Dental caries

Preventive Dentistry I & IIDental caries

Dr.Caroline Mohamed 1

Dr. Caroline Mohamed

Objectives Define:Dental caries The dental caries processThe role of diet in dental cariesClassification of dental cariesEpidemiologyIncidence and prevalence and how can be

measured Caries risk


1. Dental caries definition

Dental caries is a multifactorial microbial disease of the calcified tissues of the teeth, characterized by demineralization of the inorganic portion and destruction of the organic substance of the tooth, which often leads to cavitations.


Two groups of bacteria are responsible for initiating caries: Streptococcus mutans and Lactobacillus. If left untreated, the disease can lead to pain, tooth loss, infection, and, in severe cases, death.

Today, caries remains one of the most common diseases throughout the world.

Cariology is the study of dental caries.


The presentation of caries is highly variable; however, the risk factors and stages of development are similar. Initially, it may appear as a small chalky area that may eventually develop into a large cavitation.

Sometimes caries may be directly visible, however other methods of detection such as radiographs are used for less visible areas of teeth and to judge the extent of destruction.


Tooth decay is caused by specific types of acid-producing bacteria that cause damage in the presence of fermentable carbohydrates such as sucrose, fructose, and glucose.

The mineral content of teeth is sensitive to increases in acidity from the production of lactic acid. Specifically, a tooth (which is primarily mineral in content) is in a constant state of back-and-forth demineralization and remineralization between the tooth and surrounding saliva.

When the pH at the surface of the tooth drops below 5.5, demineralization proceeds faster than remineralization (meaning that there is a net loss of mineral structure on the tooth's surface). This results in the ensuing decay.


Socio-Economical Situation

Knowledge

Host

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SALIVA

pH

Flow rate

Composition

Buffering capacity

Bicarbonate levels

SALIVA

Educational level

SUBSTRATE

Carbohydrates

Frequency of eating

Oral clearance

Physical nature of food

Detergency of food

FLORA

Fluoride in plaque

Lactobacilli

Oral Hygiene

Streptococci

Virulence factors

Transmissibility

HOST

Age

Fluoride

Genetics

Morphology

Nutrition

Behavior

Dr.Caroline Mohamed

The role of diet in dental caries


Substrate

Readily fermentable Sucrose- arch criminalCariogenicity determined by

1. Frequency of ingestion2. Physical form3. Chemical composition-detergency4. Texture of food5. Presence of other constituents


Dr.Caroline Mohamed

Cariogenicity determined by

Frequency of ingestion

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Frequency of ingestion

D Caroline Mohamed 13

Tooth enamel dissolves at 5.5 ph

D Caroline Mohamed 14

Dr.Caroline Mohamed

Chemical composition-detergency

Cow’s milk (cheese) contains calcium, phosphorus, and casein

Wholegrain foods require more chewing Peanuts, hard cheeses, and chewing gum Black tea extract ( fluoride)

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CARIES PROCESS


De-Remineralizat

ion

Enamel lesion

Dentin lesion

Pulpal lesion

White spot

TIME

CARIES

NO CAVITYDIAGNOSIS

RESTORATION

CAVITY

Depending on the extent of tooth destruction, various treatments can be used to restore teeth to proper form, function, and aesthetics, but there is no known method to regenerate large amounts of tooth structure, though stem cell related research suggests one possibility.

Instead, dental health organizations advocate preventive and prophylactic measures, such as regular oral hygiene and dietary modifications, to avoid dental caries.


EpidemiologyDefinition of Epidemiology

The word epidemiology comes from the Greek words:

epi , meaning on or upon demos , meaning people, and logos , meaning the study of"the study of what is upon the people",

18Dr.Caroline Mohamed

Incidence and prevalence and how can be measured Prevalence • Number or proportion of persons in a population affected

by a condition at a given point of time• Can be expressed as, count, proportion or percentage.

• Incidence Number of new cases of condition over a given point of

time.Change in prevalence or severity. The period of time depend

on time needed to disease to be observedexpressed as a rate (case per the population per time) Determine the progress of condition


Different Age GroupsKey risk groups from agesAge-Three peaks 4-8yrs 11-18yrs 55-65yrs1 to 2 years ( baby bottle caries)5 to 7 years ( primary caries)11 to14 yearsKey risk age group in young adults and adults ( secondary caries/ root caries) Sex- both sexes early eruption in females


Adults continue to experience primary dental caries, but they also experience a significant amount of secondary caries around existing restorations.

Children today, in developed countries, have comparatively few, if any restorations and experience mostly primary caries of the noncavitated type.

Between 40 and 76% of dental carie in adults are arrested, a condition uncommoly observed in children.


Variation within dentition:


Early plaque formation occurs faster.

1.In lower jaw, compared to upper jaw.

2.In molars areas.

3.On buccal tooth surfaces, compared to oral sites.

4.In interdental regions compared to strict buccal or oral surface.

Tooth composition


Mineralization-

Hypomineralization/ Dentinogenese imperfecta Trace elementsFluoride/ dental fluorose


Dentinogenese imperfecta Dental Fluorose

Individual Teeth


First primary molars and first permanent molars are high risk.

Different tooth surfaces:


Are high risk:Interproximal surfaces of primary molars.Occlusal surfaces of first permanent

molars.

Tooth morphology


Pits & fissuresIrregularities in arch formCrowdingOverlapping

Tooth morphology


Behavior

Age


Regularity of snaks, more than 3 times a day, snacking between meals, this increases the acid challenge to the teeth for a high level

Nocturnal bottle usage- additiveOn pacifier during sleepBreast feeding

(Kawaba et al., 1997)


Drinking sweet beverageBrushing by mother(Kawaba et al., 1997)


Dental Caries classification1.based on anatomical site

2.based on progression

3.based on virginity of lesion

4.based on extend of caries

5.based on tissue involvement

6.based on chronology

7. based on whether caries is completely removed or not.

8.based on surfaces to be restored

9. WHO system

9.Black’s classification

10.Caries risk Assessement


Classification: 1) Based on anatomic site:

Crown caries Root caries

Pit & Fissure Caries

Smooth surface Caries


Pits and fissures are anatomic landmarks on a tooth where the enamel folds inward. Fissures are formed during the development of grooves but the enamel in the area is not fully fused. As a result, a deep linear depression forms in the enamel's surface structure, which forms a location for dental caries to develop and flourish.Fissures are mostly located on the occlusal surfaces of posterior teeth and palatal surfaces of maxillary anterior teeth.


Pits are small, pinpoint depressions that are most commonly found at the ends or cross-sections of grooves. In particular, buccal pits are found on the facial surfaces of molars. For all types of pits and fissures, the deep infolding of enamel makes oral hygiene along the surfaces difficult, allowing dental caries to develop more commonly in these areas.


The occlusal surfaces of teeth represent 12.5% of all tooth surfaces but are the location of over 50% of all dental caries.Among children, pit and fissure caries represent from 80 to 90% of all dental caries. Pit and fissure caries can sometimes be difficult to detect. As the decay progresses, caries in enamel nearest the surface of the tooth spreads gradually deeper. Once the caries reaches the dentin at the dentino-enamel junction (DEJ), the decay quickly spreads laterally.


Within the dentin, the decay follows a triangle pattern that points to the tooth's pulp. This pattern of decay is typically described as two triangles (one triangle in enamel, and another in dentin) with their bases conjoined to each other at the DEJ. This base-to-base pattern is typical of pit and fissure caries, unlike smooth-surface caries (where base and apex of the two triangles join).


Clinical Manifestation:

Entry site may appear much smaller than actual lesion, making clinical diagnosis difficult.In cross section, the gross appearance of pit and fissure lesion is inverted V with a narrow entrance and a progressively wider area of involvement closer to the DEJ. a) Initially, caries of pit & fissures appears brown or black in color & with fine explorer, it will feel soft & a catch is felt ( don´t do it ).b) The enamel which borders the pit & fissures appears opaque bluish white.

Shape, morphological variation and depth of pit and fissures contributes to their high susceptibility to caries.

The appearance of s.mutans in pits and fissures is usually followed by caries 6 to 24 months later.

Sealing of pits and fissures just after tooth eruption may be the most important event in their resistance to caries.


Smooth surface caries Smooth surface caries occurs on the gingival third of the buccal, lingual & proximal surfaces. • On proximal surface, caries begins below the contact area & in early stage this appear as a faint white opacity of enamel without loss of continuity of surface.• As caries progresses, it appears bluish white in later stage.• Caries in cervical area are in the form of crescent shaped cavities. It appear as a slightly roughened, chalky area which gradually becomes deeper

Types of smooth surface caries

1. Proximal caries, also called interproximal caries,

form on the smooth surfaces between adjacent

teeth.

2. Root caries form on the root surfaces of teeth.

3. The third type of smooth-surface caries occur on any

other smooth tooth surface. Less favorable site for

plaque attachment, usually attaches on the smooth

surface that are near the gingiva or are under

proximal contact.


Proximal caries are the most difficult type to detect. Frequently, this type of caries cannot be detected visually or manually with a dental explorer.

Proximal caries form cervically (toward the roots of a tooth) just under the contact between two teeth. As a result, radiographs (bitewings) are needed for early discovery of proximal caries.



In very young patients the gingival papilla completely

fills the interproximal space under a proximal

contact and is termed as col. Also crevicular spaces in

them are less favorable habitats for s.mutans.Consequently proximal caries is less lightly to

develop where this favorable soft tissue architecture

exists.

Proximal surfaces CariesThe proximal surfaces are particularly susceptible to

caries due to extra shelter provided to resident plaque owing to the proximal contact area immediately occlusal to plaque.

Lesion have a broad area of origin and a conical, or pointed extension towards DEJ.

V shape with apex directed towards DEJ.After caries penetrate the DEJ softening of dentin

spread rapidly and pulpally


Root surface caries The proximal root surface, particularly near the cervical

line, often is unaffected by the action of hygiene procedures, such as flossing, because it may have concave anatomic surface contours (fluting) and occasional roughness at the termination of the enamel.

These conditions, when coupled with exposure to the oral environment (as a result of gingival recession), favor the formation of mature, caries-producing plaque and proximal root-surface caries.


Root-surface caries is more common in older patients. Caries originating on the root is alarming because: 1. It has a comparatively rapid progression 2. it is often asymptomatic 3. it is closer to the pulp4. it is more difficult to restore


Characteristics of root caries:Root caries lesions have less well-defined margins,

tend to be U-shaped in cross sections, and progress more rapidly because of the lack of protection from and enamel covering.


When the gingiva is healthy, root caries is unlikely to develop because the root surfaces are not as accessible to bacterial plaque.

The root surface is more vulnerable to the demineralization process than enamel because cementum begins to demineralize at 6.7 pH, which is higher than enamel's critical pH.

Regardless, it is easier to arrest the progression of root caries than enamel caries because roots have a greater reuptake of fluoride than enamel.


Root caries are most likely to be found on facial surfaces, then interproximal surfaces, then lingual surfaces.

Mandibular molars are the most common location to find root caries, followed by mandibular premolars, maxillary anteriors, maxillary posteriors, and mandibular anteriors.


Progressive caries Arrested caries

Rapidly progressive - Acute Slowly progressive- Chronic

Nursing caries Radiation caries

2) BASED ON THE PROGRESSION OF THE LESION:

Acute caries

Acute caries is a rapid process involving a large number of teeth.

These lesions are lighter colored than the other types, being light brown or grey, and their caseous consistency makes the excavation difficult.

Pulp exposures and sensitive teeth are often observed in patients with acute caries.

It has been suggested that saliva does not easily penetrate the small opening to the carious lesion, so there are little opportunity for buffering or neutralizaton


Nursing cariesNursing caries can also be called as:

1. Nursing bottle caries

2. Nursing bottle syndrome

3. Milk bottle syndrome

4. Baby bottle tooth decay

5. Early childhood caries

The new name given for early childhood caries is “maternally derived streptococcus mutans disease (MDSMD)”


NURSING CARIES

This is the type of acute carious lesion,

which occurs among those children who

take milk or fruit juices by nursing bottle, for a considerably longer duration of time, preferably during sleep.

As the child takes larger amount of easily fermentable sugars along with the milk, the sugar facilitates the cariogenic bacteria to produce caries at a rapid pace by fermenting those sugars. Nursing bottle caries commonly occurs in the upper anterior teeth (as these are constantly coming in contact with the sweetened milk); while the lower teeth are not usually affected as they remain under the cover of the tongue.

Radiation cariesRadiotherapy is frequently associated with xerostomia

due to decreased salivary secretion

This and other cause of decreased salivation may lead to a rampant form of caries, indicating the significance of saliva in preventing caries.


Radiation caries


Three types of defects due to irradiation

1. Lesion usually encircling the neck of teeth amputation of crowns may occur

2. Begins as brown to black discolouration of tooth .occlusal surface and incisal edges wear away

3. Spot depression which spreads from any surface

Chronic caries

These lesions are usually of long-standing involvement, affect a fewer number of teeth, and are smaller than acute caries.

Pain is not a common feature because of protection afforded to the pulp by secondary dentin

The decalcified dentin is dark brown and leathery.Pulp prognosis is hopeful in that the deepest of lesions usually

requires only prophylactic capping and protective bases.The lesions range in depth and include those that have just

penetrated the enamel.


Arrested cariesCaries which becomes stationary or static and does not

show any tendency for further progressionBoth deciduous and permanent affected. With the shift in the oral conditions, even advanced

lesions may become arrested .Arrested caries involving dentin shows a marked

brown pigmentation and induration of the lesion (the so called ‘eburnation of dentin’).

Sclerosis of dentinal tubules and secondary dentin formation commonly occur.


Arrested cariesExclusively seen in

caries of occlusal surface with large open cavity in which there is lack of food retention.

Also on the proximal surfaces of tooth in cases in which the adjacent approximating tooth has been extracted


3) BASED ON THE VIRGINITY OF THE LESION:

Primary Caries Secondary or Recurrent caries Recurrent caries is that occurring immediately next to a restoration. It may be the result of poor adaptation of a restoration, which allows for a marginal leakage, or it may be due to inadequate extension of the restoration.

In addition, caries may remain if there has not been complete excavation of the original lesion, which later may appear as a residual or recurrent caries.

Primary cariesA primary caries is one in which the lesion constitutes the

initial attack on the tooth surface.The designation of primary is based on the initial

location of the lesion on the surface rather than the extent of damage.


Secondary caries (Recurrent)

This type of caries is observed around the edges and under restorations.

The common locations of secondary caries are the rough or overhanging margin and fracture place in all locations of the mouth.

It may be result of poor adaptation of a restoration, which allows for a marginal leakage, or it may be due to inadequate extension of the restoration.

In addition caries may remain if there has not been complete excavation of the original lesion, which later may appear as a residual or recurrent caries.


4.Based on the extend of the lesion- severity

INCIPIENT CARIES

OCCULT CARIES

CAVITATION


Incipient caries

The early caries lesion best seen on the smooth surfaces of the teeth, is visible as a ‘White Spot’

Histologically, the lesion has an apparently intact surface layer overlying subsurface demineralization.

Significantly many such lesions can under go remineralization & thus the lesion is not an indication for restorative treatmentRemineralised with fluoride applicationD/d: developmental defects of enamel


Occult caries

Occult or hidden caries is used to describe such lesion, which is not clinically diagnosed but detected only on radiographs.

It is believed that bitewing & OPG radiographs along with other noninvasive adjuncts like fibrooptic transillumination (FOTI), LASER luminescence, electrical resistance method(ERM) are used for diagnosing these occlusal lesions.

Prevalence-0.8%-50% in age range of 14 -20 yrs


CavitationOnce it reaches the

dentinoenamel junction, the caries process has the potential to spread to the pulp along the dentinal tubules and also spread in lateral direction.

Thus some amount of sensitivity may be associated with this type of lesion.

This may be generally accompanied by cavitation


5. Based on tissue involvement

1. Initial caries- demineralization

2. Superficial caries- enamel

3. Moderate caries- dentin caries

4. Deep caries – dentin close to the pulp

5. Deep complicated caries – pulp involvement


Dental caries can be divided into 4 or 5 stages 1. Initial caries: Demineralization without structural

defect. This stage can be reversed by fluoridation and

enhanced mouth hygiene

2. Superficial caries (Caries superficialis):Enamel caries, wedge-shaped structural defect.

Caries has affected the enamel layer, but has not yet penetrated the dentin. Includes larger lesions with adequate tooth structure to support the restoration


3. Moderate caries (Caries media): Dentin caries. Extensive structural defect. Caries has penetrated up to the dentin and spreads two-dimensionally beneath the enamel defect where the dentin offers little resistance.

4. Deep caries (Caries profunda): Deep structural defect. Caries has penetrated up to the dentin layers of the tooth close to the pulp.

5. Deep complicated caries (Caries profunda complicata) :Caries has led to the opening of the pulp cavity (pulpa aperta or open pulp).


6. Based on chronology

EARLY CHILDHOOD CARIES

ADOLESCENT CARIES

ADULT CARIES


Early childhood cariesEarly childhood caries would include, two variants:

Nursing caries and rampant caries.The difference primarily exist in involvement of the

teeth (mandibular incisors) in the carious process in rampant caries as opposed to nursing caries.


Teenage caries (adolescent caries)This type of caries is a variant of rampant caries

where the teeth generally considered immune to decay are involved.

The caries is also described to be of a rapidly burrowing type, with a small enamel opening.

The presence of a large pulp chamber adds to the woes, causing early pulp involvement.


Adult cariesWith the recession of the gingiva and sometimes

decreased salivary function due to atrophy, at the age of 55-60 years, the third peak of caries is observed.

Root caries and cervical caries are more commonly found in this group.

Sometime they are also associated with a partial denture clasp.


7.Based on whether caries is completly removed or not during treatment

RESIDUAL CARIESResidual caries is that which is not removed during a

restorative procedure, either by accident, neglect or intention.

Sometimes a small amount of acutely carious dentin close to the pulp is covered with a specific capping material to stimulate dentin deposition, isolating caries from pulp.

The carious dentin can be removed at a later time.

8.Based on surfaces to be restored

Most widespread clinical utilization

O for occlusal surfaces

M for mesial surfaces

D for distal surfaces

F for facial surfaces

B for buccal surfaces

L for lingual surface

Various combinations are also possible, such as MOD –for mesio-occluso-distal surfaces.

9.World health organization (WHO) systemIn this classification the shape and depth of the caries

lesion scored on a four point scale

D1. clinically detectable enamel lesions with intact (non

cavitated) surfaces

D2. Clinically detectable cavities limited to enamel

D3. Clinically detectable cavities in dentin

D4. Lesions extending into the pulp

10. Assessement tools

Stepwise progression toward diagnosis & treatment planning depends on thorough assessment of the following

Patient History Clinical examination Nutritional analysis Salivary analysis Radiographic assessment


Conventional techniques of measuring and recording decay


Visual examMirror and explorerDental radiographsDyesTransilluminationDmfs/dmft

VISUAL-TACTILE METHODS Visual methods:Detection of white spot, discoloration / frank

cavitations.Unable to detect subsurface caries.Magnification loupes- Head worn prism loupes (X 4.5)

or surgical microscopes (X 16) may be used.Use of temporary elective tooth separation.


Tactile methods:Explorers,Dental floss.

Use of explorer is not advocated because;Sharp tips physically damage small lesions with intact

surfaces.Probing can cause fracture & cavitation of incipient

lesion. It may spread the organism in the mouth.Mechanical binding may be due to non-carious

reasons Shape of fissure

Sharpness of explorer

Force of application

Path of explorer placement

Explores should be used to clean debris

from teeth.


X-rays+ non –destructive+ can detect subsurface caries- limited safety- unable to detect incipient

demineralization- low resolution


Bitewings/ Periapical


Radiographic imaging of pit and fissures is of minimal diagnostic value because of the large ammount of sorrounding enamel enamel.

It is detrimental if used for non-invasive remineralization methods.

Direct fiberoptic transillumination


Enhanced visual technique that uses the principle of illuminating teeth to detect the presence of caries.

. (Pretty, Maupomé, 2004)

Dental Caries Index DMF-T Decayed, Missed, Filled Teeth

D = Decayed / not treated yet M = Missed / extracted because decayed F = Filled / restored after decay T = Permanent teeth

dmf-t = Primary teeth

S = Surface DMF-S / dmf-s ( Mesial/ Distal/ Vestibular/ Occlusal)


DMF-T CHART


10. G. V. BLACK CLASSIFICATION:


CLASS 1: pit and fissure cavities that occur in the occlusal surfaces of bicuspids and molars, the occlusal two thirds of the buccal and lingual surfaces of the molars, and the lingual surfaces of incisors. Cavities beginning in structural defects that occasionally occur on the occlusal or incisal two third of all teeth.


CLASS 2: cavities in the proximal surfaces of bicuspids and molars


CLASS 3: Cavities in the proximal surfaces of incisors and cuspids, not involving the incisal angle


CLASS 4: Cavities in the proximal surfaces of incisors and cuspids involving the incisal angle

CLASS 5: Cavities in the gingival third, not pit and fissures cavities, of the labial, buccal and lingual surfaces of all teeth


CLASS 6: Cavities on both mesial and distal proximal surfaces of bicuspid and molars that when restored will share a common isthmus; or cavities on the incisal edges of anterior or cusp tip of posterior teeth.

HIGH RISKHIGH RISK LOW RISKLOW RISK

Social HistorySocial History

Socially deprivedSocially deprived

High caries in siblingsHigh caries in siblings

Low knowledge of cariesLow knowledge of caries

Middle class Middle class

Low caries in siblingLow caries in sibling

High dental aspirationsHigh dental aspirations

Medical HistoryMedical History

Medically compromisedMedically compromised

XerostomiaXerostomia

Long-term cariogenic Long-term cariogenic medicinemedicine

No such problemNo such problem

Dietary habitsDietary habits

Sugar intake: frequentSugar intake: frequent Infrequent Infrequent



Use of fluorideUse of fluoride

Non-fluoridated areaNon-fluoridated area

No fluoride supplementsNo fluoride supplements

Fluoridated areaFluoridated area

Fluoride supplements usedFluoride supplements used

Plaque controlPlaque control

Poor oral hygiene Poor oral hygiene maintenancemaintenance

Good oral hygiene Good oral hygiene maintenancemaintenance

SalivaSaliva

Low flow rate& buffering Low flow rate& buffering capacitycapacity

S.mutans & lactobacillus S.mutans & lactobacillus countscounts

Normal flow rate& buffering Normal flow rate& buffering capacity capacity

S.mutans & lactobacillus S.mutans & lactobacillus countscounts



Clinical evidenceClinical evidence

New lesionsNew lesions

Premature extractionsPremature extractions

Anterior caries restorationsAnterior caries restorations

Multiple/repeated Multiple/repeated restorationsrestorations

No fissure sealantsNo fissure sealants

Multi-band orthodonticsMulti-band orthodontics

No new lesionsNo new lesions

No extraction for cariesNo extraction for caries

Sound anterior teethSound anterior teeth

No/few restorationsNo/few restorations

Fissure sealedFissure sealed

No appliancesNo appliances


Thank you


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