Dental Dental CariesCaries

Contents Contents

IntroductionIntroduction History History Definitions Definitions EpidemiologyEpidemiology Classification Classification Carious processCarious process Concepts of caries developmentConcepts of caries development

Plaque Plaque Host factors-tooth ,salivaHost factors-tooth ,saliva Substrate Substrate Socioeconomic factors Socioeconomic factors Summary Summary ReferencesReferences

IntroductionIntroduction

Dental caries is the most common chronic disease (5 billion people worldwide)

It is costly in terms of time and work hours lost, money spent. In addition the expense incurred in education of health professional required to cope with this disease in terms of prevention, treatment and oral rehabilitation.

HISTORYHISTORY Aristotle, Hippocrates and Aristotle, Hippocrates and

Shakespeare have all written on dental Shakespeare have all written on dental caries in their writings.caries in their writings.

Some theories put forward are the Some theories put forward are the Worm theory, Vital theory etc.Worm theory, Vital theory etc.

L. S. Parmly (1819)-first contributed to L. S. Parmly (1819)-first contributed to current understanding of caries current understanding of caries mechanismmechanism

Emil Magitot experimented using Emil Magitot experimented using Pasteur findings. He produced artificial Pasteur findings. He produced artificial carious lesions in extracted teeth.carious lesions in extracted teeth.

W.D.Miller (1890) Chemo parasitic W.D.Miller (1890) Chemo parasitic theory.theory.

Gottlieb (1941) – Proteolysis theory. Gottlieb (1941) – Proteolysis theory. Schatz & Martin(1955) –Proteolysis Schatz & Martin(1955) –Proteolysis

chelation theory.chelation theory.

DefinitionsDefinitions

Dental cariesDental caries is a microbial disease of is a microbial disease of the calcified tissues, characterized by the calcified tissues, characterized by demineralization of the inorganic demineralization of the inorganic portion and destruction of organic portion and destruction of organic portion of the tooth. portion of the tooth. (Shafer)(Shafer)

Dental cariesDental caries is an infectious is an infectious microbiologic disease of the teeth that microbiologic disease of the teeth that results in localized dissolution and results in localized dissolution and destruction of the calcified tissues. destruction of the calcified tissues. (Sturdevant)(Sturdevant)

Dental cariesDental caries is defined as a is defined as a progressive, irreversible progressive, irreversible multifactorial in nature affecting the multifactorial in nature affecting the calcified tissues of teeth, calcified tissues of teeth, characterized by demineralization of characterized by demineralization of the inorganic portion and the inorganic portion and destruction of organic portion of the destruction of organic portion of the tooth. tooth. (Soben peter)(Soben peter)

EPIDEMIOLOGYEPIDEMIOLOGY

Prehistoric man skulls-very Prehistoric man skulls-very infrequent caries. attributed to infrequent caries. attributed to rough coarse nature of food rough coarse nature of food consumed.consumed.

Exposure to processed foods, refined Exposure to processed foods, refined carbohydrates, soft drinks and carbohydrates, soft drinks and snacks has been shown to increase snacks has been shown to increase the frequency of caries.the frequency of caries.

EpidemiologyEpidemiology

Decline in caries prevalence in Decline in caries prevalence in developed countries.developed countries.

Increasing prevalence of caries in Increasing prevalence of caries in less developed countries.less developed countries.

Polarization of cariesPolarization of caries

Most common epidemiologic measure Most common epidemiologic measure of caries is evaluation of measure of of caries is evaluation of measure of permanent teeth that are diseased, permanent teeth that are diseased, missing or filled (DMF)missing or filled (DMF)

Either reported as no of teeth (DMFT) Either reported as no of teeth (DMFT) or no of surfaces (DMFS) affected.or no of surfaces (DMFS) affected.

A cumulative index.A cumulative index. But over-estimates the prevalence of But over-estimates the prevalence of

caries.caries.

Geographical Geographical differencesdifferences

More remote areas of world with More remote areas of world with less access to refined foods shows less access to refined foods shows decreased incidence of caries.decreased incidence of caries.

Caries often rightly called Caries often rightly called Disease of Disease of the civilization the civilization

Family differencesFamily differences

More caries rate seen in siblings of More caries rate seen in siblings of individuals with high caries rates & individuals with high caries rates & less incidence seen in siblings of less incidence seen in siblings of caries immune individuals.caries immune individuals.

Children of high caries incident Children of high caries incident parents shows higher caries incidence.parents shows higher caries incidence.

Attributed mainly to Attributed mainly to genetic factorsgenetic factors such as tooth morphology, salivary such as tooth morphology, salivary flow rate and also to dietary habits and flow rate and also to dietary habits and oral hygiene habits of the family.oral hygiene habits of the family.

Gender Gender

GirlsGirls show high caries incidence show high caries incidence than boys of same age till early than boys of same age till early teens.teens.

Attributed to earlier eruption of Attributed to earlier eruption of teeth in girls because of early teeth in girls because of early growth spurt.growth spurt.

Significant as teeth are maximally Significant as teeth are maximally susceptible to caries immediately susceptible to caries immediately after eruption.after eruption.

AgeAge

Even at age six around Even at age six around 20% of the 20% of the childrenchildren have caries incidence in have caries incidence in their permanent dentition.their permanent dentition.

Most frequently involved is the first Most frequently involved is the first permanent molar (six yr molar)permanent molar (six yr molar)

Caries susceptibility in Caries susceptibility in permanent dentitionpermanent dentition

Sites ranked in decreasing order of occurrenceSites ranked in decreasing order of occurrence

1)1) Fissure of the molarsFissure of the molars

2)2) Mesial & distal surface of first molars.Mesial & distal surface of first molars.

3)3) Mesial surface of second molars & distal Mesial surface of second molars & distal surface of second premolars.surface of second premolars.

4)4) Mesial & distal surface of maxillary first Mesial & distal surface of maxillary first premolarspremolars

5)5) Distal surface of canines & Mesial surface of Distal surface of canines & Mesial surface of mandibular first premolarsmandibular first premolars

6)6) Approximal surface of maxillary incisorsApproximal surface of maxillary incisors

CLASSIFICATIONCLASSIFICATION

I.I. STURDEVANTSTURDEVANT

Based on - LocationBased on - Location

- Extent- Extent

- Rate of progression- Rate of progression

According to location:According to location:

a. Primary cariesa. Primary caries

b. Caries of pit and fissure originb. Caries of pit and fissure origin

c. Caries of enamel smooth surface c. Caries of enamel smooth surface originorigin

d. Backward cariesd. Backward caries

e. Forward cariese. Forward caries

f. Residual cariesf. Residual caries

g. Root surface cariesg. Root surface caries

h. Secondary (recurrent) caries h. Secondary (recurrent) caries

According to extent:According to extent: a. Incipient (reversible) cariesa. Incipient (reversible) caries b. Cavitated (irreversible) cariesb. Cavitated (irreversible) caries

According to rate of progression:According to rate of progression: a. Acute (rampant) cariesa. Acute (rampant) caries b. Chronic (slow or arrested) cariesb. Chronic (slow or arrested) caries

II. DCNA:II. DCNA: According to tooth type:According to tooth type: a. Deciduous (A-T)a. Deciduous (A-T)

b. Permanent (1-32)b. Permanent (1-32)

According to anatomic siteAccording to anatomic site a. Pit and fissure cariesa. Pit and fissure caries b. Smooth surface caries- inter proximal, cervicalb. Smooth surface caries- inter proximal, cervical c. Root surface cariesc. Root surface caries

According to hard tissue affected:According to hard tissue affected: a. Enamela. Enamel b. Dentinb. Dentin c. Cementumc. Cementum Others:Others: a. Primary caries & secondary cariesa. Primary caries & secondary caries b. Nursing cariesb. Nursing caries c. Radiation cariesc. Radiation caries d. Rampant cariesd. Rampant caries

III.GORDANIII.GORDAN

Based onBased on

1.1. Morphology (anatomical site )Morphology (anatomical site )

2.2. Dynamics (severity and rate of Dynamics (severity and rate of progression) progression)

3.3. Chronology (age patterns)Chronology (age patterns)

According to morphology:According to morphology:

a. Occlusal pit and fissure and smooth a. Occlusal pit and fissure and smooth surface cariessurface caries b. Root cariesb. Root caries c. Linear enamel caries (Odontoclasia)c. Linear enamel caries (Odontoclasia)

According to rate of progression:According to rate of progression:

a. Rampant cariesa. Rampant caries b. Incipient cariesb. Incipient caries c. Arrested cariesc. Arrested caries d. Recurrent cariesd. Recurrent caries e. Xerostomia induced caries (radiation caries)e. Xerostomia induced caries (radiation caries)

Black’s classification of Black’s classification of tooth preparationtooth preparation

Class-I:Class-I: -- caries on the occlusal surfaces of caries on the occlusal surfaces of molars and premolarsmolars and premolars

- occlusal 2/3 of the buccal and - occlusal 2/3 of the buccal and lingual surfaces of molarslingual surfaces of molars

- lingual surfaces of the anterior - lingual surfaces of the anterior teeth.teeth.

Class II-Class II- restorations on proximal surfaces restorations on proximal surfaces of posterior teeth.of posterior teeth.

Class III-Class III- restorations on anterior teeth restorations on anterior teeth that do not involve the incisal angles.that do not involve the incisal angles.

Class IV-Class IV- Restorations on anterior Restorations on anterior teeth that involve the incisal angles.teeth that involve the incisal angles.

Class VClass V-- Restorations on all gingival Restorations on all gingival third of facial or lingual surfaces of third of facial or lingual surfaces of all teeth (except pit and fissure all teeth (except pit and fissure lesions)lesions)

Class VI-Class VI- restorations on incisal edge restorations on incisal edge of anterior teeth or the occlusal cusp of anterior teeth or the occlusal cusp heights of posterior teeth.heights of posterior teeth.

proposed byproposed by SiomonSiomon

1.1. Simple caries:Simple caries: one one surface is involvedsurface is involved

2.2. Compound caries:Compound caries: two surfaces are two surfaces are involvedinvolved

3.3. Complex cariesComplex caries:: three or more three or more surfaces are surfaces are involved involved

WHO classificationWHO classification The The shape and the depthshape and the depth of the carious of the carious

lesion can be scored on a 4 point scalelesion can be scored on a 4 point scale DD11 -Clinically detectable enamel lesions -Clinically detectable enamel lesions

with intact (non cavitated) surfaceswith intact (non cavitated) surfaces DD2 2 -Clinically detectable cavities limited -Clinically detectable cavities limited

to enamelto enamel DD 3 3 -Clinically detectable lesions in -Clinically detectable lesions in

dentin (with and without cavitation of dentin (with and without cavitation of dentin)dentin)

DD 4 4 – Lesions into the pulp.– Lesions into the pulp.

Mounts classificationMounts classification According to site and size of the lesionAccording to site and size of the lesion Site 1-Site 1- pits,fissures and enamel defects pits,fissures and enamel defects

on occlusal surfaces of posterior teeth or on occlusal surfaces of posterior teeth or other smooth surfaces, such as cingula other smooth surfaces, such as cingula pits on anterior teeth.pits on anterior teeth.

Site 2-Site 2- Approximal enamel immediately Approximal enamel immediately below contact areas with adjacent teethbelow contact areas with adjacent teeth

Site 3-Site 3- the cervical third of the crown or the cervical third of the crown or following gingival recession, the exposed following gingival recession, the exposed root surface.root surface.

According to the sizeAccording to the size

Size 1-Size 1- Minimal involvement of the Minimal involvement of the dentin but beyond treatment by dentin but beyond treatment by remineralization alone.remineralization alone.

Size 2-Size 2- moderate involvement of moderate involvement of dentin. following cavity preparation, dentin. following cavity preparation, remaining enamel is sound, well remaining enamel is sound, well supported by dentin and unlikely to supported by dentin and unlikely to fail under normal occlusal load.fail under normal occlusal load.

Size 3-Size 3- enlarged beyond moderate. enlarged beyond moderate. Remaining tooth structure is Remaining tooth structure is weakened to the extent that cusps or weakened to the extent that cusps or incisal edges are split or likely to fail incisal edges are split or likely to fail if left exposed to occlusal or incisal if left exposed to occlusal or incisal load. The cavity needs to be further load. The cavity needs to be further designed to provide support and designed to provide support and protection to the remaining tooth protection to the remaining tooth structure.structure.

Size 4-Size 4- extensive caries with bulk loss extensive caries with bulk loss of tooth structure.of tooth structure.

Classification of root Classification of root cariescaries

Grade I ( Incipient)Grade I ( Incipient) Surface texture: Soft, can be penetrated Surface texture: Soft, can be penetrated

with a Dental Explorerwith a Dental Explorer No surface defectNo surface defect Pigmentation: variable; Light tan to brownPigmentation: variable; Light tan to brown

Grade II (shallow)Grade II (shallow) Surface texture: Soft, irregular, rough can Surface texture: Soft, irregular, rough can

be penetrated with a Dental Explorerbe penetrated with a Dental Explorer Surface defect (<0.5mm in depth)Surface defect (<0.5mm in depth) Pigmentation: variable; Light tan to brownPigmentation: variable; Light tan to brown

Grade III (Cavitation)Grade III (Cavitation) Surface texture: Soft, can be penetrated Surface texture: Soft, can be penetrated

with a Dental Explorerwith a Dental Explorer Surface defect: Cavitation present (> Surface defect: Cavitation present (>

0.5mm in depth): no pulpal involvement0.5mm in depth): no pulpal involvement Pigmentation: variable; Light tan to brownPigmentation: variable; Light tan to brown Grade IV (pulpal)Grade IV (pulpal) Deeply penetrating lesion with pulpal or Deeply penetrating lesion with pulpal or

root canal involvement.root canal involvement. Pigmentation: variable; Light tan to brownPigmentation: variable; Light tan to brown

From Billings (1986)From Billings (1986)

Ekstrand classificationEkstrand classification

Three criteria used in the Three criteria used in the classificationclassification

Visual, Radiographic and Visual, Radiographic and Histological examinationsHistological examinations

Caries research1998;32;247-254

Visual examinationVisual examination0 –No or slight change in enamel translucency 0 –No or slight change in enamel translucency

after prolonged air drying(>5 sec)after prolonged air drying(>5 sec)1 –Opacity (white) hardly visible on the wet surface 1 –Opacity (white) hardly visible on the wet surface

but distinctly on the wet surface after air drying.but distinctly on the wet surface after air drying.1 a- Opacity (brown) hardly visible on the wet 1 a- Opacity (brown) hardly visible on the wet

surface but distinctly on the wet surface after air surface but distinctly on the wet surface after air drying.drying.

2- Opacity (white) distinctly visible without air 2- Opacity (white) distinctly visible without air drying.drying.

2a- Opacity (brown) distinctly visible without air 2a- Opacity (brown) distinctly visible without air drying.drying.

3 –Localized enamel breakdown in opaque or 3 –Localized enamel breakdown in opaque or discoloured enamel and /or greyish discoloured enamel and /or greyish discolouration from underlying dentin.discolouration from underlying dentin.

4- Cavitation in opaque or discoloured enamel 4- Cavitation in opaque or discoloured enamel exposing the underlying dentin.exposing the underlying dentin.

Radiographic Radiographic examinationexamination

0- No radioluscency visible0- No radioluscency visible

1- Radioluscency visible in the enamel1- Radioluscency visible in the enamel

2- Radioluscency visible in the dentin 2- Radioluscency visible in the dentin but restricted to the outer third of the but restricted to the outer third of the dentindentin

3- Radioluscency extending to middle 3- Radioluscency extending to middle third of the dentinthird of the dentin

4- Radioluscency in the pulpal third of 4- Radioluscency in the pulpal third of the dentinthe dentin

Histological examinationHistological examination

0- No enamel demineralization or a narrow 0- No enamel demineralization or a narrow surface zone of opacity (edge phenomenon)surface zone of opacity (edge phenomenon)

1- Enamel demineralization limited to outer 1- Enamel demineralization limited to outer 50% of enamel layer50% of enamel layer

2- Demineralization involving between 50% of 2- Demineralization involving between 50% of the enamel and1/3the enamel and1/3rdrd of dentin of dentin

3- Demineralization involving middle1/33- Demineralization involving middle1/3rdrd of of dentindentin

4- Demineralization involving inner 1/34- Demineralization involving inner 1/3rdrd of of dentindentin

PIT AND FISSURE CARIESPIT AND FISSURE CARIES Limited to the – occlusal surfaces of Limited to the – occlusal surfaces of molars and premolarsmolars and premolars - buccal pits of molars- buccal pits of molars - lingual surfaces of - lingual surfaces of maxillary anterior teethmaxillary anterior teeth Poor self cleansing featuresPoor self cleansing features Usually occurs before smooth surface cariesUsually occurs before smooth surface caries Clinically -Clinically - black or brown in black or brown in colorcolor - slightly soft consistency- slightly soft consistency -- “catch”“catch” the tip of a fine the tip of a fine explorerexplorer Adjacent enamel appears bluish whiteAdjacent enamel appears bluish white ““Internal Caries”Internal Caries”

Smooth Surface CariesSmooth Surface Caries Develops on - proximal surfaces of the teethDevelops on - proximal surfaces of the teeth - gingival third of the buccal and - gingival third of the buccal and lingual surfaces (cervical caries)lingual surfaces (cervical caries)

Preceded by the formation of dental plaque.Preceded by the formation of dental plaque.

Usually initiate justUsually initiate just below the contact pointbelow the contact point..

Clinically- initially as faintClinically- initially as faint white opacity or white opacity or yellow brown pigmented area.yellow brown pigmented area.

Adjacent enamel appears bluish white.Adjacent enamel appears bluish white.

Cervical CariesCervical Caries

Appears asAppears as crescent shaped lesioncrescent shaped lesion.. May extend proximally.May extend proximally. Almost always anAlmost always an open cavityopen cavity.. Lack of oral hygieneLack of oral hygiene on the part of on the part of

patient.patient.

Backward CariesBackward Caries

Lateral spread of the lesion along Lateral spread of the lesion along the DEJ exceeds the caries in the the DEJ exceeds the caries in the contiguous enamel, caries extends contiguous enamel, caries extends into this enamel from the junction.into this enamel from the junction.

Forward CariesForward Caries Caries cone in enamel is larger or at Caries cone in enamel is larger or at

least the same size as that in dentinleast the same size as that in dentin

Residual CariesResidual Caries

Caries that remains in a completed Caries that remains in a completed cavity preparationcavity preparation

Not acceptable if - present at DEJNot acceptable if - present at DEJ

- prepared - prepared enamel wallenamel wall

Root Surface CariesRoot Surface Caries

InIn old age patientsold age patients Initiates at the surface of a Initiates at the surface of a

mineralized dentin and Cementum mineralized dentin and Cementum which have greater organic contentwhich have greater organic content

Usually haveUsually have rapid clinical courserapid clinical course

Recurrent (secondary) Recurrent (secondary) caries:caries:

Occurs at theOccurs at the junction of junction of the restoration and the the restoration and the cavosurface of the cavosurface of the enamelenamel

May extend beneath the May extend beneath the restorationrestoration

Indicates unusual Indicates unusual susceptibility to caries susceptibility to caries attack, poor cavity attack, poor cavity preparation, defective preparation, defective restoration.restoration.

Also indicates presence Also indicates presence ofof microleakage.microleakage.

First evidence of caries First evidence of caries activity in enamelactivity in enamel

Clinically as white opaque Clinically as white opaque regionregion

Subsurface Subsurface demineralization has demineralization has occurred but no cavitationoccurred but no cavitation

May take up extrinsic stains May take up extrinsic stains May undergo May undergo

remineralization-remineralization- called ascalled as “caries reversibility”“caries reversibility” oror “consolidation”“consolidation” of early of early enamel carious lesion enamel carious lesion

Incipient (reversible) Incipient (reversible) caries:caries:

Cavitated (irreversible) Cavitated (irreversible) caries:caries:

Lesion that has Lesion that has advanced into dentin advanced into dentin with broken surfacewith broken surface

Remineralization is Remineralization is not possiblenot possible

Treatment include Treatment include cavity preparation cavity preparation and restoring with and restoring with suitable material.suitable material.

Linear enamel caries Linear enamel caries (odontoclasia):(odontoclasia):

Atypical form of dentalAtypical form of dental

caries incaries in primary dentitionprimary dentition Lesion predominates on Lesion predominates on

thethe labial surface of the labial surface of the maxillary anteriormaxillary anterior teeth in teeth in the region of neonatal the region of neonatal zonezone

Lesion isLesion is crescent shapecrescent shape Increase caries Increase caries

susceptibility of posterior susceptibility of posterior teeth.teeth.

Odontoclasia:Odontoclasia:

-- variant of linear enamel caries variant of linear enamel caries

- results in gross destruction of the- results in gross destruction of the

labial surfaces of incisor teethlabial surfaces of incisor teeth

- cause may be an- cause may be an inherent inherent

structural defectstructural defect

Acute dental caries:Acute dental caries:

Rapid clinical courseRapid clinical course resulting in early resulting in early pulp involvementpulp involvement

Frequently inFrequently in children and young children and young adultsadults

Entry of lesion remains small while Entry of lesion remains small while rapid spread along the DEJrapid spread along the DEJ

Clinically appears light yellow in Clinically appears light yellow in colourcolour

Pain is often presentPain is often present

Chronic dental cariesChronic dental caries

Common inCommon in adultsadults Large entranceLarge entrance of the lesionof the lesion Dentin is stained deep brown Dentin is stained deep brown Moderate lateral spread of caries at Moderate lateral spread of caries at

DEJDEJ Pain is not a commonPain is not a common clinical finding.clinical finding. Slowly progressiveSlowly progressive lesion that lesion that

involvesinvolves pulp much laterpulp much later

Rampant caries:Rampant caries:

Sudden and rapid onsetSudden and rapid onset and almost and almost uncontrollable uncontrollable destruction of teethdestruction of teeth

Involves teeth that are Involves teeth that are ordinarily caries free ordinarily caries free (mandibular incisors)(mandibular incisors)

Ten or more new Ten or more new increments of carious increments of carious lesion in one year lesion in one year

Nursing Bottle (Infancy or Nursing Bottle (Infancy or Soother) CariesSoother) Caries

Rapidly progressing caries Rapidly progressing caries affecting primary dentition affecting primary dentition usuallyusually during first 2 yearsduring first 2 years of of lifelife

4 maxillary anterior4 maxillary anterior are are affected firstaffected first

If unchecked, maxillary and If unchecked, maxillary and mandibular molars may also mandibular molars may also get involvedget involved

Lower anterior are sparedLower anterior are spared (characteristic feature)(characteristic feature)

Adolescent caries:Adolescent caries: Acute caries attack atAcute caries attack at 11-11-

18 18 years of ageyears of age Lesion in teeth and Lesion in teeth and

surfaces that are relatively surfaces that are relatively immune to cariesimmune to caries

Small opening in enamelSmall opening in enamel with extensive with extensive underminingundermining

Rapid clinical courseRapid clinical course Little or no secondary Little or no secondary

dentin formationdentin formation

Arrested caries:Arrested caries: Caries which becomes static or Caries which becomes static or

stationary and does not show stationary and does not show any tendency for progressionany tendency for progression

Almost exclusively occurs onAlmost exclusively occurs on occlusal surfacesocclusal surfaces

Both dentitionsBoth dentitions are affectedare affected Lesion appears as large open Lesion appears as large open

cavity with lack of food cavity with lack of food retentionretention

Superficially softened and Superficially softened and decalcified dentin gets decalcified dentin gets burnished and has brown burnished and has brown stained polished appearancestained polished appearance

““Eburnation of dentin”Eburnation of dentin”

Xerostomia induced caries Xerostomia induced caries (radiation caries)(radiation caries)

Complication of radiation Complication of radiation therapy of oral cancer therapy of oral cancer lesionlesion

Radiation induced Radiation induced xerostomia produces caries xerostomia produces caries conducive environmentconducive environment

Carious lesion develops asCarious lesion develops as early asearly as 3 months3 months after after onset of xerostomiaonset of xerostomia

May be caused by other May be caused by other factors like salivary gland factors like salivary gland tumors, autoimmune tumors, autoimmune diseases, prolong illnessdiseases, prolong illness

Senile CariesSenile Caries

Caries activity thatCaries activity that spurts up during spurts up during the old age.the old age.

They are located exclusively on theThey are located exclusively on the root surfacesroot surfaces of the teeth.of the teeth.

Also seen in association with partialAlso seen in association with partial denture claspsdenture clasps..

Causes: gingival recession, decreased Causes: gingival recession, decreased salivary secretion, poor oral hygiene.salivary secretion, poor oral hygiene.

Occult Caries / Hidden Occult Caries / Hidden CariesCaries

Not clinically diagnosed, but Not clinically diagnosed, but detected only on radiograph.detected only on radiograph.

Seen in persons with low caries Seen in persons with low caries index suggestive of increased index suggestive of increased fluoride exposure.fluoride exposure.

Also called asAlso called as fluoride bombsfluoride bombs or or fluoride syndromefluoride syndrome

LimitationsLimitations

Did not explain sub-surface Did not explain sub-surface

demineralizationdemineralization

Failed to justify rampant cariesFailed to justify rampant caries

Did not explain caries in Did not explain caries in

impacted toothimpacted tooth

Phenomenon of arrested caries Phenomenon of arrested caries

is not explainedis not explained

Smooth surface caries is not Smooth surface caries is not

accounted in this theoryaccounted in this theory

Morphology:Morphology: Accentuated pits and fissuresAccentuated pits and fissures Enamel hypoplasiaEnamel hypoplasia Mottled enamelMottled enamel Bucco-lingual width of carious teethBucco-lingual width of carious teeth Position:Position: Malpositioned teethMalpositioned teeth Rotated teethRotated teeth

TEETHTEETH

3.3. Composition: Composition: Surface vs subsurface enamelSurface vs subsurface enamel

DIETDIET Carbohydrate is a cariogenic dietCarbohydrate is a cariogenic diet Cariogenicity is based onCariogenicity is based on1.1. Physical naturePhysical nature2.2. Chemical natureChemical nature3.3. Mode of intakeMode of intake4.4. Clearance rateClearance rate5.5. Frequency of intake Frequency of intake 6.6. Other dietary factorsOther dietary factors

PLAQUE AND PLAQUE AND MICROORGANISMSMICROORGANISMS

PLAQUE:PLAQUE: The concept about dental plaque was first The concept about dental plaque was first

proposed by Williams in 1897proposed by Williams in 1897 Consist of Consist of

- salivary component- mucin- salivary component- mucin

- desquamated epithelial cells- desquamated epithelial cells

- microorganisms- microorganisms

- calcium and phosphate- calcium and phosphate

To produce caries, micro organisms To produce caries, micro organisms should have following properties:should have following properties:

1.1. Should be acedogenic.Should be acedogenic.2.2. Should be aceduric.Should be aceduric.3.3. Should posses attachment Should posses attachment

mechanism.mechanism.4.4. Should have the capacity to store Should have the capacity to store

sucrose.sucrose.5.5. Should be able to synthesize Should be able to synthesize

extracellular glucans. extracellular glucans.

1.1. Pioneer / primary bacteriaPioneer / primary bacteria – initiate – initiate cariescaries

S.mutans (smooth surface caries)S.mutans (smooth surface caries) Lactobacillus acidophilus (pit & Lactobacillus acidophilus (pit &

fissure caries)fissure caries) Actinomyces (root surface caries)Actinomyces (root surface caries)

2.2. Invaders / secondary bacteriaInvaders / secondary bacteria Staphylococcus, VeillonellaeStaphylococcus, Veillonellae

Streptococci mutans:Streptococci mutans: Chief etiological agent in dental caries diseaseChief etiological agent in dental caries disease 1.1. it can produce low pH it can produce low pH ((acidogenicacidogenic)) 2.2. it can survive in low pH (acidouric)it can survive in low pH (acidouric) 3.3. utilize sucrose at a faster rate than other utilize sucrose at a faster rate than other bacteriabacteria 4.4. can metabolize sucrose to synthesize glucan can metabolize sucrose to synthesize glucan and fructan (and fructan ( attachment mechanismattachment mechanism )) 55. . it can store intracellular glycogen amylopectin it can store intracellular glycogen amylopectin

type polysaccharides that act as a reservoir of type polysaccharides that act as a reservoir of substrate and prolongs its metabolic activity substrate and prolongs its metabolic activity

Other BacteriaOther Bacteria

Lactobacillus acidophilusLactobacillus acidophilus Found in carious dentin & saliva of persons Found in carious dentin & saliva of persons

with high caries activitywith high caries activity Release lactic acidRelease lactic acid

ActinomycesActinomyces Found esp. in root cariesFound esp. in root caries Acidogenic Acidogenic Attachment to tooth by glycoprotein called Attachment to tooth by glycoprotein called

LectinLectin

Acids produced areAcids produced are

a)a) Lactic acid Lactic acid

b)b) Acetic acidAcetic acid

c)c) Butyric acid Butyric acid

d)d) Propionic acidPropionic acid

e)e) Traces of formic acidTraces of formic acid Lactic acidLactic acid is the strongest acidis the strongest acid

Plaque pH:Plaque pH:

Critical pH-Critical pH- 5.55.5 Caries active, pH-Caries active, pH- 5 to 5.55 to 5.5 Caries immune, pH-Caries immune, pH- 6.86.8

STEPHEN’S CURVE

Concept of critical pHConcept of critical pH pH at which any particular saliva ceases pH at which any particular saliva ceases

to be saturated with calcium and to be saturated with calcium and phosphorus ions is referred to as critical phosphorus ions is referred to as critical pH.pH.

Below this value the inorganic Below this value the inorganic constituents dissolve .constituents dissolve .

With conc. of HWith conc. of H+ + ions, more phosphate ions, more phosphate ions leave the solid apatite phase.ions leave the solid apatite phase.

Above this pH the remineralization takes Above this pH the remineralization takes placeplace

STEPHAN CURVESTEPHAN CURVE

Approximately twenty minutes after ingestion of sucrose, and once the supply of Approximately twenty minutes after ingestion of sucrose, and once the supply of fermentable nutrients is exhausted, the bacterial will cease to produce acids and fermentable nutrients is exhausted, the bacterial will cease to produce acids and the plaque pH will gradually return to a slightly alkaline resting level.the plaque pH will gradually return to a slightly alkaline resting level.

MINOR FACTORSMINOR FACTORS

I.I. SALIVA:SALIVA:

1.1. Flow rateFlow rate2.2. ViscosityViscosity3.3. Buffering capacityBuffering capacity4.4. Amount of salivaAmount of saliva

Components of saliva:Components of saliva: BicarbonatesBicarbonates Anti-bacterial agentsAnti-bacterial agents Ig-AIg-A Salivary urea and bicarbonatesSalivary urea and bicarbonates

II. Dietary factorII. Dietary factor Diet containingDiet containing Phosphates Phosphates decreases cariesdecreases caries Proteins & fatProteins & fat also prevents or decreases caries, as also prevents or decreases caries, as

they prevent attachment of carbohydrates to tooththey prevent attachment of carbohydrates to tooth Trace elements ofTrace elements of Vanadium & MolybdenumVanadium & Molybdenum

decreases cariesdecreases caries SeleniumSelenium increases risk of cariesincreases risk of caries Vitamin A & BVitamin A & B are important in formation of hard are important in formation of hard

tissues. Thus if they are deficient, hypoplasia of tissues. Thus if they are deficient, hypoplasia of teeth is seen, teeth more prone to cariesteeth is seen, teeth more prone to caries

Fibrous foodFibrous food help in cleansing of teeth, removal of help in cleansing of teeth, removal of lodged foodlodged food

III. Hereditary factors:III. Hereditary factors:

HISTOPATHOLOGYHISTOPATHOLOGY

Important for:Important for:1.1. Research purposeResearch purpose2.2. To know the changes taking place in To know the changes taking place in

dental cariesdental caries Not important for diagnosis.Not important for diagnosis.Studied under:Studied under: Light microscopeLight microscope Electron microscopeElectron microscope Polarized microscopePolarized microscope

Loss of inter-rod substanceLoss of inter-rod substance

prominent enamel-rodsprominent enamel-rods

Appearance of transverse Appearance of transverse

striations of enamel rods striations of enamel rods

due to segmental due to segmental

demineralizationdemineralization

Accentuation of incremental Accentuation of incremental

striae of Retziusstriae of Retzius

Histological Features of early Histological Features of early enamel cariesenamel caries

Preferential loss of Preferential loss of Interprismatic SubstanceInterprismatic Substance

Histological Features of Advanced Histological Features of Advanced

enamel cariesenamel caries

Classified on the basis of pore volume and Classified on the basis of pore volume and

mounting media usedmounting media used

Zone 1 –Zone 1 – Translucent zoneTranslucent zone

Zone 2 –Zone 2 – Dark zoneDark zone

Zone 3 –Zone 3 – Body of lesionBody of lesion

Zone 4 –Zone 4 – Surface zoneSurface zone

These zones are from the dentin towards the outer These zones are from the dentin towards the outer

enamel surfaceenamel surface

NORMAL ENAMEL

DEJ

SURFACE LAYER

BODY OF THE LESION

DARK ZONE

TRANSLUSCENTZONE

Translucent ZoneTranslucent Zone Is deepest & forms advancing front of Is deepest & forms advancing front of

lesionlesion Not seen always, seen inNot seen always, seen in 50%50% of cases. of cases.

WhenWhen seen,seen, appear clearappear clear due to due to mounting media which enters these big mounting media which enters these big pores making them look clear/brightpores making them look clear/bright

Pore volume isPore volume is 1%,1%, which is more than which is more than normal (0.1%)normal (0.1%)

Zone cant be easily identified clinically / Zone cant be easily identified clinically / radiographicallyradiographically

Dark zone / positive zoneDark zone / positive zone

Dark zone as mounting media cant penetrate this Dark zone as mounting media cant penetrate this zone. Positive zone as it iszone. Positive zone as it is always presentalways present

Pore volume –Pore volume – 2-4%.2-4%. 2 types of pores seen here 2 types of pores seen here large & smalllarge & small

Initially only large pores, later change to micro-Initially only large pores, later change to micro-pores. This change mainly due to pores. This change mainly due to demineralization occurring in deeper areas demineralization occurring in deeper areas which release ions & there iswhich release ions & there is remineralization remineralization of of superficial areas superficial areas

This zone is narrower in rapidly advancing caries This zone is narrower in rapidly advancing caries & wider in slowly advancing caries& wider in slowly advancing caries

Dark zone / positive zoneDark zone / positive zone

Body of the lesionBody of the lesion

Largest zone, between dark & surface Largest zone, between dark & surface zonezone

Greater amount of demineralization taking Greater amount of demineralization taking place. Pore size –place. Pore size – 5-25%5-25%

5% variation is near periphery, 25% at 5% variation is near periphery, 25% at centercenter

ProminentProminent striae of Retziusstriae of Retzius due to due to demineralization of inorganic mineralsdemineralization of inorganic minerals

ContainsContains apatite crystals largerapatite crystals larger than that than that foundfound in normal enamelin normal enamel

Body of the lesionBody of the lesion

Surface ZoneSurface Zone

Quite intact, appearsQuite intact, appears radio-radio-

opaque opaque

UnaffectedUnaffected despite subsurface despite subsurface

demineralization; may be due demineralization; may be due

to:to:

surface remineralization by surface remineralization by

salivary ionssalivary ions

More amount of fluorideMore amount of fluoride

Dentinal CariesDentinal Caries Once lesion spreads to DEJ, there is Once lesion spreads to DEJ, there is

lateral spread of carieslateral spread of caries

Surface enamel gets unsupported Surface enamel gets unsupported

enamel rods enamel rods enamel # enamel # greater greater

cavitationcavitation

Zones of dentinal caries.Zones of dentinal caries.

Zones start from pulpal side towards Zones start from pulpal side towards

dentinal sidedentinal side

1.1. Zone ofZone of Fatty Degeneration of Tomes’ processFatty Degeneration of Tomes’ process

2.2. Zone ofZone of Sclerosis Sclerosis

3.3. Zone ofZone of Decalcification Decalcification withoutwithout Bacterial Bacterial

Invasion Invasion

4.4. Zone ofZone of Decalcification Decalcification withwith Bacterial Invasion Bacterial Invasion

5.5. Zone ofZone of Decomposed Dentin / Infected dentinDecomposed Dentin / Infected dentin

DENTINAL CARIESDENTINAL CARIES

Zone of Decomposed dentin Zone of

Bacterial

invasion Zone of

Demineralisation

Zone of Dentinal sclerosis

Zone of Fatty degeneration

Retreating Odontoblastic process

INFECTED DENTIN AFFECTED DENTIN

Fatty Degeneration of Tomes’ Fatty Degeneration of Tomes’ ProcessProcess

Innermost layerInnermost layer of dentinal caries towards of dentinal caries towards

pulppulp Due to deposition of fatty tissue in Due to deposition of fatty tissue in

odontoblastic processesodontoblastic processes Seen usually in rapidly progressing cariesSeen usually in rapidly progressing caries No crystals or bacteriaNo crystals or bacteria in lumen of in lumen of

tubulestubules Intertubular dentin Intertubular dentin normal normal

Zone of Sclerosis/Sub-Zone of Sclerosis/Sub-Transparent DentinTransparent Dentin

As the microorganisms cause destruction to As the microorganisms cause destruction to dentin, initially there is an attempt to stop dentin, initially there is an attempt to stop the advancement of caries by depositing the the advancement of caries by depositing the minerals.minerals.

There is a deposition of mineral in There is a deposition of mineral in intertubular dentin.intertubular dentin.

Zone is calledZone is called “transparent zone”“transparent zone” Odontoblasts are also start depositing Odontoblasts are also start depositing

dentin.dentin. At the periphery of sclerotic dentin,At the periphery of sclerotic dentin, dead dead

tractstracts are present.are present.

Zone of Decalcification Zone of Decalcification without Bacterial Invasion / without Bacterial Invasion /

Transparent DentinTransparent Dentin Decalcification is by bacterial acid diffusionDecalcification is by bacterial acid diffusion

VeryVery narrow zonenarrow zone, softer than normal dentin, softer than normal dentin

Further loss of minerals from inter tubular Further loss of minerals from inter tubular

dentindentin

Large crystalsLarge crystals within lumen of dentinal within lumen of dentinal

tubulestubules

Zone of Decalcification with Zone of Decalcification with Bacterial Invasion / Turbid Bacterial Invasion / Turbid

DentinDentin Initially only few tubules are involved & micro-Initially only few tubules are involved & micro-

orgs also lessorgs also less

These are acidogenic, pioneer bacteria These are acidogenic, pioneer bacteria

(initiators), present long before lesion is (initiators), present long before lesion is

clinically detected clinically detected

Bacteria multiply within tubules & are seen in Bacteria multiply within tubules & are seen in

advancing front of lesionadvancing front of lesion

Walls of tubules are thin & when micro-orgs Walls of tubules are thin & when micro-orgs penetrate, they cause penetrate, they cause irregularities/distensionsirregularities/distensions of walls of walls ROSARY BEADROSARY BEAD appearance appearance

Later, bacteria have proteolytic activity, Later, bacteria have proteolytic activity, areas of proteolysis appear as spaces areas of proteolysis appear as spaces containing necrotic material & bacteriacontaining necrotic material & bacteria

These areas These areas “Liquefaction Foci of “Liquefaction Foci of Miller”.Miller”.

These areas vary in number & are parallel to These areas vary in number & are parallel to dentinal tubulesdentinal tubules

Zone of Decomposed Dentin / Zone of Decomposed Dentin / Infected DentinInfected Dentin

Outermost zone, large scale Outermost zone, large scale

destruction of dentindestruction of dentin

Foci of Miller join togetherFoci of Miller join together

Areas of dentin decomposition, Areas of dentin decomposition,

occur perpendicular to occur perpendicular to

dentinal tubules dentinal tubules

“Transverse Clefts”“Transverse Clefts”

Mechanism of formation ofMechanism of formation of CleftsClefts - not known- not known

May follow course of incremental lines or May follow course of incremental lines or

May result from coalescence of liquefaction of May result from coalescence of liquefaction of

adjacent tubulesadjacent tubules

Also may rise by extensive proteolytic activity Also may rise by extensive proteolytic activity

along interconnecting lateral branches of along interconnecting lateral branches of

odontoblastic processesodontoblastic processes

Bacteria shiftBacteria shift from dentinal tubules to the peri & from dentinal tubules to the peri &

inter tubular dentininter tubular dentin

Secondary / Reactionary Secondary / Reactionary dentindentin

Protective mechanismProtective mechanism to protect pulpto protect pulp

Develops as a result of localized, non-specific Develops as a result of localized, non-specific

irritation to odontoblastsirritation to odontoblasts

Hyper mineralized, less number of dentinal Hyper mineralized, less number of dentinal

tubules having irregular & torturous coursetubules having irregular & torturous course

Root Caries / Cemental CariesRoot Caries / Cemental CariesHistopathology:Histopathology: Outer surface of Outer surface of

cementum – hyper cementum – hyper mineralized, thus mineralized, thus more caries resistantmore caries resistant

Resistance due toResistance due to Reprecipitation of Reprecipitation of

minerals from minerals from withinwithin

Precipitation of Precipitation of minerals from minerals from PlaquePlaque

CleftsClefts formed, through which formed, through which bacteria penetrate & cause tooth bacteria penetrate & cause tooth structure destructionstructure destruction

Penetration occurs along course ofPenetration occurs along course of Sharpey's fibers Sharpey's fibers

Once cementum completely exposed Once cementum completely exposed & destroyed, underlying dentin is & destroyed, underlying dentin is involved involved

Microorganisms found in Microorganisms found in various types of carious various types of carious

lesionslesionsPit and fissuresPit and fissures S.mutansS.mutans, ,

S.sanguis,lactobacilluS.sanguis,lactobacillus sp.actinomycess sp.actinomyces

Smooth surface Smooth surface cariescaries

S.mutansS.mutans, , S.salivariusS.salivarius

Root cariesRoot caries Actinomyces Actinomyces viscosus, viscosus, A.naeslundiiA.naeslundii, , s.mutanss.mutans, , s.sanguis,s.salivariuss.sanguis,s.salivarius

Deep dentinal cariesDeep dentinal caries Lactobacillus spLactobacillus sp, , Actinomyces Actinomyces viscosus, viscosus, A.naeslundiiA.naeslundii

Human longitudinal Human longitudinal interventional studiesinterventional studies

1)1) Vipeholm studies-Gustaffson et al Vipeholm studies-Gustaffson et al 19541954

2)2) Turku sugar studies-Schenin, Turku sugar studies-Schenin, Makinen 1975Makinen 1975

3)3) Hereditary fructose intolerance-Hereditary fructose intolerance-Newbrun 1969Newbrun 1969

4)4) Hopewood house-Sullivan & Harris Hopewood house-Sullivan & Harris

5)5) Von der Fehr et al(1970) and Loe et Von der Fehr et al(1970) and Loe et al(1972)al(1972)

Vipeholm studies-Vipeholm studies-Gustaffson et al 1954Gustaffson et al 1954

Five yr interventional study by Five yr interventional study by Gustaffson et al on 436 inmates in a Gustaffson et al on 436 inmates in a mental institution in Vipeholm mental institution in Vipeholm district hospital, Sweden.district hospital, Sweden.

It was done to determine the It was done to determine the relation between caries and sugar relation between caries and sugar consumptionconsumption

The experimental design divided The experimental design divided inmates into 7 groups.inmates into 7 groups.

Experimental groupsExperimental groups

1)1) Control group-low sugar diet only at Control group-low sugar diet only at mealsmeals

2)2) Sucrose group-high sugar mostly in Sucrose group-high sugar mostly in drinks with mealsdrinks with meals

3)3) Bread group-received sugar intake half Bread group-received sugar intake half or equal to normal in sweetened bread or equal to normal in sweetened bread at mealsat meals

4)4) Caramel group-22 sticky candies in two Caramel group-22 sticky candies in two portions at meals or 4 portions between portions at meals or 4 portions between meals.meals.

5)5) 8 toffee group-8 toffees in two 8 toffee group-8 toffees in two portions at meals or 4 portions portions at meals or 4 portions between mealsbetween meals

6)6) 24 toffee group-24 toffees at their 24 toffee group-24 toffees at their pleasure throughout the daypleasure throughout the day

7)7) Chocolate group-given milk Chocolate group-given milk chocolates in 4 portions between chocolates in 4 portions between meals.meals.

ConclusionsConclusions

Consumption of sugar is associated with Consumption of sugar is associated with only slight increase in caries incidence if only slight increase in caries incidence if ingestion is limited to meal times(4 times ingestion is limited to meal times(4 times a day)a day)

In subjects with poor oral hygiene, In subjects with poor oral hygiene, consumption of sugar both b/w meals & consumption of sugar both b/w meals & at meals is associated with marked at meals is associated with marked increase in caries incidenceincrease in caries incidence

Caries activity subsides once sugar rich Caries activity subsides once sugar rich foods are withdrawn from dietfoods are withdrawn from diet

In subjects with poor oral hygiene, In subjects with poor oral hygiene, caries develops despite avoidance of caries develops despite avoidance of sugar.sugar.

Increase in caries activity varies Increase in caries activity varies widely between individualswidely between individuals

Turku sugar studies-Turku sugar studies-Schenin, Makinen 1975Schenin, Makinen 1975

Done in Turku, Finland (1972-1974)Done in Turku, Finland (1972-1974) Done to study effect of dental caries in Done to study effect of dental caries in

almost total substitution of sucrose with almost total substitution of sucrose with fructose or xylitol.fructose or xylitol.

125 young adults divided into 3 groups.125 young adults divided into 3 groups. Sucrose -35,fructose -38, xylitol-52Sucrose -35,fructose -38, xylitol-52 Evaluated by two standardized bitewing Evaluated by two standardized bitewing

radiographs on each side of mouthradiographs on each side of mouth

Results –dramatic reduction in Results –dramatic reduction in caries prevalence was seen after two caries prevalence was seen after two yrs of xylitol consumption.yrs of xylitol consumption.

Fructose was as cariogenic as Fructose was as cariogenic as sucrose in 1sucrose in 1stst 12 months but became 12 months but became less cariogenic at end of 24 months.less cariogenic at end of 24 months.

Turku sugar studiesTurku sugar studies7

6

5

4

3

2

1

00 2 4 6 8 10 12 14 16 18 20 22 24

SucroseFructoseXylitol

Months

Hopewood house-Sullivan & Hopewood house-Sullivan & HarrisHarris

Study was done on institutionalized children Study was done on institutionalized children aged 3-14 yrs residing at Hopewood house, aged 3-14 yrs residing at Hopewood house, Bowral, New South Wales, Australia.Bowral, New South Wales, Australia.

The main feature was absence of meat and The main feature was absence of meat and rigid restriction of refined carbohydrates. The rigid restriction of refined carbohydrates. The meals were supplemented by vitamin meals were supplemented by vitamin concentrates and occasional serving of nuts concentrates and occasional serving of nuts and honey.and honey.

At end of 10 yr period, DMFT index score was At end of 10 yr period, DMFT index score was 1.1 just 10% of the score of other state 1.1 just 10% of the score of other state schools in Australia.schools in Australia.

As the children grew older and moved As the children grew older and moved out of Hopewood house,they no longer out of Hopewood house,they no longer adhered to the original diet and there adhered to the original diet and there was a steep increase in DMFT index was a steep increase in DMFT index again.again.

Thus this study demonstrated that Thus this study demonstrated that dental caries can be reduced by dental caries can be reduced by restricted diet even in absence of restricted diet even in absence of beneficial effects of fluoride and beneficial effects of fluoride and unfavorable oral hygiene.unfavorable oral hygiene.

But the resistance is not permanent.But the resistance is not permanent.

PREVENTION OF PREVENTION OF DENTAL CARIESDENTAL CARIES

“An ounce of prevention

is worth a pound of dental

cure”.-Old Dental Public Health

Proverb

AIMS OF PREVENTIONAIMS OF PREVENTION

AIMS OF PREVENTION (Sturdevant):AIMS OF PREVENTION (Sturdevant):

1.1. Limiting Limiting pathogen growthpathogen growth & metabolism & metabolism

2.2. Increasing Increasing resistance of tooth surfaceresistance of tooth surface to demineralization to demineralization

3.3. Caries control methodsCaries control methods which include operative which include operative

procedures procedures

CLASSIFICATION OF METHODS CLASSIFICATION OF METHODS FOR PREVENTIONFOR PREVENTION

According toAccording to SHAFER:SHAFER:

CHEMICAL MEASURESCHEMICAL MEASURES

Substances which Substances which alter toothalter tooth surface/structuresurface/structure FluorineFluorine Bis-biguanidesBis-biguanides Silver nitrateSilver nitrate Zinc chloride & potassium ferrocyanideZinc chloride & potassium ferrocyanide

Interfere with Interfere with carbohydrate carbohydrate degradationdegradation through enzymatic through enzymatic alterationsalterations Vitamin KVitamin K SarcosideSarcoside

Interfere with Interfere with bacterial growthbacterial growth & & metabolismmetabolism Urea & ammonium compoundsUrea & ammonium compounds ChlorophyllsChlorophylls Nitrofurans Nitrofurans PenicillinsPenicillins Other antibioticsOther antibiotics Caries vaccine Caries vaccine Ozone technologyOzone technology

Mechanism Of Action Of Mechanism Of Action Of FluoridesFluorides

Increased Increased enamelenamel resistanceresistance/reduction in /reduction in enamel solubilityenamel solubility Formation of fluorapatiteFormation of fluorapatite

Increased rate of Increased rate of post eruptive maturationpost eruptive maturation Deposition of minerals in hypomineralized Deposition of minerals in hypomineralized

areasareas

RemineralizationRemineralization of incipient lesions of incipient lesions Enhances remineralization rateEnhances remineralization rate Larger crystals are formedLarger crystals are formed

Inhibition of Inhibition of demineralizationdemineralization Well formed surface layer also seenWell formed surface layer also seen

Interference with Interference with plaque plaque microorganismsmicroorganisms High conc-bacteriocidalHigh conc-bacteriocidal Low concentration-bacteriostaticLow concentration-bacteriostatic Enzymatic interference-enolase, protein-Enzymatic interference-enolase, protein-

extruding ATPase, sugar transportextruding ATPase, sugar transport

Modification in Modification in tooth morphologytooth morphology Smaller, shallow fissuresSmaller, shallow fissures

NUTRITIONAL MEASURESNUTRITIONAL MEASURES

Diet counselingDiet counseling

restriction of refined carbohydratesrestriction of refined carbohydrates

Phosphated dietsPhosphated diets

Calcium phosphate rich diet.Calcium phosphate rich diet.

Sugar substitutesSugar substitutes

Non-caloric sweeteners-aspartame, saccharineNon-caloric sweeteners-aspartame, saccharine

Caloric sweeteners-sorbitol, Xylitol, MannitolCaloric sweeteners-sorbitol, Xylitol, Mannitol

MECHANICAL MEASURESMECHANICAL MEASURES

Dental prophylaxisDental prophylaxis Tooth brushingTooth brushing Mouth rinsing Mouth rinsing Dental flossDental floss Oral irrigatorsOral irrigators Detergent foodsDetergent foods Chewing gumChewing gum Pit & fissure sealantsPit & fissure sealants Preventive resin Preventive resin

restorations restorations

SummarySummary Dental caries is an oral infection. Dental caries has a multi-factorial

causation involving the interaction of host involving the interaction of host factors (tooth surface, saliva, acquired factors (tooth surface, saliva, acquired pellicle), diet, and dental plaque (biofilm).pellicle), diet, and dental plaque (biofilm).

Besides these other modifying factors like socioeconomic status and behavioral patterns also greatly influence the caries process in a complex manner.

A good understanding of the caries process can help in formulation of better diagnosis,prevention and treatment of dental caries.

ReferencesReferences

1)1) Sturdevant's Art and Science of Sturdevant's Art and Science of Operative Dentistry-5Operative Dentistry-5thth edition edition

2)2) Cariology Ernest Newbrun- 3Cariology Ernest Newbrun- 3rdrd edition edition3)3) Diagnosis & Risk prediction of dental Diagnosis & Risk prediction of dental

caries-Per Axelsson.caries-Per Axelsson.4)4) The biologic basis of dental caries-The biologic basis of dental caries-

Lewis MenakerLewis Menaker5)5) Essentials of Preventive and Essentials of Preventive and

Community dentistry- Soben Peter -2Community dentistry- Soben Peter -2ndnd editionedition