Norwegian Group: Almost all participants between 16 and 55 years of age had some calculus. Approximately 55% had one or more sites with supra-g calculus only, and 36% had sub-g calculus only or both. Good OH, low levels of calculus, with supra-g deposits usually in maxillary molar and mandibular incisor areas of teenagers. Supra-g calculus did not increase in frequency from adolescence to the 40s.. Sub-g calculus had no predilection in distribution, began in early 20s. Approximately 70% of the interproximal surfaces were calculus free after 40-59 years of age. Calculus formation had little or no influence on attachment levels. There were no difference in the level of supra-g and sub-g calculus in smokers and non-smokers.

Sri Lankan Group: All Sri Lanka tea laborers had calculus. Supra-g calculus only was found in less than 1% of the participants, whereas sub-g calculus alone or in combination with supra-g calculus occurred in almost 99% of the population. Persons under 20 years of age, calculus was found in 65-80% of the interproximal surfaces and in 55-70% of the buccal surfaces. By 40 years and beyond, virtually all interproximal surfaces had calculus. Both supra-g and sub-g calculus started before 14 years of age. Supra-g calculus was mostly found around maxillary molars and mandibular incisors. Maxillary and mandibular bicuspids had the lowest calculus scores. Smokers and betel nut chewers had highest calculus scores. Individuals who neither smoked nor chewed had the lowest calculus scores. Teeth with calculus showed higher rate of attachment loss than those calculus-free.

C: Good OH and frequent dental visits are consistent with low levels of supra-g and sub-g calculus, and in these people supra-g and sub-g calculus have little or no influence on attachment loss.

Tan, 2004                       ARTICLE

P: To investigate the viability of bacteria within the unmineralized channels and lacunae contained in supragingival calculus

M+M: Six samples of supragingival calculus were removed from patients with moderate to advanced chronic periodontitis. Patients were healthy, no professional prophylaxis for at least 6 months. Samples placed in a -70 C freezer. Fluorescence microscopy: only sections from the middle portion of the calculus were used to avoid confusion with the external plaque. Negative controls were placed above a Bunsen flame for 1min to kill any bacteria prior to staining. Confocal Laser Scanning Microscopy: 4 additional calculus samples were stained as described above but examined as above with the CLSM, which has the ability to image a virtual section through the middle of a specimen without the need to section. This was done to avoid the possibility of external soft plaque being physically introduced into the middle of the calculus. Bacterial culture: 9 additional samples of calculus were cultured. The controls were placed on a vibrator in UV light overnight and then weighed. Both groups were crushed and put in a phosphate buffered solution. They were then centrifuged and the pellet was cultured in aerobic and anaerobic conditions.

R: Fluorescence: No viable bacteria were found in the heat-killed control group. Viable bacteria were frequently observed in the calculus groups. In all samples, the viable bacteria were lining the walls of the non-mineralized cavities and in the channels leading from the lacunae. Groups of live and dead bacteria were found in the mineralized areas. All six groups demonstrated viable and non-viable bacteria, although the location was only evident in 3 of the groups.

CLSM: Groups of viable and non-viable bacteria were observed in the lacunae.

Bacterial culture: The control samples had no growth in anaerobic or aerobic conditions. 1 test group showed no growth at all, 1 showed bacterial growth only under aerobic conditions. 5 samples displayed growth under both conditions, the anaerobic group having a higher number of colonies (not statistically evaluated).

BL: Supragingival calculus contains viable and non-viable bacteria. Bacteria within the calculus may recontaminate a pocket or release toxic substances creating an inflammatory response and recurrence of periodontal disease if supragingival calculus is not completely removed.

Davies, 1997                       ARTICLE

D: Supragingival calculus predisposes to the development of periodontal disease by providing a retentive surface for plaque bacteria and impeding attempts to maintain an effective level of plaque control. There is relatively little detailed information on the prevalence, extent and intraoral distribution of supragingival calculus. In the USA a survey showed that 34% of children aged 14-17 had only supragingival calculus and 23% had subgingival with or without supragingival calculus. Prevalence was higher in non-white kids and 3% higher in boys. The rate of formation varies between individuals and between different populations. For adults in the US, 87% of employed men and 80% of employed women had calculus; 30% only supragingival deposits and 54% had subgingival deposits or a combination of both. Intraoral distribution is very distinctive, being localized primarily to the lingual aspect of the lower anterior teeth and the buccal surfaces of the upper molars (calculus present 6x more on mandibular incisors than at maxillary molars, and rarely seen at other locations). This is due to the proximity to the openings of submandibular and parotid glands. It has been proposed that these sites are more prone to calculus than caries because of the high saliva film velocity, which promotes clearance of salivary sugar and acid from plaque, and the higher resting plaque pH because of better access to salivary urea. The formation of supragingival calculus involves both biological and physical-chemical processes. The initial stages involve the adsorption of salivary proteins on the tooth surface and the colonization of the pellicle by bacteria this provides an environment within which mineralization may occur, resulting with the formation of calculus. The mineralization process appears to be phasic, with periods of mineralization being interspersed with periods during which further deposits of salivary protein and bacteria accumulate on the surface. Inhibition of formation may be prevented by reducing the amount of plaque available for mineralization, modifying the attachment of plaque by anti-adhesive agents, and by inhibiting the process of mineralization by crystal growth inhibitors. Currently, the most effective products contain crystal growth inhibitors that inhibit crystal growth about 30%. Mineralization inhibitors include chemicals such as pyrophosphates, diphosphonates and zinc salts that absorb to the surface of crystals, reducing the rate of crystal growth.

Mandel 1986                       ARTICLE

Purpose: Review of studies on the relationship of supra and subgingival calculus to periodontal disease. Studies were classified as epidemiological, clinical, morphologic and experimental.

Epidemiologic studies: Several studies (Skougaard 1969, Ainamo 1970) supported the idea that calculus could be the result rather than the cause of dental plaque. Alexander 1971, Douglas 1983, Enzer 1960, noted match in distribution patterns between gingival index and plaque, more than gingival index and calculus. Authors note that clinical studies may be more useful than epidemiologic studies to correlate plaque or calculus to periodontal disease.

Clinical studies: Suomi 1969, 1971 correlate improvement in oral hygiene with less sub and supragingival calculus formation. Axelsson and Lindhe, Michigan and Goteborg university studies have shown the importance of mechanical debridement in reducing gingival inflammation, pocket depth and clinical attachment.

Tagge 1975 evaluated soft tissue response of periodontal pockets after SRP and oral hygiene vs oral hygiene alone and results were significantly better in the first group since in the second group subgingival deposits could not be removed. Morrison 1980 also showed the importance of subgingival calculus removal in healing of pockets up to 7mm.

Cercek 1983 came to the conclusion that subgingival plaque could not be completely removed if sub-g calculus remained, or calculus can perpetuate periodontal disease itself.

Clinical evidence for mechanical control of supragingival calculus is strongly suggestive that there is a direct role for subgingival calculus in progression of periodontitis.

Morphologic studies: Jones 1972 and Bauhammers 1973 noted the marked roughness on calculus surface and retention of bacterial plaque ,while Friskopp and Hammarstrom 1980 found differences in the nature of microbial coverings, with subg calculus covered by cocci, rods and filaments with no distinct pattern of orientation.

Experimental studies: Baumhammera and Rohrbaugh 1970 showed that calculus is permeated and can act as a reservoir for irritating substances, and Patters’s 1982 study provided strong evidence of the pathogenic potential of subgingival calculus.

Conclusion: calculus is no longer considered to be a primary etiology in periodontal disease, but it appears that removing calculus regularly can successfully maintain periodontal health. Calculus contributes significantly to the chronicity and progression of the disease.

Richardson 1990                       ARTICLE

Purpose: To evaluate the relationship between apical calculus position and the depth/morphology of intrabony defects.

Materials and methods

Results

BL: Calculus depth related to depth of osseous defect. Biopsies demonstrated attachment apparatus repair to level of calculus groove.

White, 1997                       ARTICLE

Review of dental calculus

Overview

- Calculus is mineralized dental plaque which forms both supragingival and subgingival

- Composition depends on the location of its formation and age, typically calcium phosphate salt including dicalcium phosphate dehydrate (DCPD), octacalcium phosphate (OCP), substituted hydroxyapatite (HAP), and magnesium substituted tricalcium phosphate (Whitlockite)

Epidemiology

- High prevalence of calculus (70-100%) from multiple studies

- Summary of Anerud et al, 1991

Regular OH and access to professional care

Without access of regular professional care and/or inadequate OH

Supragingival calculus

> 50-100%

100%

Early teen years. Rate of accumulation not significantly increase with age

Starts soon after tooth eruption and continues to a maximum at age 30

Restricted to mandibular lingual surfaces of anterior teeth and buccal surfaces of maxillary molar

Throughout the dentition

Subgingival calculus

> 50-100%

100%

Throughout the dentition

Throughout the dentition

Association of calculus with disease

- Supragingival calculus: location precludes its direct participation in advanced periodontal disease. Some studies showed no correlation with disease, others have showed correlation. It is difficult to separate effects of plaque versus calculus as etiologic factors. Recent studies support the lack of gingival pathogenicity of supragingival calculus.

- Subgingival calculus: calculus itself contains few viable bacteria, but a dental plaque virtually always covers the calculus surface. Subgingival calculus has been demonstrated to retain significant levels of endotoxin due to its porosity.

Mechanisms of calculus mineralization

- After prophylaxis, a mixture of pellicle proteins rapidly adsorb onto the enamel surface

- Bacterial adhesion and development of a plaque biofilm proceeds

- Plaque absorbs calcium and phosphate out of saliva for supragingival calculus and crevicular fluid for subgingival calculus

- The supersaturation of plaque fluid is prerequisite to mineralization of partially soluble calcium phosphate minerals within calculus

- Once mineralized, crystals in calculus are found in aggregates with individual crystallites measuring 10-300 nm in length and 2-30 nm in width

Tartar control

- Multiple mineralization inhibitors have been proven clinically effective, but the mechanism of action is not completely understood

- They all have in common: The ability to inhibit calcium phosphate nucleation and/or crystal growth processes and the transformation of precursor calcium phosphate mineral phases into more stable calcium phosphates. Ability to slow initial plaque mineralization in biofilm models.

 

 

Roberts-Harry, 2000 (Review)                       ARTICLE

P: To critically analyze the formation, composition, ethnic variations and pathogenic potential of subgingival calculus in comparison with supragingival calculus.

M&M: 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.

Supragingival

Subgingival

Location

Coronal to gingival margin

Apical to gingival margin

Color

Yellow/white

Brown/Black

Distribution

Adjacent to salivary duct opening

Randomly around mouth

Composition

Concentration of Ca, Mg, F, Sr, & Zn lower and of carbonate & Mn higher than sub-g calculus.

Concentration of Ca, Mg & F higher. More irregular distribution of F.

Mineral content & source

Average 37% from saliva by volume

Average 58% from GCF by volume

Crystal type & size

Mostly OCP & HAP, some DCPD. Small needle-shape & large ribbon-like

Mostly WHT, no DCPD. Small crystals only

Formation

Heterogeneous nucleation & crystal growth. More variable calcification

Heterogeneous nucleation & crystal growth.

More uniform calcification.

Microorganisms

Dominated by microorgamism, some non-calcified areas. More filamentous organisms, faster growth

Very few non-calcified microorganisms. Less filamentous organisms, slower growth.

Influence of race

Greater prevalence & quantities in Asian populations

In Asian pop associated with more extensive attachment loss. Lower levels of Na and Mg in more apical sub-g calculus in Indo-Pakistanis than Caucasians.

Morphology

Undifferentiated

Several types identified: spiny, crusty, nodular; ledge/ring; individual islands; smooth veneers; finger/fernlike

Pathogenic potential

Little evident

Associated with periodontal disease.

OCP=octacalcium phosphate; HAP=carbonate-containing hydroxyapatite;

DCPD=brushite or dicalcium phosphate dehydrate; WHT=magnesium containing whitlockite


 

Calculus Attachment

How does calculus attach to the tooth root?

Zander, 1953                       ARTICLE

Purpose: To investigate the mode of attachment of calculus on the root surfaces.

M&M: 50 teeth with gross calculus and cementum and dentin intact were cut immediately after extraction. Two cuts were made on either side of the calculus and a piece of the tooth was cut out. After decalcification and fixation they were stained with H&E and bacterial tissue stains.

Results: Four modes of attachment of the organic calculus matrix to the root surface were observed;

Usually, a combination is observed (modes 3 and 4 are the most frequent). Often a space exists between cementum & enamel, so dentin is exposed ideal spot for anchorage & attachment of the bacterial matrix.

BL: The finding provides an explanation for the ease or difficulty of calculus removal and emphasizes the need of careful curettage.

Kopczyk, 1968                       ARTICLE

Purpose: To determine the mode of attachment of calculus to root surfaces following root planing.

M&M: All sides of 63 teeth were scaled except for one surface on each tooth (served as control). Teeth were allowed to remain in situ for periods ranging from 1.5 to 4.5 months to allow new calculus to develop. Teeth then extracted, sectioned, and stained for analysis. Only 16 teeth included because they had clinically detectable calculus, four other teeth were root planed and extracted, some showed caries.

R/BL: Calculus was most commonly associated with a cuticle-like attachment or direct attachment of microorganisms to tooth. Also seen was the contributing mode of mechanical locking into planing grooves or dentin splits. There was no bacterial penetration into cementum (except where caries was detected in excluded teeth). Cementum was not completely removed by the process of root planing.

Moskow, 1969                       ARTICLE

P:  To describe a mode of calculus attachment to the root surface other than the 4 described by Zander (1. Calculus matrix attached to minute irregularities of root surface, 2. Attachment of deposits into cemental defects associated with resorptive and appositional changes resulting from occlusion, 3. Penetration of microorganisms into cemental surface and 4.Secondary cuticle).

M & M: Sections of 135 human teeth and adjacent periodontal structures were examined under the light microscope. All specimens demonstrated deposits of plaque and calculus on the teeth. All specimens were prepared in celloidin so that the proper relationship of all tissues could be maintained. The specimens were stained with hematoxylin and eosin.

R: In the cervical portion of the roots of a number of teeth examined, particularly in the area of the CEJ different degrees of separation of cementum from dentin were observed. The separation is most commonly seen at the dentin-cementum junction. The length and the width of the cemental separation varied considerably in different specimens. Within the space created by separation of the cementum, accumulations of plaque and calculus could often been seen. The material filling this space had similar morphologic characteristics and staining qualities as the calcified deposits on the pocket side of the root surface. A layer of acellular cementum is interimposed between zones of calculus. This mode of attachment occurred in combination with the other 4 modes of attachment. Author proposes separations or tears were due to external stimuli (excessive forces, tooth instrumentation and/or hygiene aids) and internal stimuli (caries).

BL: A 5th mode of attachment described. Cementum separations (tears) are frequent accumulation sites for plaque/calculus. They are more common at the DCJ. In denuded roots, separations can act as a factor for additional deposits. Therefore, author recommends root planning to intact dentin to insure complete calculus removal

Canis, 1979                       ARTICLE

B: A review of previous findings on modes of calculus attachment on tooth surface and re-examination of previous investigations with light microscopy and ultrastructural techniques. Previous studies supported the following:

P: To re-examine previous investigations with light microscopy and ultrastructural techniques.

M+M: 63 freshly extracted teeth were prepared for histologic (light microscopy) and ultrastructural observation (scanning electron microscopy and transmission electron microscopy).

R: Light microscopic examination: The presence of a cuticle between calculus deposit and tooth surface was frequently observed. Penetration of the calculus organisms into intact tooth structure was not observed. A fairly common mode of attachment was the mechanical locking of calculus into undercuts. Also, direct attachment of calculus matrix to the microscopic irregularities of the cementum was frequently noticed.

Scanning electron microscopic examination: A cuticle between calculus and tooth was noticed. Calculus was seen to follow the irregularities of the cementum, mechanically locking into these surface defects.

Transmission electron microscopic examination: No organisms were seen within the tooth structure and there was no evidence of bacterial penetration. The most common mode of attachment was calculus abutting the surface of cementum with no penetration into tooth surface.

BL: Previously reported histologic findings of cuticular attachment, mechanical locking into undercuts and direct attachment of calculus matrix to tooth surface was affirmed. The claim of bacterial penetration has been rejected. Ultrastructural evidence of cuticular attachment was presented for the first time in this study. The most frequent method of calculus attachment was the apparent melding of calculus matrix to the surface of the cementum, often times being indistinguishable.


Tooth Anatomy

Everett, 1972                       ARTICLE

P: To report on the disto-lingual groove that is a common anomaly of max lateral incisor and examine if it predisposes the tooth the localized periodontal diseas.

M&M: Eval of 625 max laterals (cleaned and root planed after ext, studied with a loupe) and 6 case reports to study the disto-lingual groove.

R: 1. 97.2% showed no coronal or radicular grooving.

2. 1.9% (12/625) had shallow radicular grooves extending from coronal groove to just short of apex.

3. ~0.5% (3/625) had deep radicular groove not extending to the apex and ~0.5% (3/625) had a groove extending almost to the apex. Radiographically may look like a para-pulpal line or additional pulp chamber (consider endo/perio implications).

Overall, 2.8% prevalence

6 Case reports: Severe perio dz in the presence of the DL groove is not very favorable & depends in part on the depth and length of the groove. Can present as pain in the palate or deep vertical defect on the lingual. Sometimes odontoplasty is possible.

BL: Not every case of DL groove leads to periodontal breakdown, but the groove does constitute as a periodontal hazard. The worst case is if the groove extends to apex.

Withers 1981                       ARTICLE

Purpose: To determine the prevalence of the palato-gingival groove in maxillary incisor teeth and the health status of the lingual periodontal tissues adjacent to maxillary incisor teeth with and without the palato-gingival groove.

(Prichard 1965 was the first to state that the grooves on maxillary incisor teeth are a predisposing factor to localized severe periodontal destruction).

Materials and methods: 531 military trainees 17-35 years (mean 19.37) were examined. Grooves apical to the CEJ, age, sex, race, PI, GI, mobility and Periodontal Disease Index (PDI) for the lingual side of the 4 incisors were recorded.

Results: 8.5% of the patients (45) had palato-gingival grooves.

Conclusion: Presence of palato-gingival groove is associated with poorer periodontal health.

Kogon 1985                        ARTICLE

Purpose: To examine a large collection of extracted teeth with a view to resolving differences in reported prevalence of palato-radicular grooves (PRG).

Materials and methods:

This study examined 3,168 extracted maxillary lateral and central permanent incisors.

Results:

BL: 4.6% prevalence. Focal loss of periodontal attachment associated with these grooves could result in a poor prognosis.

Hou 1993                       ARTICLE

P: To study the relationship between palato-radicular grooves (PRGs) and periodontitis in Chinese adults.

M&M: 404 maxillary incisors without caries or restorations were examined for the presence of mesial, distal, or midpalatal PRGs (in crown or root) in 101 people. Clinical probing, x-rays, flaps, and an enlarging oral mirror were used to identify the PRGs. PI, GI, and PPD (if 4mm or greater) were recorded.

R: Of all the incisors examined, 20% presented PRGs in males and 14% in females (not statistically significant). The chance of a person having one of their teeth with a PRG was 45% for men and 43% for women. Maxillary lateral incisors presented a prevalence of 30.2%, central incisors 5.9%, and 4% of the subjects had PRGs in all maxillary incisors. With respect to location, 27% were on the mesial, 30% on the distal, and 43% on the midpalatal. PPDs were found in 26% of PRG sites, occurring more frequently in lateral incisors (18/19 affected teeth). PPD associated with PRGs were more prevalent in the distal (36%) and mesial (25%) than in the midpalatal (19%). Also, there was a tendency for higher GI and PI scores in teeth with PRGs. Bilateral symmetry was observed in 4% of the cases.

BL: PRGs are prevalent in both sexes, especially in lateral maxillary incisors, and are associated with PPD.

 

Leknes, 1994                       ARTICLE

P: To determine whether periodontal attachment loss was different for root surfaces with and without grooves.

M&M: 86 incisors and 17 premolars (single-rooted) with clinical attachment loss present, intact CEJ with one side being flat or convex and the other side displaying a groove were analyzed. Extraction history was unknown, but there was no visible damage from extraction procedures. The roots were stained with toluidine blue to identify PDL remnants. Measurements were taken from CEJ to most coronal fibers.

R: Incisors demonstrated most U-shaped groove and premolars had a V-shaped groove. Incisors: mean CAL loss = 8.1 mm grooved (3.2-15.1) and 7.1 on non-grooved. Premolar: grooved 6.2 mm (1.9-9.6) and non-grooved 4.0 mm. Deeper grooves correlated to the areas of extensive CAL loss. For both groups, a SSD greater loss of CAL was present on grooved than non-grooved surfaces. A small group of incisors exhibited confounding findings due to aberrant CEJ positions and cemental tears.

BL: Root grooves may exhibit a negative effect due to their plaque promoting effect and difficulty in OH maintenance.

 

Gher and Vernino, 1981                       ARTICLE

Purpose: To examine the root anatomy as a local factor in inflammatory periodontal dz.

M & M: Teeth with likely contributory anatomy (Max/Mand 1st premolars, Max laterals , and Max/Mand molars were debrided, embedded and cut in cross-section from CEJ to apex after ext.

Results:

Max 1st PM: 56% has 2 roots w/bifurcation in middle 1/3. Mesial concavity, which can deepen apically into severe developmental groove, may complicate OH measures. Furcation groove may present on facial and/or palatal aspect of buccal root (3 distinct roots seen in ~4%). Furcation involvement yields poor prognosis. Single-rooted PMs (40%) may have deep mesial depression from middle 1/3 to apex.

Mand 1st PM: Mesial developmental groove (starts 1-2 mm apical to CEJ). Less frequent groove on distal.

Max Lateral: crown and root morphology is extremely variable, such as with peg lateral. Palatogingival groove is reported in ~2% of extracted laterals (Everett) may extend to apex. If very severe and not able to eliminate, poor prognosis.

Max/Mand Molars: Furcation entrance narrower than instruments. Concavities may be present (Max: MB 94% > DB 31% > P 17%). Intermediate bifurcation ridges may be found on 73% of Mand 1st Molars (Everett). These ridges are composed of cementum which compromises access to furcation—need to recontour to access.

BL: Various root morphologies contribute to inflammatory periodontal disease by complication of OH and instrumentation of root.

 

Gher, 1985                       ARTICLE

P: to determine root surface area (RSA) in 1mm increments from the CEJ to the apex of maxillary 1st molar and the location of furcation entrances.

M&M: 20 teeth, excluded fused roots. Teeth were cut and prepared as per Gher 1980, photographed and then projected. 1mm sections were circumferentially measured on coronal and apical sides and RSA = circumference x 1mm. Mean to RSA = of segmental RSA's

R/DISC:

Distance from CEJ(mm)

% RSA

3

21.5

5

40.4

7

59.5

BL: The largest root surface area percentage values clustered around the furcation- 38% of the total root surface area was w/in 2mm of root separations

Dunlap & Gher, 1984                       ARTICLE

P: To determine the linear variation of Root Surface Area (RSA) in 1- mm increments from the CEJ to the apex for the mandibular 1st molar.

M&M: 20 extracted mandibular 1st molars. Teeth were embedded in blocks of self-curing resin and were cross-sectioned at 1-mm increments. Coronal and apical sides of the sections were photographed and the circumference of the root was measured. RSA for each 1-mm section was determined by averaging the actual root circumferences of the apical and coronal sides of the section and multiplying by the root length represented by each section (1 mm). Additional data collected included mean distances apical to the CEJ for the buccal and lingual root concavities, mesial and distal root separation, mean root length and the presence of the “intermediate bifurcation ridge.

R:

- The largest RSA and % total RSA values were located 4 to 7 mm apical to CEJ. 48.7% of the RSA was located in the coronal 6mm of total root length root (mean length 14.4mm).

- Root separation occurred 4 mm apical to CEJ with no teeth having a root trunk longer than 6mm. B and L root concavities were first present 0.7mm and 0.3mm apical to CEJ, respectively.

- The mean RSA of the mesial root was SSD greater than the distal root and both had greater RSA than the root trunks.

-All mesial roots demonstrated an hourglass or figure-eight shape due to the constantly present mesial and distal concavities. Mesial roots were wider in buccal-lingual direction and narrower in a mesial-distal dimension than the distal roots.

- Distal roots were always more conical in shape than mesial roots. 70% of the teeth had an intermediate bifurcation ridge.

BL: The largest mean RSA was just apical to the level of the root separation. Early detection and therapy could stop the disease progression and avoid furcation involvement as well as attachment loss in areas where a major portion of the tooth support is located. Mesial root had a significantly greater RSA than did the distal root. When hemisection or root amputation is proposed, the RSA ratio should be considered. Through and through furcation involvement should be expected when PDs in the area of the bifurcation are greater than 5-6mm from the CEJ.70% of the teeth had intermediate bifurcation ridge.

Booker, 1985                       ARTICLE

P: To study the morphology of the mesial root surface of the maxillary 1st premolar (PM) and establish incidence and frequency of furcation, along with baseline measurements pertaining to that aspect of the root.

M+M: 25 single rooted and 25 two-rooted adolescent maxillary 1st PMs were extracted then sectioned in 2-mm thick sections apical to the CEJ. Under dissecting microscope, the mesial concavity depth and the cementum and dentin thickness were measured in the sections.

R:

BL: Any attachment loss around the max 1st PM involves surfaces which are most likely concave. These concave surfaces make both plaque removal and periodontal treatment difficult. Removal of M concavity is contraindicated due to potential pulp exposure.

Ferreira et al 2000                       ARTICLE

P: To present a case report describing the use of GTR and DFDBA to treat a localized periodontal bone defect associated with a palatal groove (PG).

M&M: 49 y old female with local periodontal destruction, 8 mm PD and BOP on a vital #7 with PG. Bony defect present b/w # 7-8. Initial therapy performed and 4 weeks later the pt had the sx.

-Intrasulcular incision, FTF. PG reduced & SRP. DFDBA in defect and resorbable collagen membrane. Antibiotics & CHX given. The pt was examined weekly for 6 weeks and then monthly up to 6 months. The follow-up was 3 years after sx.

R: Radiographic bone fill and reduced PD by 5mm with no BOP.

BL: PG is local disposing factor for periodontitis. GTR is a good alternative therapy for bone defects.

Cr: PAs not standardized.

Everett 1958                       ARTICLE

Purpose: To study the morphology of the bifurcation of the lower first molar.

Materials and methods: 328 extracted lower molars, divided into 3 groups.

Results: In majority of specimens, a distinct ridge running across the bifurcation in a mesiodistal direction was noticed, originating on the mesial surface of the distal root about 2mm from the height of the bifurcation.. This was called intermediate bifurcational ridge.

Presence of intermediate bifurcational ridge:

At the height of the bifurcation in a buccal-lingual direction can be noted a:

Where a buccolingual plane or concavity was present in the bifurcation, it was delineated by buccal and lingual bifurcational ridges.

Is the lingual or the buccal bifurcation ridge the more acute?

Histologic findings: The intermediate ridge is formed primarily by cementum . However, this ridge has a basis in dentin on which the extensive cementum deposition occurs. The buccal and lingual ridges are essentially dentin formations covered with only a small amount of cementum.

Moskow, 1990                        ARTICLE

Purpose: To describe the various forms of enamel on root surfaces, their morphology, the histogenesis of their formation, their incidence in humans, their relationship to adjacent periodontal structures, and their role in periodontal destruction.

Discusion:

 

Masters 1964                       ARTICLE

P: to evaluate the anatomic variation of enamel projections into the furcation.

M&M: Evaluation of 474 extracted maxillary and mandibular molars was done. No attempt was made to only select periodontally involved teeth, and teeth were collected from OMFS offices.

R/Disc:

A grading system was described as follows:

 

Swan1976                       NO ARTICLE

BG: Cervical enamel projection (CEP) is defined as the dipping of the enamel from the CEJ toward the furcation area of the molars.

P: To study the degree, if any, to which CEP is involved in the origin of periodontally involved furcation.

M&M: 200 dried East Indian skulls (2,000 molars) from the department of gross anatomy. The occurrence, location and the grade of the CEP on maxillary and mandibular 1st , 2nd and 3rd molars were recorded (980 maxillary molars and 1,020 mandibular molars). Masters and Hoskins’ grading system was used. Furcation involvement associated with tooth surface with or without CEP was recorded.

R: The incidence of CEP in molars was 32.6%. The mandibular second molars showed the highest incidence of CEP (51.0%), followed by the maxillary second molars (45.6%). The lowest incidence was seen in the maxillary first molars (13.6%). 78% of CEP were found buccal surface of the tooth. 7.9% of the tooth surfaces with CEP had furcation involvement. 6.0% of tooth surfaces had furcation involvement without the presence of CEP. Grade1 CEP was the most frequently encountered. There was a positive, SS relationship between tooth surfaces with grade 2 and 3 CEP and periodontally involved furcation. However, no etiologic relationship was found between grade 1 CEP and furcation involvements.

Mandibular 2nd molar

51.0%

Maxillary 2nd molar

45.6%

Maxillary 3rd molar

35.1%

Mandibular 1st molar

27.5%

Mandibular 3rd molar

22.6%

Maxillary 1st molar

13.6%


Conclusion: There seems to be a physiologic relationship between bone and CEP. The alveolar crest has a tendency to follow the outline of the CEP, and a channel much wider than a normal periodontal membrane space accommodates the CEP as it extends toward the furcation. The results indicate that when CEPs are severe enough to approach or enter the furcation area (grades 2 and 3), they may be an etiologic factor.

Tooth Contacts/Food Impaction

Hirshfield 1930                        ARTICLE

Purpose: To discuss factors related to food impaction.

Discussion: Preventive factors against food impaction: contiguity of the arch, proper location of contact points, presence of a marginal ridge and groove

Mechanism for prevention of food impaction: Embrasure is a small wedge-shaped funnel and cusp is a plunger forcing food interproximally. The potency of the mechanism is directly related to the degree of proximal occlusal interdigitation. The nearer the contact point to the occlusal plane, the less the tendency to impaction. The marginal ridge and groove are designed to prevent wedging and packing action (forces teeth apart).

Etiology:

Class I- Occlusal wear

Wedging action produced by the transformation of occlusal convexities into oblique facets, remaining obliquely worn cusp of an upper tooth overhanging distally its opposing tooth, obliquely worn lower tooth overlapping its opposing tooth distally

Class II- Loss of proximal support

Loss of distal support through the removal of a distally adjacent tooth, loss of mesial support due to extraction, oblique drifting due to non-replacement of a missing tooth, permanent occlusal openings to interdental spaces

Class III- Extrusion of teeth beyond the occlusal plane

Extrusion of the distal tooth of the arch, extrusion of a tooth retaining contiguity on both sides

Class IV- Congenital morphologic abnormalities

Position of a tooth in torsion, emphasized embrasures between thick-necked teeth, buccolingual tilting, lingual or buccal position of a tooth

Class V- Improperly constructed restorations

Omission of contact points, improper location of restored contact points, improper occlusal contour, improperly constructed cantilever restorations, scalloped cervical bevels on rubber dentures

Emphasizes the importance of retaining the normally erupted 3rd molars, because if they are lost will lead to food impaction.

Lorato 1971                       ARTICLE

P: To determine if there is relationship b/w food impaction & interproximal intrabony lesions.

M&M: 121 dry skulls (Mexican and European) having one or more intrabony defects were evaluated. Skulls divided into 3 age groups (16-30, 31-55, &> 56, age estimated by degree of suture closure). Factors that may contribute to food impaction were identified (plunger cusp, open contacts, marginal ridge discrepancy, tooth misalignment)

R/Disc: 206 defects evaluated. Average # of intrabony lesions increased with age. The majority (66%) of lesions occurred in the molar areas. 39 lesions were associated with one of the previous factors (18%). Authors point out the limitations of this study, since the chewing pattern, diet and OH of the individuals were not available.

BL: Only 18% of intrabony lesions in dry skulls were associated w/ factors able to cause food impaction.

Kepic, O'Leary 1978                       ARTICLE

P: To determine if uneven marginal ridges of posterior teeth are a significant factor in the etiology and progression of periodontal disease.

M&M: 100 patients ranging in age from 21-66 years were included in the study. The interproximal contacts of posterior teeth were evaluated. Modified Gingival Index (0 = health, 1 = slight-moderate inflammation, 2 = marked inflammation or gingival contour changes). OH Index (0 = no plaque, 1= <⅓ of cervical tooth surface 2 = > ⅓ of exposed root surface). Calculus score (0 = no calculus, 1 = slight, 2 = gross). CAL loss and PDs were assessed. Marginal ridge relationships were assessed on study casts using a probe calibrated in 1-mm increments, which was positioned coronal to the contact area in the long axis of the teeth. Scoring of marginal ridge status (0 = no discrepancy, 1 = slight up to 1mm, 2 = severe >1mm).

R:

High to moderate correlation

Low correlation

PD \ gingival status

PD + marginal ridge discrepancy

PD \ calculus

CAL + marginal ridge discrepancy

Plaque \ gingival status

Plaque + marginal ridge discrepancy

CAL \ plaque

Calculus + marginal ridge discrepancy

PD \ plaque

GI + marginal ridge discrepancy

BL: Plaque and calculus are more important than marginal ridge relation in determining periodontal health.

Hancock 1980                       ARTICLE

P: To compare the integrity of the interdental contact with the periodontal status and the occurrence of plaque, calculus, carious lesions, and food impaction.

M+M: 40 adult males (17-19 yrs old) at the Naval Training Center were examined for GI, PI, food impaction, PD, carious lesions, calculus, restorations and overhangs. Integrity of the contact was tested using O’Leary classification: tight (definite resistance to the passage of floss), loose (minimal resistance) or open contact (no resistance) based off resistance to double strand of unwaxed dental floss. 1,040 interdental areas were examined.

R: 841 sites or 80% of all sites had signs of moderate-severe gingival inflammation. 73% of the subjects had at least one >4mm pocket, most commonly in posterior. 4% of all areas exhibited food impaction. No significant relationship was found between contact type and GI or PD. But significant relationship was found between food impaction and contact type and between food impaction and PD. Calculus deposits seen in 16% of interproximal areas; but the occurrence of calculus or overhangs association with proximal restorations was 46%. Calculus does not appear to be related to food impaction, but calculus was SS related to PD. Food impaction was most commonly associated with loose (not open) proximal contacts. However, food impaction might have been underestimated in this study. Other factors thought to be involved were location and area of the contact, marginal ridge integrity, and plunger cusp mechanisms.

BL: Areas of mechanical retention for bacterial plaque are almost impossible for the patient to clean. Important to eliminate factors associated with food impaction early in treatment, as food impaction does contribute to causing periodontal disease.

Jernberg, 1983                       ARTICLE

P: To investigate whether a relationship exists between open contacts and periodontal disease in a cross-sectional study.

M&M: 104 adults, mean age 43 years. An open contact was defined by unrestricted passage of unwaxed dental floss through the interproximal area. GI, bleeding, PD, CPAL, debris, occlusal interferences, calculus, and food impaction evaluated. 75% of these open contacts studied were in anterior teeth. Sites with open contacts were compared to contralateral sites without an open contact.

R: Slight, but significantly greater CA Loss and probing depth (PD) were observed at open contact sites: 60.6% of patients had greater CA Loss at open contacts compared to 17.3% at closed contacts. Similarly, 49% of patients had deeper PD at open contacts compared to 22.1% at closed contacts. Mean CAL and PD were 2.80 mm and 3.04 mm for open contacts versus 2.32 mm and 2.77 mm for closed contacts, respectively. Significantly greater prevalence of food impaction and occlusal interference was found at open contacts. NSSD for GI, BOP or calculus.

BL: Increased PD (0.27 mm) and CA Loss (0.48 mm) at open contacts. More occlusal discrepancies and food impaction also present (SS). It may be beneficial to close open contacts.

Cr: Differences were statistically but maybe not clinically significant. Cross-sectional study.

 

 

Miscellaneous Local Factors – Mouthbreathing

Wagaiyu 1991                       ARTICLE

Purpose: To assess the influence of either the lip coverage of upper incisor teeth, lip seal or mouthbreathing on susceptibility to chronic marginal gingivitis.

Materials and methods: Gingival health of 208 school children (11-14 years old) was assessed at 6 sites on all incisor and first molar teeth by recording presence of redness, plaque accumulation and bleeding on probing. Crowding of incisor teeth was recorded as labio-lingual displacement and mesiodistal overlap. Mouthbreathing, lip seal, and upper lip coverage of the maxillary incisors were also assessed. Two examiners were used and statistical analysis was performed.

Results: 7 subjects were excluded from the analysis due to missing data. 86 females and 115 males. 65 subjects categorized as being predominantly mouth breathers. Subjects with wide lip separation were more likely to be mouthbreathing (81%).

Mouthbreathing, increased lip separation and decreased upper lip coverage at rest were all associated with higher levels of plaque and gingival inflammation. Mouthbreathing and decreased upper lip coverage were was most evident in upper anterior segment

Conclusion: Mouthbreathing or a high lip line increase susceptibility to gingival inflammation in children, particularly in the maxillary anterior segment.

Matthews 2004                      

Purpose: To review the detection and the role of local factors in periodontal disease

Review:

-Highly glazed porcelain less plaque retentive than enamel

BL: Awareness and treatment of etiologic factors that cause a compromise in periodontal health may prevent future attachment loss.

 

 

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