Caries Risk Indices

ll
Epidemiology of Dental Caries

• It studies the spread of dental caries

among a group of the population.
 Global burdens of caries disease
• In 2010, untreated caries in permanent teeth
was the most prevalent condition worldwide,
affecting 2.4B people, amd untreated caries in
deciduous teeth was 10th most prevalent
condition, affecting 621M children worldwide
 Oral Health Indicators
• Data presented to indicate the health
situation of the population.
• It's measurable & calculated.
• Examples:

DMF
RCl
CPlTN
 Indices for Dental Disease/
Oral Health Indicators
• DMF expresses dental caries experience
in permanent dentition.
(Decay - Missing due to caries-Filling).
dmf .. Deciduous dentition or def
• RCI Root Caries Index
• CPITN (Community Periodontal Index of
Treatment Needs).
 DMF

D Decayed Teeth
Decayed
M Missing Teeth
Missing
F Filled Teeth
Filled
 DMF

• Describes the prevalence of dental

caries in an individual.
• It is thus used to get an estimation
illustrating how much the dentition
until the day of examination has
become affected by dental caries.
• DMFT (Teeth) --- DMFS (Surfaces)
 DMFT
• How many teeth have caries
lesions (incipient caries not
included)? D (cavitated caries)

• How many teeth have been

extracted (due to caries)? M

• How many teeth have fillings or

crowns (due to caries)? F
 DMFT

• Note: If a tooth has both a caries lesion

and a filling (recurrent caries) it is
calculated as D only.
 DMFT
• DMFT: Mean number of Decayed, Missing
& Filled teeth.
• % DMFT: Percentage of Population
affected with dental caries.
• % D: Percentage with untreated decayed
teeth.
• DT: Mean number of Decayed Teeth
• MT: Mean number of Missing Teeth
• FT: Mean number of Filled Teeth
 DMFT calculation
• It is either calculated for 28 (permanent)
teeth, excluding (the "wisdom" teeth)
• or for 32 teeth including wisdom teeth

DMTF percentages:
 Percent D/DMFT : percent of decayed teeth within
total caries experience index
 Percent M/DMFT: percent of missing teeth due to
caries within total caries experience index
 Percent F/DMFT: percent of filled teeth within
total caries experience index
 DMFS calculation
• Molars and premolars are considered
having 5 surfaces, front teeth 4
surfaces.

• Again, a surface with both caries and

filling is scored as D.

• Maximum value for DMFS comes to 128

for 28 teeth.
 Primary Dentition

• dmft and dmfs (decayed – missing – filled)

Or
• deft and defs (decayed – extracted – filled)
Diet and Dental Caries
Systemic Effect of Diet

 Topical effect of diet in mouth following tooth

eruption plays role in dental caries.
 Undernutrition and nutrients deficiencies
influence development of teeth formation,
function & secretion of salivary glands
susceptibility to DC
 Nutrition Transition to westernized diet (high
in free sugar)
 Undernutrition & Dental Caries
 Undernutrition is associated with enamel
hypoplasia caries susceptibility

 Undernutrition leads to salivary gland atrophy

(Vit A deficiency) reduced salivary flow
rate caries susceptibility.
 Diet & Sugar
 Poor diet high in sugar DC
 DC pain, tooth loss and less eating ability.
 Tooth loss reduce healthy diet intake (fruits &
vegetables)
 Low income & undernourished countries,
malnutrition associated with high sugar intake.
Nutrition Vs Enamel Defects

 Malnutrition is one of many causes of

enamel developmental defects.

 Undernourished linear enamel hypoplasia

non smooth surface
Vitamin D and Teeth
 Diet deficient in Vitamin D results in:
Delayed development of teeth
Teeth poorly calcified
Teeth poorly aligned

Enamel hypoplasia increased susceptibility to

dental caries & Vitamin D supplements
reduced incidence of caries in children
Lady May Mellanby studies, early 20 century
White enamel lesion

 Enamel hypomineralization
 Enamel hypoplasia
 White spots (incipient caries)
 Dental fluorosis
Enamel hypomineralization Causes
Perinatal problems
Premature birth
Low birth weight
Chronic infections (middle ear)
Trauma to permanent teeth
white _ yellow _ brown
Ameloblasts sensitive to temperature changes
changes in ameloblasts function altered
deposition in enamel matrix also in hypoplasia
Enamel hypomineralization

 Defects usually well demarcated /Affect few teeth

 Change in enamel translucency (white, cream, yellow)
 Smooth enamel surface / normal enamel thickness
affect few teeth , not symmetric , on one side , normal teeth
shape
Enamel hypoplasia

 Quantitative defect of enamel

 Occur in several forms including grooves, pits
or row of pits
 Occurs on several teeth
 Stepped or linear appearance/enamel surface
not smooth
treat with composite restoration
White spot lesions
at cervical area we must
dry the teeth (incipient
caries)
Sreebny 1982 Study
 Correlated dmft of 5-6 years old with sugar
supplies of 23 countries.
 Correlated DMFT of 12 years old to sugar
supplies data of 47 countries.
 Found that 52% of the variation in caries
levels could be explained by the per capita
availability of sugar.
Sreebny 1982 Study

 For every 25g of sugar per day one tooth

per child would become D or M or F.
 In countries with sugar intake below
18kg/person (50g/person/day) caries
experience was consistently below DMFT 3.
 In countries with excess sugar intake
44kg/person (120g/person/day) caries
experience was high, above DMFT 3.
 Vipehlom Study
 1945-1953 Sweden
 964 mentally deficient patients
 The study investigated the effects of consuming
sugary foods of varying stickiness (i.e. different oral
retention times) and at different times throughout
the day on the development of caries
 Sugars and potential in caries induction
Non sticky form
sticky form
Between meal and sticky form
 1 control and 6 main test groups
 Vipehlom Study

 Control group (low sugar diet)

 Sucrose group (at meals)
 Bread group (at meals)
 Chocolate group (at & between meals)
 Caramel group (at &between meals)
 8 toffee group (per day)
 24 toffee group (per day)
 The
Vipehlom
Study
- - - - - at meals only
‫ ـــــــــــــــــ‬at & between meals
The
Vipehlom
Study
 The Vipehlom Study Conclusion

 Sugar has a topical effect on teeth

 Bread is not as cariogenic as sugar
 The frequency of eating is more important than the
amount.
 Carious lesions occurred in control group with low
sugar diet.
 Physical form of sugar matters
 Consumption of sugar in between meals increased
caries
 Dietary Sugars & Dental Caries

 Sugars are undoubtedly the most important

dietary factor in the development of dental
caries.

 Evidence collected from many different kinds

of investigations including studies, research and
experiments.
 Dietary Sugars & Dental Caries

 Sugars refer to all monosaccharides and

disaccharides.

 Sugar refers to Sucrose.

 Free sugars refer to all sugars added to foods

by the manufacturer, cook, consumer plus
sugars naturally found in fruit juices and
syrups.(extrinsic )
 Frequently & Amount of Sugars
Consumption
 The two variables are hard to distinguish from
each other.
 Several studies (Vipeholm study in Sweden)
indicated that caries experience increase with
increased frequency in sugars intake esp in
between meals.
 Other studies (longitudinal) proved that the
high amount of sugars intake increase
caries level.
Frequently & Amount of Sugars
Consumption

In terms of caries development, both

the frequency and the amount of
sugars intake are important in the
development of dental caries.

CONCLUSION
 Cariogenicity of Sugars

 Sucrose
 Glucose, fructose & maltose have similar
cariogenicity.
 Lactose is less acidogenic & less cariogenic.
 Cariogenicity of Sugars
 Free sugars (extrinsic sugars) include milk sugars and "non
milk extrinsic sugars.
 Milk sugars present naturally in milk and milk products
less cariogenic (normally)
 Non milk extrinsic sugars are harmful to teeth/highly
cariogenic
Cariogenicity of Sugars
 The adhesiveness or
stickiness of sugar increase
the potential of caries.

 Also, the consumption of

sugar containing drinks (non
sticky) is associated with
increased risk of dental
caries (Consumption of sweet tea &
dental caries 1997. Carigenicity of soft
drinks in USA 1984)
 Starches & Dental Caries
 Starch is of low risk to dental caries. (Studies)
 Cooked starchy food as rice & potatoes
low cariogenicity
 People consuming high starch/low sugars
diet generally have low levels of caries.
 People consuming low starch/high sugars
diet have high level of caries.

Fisher, Harris, Newbrun, Rugg-Gunn,...

 Starches & Dental Caries
 Raw starch is of low cariogenicity.
 Cooked starch is about one third to one half
as cariogenic as sucrose.
 Mixtures of starch and sucrose are potentially
more cariogenic than starch alone.
 Cooked starch with amounts of sucrose
seems to be as cariogenic as similar
quantities of sucrose.
Fruit & Dental Caries
 Fruit & Dental Caries

 Health reports encourage increase consumption

of fruits & vegetables (5 portions/day).
 Fresh fruits should replace cariogenic sugars
 Fresh fruit mastication good stimulus to
salivary flow
 Fruit juices contain non milk extrinsic sugars
cannot be 100% safe
 Fruit & Dental Caries

 Little evidence is available to show that fruits

play a role in developing DC.
 Few studies found that some fruit are
acidogenic but less than sucrose.
 The consumption of fruits in very high
frequencies (e.g 17 times /day) induce
but less than sucrose
Drinks That Eat Teeth

Drink Type Acidity (PH)

Lemon juice 2.00-2.60
Pepsi 2.49
Coke Classic 2.53
Power Horse 2.75
Diet Pepsi 3.05
Mountain Dew 3.22
Diet 7UP 3.67
Instant Coffee 5.51
Drinks & PH

Drink Type Acidity (PH)

Guava Nectar 5.50
Milk, Cow 6.40-6.80
Water 7.00
Tea (Unsweetened) 7.20
Foods that cause the pH of
interproximal plaque to fall less than 5.5
Candy
Cereals (ready to eat)
Chips
Cookies
Crackers
Doughnuts
Dried fruits
Peanut Butter
 Nutritional Risk Assessment
Dietary Screening Questions For Caries Risk
Question Points*
1. Do you eat foot or beverages drink five or more times 1 point if yes
a day?
2. Do you chew regular (non-sugar free) gum? 1 point if yes

3. Do you drink any sweetened beverages between 2 points if yes

meals?
4. Do you eat mints, candies, chips, etc, between meals? 2 points if yes

5. Do you drink milk or eat cheese every day? 1 point if no

Total (If the total number of points is equal to or greater than 4, the diet is
considered to be a major contributor categorizing the individual at high caries risk)
Fructose & Sucrose Medical & Dental Facts
• Lecture by Dr. Robert Lustig (pediatric
endocrinologist).. “Sugar: the bitter truth” .
• Fructose leads to fatty liver in toddlers .
• He called Sucrose “the alcohol of the child” .
• Sucrose = Fructose & Glucose
• Fructose & Sucrose Medical & Dental Facts
 High density fructose from the juices of fruits or corn
has found its way to nearly every food available to
humans from infant formula to flavored corn chips.
 Our daily exposure to fructose is nearly immeasurable
 Adding fructose to foods fuels the desire for more
 Fructose Medical Facts
• Although people don't die immediately they suffer a slow decades – long
death
• Ingested fructose stored in liver → converted to uric acid
• Hyperuricemia (excessive uric acid in blood) →
 Hypertension
 Metabolic syndromes (like Type 2 Diabetes)
 Cardiovascular disease
 Alzheimer's disease

 Food & Food Ingredients Illustrate Diversity of Products having Fructose .

 Caramel
 High – fructose corn syrup
 Honey
 Invert sugar
Dental Implications of Fructose
 Molasses
• Similar drop in pH in biofilms as sucrose
 Palm sugar • In vitro studies → pH drop to 5 four hours after the challenge
 Pancake syrup and continues to fall for 48 hours →→ Cariogenic.
• Fructose is NOT a dentally safe alternative to sucrose
 Sucrose
 Disaccharide (fructose & glucose) .
 Fructose molecule is the most damaging part
 Sucrose is everywhere → even as coating on French fries
 Sucrose in products ingredients is hidden under deceptive names
→ we consume more than we realize

 WHO & Sucrose

• WHO → limit free sugar intake to only 5% of total energy
consumed
• WHO: “Free sugars are all sugars added to foods or drinks by the
manufacturer, cook, or consumer as well as sugars naturally
present in honey, syrups, fruit juices and fruit juices concentrates“
 Dextrose, a form of sugar, is in the coating of French fries to help
fries turn brown by a process called Maillard Reaction
• Dextrose is the name of a simple sugar that is made from corn and
is chemically identical to glucose, or blood sugar. Dextrose is often
used in baking products as a sweetener, and can be commonly
found in items such as processed foods and corn syrup.
 Medical Implications of Sucrose :
• Many studies link Sugar to Cancer Cells Growth and
Development .
• Other studies link sucrose
• Cardiovascular disease
• Diabetes
• Obesity
• Pain reduction in neonates (painful procedures like heel
pricks)

 Dental Implications of Sucrose:

• Oral biofilms mature faster .
• Express a lower pH .
• Biofilms become denser & affix more firmly to enamel
• Nourish Glucans in biofilm so stabilize plaque more and more
Dietary Factors Against Caries
MILK… MILK…MILK
Cariostatic
 Milk sugar is lactose less acidogenic.

 The fall in plaque ph following milk

consumption is negligible. (Rugg Gunn,
Frostell)

 Milk contains phosphorus, calcium and casein

where all are cariostatic and protect against
demineralization.
MILK… MILK…MILK

 Many experiments showed that MILK

reduces the cariogenic potential of sugar
containing foods reduces the
prevalence of caries.

 MILK can be used safely by patients with

low salivary flow as a saliva substitute
(concluded from experiments on rats)
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Cheese
 Anticariogenic (many studies).
 Cheese consumption following sugary snack
stop the usual fall in pH after sugars intake.
 Cheese stimulates salivary secretion.
 Cheese increases plaque calcium
concentration strongly influence the
balance between demineralization and
remineralization.
Cheese

 A controled clinical trial showed fewer caries

development over a 2 years period in children
who ate 5g of piece of hard cheese daily
following breakfast compared with a control
group who did not consume the extra cheese.
Chocolate (without Sugar)

 Chocolate (Cocoa factor) has protective

effect (studies).
 Theobromide in chocolate is able to increase
crystal size in enamel increase resistance
to acid demineralization.
 Milk chocolate contains Calcium and Casein
(phospoprotein) and in fat helps in
oral clearance.
Tea
 Contains polyphenols (antioxidants)
which have antibacterial properties
(studies)
 Contains fluoride.
 Black tea extracts inhibit salivary
amylase activity & reduce dental caries
in animal studies.
 Lower caries rates among green tea
drinkers.
Non Sugars Sweeteners

 Two major groups:

1.Intense Sweeteners

2.Bulk Sweeteners
Intense Sweeteners
 Used in food products (soft drinks, desserts,
ice cream, jam)
 Used in dentifrices and as sweetening tablets
for tea, coffee.
 30% of Carbonated beverages (soft drinks)
have Aspartame which comprises of aspartic
acid and phenylalanine.
Intense Sweeteners

 Are not metabolized to acids by

microorganisms cannot cause DC.
 Limitations: poor taste quality – instability –
lack of volume.
 Bitter taste in conc less than 0.1%
 Along with citric acid or phosphoric acid in
beverages cause dental erosion.
 Sweeter than sucrose.
Bulk Sweeteners
 Many are sugar alcohols and chemically
similar to sugars
 Add sweetness and bulk
 Used in chewing gums, preserves.
 May induce gastrointestinal disturbance.
 E.g. xylitol, mannitol, sorbitol
Non Sugars Sweeteners
 Are generally non cariogenic
 Chewing gums (Xylitol) protect against DC
due to non cariogenicity and stimulation of
salivary flow.

The sugar substitute has to be looked upon

from different aspects; cariological,
nutritional, economic & toxicological
Xylitol dental implications
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ERYTHRITOL
SWEETENER
Ketogenic diet (high fat, moderate protein,
carbohydrates below 30 grams per day)
 Erythritol
Erythritol Dental Implications
• Affects cariogenic and periodontal
pathogens in direct contact
ERYTHRITOL
WHATS IT FOR?

K_TO
OIABI!TI!S
CAVITIES