DS125 - 2019

Root Caries

Peter Rechmann
Peter.Rechmann@ucsf.edu

University of California San Francisco

Course Objective

To understand the etiology and

mechanism of root caries formation
and the differences
compared to enamel caries

Root Caries
 Root caries =
decay
Protective of the
Factors
tooth root.
Requires
gingival
recession

Root caries =
decay of the
tooth root.
Requires
gingival
Protective Factors
recession

Root Caries vs Age in 5 Studies

Protective Factors

Beck, J. 1989
 Beck et al studied an elderly Iowa
population 65 plus years of age.

u 11.6 teeth at risk per person

u 28% unfilled root caries
u 50% had > 1 root caries lesions
u Annualized incidence rate [“attack rate”]
of 2.2 surfaces at risk per 100 surfaces
u Common factors: age and gingival
recession
Beck, JADA 1985

Root caries incidence and increment – A systematic

review, meta-analysis and meta-regression

u 0.45 annual mean root caries increment

Hariyani, J Dent Res 2018

Enamel
Cross
section of
normal CEJ
viewed in
Dentin polarized
light
CEJ

Cementum Tubule
 Early root
caries
lesion. Not Early
clinically lesion
detectable. viewed in
water
Protective Factors
Viewed in
quinoline

Root Caries Lesion

cross section
viewed in polarized
light (in quinoline)

Unchanged surface zone, Blue colored frontal zone

“body zone” = “structureless zone”

Protective Factors

Advanced
Advanced artificial
natural lesion lesion
 Natural root caries: a histological and
microradiographic evaluation.
Wefel et al. J Oral Path. 14:615-623, 1985.

u Lesion body is present in all cases

u In
quinoline under polarized light
Wefel described a “structureless zone”.
McIntyre et al (2000) later called this the frontal
zone.
u Partially
radiopaque surface zone sometimes
observed (Wefel reported 40%, McIntyre 2001
reported none)

Unchanged surface zone, Blue colored frontal zone

“body zone” = “structureless zone”

Protective Factors

Advanced
Advanced artificial
natural lesion lesion

Bacteria on
dentin, over
natural root
caries
Protective Factors
 Bacteria on dentin,
over natural root
caries

Protective Factors

Ellen and Banting reported in

epidemiological studies that the Root Surfaces
primary bacteria that cause root biofilms and caries
caries are mutans streptococci Phil Marsh et al.
and lactobacilli. Others also
implicate Actinomyces, yeasts? Monogr Oral Sci 2017

Dental Caries Initiation = Demineralization

Cariogenic Organic Acids

Fermentable
Bacteria + Lactic, acetic,
Carbohydrates formic,
propionic
Dissolve tooth
mineral

Same as enamel caries

Demineralization

Dental Mineral = Demineralization

Organic
Carbonated + Acids Calcium and
Hydroxyapatite phosphate into
solution

Similar to enamel caries except that

collagenase enzymes break down collagen
after mineral is dissolved
 Hard Tissue Composition
Enamel Dentin/
Cementum
Weight Volume Weight Volume
% % % %
Carbonated 96 85 70 47
.
Hydroxyapatite
Protein and 1 3 20 33
Lipid
Water 3 12 10 20

The Caries Process is Diffusion-

controlled
u Acid produced by bacteria in the plaque
diffuses rapidly through the plaque and into
the enamel or dentin, travelling amongst the
crystals
u After demineralization the dissolved calcium
and phosphate each diffuse out to the plaque
u Diffusion occurs from a high concentration to
a low concentration

Tooth Cross Plaque on

Section outer surface

Enamel
crystals

DEJ
Dentin
crystals
Devils Post pile
Schematic representation of
diffusion of ions and molecules
amongst the crystals

Protective Factors

Dentinal tubules
1-3 µm diameter
30,000/mm2

Linde, Dentin: structure, chemistry and formation.

Dentin and Dentin reactions in the Oral cavity.

u Review summarizes protein and lipid content of

dentin and describes physical structure
u Organic matrix is a mineral template.
u 90 % of protein is collagen type I (as in bone)
synthesized in odontoblasts
u ~ 10% of protein is non-collagenous:
Phosphoproteins, proteoglycan
u ~ 0.5% lipid

Linde, IRL Press, Oxford, England. pp 17-26, 1987

 Effects of collagenase on root
demineralization

u Caries demineralization exposes collagen

u Collagenase destroys collagen, but only
after acid demineralizes the protein matrix
u Protein breakdown can occur at neutral pH

Collagenase = proteolytic enzyme

Kawasaki, Featherstone, J Dent Res 76:588-595, 1997

Coronal Caries versus Root Caries - A

u Both are plaque related with the same bacteria and

the same acids dissolving carbonated hydroxyapatite
mineral leading to a subsurface lesion body

u Enamel lesions often have an “intact surface layer”.

Root caries has this only sometimes.
Enamel “white spots” do not occur in roots
u After acids expose collagen in the root dentin
bacterial enzymes break down the collagen, causing
lesion collapse

Coronal Caries versus Root Caries - B

u Dentin mineral is more soluble than enamel mineral

u Mineral is lost at a similar or up to double the rate from

dentin compared to enamel

u Dentin has only half the mineral by volume that

enamel has, so the same amount of mineral loss
is double serious
 Fluoride, remineralization and root caries

u Caries in tooth roots has similar mechanism to

enamel caries
u Remineralization in tooth roots is enhanced by
fluoride

Featherstone, Am J Dent 7:271-274, 1994

Fluoride and Root Caries

u Fluoride inhibits demineralization
u Fluoride enhances remineralization
u Higher concentrations are needed for severe root
caries
u Jensen and Kohout showed 1100 ppm F dentifrice
reduced root caries vs placebo (JADA 1988)

u Baysan, Lynch et al, Caries Res, 2001,

showed a 5000 ppm F dentifrice (Prevident)
was very effective against root caries
– better than 1100 ppm F dentifrice.

Reversal of Primary Root Caries Using Dentifrices

Containing 5,000 and 1,100 ppm Fluoride

u 201 subjects with at least one root caries lesion

u After 3 and 6 months, assessed by visual,
tactile and electrical conductance

u Root caries lesions were remineralized better

by 5,000 ppm F than 1,100 ppm F

Baysan, et al., Caries Res 2001;35:41-46

Course Objective

To understand the etiology and

mechanism of root caries formation
and the differences
compared to enamel caries