EPIDEMIOLOGICAL FACTORS OF DENTAL CARIES

 Caries is a multifactorial disease mainly consist of 3 parameters :

i. Host factors
ii. Agent Factors
iii. Environment Factors
 The interaction of the above 3 factors under conducive conditions leads
to dental caries development.

I. HOST AND TEETH FACTOR

a) TOOTH

i. Composition:
Number of studies has shown that there was a significant difference in
fluoride content of sound teeth and carious teeth i.e. more fluoride in
sound teeth.
Surface enamel is more resistant to caries than subsurface enamel. Surface
enamel is more highly mineralized & lower in carbon dioxide, dissolves at a
slower rate in acids and has more organic material than subsurface
enamel. These factors contribute to caries resistance.
 ii. Morphology:
Morphologic features which may pre dispose to the development of caries
are the presence of deep, narrow occlusal fissure or buccal or lingual pits.
These fissure trap food, bacteria and debris leading to development of
caries.

iii. Position:
Malaligned teeth are difficult to clean, favoring the accumulation of food
and debris. This may predispose to the development of caries.

iv. According to the tooth attacked:

The lower incisors are less frequently attacked than any other teeth. The
opening of major salivary ducts near the lower incisors has been put forth
as a reason for this resistance to caries but the opening of the parotid
glands near the upper molar teeth has failed to give these teeth similar
protection.

b) SALIVA
 Saliva has a flushing action on teeth.

 Saliva provides calcium, phosphate, proteins, lipids and antibacterial

substances and buffers.

Buffering and neutralization:

 pH of saliva depends on the bicarbonate concentration. Saliva is alkaline
and is an effective buffer system.
 These properties protect the oral tissues against acids and plaque. This
salivary neutralization and buffering effect markedly reduces the cariogenic
potential of foods.

Quantity:
 Mild increase or decrease in flow may be of little significance, near total
reduction in salivary flow adversely affects dental caries. There is an
inverse relation between salivary flow and dental caries.

c) SEX:
 Many studies have shown higher caries experience in girls than boys during
childhood period and also later at adolescence period.
 However, there are some studies which have shown no difference
between girls and boys.
 Root caries is seen more in males. This could be attributed to poor
maintenance of oral hygiene in older aged males.
 The increased susceptibility of girls to caries may be explained by:
(i) Early eruption of teeth,
(ii) Increased fondness towards sweets among girls (females) and
(iii) Due to hormonal changes.

d) AGE
 Although present in all ages, it was believed that dental caries was disease
of childhood but it shows 3 peaks: at ages of 4-8 years, 11-19 years and 55-
65 years.
 Root caries is seen in over 60 year’s age group people, mainly due to
denuded root surface because of gingival recession.

e) RACE AND ETHINICITY

 A number of studies indicate that blacks [Negroes] of comparable age and
sex have a lower caries scores than Caucasians.
 Chinese population has shown to have a lower caries rate than
corresponding white population. These differences are probably more due
to environmental factors.

f) SOCIOECONOMIC STATUS (SES)

 There is an inverse relationship between SES and dental caries experience
in primary dentition. Many studies concluded that low SES groups had
more number of decayed and missing teeth but less number of filled teeth
and vice versa in higher SES groups.
 Nowadays caries is considered to be a "disease of poverty" or "social
behavioural disease."

g) HEREDITY
 "Good or bad teeth run in the family." Family studies have shown that
offsprings have the same score as parents.
 While some researchers speculated that caries prevalence is hereditary or
genetically based or shows sex-linked inheritance. Further research
revealed that environmental factors like morphology, occlusion, salivary
flow or composition, similar habits in family are important contributory
factors for variation in dental caries activity.
 h) EMOTIONAL DISTURBANCES
 Emotional disturbances, particularly transitory anxiety states tend to
increase the incidence of dental caries.

II. AGENT FACTORS

A. MICROORGANISMS

MUTANS streptococci (MS): Development of early carious lesions in enamel

LACTOBACILLI acidophillus : Associated with dentinal caries

Actinomyces viscosus & A. naeslundii: associated with root surface caries

Mutans streptococci (MS)

 Mutans streptococci are the foremost cariogenic pathogens in tooth decay.
They are highly acidogenic, producing short-chain acids which soften hard
tissues of teeth.
 2 species of the “mutans streptococci” viz. Streptococuus mutans &
Streptococcus sobrinus are the principal agents of enamel caries. S.mutans
is more cariogenic than S.sobrinus because of specific cell-surface
proteims, which assist in its primary attachment to the tooth. But such
proteins are deficient in S. sobrinus.

B. DENTAL PLAQUE
 Bacterial plaque is a dense non-mineralized, highly organized mass of
bacterial colonies in a gel-like intermicrobial, enclosed matrix or slime
layer.
 Dental plaque happens to be a diverse community of
the microorganisms found on the tooth surface.
 Cariogenic plaques result when acidogenic and aciduric bacterial species
increase following high frequency of exposure to carbohydrate.
 PROPERTIES OF CARIOGENIC PLAQUE
 The rate of sucrose consumption is noticeably higher in cariogenic plaques.
 Bacteria in cariogenic plaques synthesize more intracellular glycogen-
amylopectin type polysaccharides.
 Up to 20% of the sucrose consumed within 15 mins, is converted into
intracellular polysaccharides by carogenic plaque.
 Cariogenic plaque forms more lactic acid from stored intracellular
polysaccharides.
 Cariogenic plaque forms approximately twice as much extracellular
polysaccharide from sucrose as do non-cariogenic plaque.
 Cariogenic plaque contains higher levels of S. Mutans than non-cariogenic
plaques.
 Non-cariogenic plaque harbor higher levels of S.sanguis & Actinomyces
than cariogenic plaque.
 Non-cariogenic plaque has higher levels of Veilonella & slightly lower
concentration of lactic acid.

 There are 3 microbial hypotheses regarding the etiology of dental caries,

namely the specific plaque hypothesis, the non-specific plaque hypothesis,
and the ecological plaque hypothesis.
 The specific plaque hypothesis has proposed that only a few species of the
total microflora are actively involved in disease. Of which the most
relevant were mutans streptococci [main species: Streptococcus
mutans (S. mutans) and Streptococcus sobrinus] and lactobacilli .
 Contrary to the specific plaque hypothesis, the non-specific plaque
hypothesis suggests that caries is the consequence of the overall
interaction of all the groups of bacteria within plaque.
 The ecological plaque hypothesis suggests that caries is the result of an
imbalance in the microflora due to ecological stress, resulting in an
enrichment of certain disease-related micro-organisms.

III. ENVIRONMENTAL FACTORS

A. DIET (described in detail as a separate topic)

 The presence of refined carbohydrate as sugar is essential for the majority
of caries development and sucrose is the most cariogenic of all sugars.
 It has been indicated as 'the arch criminal' in the aetiologyof caries. The
evidence linking diet and dental caries has been taken from
 epidemiological studies, human clinical studies, animal experiments and
plaque pH studies.

B. GEOGRAPHIC VARIATION
1. Latitude: In the USA, the north-eastern region has the highest and south
central region the lowest prevalence of caries. The countries near the
equator like India, Ethiopia and China showed less caries compared to
countries away from the equator like Australia and New Zealand.
2. Distance from seacoast: Caries prevalence is maximum at the seacoast
and more the distance travelled away from the coastal region there will be
less caries activity.

C. CLIMATE
 Sunshine and high temperature areas seems to have lower dental caries
[inverse relationship].
 Whereas areas with more relative humidity and rainfall have shown
increase dental caries.
 Rainfall acts by leaching off minerals including fluoride from the soil and
also by blocking sunlight.
 Rainfall and humidity are linked to dental caries prevalence, either
separately or together.
D. SOIL
 Trace elements in soil have shown a relation with caries. An increase in
dental caries is seen in areas where selenium is present in soil, whereas
molybdenum and vanadium are said to decrease dental caries.

E. FLUORIDE:
 Higher the fluoride content in soil and groundwater, lesser the caries.

F. URBANIZATION:
 A careful study by WHO has showed higher caries scores in urban areas
where the higher consumption of refined foodstuffs by the urban
community is observed.

G. ORAL HYGIENE
 Inverse relationship has been seen between oral hygiene and dental caries.
Poor oral hygiene increases the rate of dental caries.