Gottlieb in 1942, concluded that continual cementum deposition was necessary to maintain periodontal health, once periodontal disease is a disease of cementum. Also, extracted cementum endotoxins were able to decrease fibroblast growth in tissue culture media. It has not been shown if endotoxins really invade cementum or if they are just present as part of bacterial plaque trapped in areas of cementum decalcification but, endotoxins are inflammatory agents that do not allow eradication of disease. They are more numerous in calculus deposit areas. It was speculated that they may be the bacterial portion of the calculus attachment.
Granules disappear when decalcification processes are applied.
The vacuoles follow intact collagen fibers orientation and may be where the collagen fibers degenerated. Lacunar resorption has been observed to be increased in periodontally diseased teeth, although the mechanism by which it happens has not been elucidated. Hypermineralization may occur by the presence of higher concentrations of Ca and phosphate of plaque in contact with cementum when compared to their concentration in the saliva. Other investigators think that calcium and phosphate concentrations in saliva itself are enough to produce a hypermineralized zone. Hypermineralization comes from surrounding fluids and not from adjacent mineral tissues, once no decrease in mineralization was observed in areas under the hypermineralized areas.