Prevention / 5th class ‫ مظفر فاضل‬.

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Lec. 2
The development of dental caries
The word 'caries' is derived from the Latin word "rottenness". Dental caries can
be defined as a localized chemical dissolution of the tooth structure which take
place when "acid produced by bacterial action on fermentable substrates
diffuses into the tooth structure". Dental caries is a multifactorial disease which
characterized by demineralization of the inorganic (mineral) constituents
followed by the dissolution of the organic constituents of the tooth. Dental
caries affected almost all human populations, at wide range of socioeconomic
levels, and at all age groups.

Theories of dental caries

Many theories for more than a century ago have been placed to discuss the
etiology of dental caries, some are mentioned below :-
@ The legend of the worms/ An ancient Sumerian text has been founded, it
goes back to about 5000 BC.
@ Humoral theory/ An imbalance between the humors of the body could be the
cause of dental caries, this theory goes back to ancient Greeks.
@ Vital theory/ It goes back to the 18th century. It suggests that the tooth decay
is originated from within the tooth itself, like the bone gangrene.
@ Chemical (acid) theory/ The findings of Robertson (1835) and Regnart
(1938) suggested that the tooth decay is attributed to acid produced due to the
fermentation of food particles around the tooth surface.
@ Parasitic (septic) theory/ This could be considered as the first theory that
relating the caries with the microorganisms. Accordingly, (Erdl, 1843)
described that filamentous parasites in the surface membrane (plaque) of the
teeth. Shortly thereafter, Ficinus, observed filamentous microorganisms, which
he called denticolae, in material taken from carious cavities.
@ Chemo-parasitic (acidogenic) theory/ W. D. Miller (1890) in his book "The
microorganisms of the human mouth" explain that the degradation of the
carbohydrates in food by oral microorganisms was able to explain the carious
process. Hence, Miller advocated an essential (3) factors for the carious process
to take place, these are the oral microorganisms, the carbohydrate substrates,
and the acid.

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@ The proteolytic theory/ Gottlieb (1944), has proposed that the organic and
protein elements (not the inorganic) of the tooth are the initial pathway for the
invasion by microorganisms (i.e. certain structures of the enamel, like enamel
lamellae and enamel rod sheaths, which have a high organic material constituent
could serve as a good pathway for microorganism invasion throughout the
enamel). The organic component is more vulnerable and is attacked by
hydrolytic enzymes of oral microorganisms.
@ The proteolysis-chelation theory/ A chelate is a chemical compound
composed of an organic ring and metallic ions. This theory was putted forward
by Schwartz and his co-workers in 1955. It supposed that a poorly dissociated
or weakly ionized compound resulted from a complex process of chelation is
the cause of dental caries. In biology, there are many well-known chelates such
as (hemoglobin, chlorophyll, and vitamin B-12).

The current concept of etiology of dental caries

The current concept of dental caries suggests that the dental caries is a
multifactorial disease, which results from the inter-correlation among (3)
essential factors (in the presence of time as a fourth factor), these are:-
1) Host factors.
2) Plaque microorganisms.
3) Substrate.

Host factors :- This involves the susceptible teeth and saliva.

A- The teeth
 Tooth morphology: Dental caries may develops at any area of the tooth
surface where the biofilm can be developed and remains for a suitable
time. However, sites on the tooth such as grooves, pits and fissures in the
occlusal surfaces of the posterior teeth, the approximal surfaces cervical
to the contact area and along the gingival margin, exposed root surfaces
and tooth surfaces adjacent to dentures and bridges are more susceptible
as food particles can stagnate for longer time and are difficult to clean.
 Tooth position: Posterior teeth are more susceptible to carious process
than the anterior teeth. The mandibular first molar followed by the
maxillary first molar are more susceptible.
 Composition of the teeth: The teeth are composed mainly from inorganic
elements (96% of enamel and 70% of dentin) and the remaining are

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 organic material and water. Composition of the teeth is affected by an
environmental factors (diet and nutrition).

The inorganic elements are mainly calcium, phosphate and hydroxyl group
which constitute the hydroxyapatite crystals of the teeth { Ca10(Po4)6 (OH)2 }.
Several minor elements are also present as zinc, copper, magnesium and
fluoride. Some of these elements, like fluoride, when incorporated within the
enamel can increase the tooth resistance to dental caries, were as other elements,
like magnesium, can increase the tooth susceptibility to dental caries.

The organic constituents and water of enamel and dentin may act as a pathway
for acid diffusion and subsequent tooth destruction.

B- The saliva
The flow rate, composition, PH, and buffering system of saliva have an effect
on the integrity of the teeth.

Plaque microorganisms :- Bacteria adhere to the tooth surface and

ferment substrates causing release of acids resulting in dental caries. Plaque
quantity and quality can greatly affect the caries etiology. The cariogenic
bacteria in dental plaque are mainly mutans streptococci and lactobacilli.

Substrates :- Fermentable carbohydrates are one of the most important

causative factor in caries etiology as these represents the substrates for the
cariogenic bacteria in the oral cavity.

Terms in dental caries

- Pit and fissure caries: affecting the occlusal surface of the tooth.
- Smooth surface caries: affecting the smooth surface of enamel.
- Root caries: affecting the exposed root cementum or dentin.
- Arrested caries: lesion has been founded years ago and now is stopped
to progress.
- Rampant caries: multiple active carious lesions affecting the patient.
- Nursing baby (bottle) caries: affecting the primary dentition due to
sugar present in the baby nursing bottle.
- Secondary (recurrent) caries: developed adjacent or beneath the already
established filling restoration.

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Three obvious stages existed in the development of the carious lesion, these
are:-
 The earliest (initial) stage- is the incipient lesion, macroscopically
obvious on the tooth surface as an area of white opacity on the enamel
(white spot lesion) accompanied by a number of zones of histological
changes.
 The second stage- in which the progress of demineralization process takes
place towards the dentino-enamel junction and/or the dentin.
Microscopically, the affected dentin displays a brown to dark brown or
black discoloration accompanied with a different changes of zones in
dentine obvious histologically.
 The final stage of carious process in which an overt or frank lesion of
cavitation is a characteristic.

Enamel caries
Enamel is the most highly mineralized tissue in the body, it is stronger than the
bone. It consisted chemically from about 95% of inorganic material, while the
organic material and water constitute about 5%. Histologically, enamel consists
of a crystals of hydroxyapatite arranged in layers or rods (known also as
prisms). On smooth enamel surfaces, the earliest visible changes are usually
manifested as a loss of transparency, resulting in an opaque chalky area termed
(the white spot).

The caries of enamel can be represented microscopically by four zones of

histological changes, these are:-

Zone (1) (the translucent zone).

- not always founded.
- lies at the advanced front of the lesion.
- appears structurless.
- slightly more porous than sound enamel (1.2% loss of mineral per unit
volume).

Zone (2) (the dark zone).

- referred to as a positive zone.
- a common feature of the carious lesion.
- formed due to massive demineralization.
- (average of 6% loss of mineral per unit volume).

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Zone (3) (the body of the lesion).
- the largest zone
- founded between the dark and surface zones.
- (24% loss of mineral per unit volume)

Zone (4) (the surface zone).

- relatively unaffected area in the initial lesions (due to greater degree of
remineralization and greater fluoride concentration).
- (10% loss of mineral per unit volume).

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Dentin caries
On reaching the dentin, the carious lesion spreads laterally along the DEJ, often
undermining the enamel. As caries invades the dentin, it proceeds along a
saucer-shaped front and follows the direction of the dentinal tubules. The
resulting lesion is cone-shaped with the base at the DEJ while its apex towards
the pulp. Clinically, the affected dentin displays different degrees of
discoloration from a brown to dark brown or black.
Microscopically, the carious lesion of dentin can be represented by five zones of
histological changes, these are:-zone of decomposed dentin, zone of bacterial
invasion, zone of demineralization, zone of dentinal sclerosis, zone of fatty
degeneration. The most noticeable change in the carious dentin is the zone of
bacterial invasion.

Root surface caries

Root caries differs from coronal (enamel and dentin) caries in several
histopathological aspects (mineralization and bacterial invasion). It just
happened when the root surface becomes exposed to the oral environment. The
microorganisms invading the cementum either along the Sharpey’s fibers or
between the bundles of the fibers and spreading laterally (since cementum is
formed in concentric layers). Clinically, root caries comprises a wide range of
manifestations from a small, slightly softened and discoloured areas to an
extensive, yellowish-brown soft or hard tissue, which sometimes encircles the
entire root surface. Complete loss of cementum leading to dentin exposure
;however, the lesion may or may not be cavitated or involving the pulp as it may
be remineralized or arrested. The mineralized lesion appears glossy, smooth and
hard on probing with a moderate pressure.