Periodontal diseases in a university setting in Ivory Coast]

The aim of this study was to measure the prevalence and severity of periodontal diseases, and also to evaluate periodontal treatment needs of the students of Abidjan University, in Ivory Coast. 647 students were randomly selected and interviewed to determine age, sex and oral hygiene habits; the subjects were examined for tooth mobility, plaque, calculus, gingival bleeding, periodontal probing depths and gingival recessions. The oral hygiene was insufficient: 86.08% of the subjects presented calculus--The average of sextants presenting gingival bleeding was to 4.03 and to 3.43 for calculus. The prevalence and severity of periodontal pockets were low: only 0.36 sextants on average presented pockets of 4-5 mm and 0.025 sextants presented pockets of 6 mm or more. As concerns periodontal treatment needs, 89.64% of subjects needed oral hygiene advises, 84.85% needed scaling/root planning, and 1.39% needed complex periodontal treatment. Our findings confirm the fact that destructive periodontal disease is not an inevitable consequence of gingivitis. The information, screen, and prevention should begin reality in our daily practice.     

Oral cleanliness and gingival health following oral hygiene instruction by selfed-educational programs

The aim of the present study was to determine the motivational effect of using a periodontal self-examination manual prior to a self-instructional manual in oral hygiene and to examine whether instruction provided at a later time than the scaling procedure improves the effect of the instruction. 74 patients with periodontal disease were divided into 3 groups: (1) A group of 23 patients who performed a self-examination of their periodontal condition prior to self-instruction in oral hygiene; (2) a control group of 27 patients who used only the self-instructional oral hygiene manual; and (3) a group of 24 patients who were not given the self-instructional oral hygiene manual before 6 weeks after the baseline examination. All these patients had their teeth scaled at the start of the study and after 3 and 7 months. The effect of the various modes of instruction was evaluated by assessments of plaque and gingival bleeding scores. These parameters were determined at the baseline and after 2 and 6 weeks and 3 and 7 months. The results demonstrated a significant improvement in plaque and gingival bleeding scores following the use of the self-instructional manual in oral hygiene. The use of the periodontal self-examination manual or a delay of the instruction had no additional effect on oral cleanliness. The level of oral hygiene and gingival health achieved at 3 months was maintained in all 3 groups for an additional period of 4 months. After that time, they were divided into 2 other groups depending on whether or not their plaque score was less than 20%. A total of 26 in the group who had a plaque score higher than 20% demonstrated a plaque score of than 20% after having performed the tooth brushing test. 10 of the remaining patients, who still had a plaque score of more than 20% after the tooth brushing test, received additional instruction in oral hygiene which subsequently resulted in improved oral cleanliness after 6 months.     

Evaluation of various feedback mechanisms in relation to compliance by adult patients with oral home care instructions

The purpose of the present study was to examine the effect on oral hygiene and gingival health of plaque scoring and the performance of a 'tooth brushing test" at each visit during initial periodontal treatment. A total of 63 adult periodontal patients (22-67 years of age) was allocated to 4 matched groups: Brushing test group (B), open scoring group (O), minimal feedback group (M) and control group (C). The oral hygiene instruction for groups B, O and M was provided by handing out a self-educational manual on oral home care, while the patients of control group (C) received a short brochure describing the Bass brushing technique and the use of toothpicks. Feedback on the improvement of oral hygiene performance was delivered to groups B and O by scoring of plaque and gingival bleeding by probing while this feedback was avoided in the 2 other groups (M, C). The patients of group B performed a tooth brushing test at each of 3 visits. After 3 months the plaque scores of groups B (27%) and O (22%) had improved more than those of the 2 other groups (35%). However, the improvement in gingival bleeding scores was similar in all 4 groups (from 55% initially to 17% at 3 months). At later examinations only minor differences in plaque and gingival bleeding scores were recorded between the various groups. The findings show that, irrespective of the mode of instruction, a considerable improvement occurs and that this improvement is not related to open scoring of plaque or the tooth brushing test.     

Comparison of modes of oral hygiene instruction in improving gingival health

Abstract 195 Hong Kong Chinese employees from a single company participated in a 10-month longitudinal study on the effects of various modes of delivery of oral hygiene messages on their gingival health. Subjects were allocated to one of the following modes of oral hygiene education: (1) personal instruction; (2) self-education manual; (3) video; (4) a combination of 2 or more of these modes of instruction. Scaling or any other form of periodontal treatment was not given throughout the study period. Full mouth clinical examinations were carried out using a Williams Periodontal probe to examine for the presence or absence of plaque and bleeding on probing from the gingival sulcus. At 2 weeks, 4 months and 10 months, results showed significant reductions in the mean % of plaque and bleeding when compared with baseline. No significant differences were found between the groups given the various modes of oral hygiene education. The study does confirm the effectiveness of oral hygiene alone in improving gingival health, but the lack of difference in the outcome of various oral hygiene education approaches indicates that the mode of instruction is not crucially important to the end result. However, it has to be acknowledged that improvement in oral hygiene may be related to factors other than the oral hygiene programme itself. The findings have significant implications in oral health promotion programmes to improve the periodontal status of the local community.     

Periodontal disease among indigenous people in the Amazon rain forest

BACKGROUND: People are not all equally susceptible to periodontitis. To understand the epidemiology and natural history of this disease, it is important to study populations with varying genetic backgrounds and environmental exposures. AIM: Characterize the periodontal condition of a sample of indigenous adults in a remote region of the Amazon rain forest and determine the association of periodontal disease with various demographic, behavioral and environmental factors. METHODS: A cross-sectional evaluation of 244 subjects aged 20-70 years was conducted. Pocket depth (PD), clinical attachment level (CAL), bleeding on probing (BOP), plaque and calculus were assessed for the Ramfjord index teeth. RESULTS: These people had high levels of plaque, calculus and BOP. The mean PD was rather shallow (2.45 mm in 20-29 year-olds to 2.73 mm in 50+ year-olds) and did not increase significantly with age. Mean CAL (0.57 mm in 20-29 year-olds and 2.26 mm in 50+ year-olds) and mean location of the free gingival margin in relation to the cemento-enamel junction changed significantly with age (p<0.0001). Multivariate analysis revealed that increasing age, bleeding on probing and calculus scores were positively associated with mean CAL (p<0.01). Sex, ethnicity, level of modern acculturation, use of coca or tobacco paste, frequency of dental visits and plaque were not associated with mean CAL. CONCLUSIONS: Periodontal disease in these people was mainly associated with gingival recession rather than deep pockets. Most people had clinical attachment loss but despite poor oral hygiene and extensive gingival inflammation, they did not have very severe periodontal destruction.     

Research into actual conditions and preventive care in periodontal disease. Relationship between questionnaire results and periodontal disease in youth

The purpose of this study was to determine the prevalence of periodontal disease and the relationship between the results of questionnaire concerning periodontal disease and the actual periodontal condition in youth. The examination was carried out in three parts. In the first part, a questionnaire was conducted on 3,886 junior and senior high school students (12 to 18 years of age) living in Kawagoe, Japan. The questionnaire was composed by of items concerning habits of oral hygiene, periodontal symptoms, understanding of periodontal disease and history of diagnosis by dentist of periodontal disease. Secondary, mass intraoral examination was carried out on all objects. The examination covered gingival inflammation, periodontal probing depth, calculus, dental plaque, dental caries and malalignment. Lastly, we examined the relationship between the results of periodontal examination and questionnaire with the original periodontal classification. The following results were obtained: 1. As an example of items in questionnaire, 83.1% brushed their teeth more than two times daily. The understanding of oral hygiene concerning dental caries was improved, but concerning periodontal disease was still poor. 2. The symptom most frequently reported was gingival bleeding during tooth brushing (18.4%). 3. The percentage of persons with periodontal disease (moderate gingival inflammation and periodontal pocket 4 mm or deeper) was of the highest frequency at 13 years old. The proportion of males increased with the advanced state of periodontal disease. 4. A significant correlation was found (chi 2-test: alpha less than 0.001) between advanced state of periodontal disease and a decrease in tooth brushing time per day. 5. A significant correlation was found between the advance of periodontal disease and gingival bleeding on tooth brushing (chi 2-test: alpha less than 0.001). Similarly, a correlation was found between the advance of periodontal disease and gingival swelling (chi 2-test: alpha less than 0.001). 6. A significant correlation was found (chi 2-test: alpha less than 0.001) between the advance of periodontal disease and aggravation of condition of dental plaque, calculus, dental caries and malalignment.     

Professional oral hygiene treatment and detailed oral hygiene instructions in patients affected by mucous membrane pemphigoid with specific gingival localization: a pilot study in 12 patients

To cite this article:
Int J Dent Hygiene 10 , 2012; 138–141
DOI: 10.1111/j.1601‐5037.2010.00527.x Arduino PG, Lopetuso E, Carcieri P, Giacometti S, Carbone M, Tanteri C, Broccoletti R. Professional oral hygiene treatment and detailed oral hygiene instructions in patients affected by mucous membrane pemphigoid with specific gingival localization: a pilot study in 12 patients. Abstract: Objectives: The aim of this prospective case series was to assess the clinical efficiency of an oral hygiene protocol in patients affected by mucous membrane pemphigoid (MMP) with specific gingival localization, before starting any medical treatment. Methods: Patients received oral hygiene instruction followed by non‐surgical periodontal therapy including oral hygiene instructions in a 3‐week cohort study. Clinical outcome variables were recorded at baseline and 5 weeks after intervention and included, as periodontal parameters, full mouth plaque (FMPS) and bleeding (FMBS) scores and patient‐related outcomes (visual analogue score of pain). Results: A total of 12 patients were recruited. The mean age at presentation was 59.5 ± 14.52 years. Five weeks after finishing the oral hygiene and periodontal therapy protocol, a statistical significant reduction was observed for FMPS (P = 0.001), FMBS (P = 0.022) and reported pain (P = 0.0028). Conclusions: Professional oral hygiene procedures and non‐surgical periodontal therapy are connected with improvement of gingival status and decrease in gingival‐related pain, in female patients affected by MMP with specific gingival localization.     

The Cardiff Dental Survey: oral hygiene, gingival and periodontal health in relation to smoking in young adults

Abstract: Objective: To examine the relationship between tobacco smoking, oral hygiene, gingival and periodontal health in young adults. Study design: Cross‐sectional (conducted in the course of a cohort study). Setting: Cardiff, UK, 1989 and 2000. Methods: Plaque was recorded, as was presence or absence of bleeding on probing and loss of attachment (LA). Information concerning tobacco smoking was obtained from questionnaire data. Results: At age 19–20 years, smokers had statistically significantly (P < 0.01) higher whole mouth mean plaque scores than non‐smokers. Whole mouth mean bleeding scores, however, were similar in smokers and non‐smokers. The relationship of plaque to smoking was very similar at age 30–31, yet bleeding scores were approximately 25% lower in smokers than in non‐smokers (P < 0.01). Whole mouth LA scores showed small, statistically non‐significant differences between smokers and non‐smokers. At the age of 30–31 years, gender and social class had a negligible confounding effect on oral hygiene, gingival and periodontal health in smokers and non‐smokers. Conclusions: Smokers consistently demonstrated poorer oral hygiene than non‐smokers. The effect of smoking in reducing gingival bleeding was already apparent at age 19–20 years despite the fact that, at this time, subjects might be assumed to have been exposed to a relatively small dose of tobacco over a short period of time. In the follow‐up study conducted at the age of 30–31 years, the impact of smoking on the periodontal tissues was, as expected, more pronounced.     

Professional oral hygiene as a therapeutic option for pediatric patients with plasma cell gingivitis: preliminary results of a prospective case series

Background: Plasma cell gingivitis (PCG) is a rare, benign inflammatory condition of unclear etiology with no definitive standard of care ever reported to our knowledge. The aim of this case series is to ascertain the clinical efficacy of professional oral hygiene and periodontal therapy in younger individuals with a histologically confirmed diagnosis of PCG. Methods: All patients received non‐surgical periodontal therapy, including oral hygiene instructions, and thorough supragingival scaling and polishing with the removal of all deposits and staining combined with the use of antimicrobials in a 9‐week cohort study. Clinical outcome variables were recorded at baseline and 4 weeks after the intervention and included, as periodontal parameters, full‐mouth plaque scores (FMPS), full‐mouth bleeding scores (FMBS), the clinical extension of gingival involvement, and patient‐related outcomes (visual analog score of pain). Results: A total of 11 patients (six males and five females; mean age: 11 ± 0.86 years) were recruited. Four weeks after finishing the oral hygiene and periodontal therapy protocol, a statistically significant reduction was observed for FMPS (P = 0.000), FMBS (P = 0.000), reported pain (P = 0.003) and clinical gingival involvement (P = 0.003). Conclusion: Standard, professional oral hygiene procedures and non‐surgical periodontal therapy including antimicrobials were associated with a marked improvement of clinical and patient‐related outcomes in pediatric cases of PCG.     

Bleeding on probing in smokers and non-smokers in a steady state plaque environment

An altered gingival inflammatory response to supragingival plaque in smokers had been claimed by several authors. Relatively limited information exists with regard to the consistency of naturally occurring plaque and bleeding upon probing within the oral cavity under usual oral hygiene measures. The aims of the present study were to describe the distribution of tooth surfaces covered by supragingival plaque and gingival units bleeding upon probing in a steady state environment of no dental intervention. In addition relative consistency of plaque and bleeding was investigated. 65 volunteers, 14 women and 51 men in the age range of 19 to 30 years, participated. 33 volunteers were heavy smokers and 32 non-smokers. Clinical examinations revealed mild, plaque-induced gingivitis with no overt destructive periodontitis. Within a 6-month period. presence and amount of plaque, calculus and gingival bleeding was site-specifically assessed four times, i.e., every 8 weeks. Well-defined, symmetric and consistent patterns of plaque and calculus distribution within the oral cavity were observed, which were rather identical in smokers and non-smokers. Smokers had evenly more plaque in all regions of the oral cavity. In contrast, there was no obvious pattern of bleeding upon probing. Consistency of observations was considerably lower than for plaque scores. This was particularly true for smokers, where the association between bleeding scores was generally smaller than in non-smokers. A large portion of the variation of gingival bleeding may be due to presently unknown factors other than plaque and calculus with considerable consequences for preventive programmes.     

Longitudinal evaluation of a self-inspection plaque index in periodontal recall patients

This paper presents a controlled clinical trial to compare the effects of 2 programs for maintenance of oral hygiene after periodontal treatment. Oral hygiene instruction using a self-inspection plaque index was compared to traditional instruction using professional monitoring of disclosed plaque. 31 periodontal recall patients were randomly assigned to 2 groups. 15 patients in the self-inspection group were provided a manual that taught scoring of disclosed plaque on 6 teeth, a lighted dental mirror, and disclosing wafers. 16 patients in the traditional group were shown disclosed plaque in their own mouths, and were given feedback regarding oral hygiene skills. Instruction was given initially, at 2 weeks, at 1.5 months and at 3 months. The teeth were scaled at the start and at 3 months. Disclosed dentogingival plaque (before and after brushing), gingival bleeding on probing, and oral hygiene skills were assessed at 0, 1.5, 3 and 6 months. Initial mean plaque scores for only the self-inspection group decreased significantly at 1.5 months and were maintained throughout the study; however differences between groups were not observed at any time except at baseline. Gingival bleeding scores were low throughout the study for both groups. Results provide some evidence for the effectiveness of self-evaluation of disclosed plaque as a means for improving oral hygiene behavior in already-motivated patients.     

Periodontal status in patients with gingival mucous membrane pemphigoid

BACKGROUND: Mucous membrane pemphigoid (MMP) describes an autoimmune disease with a range of variants, including those with oral, ocular, and cutaneous lesions. Persistent oral lesions, lack of effective oral hygiene, and plaque accumulation may increase the risk of long-term periodontal disease. However, to our knowledge, no studies have evaluated the relationship between the presence of gingival MMP and periodontal health. The purpose of this study was to evaluate the possible impact of gingival pemphigoid lesions on the human periodontium. METHODS: Twenty patients with histologic confirmation of subepithelial separation with or without direct immunofluorescence testing were randomly chosen to participate in a study evaluating their periodontal status. Parameters evaluated included plaque score, gingival index, bleeding index, probing depths, recession, clinical attachment level, mobility, furcation involvement, number of missing teeth, and Machtei criteria, a previously defined criteria for periodontitis. Individuals matched with respect to age, gender, and smoking history were selected and evaluated for the same parameters. RESULTS: MMP patients had statistically significant larger mean gingival index scores than age, gender, and smoking history matched controls. Plaque scores, bleeding index, mobility, furcations, clinical attachment level, recession, and periodontal status did not show statistically significant differences between MMP and control patients. A statistically significant difference in plaque index was found when patients with MMP in treatment were compared to patients with MMP in remission. Among patients with MMP, those diagnosed >5 years in the past had statistically significantly greater Class I furcation involvement and recession on facial and lingual surfaces of teeth. CONCLUSIONS: A relationship was found to suggest that patients with MMP exhibit more gingival inflammation than a control population. Among patients with MMP, patients currently in treatment have higher plaque indices than those in remission and not receiving treatment. Furthermore, when comparing patients with MMP who received a diagnosis>5 years in the past to those with a diagnosis in the past 5 years, statistically significantly greater Class I furcation and facial and lingual recession were measured. Long-term follow-up in this population may provide additional information as to periodontal progression in MMP versus control patients.     

Periodontal conditions in a Swedish city population of adolescents: a cross-sectional study

The aim of this epidemiological survey was to analyze the periodontal conditions of 19-year old individuals in an urban area of Sweden, with special reference to gender and socioeconomic factors. A randomized sample of 272 individuals living in G?teborg, Sweden, was clinically examined with regard to oral hygiene, gingivitis, periodontal pockets, probing attachment loss (PAL) and gingival recession. Bitewing radiographs were used for assessments of alveolar bone level (ABL) and dental calculus. A questionnaire-based interview regarding oral hygiene habits was included. Data were analyzed with regard to differences between gender and socioeconomic grouping. The subjects showed a mean plaque score of 59% and a gingivitis score of 44%. 70% of the adolescents had a plaque score of > or = 50%, whereas corresponding figure for gingivitis was 37%. 27% of the subjects had at least one tooth with gingival recession. The mean prevalence of sites with probing depth of > or = 6 mm was 0.5, and the prevalence of PAL > or = 2 mm was 0.7. A radiographic bone level of > or = 2 mm was observed at on average 0.8 teeth per subject. Females had significantly less plaque and gingivitis than males and significantly higher number of teeth with gingival recession. There were no clinically significant differences in periodontal conditions between socioeconomic groups. In conclusion,the survey revealed higher prevalence of plaque and gingivitis among male than female adolescents but no differences between socioeconomic groups.     

The effect of mouthrinses containing zinc and triclosan on plaque accumulation, development of gingivitis and formation of calculus in a 28-week clinical test

Abstract Experimental mouthrinses containing 0.4% zinc sulphate and 0.15% triclosan, which differed in base formulations were compared to a commercially available non-active control mouthrinse. Following baseline clinical examinations for plaque, gingival bleeding and calculus, the volunteers were provided with a dental prophylaxis and given oral hygiene instruction, stratified into 3 groups and given 1 of 3 mouthrinses. Further clinical assessments were performed after 4. 16 and 28 weeks. Salivary mutans streptococci were also monitored during the study. At 4 weeks, plaque and calculus scores in all groups were low compared to baseline. During the remainder of the study, these improvements were not maintained and both plaque and calculus levels increased in all groups. Plaque was significantly lower (p<0.05) than in the control at all time points. Calculus was significantly lower at week 28 for experimental mouthrinse group 2. Gingival bleeding also decreased in the initial 4 weeks but increased thereafter in the control group. In contrast, gingival bleeding was significantly (p<0.05) lower in the two experimental groups than in the control group. No significant changes in mutans streptococci were observed.     

Oral hygiene program for orthodontic patients

The gingival and periodontal health of 62 adolescent orthodontic patients was assessed before and again after orthodontic treatment in a controlled clinical study. Before the commencement of orthodontic treatment, the experimental group received an oral hygiene program consisting of 4 weekly sessions of oral health education, instruction on plaque-control techniques and reviews in plaque removal performance. The control group did not receive this program. It was found that there was a general trend in the study population for improved gingival health as measured by the bleeding index, gingival index, plaque index and gingival crevicular fluid volume. Furthermore, the oral hygiene program induced in the experimental group significantly lower scores in the measured clinical indices compared to the control group. However, no significant difference was noted in the measured probing depths in all subjects before or after the study period.     

The effect of a single scaling with or without oral hygiene instruction on gingival bleeding and calculus formation

Abstract. 136 students of both sexes aged 14–18 years who were deprived of regular dental care participated in a 22-month longitudinal study. All students underwent scaling of the assigned teeth in 2 quadrants according to a randomized split-mouth design on contralateral quadrants. 2 groups of students were formed, one group received oral hygiene instruction (OHI). Follow-up-examinations on gingival bleeding and calculus were carried out 6, 12, and 22 months after the scaling session. The prevalence of calculus on assigned teeth at baseline was high with a mean score of 1.10. At the end of the study, new calculus formation on scaled teeth reached a mean score of 0.58. Formation of calculus still continued on non-scaled teeth, but at a lower rate than on scaled teeth. Scaling resulted in an approximately 20% reduction of the gingival bleeding score which remained during the 22 months follow-up period, OHI had no significant effect on the calculus and bleeding scores. Since the effect of scaling alone on the gingival condition was small and the effect of a single OHI negligible, the practice of occasional scaling without repeated OHI, which is commonly employed in developing countries, should be considered as clinically irrelevant and of little use in improving the standard of periodontal health.     

Periodontal conditions in mentally retarded children

The purpose of this investigation was to evaluate the standard of oral hygiene and periodontal health among institutionalized and non-institutionalized mentally retarded children with and without Down's syndrome in relation to dental care and socioeconomic status. A total of 329 persons, 6-19 yr old, were examined. In general, oral hygiene and periodontal health were poor and most of the children had gingival bleeding. The best, as well as the poorest, oral hygiene and periodontal health was found among subjects living at home. Children with Down's syndrome had less plaque and calculus but, in spite of this, a tendency to more gingivitis than others. Individuals who had their teeth brushed every day under teacher supervision had better periodontal health than others. Furthermore this study indicates a relationship between socioeconomic status and periodontal conditions.     

Periodontal status and oral hygiene in two populations of cleft patients.

OBJECTIVE: To evaluate and compare the oral hygiene and periodontal status in children with unilateral and bilateral cleft lip and palate treated in ?ód?, Poland, and Erlangen, Germany. DESIGN: Oral health was assessed by the presence of dental plaque, pocket depth, clinical attachment levels, and pathologic teeth mobility. SUBJECTS AND METHODS: Thirty-seven Polish and 63 German patients participated in this study. RESULTS: Poor oral hygiene was found in 57% of all subjects. In Erlangen, 60% of patients had optimal oral hygiene, compared to 19% in ?ód?. The highest scores for dental plaque were noted in both groups in the cleft region. Healthy periodontium was significantly more frequent among German patients, whereas gingival bleeding was significantly more frequent among Polish patients. Pocket depths greater than 6 mm occurred only in German subjects. No statistically significant difference was observed between the amount of tooth areas with gingival recessions and the country of origin. Periodontal pockets deeper than 3.5 mm occurred more frequently during active orthodontic treatment. CONCLUSIONS: The oral hygiene regimens in Germany and Poland were not comparable, as more plaque was found in the Polish than in the German population. Plaque accumulation seems not to be a key factor in causing periodontal destruction in the cleft area. Factors other than oral hygiene should be considered of major importance in relation to the development of gingival recession on teeth in cleft areas.     

Periodontal health and its relationship with salivary factors among different age groups in a Saudi population

PURPOSE: This study aimed to describe the periodontal condition of children, adolescents and young Saudi adults and to investigate its relationship with salivary variables and oral hygiene status. MATERIALS AND METHODS: A sample of 114 children, 99 adolescents and 99 young adults were randomly selected from patients attending dental clinics at the school of dentistry. Clinical examination of oral health status included using WHO Community Periodontal Index and Green and Vermillion oral hygiene index. In addition, salivary flow rate, pH, buffering capacity and microbial flora were measured. RESULTS: A healthy periodontal condition was found in 6.7% of the sample. Calculus was the most frequently encountered periodontal disease. Children had better periodontal condition than adolescents and adults. Males had higher plaque and gingival scores than females. The salivary flow rate and pH were significantly higher in individuals with good periodontal condition. The salivary level of fluoride and buffering capacity was not related to the periodontal condition. Yeast was the only microorganism related to periodontal condition. The relationship between poor periodontal condition and high plaque score was highly significant. CONCLUSIONS: Periodontal disease increased with age and was strongly related to salivary flow rate, pH value and yeast level, as well as plaque accumulation. Preventive efforts must be increased in order to achieve the WHO goal for the year 2010 of no more than one sextant showing bleeding or calculus at the age of 15.