MICROBIOLOGY AND

HISTOPATHOLOGY OF DENTAL
CARIES

Dr. DISHA JANDIAL

MDS 1st year
Deptt. Of Pediatric and
Preventive Dentistry
•Human oral cavity is a factory store of micro organisms.
•Over 700 species of bacteria, accounting a total of more than 10
lac crore, are usual inhabitants of oral cavity.
 Well! What is virulence?

•The ability of an organism/bacterium to cause infection.

•The virulence should be effective so as to invade the host tissues
and encourage bacterial colonization; subsequently damaging the
tissues.

•VIRULENCE is significant in the development of dental caries.

 Criteria for Cariogenicity

• An organism must be acidogenic.

• An organism must be aciduric.

• An organism must exhibit tropism for teeth.

• An organism must utilize refined sugar (sucrose).

(Newbrun, 1983)
 Pathogenic properties of cariogenic
bacteria

• Rapid transport of fermentable sugar and their conversion to

acids.

• Production of Extracellular Polysaccharides and Intracellular

Polysaccharides.

• Ability to maintain sugar metabolism under extreme

environmental conditions.
 The caries culprits
The main microorganisms involved in the initial caries process are :
• S.mutans.
• S.sobrinus and Lactobacillus are also involved, but must have
S.mutans present to colonize.
Microorganisms found in various types of
carious lesions

Pit and fissures: S.mutans, S.sanguis,Lactobacillus ,Actinomyces

Smooth surface caries: S.mutans, S.salivarius

Root caries : Actinomyces viscosus, A.naeslundii, S.mutans, S.sanguis,S.salivarius

Deep dentinal caries: Lactobacillus, Actinomyces viscosus, A.naeslundii

Seceondary caries: S.mutans, S.sanguis, S.orallis, S.gordonii, Actinomyces

viscosus, A.naeslundii,
 Oral streptococci
• Irrespective of the age of plaque and the diet, the predominant
organisms are gram - positive cocci of the genus streptococcus
which form about 50% of the total colony forming units.

•These streptococci have been divided into various groups based

on their colonial morphology and physiological characteristics.
Species Serotype Source
S.mutans c,e,f Human
S.sobrinus d,g,h Human
S.cricetus a Sometimes humans;
mostly rats and hamsters.
S.rattus b Sometimes humans;
mostly rats.
S.downei h Macaque monkey
S.macacae c Macaque monkey
S.ferus c Rats
 Streptococcus Mutans

In 1924 Clarke isolated a streptococcus that

predominated in many human carious lesions
and he named it streptococcus mutans
because of its varying morphology .

They are non motile , catalase-negative,

gram –positive cocci in short or medium
chains .
Streptococcus mutans exhibits several important properties ;

1) synthesizes insoluble polysaccharides from sucrose.

2) homo fermentative lactic acid former.
3) colonizes on tooth surfaces.

4) more aciduric than other Streptococci.

 VIRULENCE FACTORS

1-Aciduric
2-Acidogenic
3-Produces insoluble glucans;
Extracellular polysaccharides:
1. Glucans (dextrans) -sticky insoluble ;
2. Levans (fructans)- energy
Intracellular polysaccharides: Energy sources inside
Streptococcus;
Accumulation of intracellular amylopectin-like polysaccharides
(carbon/energy reserve)
4-Adherence: S. mutans cells binds to salivary components in the
pellicles.
How does Streptococcus mutans
attach to teeth and cause caries?
 Attachment of S.mutans on teeth
Initial attachment of S. mutans to tooth pellicle (mediated by
adhesin).

Sucrose is broken down into fructose and glucose by

glucosyltransferases (GTFs).

Glucose is stored as a glucan polymer (dextran).

Fructose and glucose are both metabolized, resulting in lactic acid

accumulation.

S. mutans accumulates as glucosyltansferases (GTFs) adhere to

glucans produced by other bacteria in plaque.
 Streptococcus sobrinus

• S. sobrinus is thought to enhance caries initiation ,progression

and development.

• Prevalence is more closely associated with high caries activity

than that of S. mutans.
• It has a higher acidogenic capacity compared to S mutans.

• It is unable to synthesize Intracellular polysaccharides .

• Requires sucrose for attachment and growth in plaque.

 Streptococcus Sanguis

•This is one of the predominant groups of

streptococci colonizing on the teeth.

• Formerly it was called streptococcus s. b.

e because of its involvement in sub acute
bacterial endocarditis.
• Caries from this strain occurs primarily in sulci and is
significantly less extensive than S. mutans.
• On blood agar S. sanguis causes (green) hemolysis.
 Streptococci Salivarius

•They have been found in the plaque, throat, nasopharynx and oral
mucosa, but their natural habitat in the dorsum of the tongue.

• In humans they have only a minor degree of cariogenic

significance.
LACTOBACILLUS
 ORAL LACTOBACILLI
Lactobacilli are gram positive ,non spore –forming rods that
generally grow best under micro aerophilic conditions.

Isolation – by the use of selective agar medium which suppresses

the growth of other oral organisms by its low pH (5.4) .
 Lactobacilli represents about 1% of the oral flora.
L. casei and L fermentum are the most common oral species.
The population of oral lactobacilli is influenced by dietary
habits.
A favourite habitat of lactobacilli is in the dentin of deep
carious lesions.
 LACTOBACILLI AND ITS ROLE IN
CARIES

Lactobacilli, have been reported in the oral cavity ever since Miller
enunciated the chemo parasitic theory.

In 1925, Bunting and his collaborators claimed that bacillus

Acidophilus was the specific etiological factor responsible for the
initiation of caries.
ORAL ACTINOMYCES
 Oral actinomyces

Actinomyces is a gram positive ,nonmotile ,non-spore-forming

organisms occurring as rods and filaments that vary considering in
length .

Filaments are usually long and slender and are branching .

The species that have been found in the oral cavity are:
 Anaerobic Facultative Anaerobic

A. A.Naeslundii A.israelii
B. Actinomyces meyeri
C. A.odontolyticus
•All species of Actinomyces ferment glucose, producing mostly lactic
acid ,lesser amounts of acidic and succinic acid ,and traces of formic
acid.

• Most interest has centered on A.viscosus and A naeslundii because of

their ability to induce root caries, fissure caries ,and periodontal
destruction when inoculated into gnotobiotic rats.
 Actinomyces is a good plaque former ,capable of adhering
to wires and forming tenacious deposits on the teeth.

It is the most common group of microorganisms isolated

from the subgingival microflora and from plaque of human
root surfaces caries.
It is found in the supragingival plaque of all children and comprises
about 50% of all cells present.

A.naeslundii predominates in the tongue ,salivary flora ,and in the

plaque of young children ,while plaque from teenagers and adults
has a higher proportions of A.viscosus.
HISTOPATHOLOGY
 DENTAL CARIES

Enamel Caries Dentin Caries Cementum Caries

Enamel Caries

Smooth surface caries Pit and fissure caries

 Speed of lesion formation

• Incipient caries to clinical caries: 18 ± 6 months

• Peak rate for incidence of caries: 2-4 yrs (avg 3yrs) after eruption

• Poor oral hygiene, excess sucrose: 3 weeks

• Radiation induced Xerostomia: 3 months

• Occlusal caries require less time than smooth surface

 ENAMEL CARIES

MACROSCOPIC FEATURES:
White spot lesion
Opaque, chalky white
Surface features-SEM (Thylstrup, 1994) :
• Irregular cracks & fissures
• Fractures of perikymata edges
• Microcavities
•Brown spot lesion

•Sites

•Occlusal surfaces:

•Fissure morphology (Newbrun, 1989)

•Starts at both sides of fissure wall

 Histological features of early enamel caries

-Loss of inter-rod substance prominent enamel-rods

-Appearance of transverse striations of

enamel rods due to segmental

demineralization

-Accentuation of incremental striae of

Retzius
 H/F of Advanced enamel caries

• Classified on the basis of pore volume and

mounting media used
Zone 1 – Translucent zone
Zone 2 – Dark zone
Zone 3 – Body of lesion
Zone 4 – Surface zone
• These zones are from the dentin
towards the outer enamel surface
•ZONE 1:TRANSLUSCENT ZONE

•At the advancing front- 5 -100 μm

•Seen with quinoline

•Pore volume: 1%

•Not always present, sometimes near lateral part

•ZONE 2: THE DARK ZONE

•More constant feature-90-95% lesions

•Pore volume -2-4%

•Why is it called dark zone?

•ZONE 3: THE BODY OF THE LESION

•Largest zone

•Pore vol.: 5% at periphery, 25% in centre

•Appears translucent in quinoline and dark with water

•Striae of retzius well marked

•Bacteria in between prisms (rods)

•ZONE 4: THE SURFACE ZONE

•20-50 μm

•Pore vol: 1%

•Negatively birefringence in water

•Importance: serves as barrier to bacterial

invasion
 Smooth surface caries
• The earliest manifestation of incipient enamel

caries is the appearance of an area of

decalcification , beneath the dental plaque, which

resembles a smooth chalky white area.

• There is loss of interprismatic substance, with

increased prominence and roughening of the ends

of the enamel rods.

White spot lesion

 Pit and fissure caries

• Fissures are diverse in shape and size

• Carious lesion starts at both sides of fissure rather

than at the base, penetrating nearly perpendicular to

the DEJ.

• Lesion is cone-shaped with base towards dentine

and apex towards enamel surface

 Ultrastructural changes in enamel
caries
•Destruction of crystals at borders & within the prism

•Arcade like defects bounded by rows of resistant crystals- “caries

crystals”

•More dissolution in heads and less in tails

 Remineralization
•Enamel most susceptible to caries during & after eruption
•1st molar:12-14 months
•2nd molar:14-18 months
•Premolars:1-2 months-less prone
{Backer-Dirks (1966)}
•Mechanism of arrest of non-cavitated lesions:
•Maintains original crystalline framework
•Etched crystallites serve as nucleating agents
•Wear & polishing of the partly dissolved external surface-regain of
surface hardness
•Remineralized area: brown or black spots
•Mechanism
•Cavitated lesions can also be arrested with proper plaque control
(thylstrup)
•New mechanism of remineralization: CPP-ACP
Clinical significance of enamel
caries
 CARIES OF DENTIN

•Begins with the natural spread of the process along the DEJ and
rapid involvement of the dentinal tubules.

• The dentinal tubules act as tracts leading tothe pulp (path for
micro-organisms).

•Caries advances more rapidly as dentin provides much less

resistance to acid attack .
 Early Dentinal Changes:

-initial penetration of the dentin by caries dentinal sclerosis,

-calcification of dentinal tubules and sealing off from further

penetration by

micro-organisms,

-more prominent in slow chronic caries.

Dentinal
sclerosis
 DENTINAL CHANGES
•Progression of enamel caries to dentin:
5.4% from 11 – 22 yrs (Mejare et al,
1999)
•MACROSCOPIC CHANGES:
•Lateral spread along DEJ
•Cone shaped-apex towards the pulp
•Affected dentin-Brown or black in
colour
•MICROSCOPIC CHANGES: (mechanism)

Caries advancement proceeds through 3 stages:

•Acids demineralize the dentin

•Organic matter degenerates

•Loss of structural integrity & bacterial invasion

•1st mild stimuli –defense reaction of dentin-tubular
sclerosis/TRANSPARENT ZONE

•Dentin demineralization-when lesion reaches DEJ

•Arrest of caries

•Cavitation of dentin-bacterial invasion

• Behind the transparent sclerotic zone, decalcification of dentin
appears.

• In the earliest stages, when only few tubules are involved,

microorganisms may be found penetrating the tubules Pioneer

Bacteria.
•This initial decalcification involves the walls allowing them to
distend as the tubules are packed with microorganisms.

• Each tubule is seen to be packed with pure forms of bacteria, eg.,

one tubule packed with coccal forms the other tubule with bacilli.
• As the microorganisms proceed further they are distanced from the
carbohydrates substrate that was needed for the initiation of the
caries.

• Thus the high protein content of dentin must favour the growth of
the microorganisms.

• Therefore proteolytic organisms might appear to predominate in the

deeper caries of dentin while acidophilic forms are more prominent
in early caries.
 Advanced Dentinal Changes
-decalcification of walls, confluence of the dentinal tubules,

tiny “liquefaction foci”, described by Miller are formed by the focal

coalescing and breakdown of dentinal tubules.

These are ovoid areas of destruction parallel to the course of the

tubules which filled with necrotic debris and increase in size by

expanding. The adjacent tubules are distorted and their course is bent

due to this expansion.

• The destruction of dentin by decalcification and then proteolysis
occurs in numerous focal areas- leading to a necrotic mass of
dentin of a leathery consistency.

• Clefts present in the carious dentin that extends at right angles to

the dentinal tubules, accounts for the peeling off of dentin in layers
while excavating.
Shape of the lesion is triangular with the apex towards the pulp
and the base towards the enamel.
Zone 1; Zone of Fatty Degeneration of Tome’s Fibers,(next to pulp)
-due to degeneration of the odontoblastic process. This occurs before
sclerotic dentin is formed
and makes the tubules impermeable.
Zone 2; Zone of dentinal sclerosis,
-deposition of Ca salts in the tubules.
Zone 3; Zone of decalcification of dentin
Zone 4; Zone of bacterial invasion
Zone 5; Zone of decomposed dentin due to acids and enzymes.
Zone of Decomposed
dentin

Zone of Bacterial
invasion

Zone of
decalcification

Zone of Dentinal
sclerosis
Zone of fatty
degenration of tome’s
fibres
ZONE OF FATTY DEGENRATION:
Of the Tomes fibres-stained by Sudan red
•Importance:
•Fat contributes to impermeability of dentinal tubules
•Maybe a predisposing factor favouring sclerosis
• Innermost layer of dentinal caries towards pulp
• Due to deposition of fatty tissue in odontoblastic processes
• Seen usually in rapidly progressing caries
• No crystals or bacteria in lumen of tubules
• Intertubular dentin normal
•ZONE OF TUBULAR SCLEROSIS:
•Reaction of vital dentinal tubules & pulp.
•Seals off tubules to further penetration by bacteria.
•Mineralization process-2 types.
•Hydroxyapatite crystals & large rhomboidal crystals (whitlockite).
•Transluscent appearance-transluscent/transparent dentin.
• As the microorganisms cause destruction to dentin, initially there
is an attempt to stop the advancement of caries by depositing the
minerals.

• There is a deposition of mineral in intertubular dentin.

• Zone is called “transparent zone”

• Odontoblasts also start depositing dentin.

• At the periphery of sclerotic dentin, dead tracts are present.

ZONE OF DEMINERALIZATION

•Narrow zone

•Occlusion of tubules

• Softer than normal dentin

•Peritubular dentin absent
•Few microorganisms in the tubules – “pioneer bacteria”

•Only walls of Dentinal tubule get decalcified

ZONE OF BACTERIAL INVASION
•Initially tubules with single type of bacteria

•Liquefaction foci-beadings, varicosities, moth-eaten,rosaries

• Decalcification is by bacterial acid diffusion

• Very narrow zone, softer than normal dentin

• Further loss of minerals from inter tubular dentin

• Large crystals within lumen of dentinal tubules

Zone of Decomposed Dentin / Infected Dentin
• Outermost zone, large scale destruction of dentin

• Foci of Miller join together

• Areas of dentin decomposition, occur perpendicular to dentinal

tubules

“Transverse Clefts”

• Mechanism of formation of Clefts - not known

• May follow course of incremental lines

• May result from coalescence of liquefaction of adjacent
tubules

• Also may rise by extensive proteolytic activity along

interconnecting lateral branches of odontoblastic processes

• Bacteria shift from dentinal tubules to the peri & inter tubular
dentin
 Zone of Decalcification with Bacterial
Invasion / Turbid Dentin
• Initially only few tubules are involved & micro-orgs also less
• Bacteria multiply within tubules & are seen in advancing front of
lesion
• Walls of tubules are thin & when micro-orgs penetrate, they cause
irregularities/distensions of walls ROSARY BEAD appearance
• Later, bacteria have proteolytic activity, areas of proteolysis
appear as spaces containing necrotic material & bacteria

• These areas are known as “Liquefaction Foci of Miller”.

• These areas vary in number & are parallel to dentinal tubules

 Root Caries
Root caries as defined by HAZEN, as a soft, progressive lesion that
is found anywhere on the root surface that has lost its connective
tissue attachment and is exposed to the environment.

The root surface must be exposed to the oral environment before

caries can develop here.
-The root surface must be exposed to the oral environment before
caries can develop here

-Micro-organisms invade the cementum either along the Sharpey’s

fibers or between the bundles of fibers.
• -spread laterally, since cementum is formed in concentric layers.

• -after decalcification of cementum, destruction of matrix occurs

similar to dentin with ultimate softening and destruction of this
tissue.

• -invasion of micro-organisms into the dentinal tubules, finally

leading to pulp involvement.

• -the rate is slower due to fewer dentinal tubules than crown area
 Histopathology:
• Outer surface of cementum – hyper mineralized, thus more caries
resistant

• Resistance due to:

• Reprecipitation of minerals from within

• Precipitation of minerals from Plaque

• Clefts formed, through which bacteria penetrate & cause tooth

structure destruction
• Penetration occurs along course of Sharpey's fibers

• Once cementum completely exposed & destroyed, underlying

dentin is involved.
1. A tooth surface without caries.
2. The first signs of demineralization.
3. The enamel surface has broken down.
4. A filling has been made but the demineralization has not
been stopped.
5. The demineralization proceeds and undermines the tooth.
6. The tooth has fractured