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INTRODUCTION
Dental caries is defined as a progressive irreversible
microbial disease affecting the hard parts of tooth
exposed to the oral environment, resulting in
demineralization of the inorganic constituents and
dissolution of the organic constituent, thereby leading to
a cavity formation.
• The word caries derived from Latin meaning ‘rot’ or
decay
• Similar to the Greek word ‘ker’ meaning death
• The relationship between diet and dental caries
Bacterial enzymes + fermentable carbohydrates = acid,
Acid + enamel = dental caries
CURRENT TRENDS IN CARIES
INCIDENCE
• In developed countries, caries prevalence
declined in last decade, causes are
multifactorial. Eg: communal water
fluoridation.
• In developing countries increase in caries
prevalence, cause is increased use of
refined carbohydrates.
CARIES SUSCEPTIBILITY JAW
QUADRANTS
• Bilateral distribution between the right and
left quadrant of both maxillary and
mandibular arches.
• Maxillary teeth more susceptible than
mandibular arch
relate to gravity and saliva, with its
buffering action, would tends to drain from
upper teeth and collect around lower teeth.
CARIES SUSCEPTIBILITY OF
INDIVIDUAL TEETH
• Upper and lower first molar 95%
• Upper and lower second molar 75%
• Upper second bicuspid 45%
• Upper first bicuspid 35%
• Lower second bicuspid 35%
• Upper central and lateral incisor 30%
• Upper cuspids and lower first bicuspid 10%
• Lower central and lateral incisor 3%
• Lower cuspids 3%
• Teeth farthest back in the mouth are more frequently carious.
• Caries susceptibility of individual tooth surface
occlusal > mesial > buccal > lingual
ECONOMIC IMPLICATION OF
DENTAL CARIES
Factors changing the economic implication of
treatment of dental caries :-
• Economic status of population
• Increasing educational status
• Growing number of dental graduates
• Insurance programs
• Commercial pressure
• Governmental influences
CLASSIFICATION OF DENTAL
CARIES
A) Black’s classification
CLASS I – cavities on the occlusal surface of premolars
and molars, on the occlusal two-third of the facial and
lingual surface of molars, on lingual surface of maxillary
incisors.
CLASS II – cavities on the proximal surface of posterior
teeth
CLASS III - cavities on the proximal surface of anterior
teeth that do not include the incisal angle
CLASS IV – cavities on the proximal surface of anterior
teeth that include the incisal angle
CLASS V – cavities on the gingival third of the facial or
lingual surface of all teeth
CLASS VI - cavities on the incisal edge of anterior teeth or
occlusal cusp height of posterior teeth
B[1] According to location on individual
teeth
- Pit and fissure caries
- Smooth surface caries
B[2] According to the rapidity of the process
- Acute dental caries
- Chronic dental caries
B[3]
- Primary caries (virgin)
- Secondary caries (recurrent)
PIT AND FISSURE CARIES
- Pits and fissures with high steep walls &
narrow base retention of food, debris,
micro organisms fermentation acid
production
- Caries appear brown/ black, feel soft
- Enamel bordering opaque bluish
white
- Large carious lesion with a tiny point of
opening
SMOOTH SURFACE CARIES
- Preceded by formation of microbial/ dental
plaque
- Begins just below contact point and appear in
early stages as faint white opacity of enamel
(chalky spot) slightly roughened
surrounding enamel bluish white as caries
penetrate enamel
- Cervical carious lesion crescent shaped
cavity (extend from areas opposite to the
gingival crest occlusally to convexity of tooth
surface)
ACUTE DENTAL CARIES
- Rapid clinical course & early pulp
involvement
- Process rapid little time for deposition of
sec. dentin. Dentin stained a light yellow
- Rampant caries, affecting deciduous dentition
nursing bottle caries
- Commonly 4 maxillary incisors followed by
first molar and then cuspids
- Absence of caries in mandibular incisors
distinguished from ordinary rampant caries
• CHRONIC DENTAL CARIES
- Progress slowly and leads to involve pulp
much later
- Sufficient time for both sclerosis deposition of
sec. dentin
- Carious dentin stained deep brown.
- cavity shallow with min. softening of dentin
- Pain and undermining of enamel not a
common feature
RECURRENT CARIES
- Occurs in immediate vicinity of restoration
- Poor adaptation of filling material
ARRESTED CARIES
- Static or stationary caries
- Exclusively in caries of occlusal surface
- Large open cavity and lack of food
retention
- Superficially retained and decalcified
dentin gradually burnished until it takes
a brown stain, polished appearance and
is hard EBURNATION OF DENTIN
- Caries on proximal surface of teeth
adjacent approx. tooth extracted
THEORIES OF CARIES
FORMATION
• Legend of the worm theory
• Endogenous theories
Humoral theory
Vital theory
• Exogenous theory
Chemical (acid) theory
Parasitic (septic) theory
Miller’s chemicoparasitic theory – Acidogenic theory
Proteolysis theory
Proteolysis chelation theory
Sucrose – chelation theory
• Other theories
Auto immune theory
Sulfatase theory
ETIOLOGIC FACTORS IN
DENTAL CARIES
Tooth position
• Which are malaligned, out of position, rotated
or otherwise not normally situated, may be
difficult to clean and tend to favor the
accumulation of food and debris which
subsequently lead to dental caries
Saliva
• Composition
• PH
• Quantity
• Viscosity
• Antibacterial factors
Composition of saliva
Inorganic:-
Positive ions:- Ca, Mg, K,
Negative ions:- CO2, Cl, F, PO4,
thiocynate
Organic:-
Carbohydrates : glucose
Lipids : cholesterol, lecithin
Nitrogen : non- protein ammonia,
nitrites & amino acids
protein globulin, mucin, total
protein
Miscellaneous : peroxides
Enzymes : carbohydrases, proteases,
oxidases
PH of saliva
• Determined by bicarbonate concentration
• PH increases with flow rate, normal PH 7.8
• Sialin is an argenine peptide described PH
rise factor, present in saliva
Quantity of saliva
• Normal quantity 700-800 ml per day
• In case of salivary gland aplasia and
xerostomia in which salivary flow may entirely
lacking, resulting in rampant dental caries
Viscosity of saliva
• Thick, mucinous saliva increases the dental
caries
Antibacterial properties of saliva
Lactoperoxidase
• They participate in killing of microorganisms
by catalyzing the H2O2 mediated oxidation of
a variety of substances in the microbes
• Utilizing thiocynate ions in saliva peroxidation
generate highly reactive chemical compound
that bond and inactivate general intracellular
microbial enzyme system, as well as
microbial surface compound.
Lysozyme
• Small, highly positive enzyme that catalyze
the degradation of negatively charged
peptidoglycan matrix of microbial cell wall
Lactoferin
• Fe binding basic protein found in saliva with mol. wt.
near 80,000.
• Tends to bind & link the amount of the free Fe which
is essential for microbial growth
IgA
• Immunoglobulin in saliva
• Inhibit adherence and prevent colonization of
microbial on tooth and mucosal surfaces
Other salivary components with protective function
Proline rich protein
• Mucus and glycoprotein
• Because of their high proline content, there are rigid
collagen like molecules designed to form a pseudo
membranous layer in the hard and soft oral surfaces
as well as on the oral flora.
Aromatic rich protein
• Statherin
• It causes remineralization
Other host factors
Age
• Dental caries decreases as age
increases
• Root caries are common in elders
• Gingival recession cemental
exposure (improper brushing)
Socioeconomic status
• High low chance
• Low more chance
II. MICROFLORA
• Strep. mutans early carious lesions of enamel
• Lactobacilli dentinal caries
• Actinomyces root caries
Role of microorganisms in dental caries
• Prerequisite for dental caries initiation
• A single type of microbe is capable of
inducing dental caries
• Ability to produce acid prerequisite
for caries induction
• Streptococcus strains are capable of
inducing caries
• Organisms vary greatly in their ability to
induce caries
Role of dental plaque
• soft, non mineralized, bacterial
deposit which forms on a teeth that
are not adequately cleaned
• Complex metabolically interconned
highly organized bacteria/
ecosystem
• Important component of dental
plaque is acquired pellicle just
prior or concomitantly with bacterial
colonization and may facilitate
plaque formation
• Microbial in dental plaque
streptococci
actinomycetes
veillonella
• Strep. mutans chief etiological
agent of dental caries
III. DIET
• Increase in carbohydrate increase carious activity
• Risk of caries is greater if the sugar is consumed in a
form that will be retained on the surface of the teeth
• Risk of sugar increasing caries activity if it is consumed
between meals
• Increasing caries activity varies widely between
individuals
• Upon withdrawal of the sugar rich foods the increased
caries activity rapidly disappears
• Carious lesion may continue to appear desperate to
avoidance of refined sugar and maximum restriction on
natural sugars dietary carbohydrates
• High concentration sugar in solution and its prolonged
retention on the tooth surface leads to increased caries
activity
• Clearance time of the sugar correlates closely with
caries activity
THE CARIES PROCESS
• Caries of enamel
smooth surface caries
pit and fissure caries
• Caries of dentin
• Caries of cementum
SMOOTH SURFACE CARIES
• Earliest manifestation is the appearance of an
area of decalcification, beneath dental plaque
with a smooth chalky white area
• Loss of interprismatic substance with increase in
prominence and roughening of ends of enamel
rods
• Accentuation of incremental striae of retzius
• As this process advances and involves deeper
layer of enamel it forms a cone shaped lesion
with apex towards DEJ and base towards
surface of teeth
PIT AND FISSURE CARIES
• Because pit and fissure provides more depth
increased food stagnation with bacterial decomposition
• Here caries follow direction of enamel rods and forms a
cone shaped lesion with apex at outer surface and base
towards DEJ
Different zones present in lesion are
Zone 1: translucent zone
Advancing front of enamel lesion, not always present
Zone 2: dark zone
Referred as positive zone formed as a result of
demineralization
Zone 3: body of lesion
Area of greatest mineralization
Zone 4: surface zone
Appears relatively unaffected
CARIES OF DENTIN
• Initial penetration of dentin by caries may result in
dentinal sclerosis
• This is a reaction of vital dentinal tubules and a vital
pulp, in which results in calcification of dentinal tubules,
that tend to seal them off against further penetration by
microorganisms
• The different zones which are present in carious dentin
are (beginning pulpally at advancing edge of lesion)
Zone 1 : zone of fatty degeneration of Tome’s fibres
Zone 2 : zone of degeneration
Zone 3 : zone of decalcification
Zone 4 : zone of bacterial invasion of decalcified but intact
dentin
Zone 5 : zone of decomposed dentin
ROOT CARIES
• Defined as soft progressive lesion that is
found anywhere on root surface that has
lost connective tissue attachment and
exposed to oral environment
• Microorganisms involved in root caries are
filamentous
• Microorganisms invade cementum, along
sharpey’s fibres
INDICES USED TO
ASSESSMENT OF DENTAL
CARIES
1. DMFT index
2. DMFS index
3. DEF index
4. Stone’s index
5. Caries severity index
Diagnosis of caries
1. Identification of subsurface demineralization
(inspection/ palpation, radiographs)
2. Bacterial testing (caries activity testing)
3. Assessment of environment conditions like salivary
PH, flow and buffering
METHODS OF CARIES CONTROL
• There are various levels for prevention of
dental caries
these include
1. Primary prevention
2. Secondary prevention
3. Tertiary prevention
levels of Primary prevention Secondary Tertiary prevention
prevention prevention
Preventive Health promotion Specific Early diagnosis Disability Rehabilitation
services protection and prompt limitation
treatment
Services Diet planning, Appropriate use Self examination Utilization of
provided demand for of fluoride, and referral, dental
by the preventive ingestion of utilization of services Utilization of
individual services, periodic fluoridated water, dental services dental services
visit to dental use of fluoridated
office dentifrices
Services Dental health Comm. or school Periodic provision of provision of
provided education water screening and dental dental services
by programs, fluoridation, referral, provision services
community promotion of lobby school fluoride of dental
efforts mouth rinse services
program, school
fluoride tablet
program, school
sealant program
Services Patient education, Topical Complete exam, Complex Removable and
provided plaque control application of prompt treatment restorative fixed
by the program, diet fluoride, of incipient dentistry prosthodontic
dental counseling, recall, supplements/ lesions, minor tooth
profession reinforcement, rinse preparation, preventive resin movement,
caries activity tests pit and fissure restoration, pulp implants
sealants capping
METHODS TO CONTROL CARIES
1. Chemical measures
2. Nutritional measures
3. Mechanical measures
1. CHEMICAL MEASURES
A vast number of chemical substances have been
proposed for the purpose of controlling dental caries
Ideal properties:
• It should be safe for intraoral use
• Must be able to penetrate dense microbial plaque
• Agent used for topical application should not be
systematically toxic if swallowed accidentally
• Should not produce local tissue irritation
• Should be rapidly bactericidal as contact time is less
• Should possess degree of specificity
• Should be destroyed or inactivated by GIT
• Should have an acceptable taste
• Medically important antibiotics should not be used
Chemical measures include:
I. Substances which alter tooth surface or
tooth structure
II. Substances which interfere with
carbohydrate degradation through
enzymatic alteration
III. Substances which interfere with bacterial
growth and metabolism
I. SUBSTANCES WHICH ALTER
TOOTH SURFACE/ TOOTH
STRUCTURE
• Chemicals falling into this categories
include
a. Fluorides
b. Iodides
c. Bisbiguanides
d. Silver nitrates
e. Zinc chloride and potassium ferrocyanates
Fluoride
• Most widely used and promising chemical in
this category
• Fluorides have been administrated
principally in two ways
a. Systemic application
eg:- School water fluoridation, community water
fluoridation, milk fluoridation, self fluoridation
b. Topical application
eg:- Sodium fluoride, aciduated phosphate
fluoride, stannous fluoride
• A fluoride concentration of 1 ppm in drinking
water is associated with a marked decrease
in dental caries
• Other methods of using fluorides are
As dietary supplementation of fluoride
Fluoride dentifrices
Fluoride in mouth washes/ rinses
Fluoride incorporated in chewing gums and dental
floss
• Rinses for caries reduction
Rinse Concentratio PH Application
n
Aqueous 0.2% 7 Once a wk/
NaF once
every 2
wk
Aqueous 0.5% 7 Once daily
NaF