Dental Caries

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DENTAL CARIES
Dr RAHUL PANDEY
1 ST YEAR MDS
DEPARTMENT OF PEDIATRIC AND PREVENTIVE DENTISTRY
BATCH 2020 5
UNDER THE GUIDANCE
Dr. AVANTIKA TULI Dr. ANSHDEEP SINGH

PROFESSOR & HEAD READER
DEPARTMENT OF PEDIATRIC DEPARTMENT OF
AND PREVENTIVE CONSERVATIVE DENTISTRY
DENTISTRY AND ENDODONTICS
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Introduction
Definition
Etiology
Pathophysiology
CONTENTS Classification
Diagnosis
Prevention
Intervention
Conclusion
7
INTRODUCTIO
N:
Latin : caries = rot or decay
It is akin to Greek word Ker for death.
Dental caries or tooth decay is a pathological process of localized destruction of

tooth tissues by microorganisms.
8
Newbrun E. Cariology, 3rd edition, Quintessence Pub. Co, Chicago; 1989: 4-35

Definition:
• “Dental caries is defined as a
pathological process of
localized destruction of tooth
tissues by microorganisms.”
by Ernest Newbrun (1989).
Machiulskiene et al. Terminology of Dental Caries and Dental Caries Management: Consensus report of a workshop organised
9
by ORCA and Cariology research group of IADR, Caries Research, 2020;54:7-14.

Definition:
• “Dental caries is an
irreversible microbial disease
of the calcified tissues of the
teeth, characterized by
demineralization of the
inorganic portion and
destruction of the organic
substance of the tooth, which
often leads to cavitation.” by
Shafer (1993).
10

Definition:
• Dental caries is a biofilm-
mediated, diet modulated,
multifactorial, non-
communicable, dynamic
disease resulting in net
mineral loss of dental hard
tissues by Fejerskov 1997;
Pitts et al., 2017.
11

Review of literature:
In 2011, Janakiram C et al, conducted a meta-analysis
According to NOHS conducted by DCI in to assess the prevalence of dental caries in India among
2004, 12 and 15 year old children, the the WHO index age groups. the total number of
prevalence of caries was found to be 81% and children in the age-group 0-6 years were reported as
93.4% respectively. 158.79 million. Nearly half of them, that is, around
79.4 million are affected by ECC in India.
Ganesh A, Muthu MS et al, 2019, systematic review on

prevalence of ECC in India concluded that there was an
overall prevalence of 49.6% and 44.3% in Uttarakhand.
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ETIOLOGY
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Early Theories of Caries Etiology
THE LEGEND OF THE WORMS
• Earliest reference to tooth decay & tooth pain came from

ancient Sumerian text known as the ‘Legend of the worms’
(5000 BC).
Shafer, William G, Maynard K. Hine, and Barnet M. Levy. A Textbook of Oral Pathology. 7th Edition, Elsevier Publications,
Philadelphia: Saunders; 2012.
ENDOGENOUS THEORIES
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HUMORAL THEORY
• Greek physicians
• Galen – ‘dental caries is produced by internal action of acid & corroding humors’. An
imbalance results in disease
• Hippocrates: accumulated debris around teeth, local & systemic factors – cause of caries
• Aristotle: soft, sweet figs adhere to teeth – caries
EXOGENOUS THEORIES
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CHEMICAL(ACID) THEORY
Parmly (1819)
Unidentified Dental decay –
Robertson (1835)
‘chymal agent’ acid formed by
– caries
Regnart (1938)
fermentation of Inorganic
food around teeth acids corroded
enamel &
dentin
PARASITIC (SEPTIC) THEORY
1843
Erdl
• Filamentous parasites in the membrane
removed from teeth
Ficinus
• Observed filamentous microbes in carious
lesions – Denticolae
1847
CHEMO-PARASITIC THEORY
• Willoughby D Miller (1890):
• Acids & Microorganisms – Decay
MILLER’S FINAL
CONCLUSION
“ Dental decay is a chemo-parasitic process consisting

of two stages: decalcification or softening of the
tissues and dissolution of the softened residue. In case
of enamel, however, the second stage is practically
wanting, the decalcification of enamel signifying its
total destruction”.
PROTEOLYTIC THEORY
• According to theory – organic component is more vulnerable & is attacked by hydrolytic
enzymes
Gottlieb (1944): Frisbie (1944) Pincus (1949):
• Initial action due to • Describes caries as • Proteolytic enzymes
proteolytic enzymes proteolytic process first attack protein
attacking lamellae, involving elements – dental
rod sheaths, tufts & depolymerization & cuticle& destroyed
walls of dentinal liquefaction of prism sheaths
tubules organic matrix of
enamel
PROTEOLYSIS-CHELATION THEORY
• Schatz et al (1955): Simultaneous microbial degradation of organic components
(proteolysis) & dissolution of minerals of tooth (chelation)
Decalcification is mediated by
Break down products of this
variety of complexing agents –
Initial attack is essentially on organic matter have chelating
anions, amino acids, peptides,
organic components of enamel properties & there by dissolve
polyphosphates, &
minerals in enamel
carbohydrate derivatives
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CURRENT CONCEPT OF CARIES ETIOLOGY
Caries – multifactorial disease

3 principal factors:
> host - tooth
> microflora - microorganisms
> substrate – diet
A fourth factor time is considered
Houte JV. Role of micro-organisms in caries etiology. J Dent Res 1994, 73(3):672-
681.
HOST
SUBSTRATE FLORA
KEYE’S RINGS (1962)
Houte JV. Role of micro-organisms in caries etiology. J Dent Res 1994, 73(3):672-681.
NEWBRUN’S CONCEPT (1989)
HOST
SUBSTRATE FLORA
TIME
Houte JV. Role of micro-organisms in caries etiology. J Dent Res 1994, 73(3):672-681.
Nikiforuk 1985–primary and secondary factors --- Geddes 1991- saliva
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Ritter A, Boushell LW, Walter R. Sturdevant’s Art and Science of Operative Dentistry, 7 th Edition, Elsevier Publications, 2019.
PATHOPHYSIOLOG
Y OF CARIES
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Critical pH
•Stephan MR. Intra-Oral Hydrogen-Ion concentrations

associated with dental caries activity. J Dent Res, 1944;
257-70.
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Sugar clocks
(Johansson and Birkhed 1994)
Frequent eating - Acid
No acid formation
FLORA
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3 Genera:
We have a lot of circumstantial evidence for organisms in three
genera as the initiators of caries:
Streptococcus
Lactobacillus
Actinomyces
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Ritter A, Boushell LW, Walter R. Sturdevant’s Art and Science of Operative Dentistry, 7 th Edition, Elsevier Publications, 2019.
Levine’s Ionic Seesaw theory:
Movement of minerals Levine proposed that the

demineralization and
Levine 1977 across Plaque, Tooth and remineralization of enamel is
Saliva. a continuous process.
If in a given interval of time,

This theory emphasizes the
more ions leave the enamel than It was proved that the ions are importance of pH of plaque,
enter it, then there is a net
demineralization, which heralds constantly exchanged between calcium and phosphate ion
enamel and plaque. concentration at the interphase
the beginning of the carious
and fluoride ion concentration.
process.
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CLASSIFICATION OF
CARIES
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Based on Based on Based on Based on
location: severity: extension: chronology:
Enamel Early childhood

Pit & Acute caries : nursing
fissure caries caries bottle caries
caries
Chronic Dentinal Teenage caries :
caries caries rampant caries
Smooth
surface Arrested Cemental
caries Adult caries :
caries caries root caries
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Mount & Hume
Classification:
•Mount GJ, Hume WR. A

new cavity classification,
Australian Dental Journal,
1988;43(3):153-9.
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Who classification
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International Caries Detection and Assessment System (ICDAS) Coordinating Committee, 2009.
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DIAGNOSIS OF
CARIES
61
•Ritter A, Boushell LW, Walter R.
Sturdevant’s Art and Science of Operative
Dentistry, 7th Edition, Elsevier Publications,
2019.
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MACRO DENTISTRY
G.V BLACKS
“EXTENSION FOR
ift
PREVENTION”
m sh
d i g
r a
Pa
MICRO
DENTISRY
“PREVENTION
OF EXTENSION”
• Objectives of diagnosis:
• Identifying lesions requiring surgical treatment
• Identifying lesions requiring non-surgical treatment
• Persons at high risk for developing caries
• Thus diagnosis / detection done using:

• Clinical criteria
• Tools
• Newer refined diagnostic /detection tools
Shift paradigm “ Restoration to Conservation”

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Visual & Tactile Examination
• The Visual method- used by many
General practitioners
• The Visual-Tactile method
11-12-06 Caries detection & diagnosis 66

Sharp eyes but
blunt probe
The enamel is
damaged by
forceful probing
with sharp sickle
probes, so probes
used to examine
occlusal surfaces
should be blunt
and the probing
forces light.
Caries detection using electric currents
• Rationale:
Caries
Increase in porosity of tissue (enamel or dentine)
Higher fluid content than sound tissue
Difference detected by electrical measurement by decreased electrical

resistance or impedance
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Electronic caries monitor (ECM)
(a) ECM machine
• Rationale (b) ECM handpiece
• employs a single, fixed- (c) site specific measurement technique
frequency alternating current
(d) surface specific measurement
• measures ‘bulk resistance’ of technique
tooth tissue at site or surface
level
• Mechanism of action
• Increase in porosity associated
with caries
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Conventional Radiograhy
Advantages
• Discloses sites inaccessible to other
methods
• Detects at early , reversible stage
• Permanent record
• Non-invasive
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Digital Subtraction Radiography
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FIBRE-OPTIC
TRANSILLUMINATIO
N
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Fibre Optic Transillumination
Can detect Discriminate b/w Detection of Particularly

Used in anteriors
Enamel crazing, early En & Dn caries on all useful at
& PMs
cracks lesions surfaces proximal lesions
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DIFOTI (DCNA 2005)
• Components
• 2 handpieces
• for smooth surface
• for occ
• Disposable mouth piece
• Foot control for selecting the images
• Computer
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Correct placement of
proximal mouthpiece
PROCEDURE
Position the hand piece
Image review
11-12-06 Caries detection & diagnosis 79

QUANTITATIVE LASER/LIGHT FLUORESCENCE
• Bejelkhagen & Sundstrom (1981)

• Components
• light box containing a xenon bulb
• Handpiece with bandpass filter
• Mechanism
• argon laser-488 nm
• Xenon arc lamp – 370 nm
Omnii InspektorPro QLF

Caries detection & diagnosis 80
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CARIES DETECTOR DYES
• 0.5% basic fuschin in propylene glycol
• Deminr dentin – denatured collagen
• Acid red
• Silver nitrate, Methyl red, Alizarin stain
• Lack of evidence for use of dyes to detect underlying dentinal

caries (McComb, J Can Dent Assoc, 2000)
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Laser fluorescence—DIAGNODent
• 1985, Sundstrom et al.

• Various excitation wavelengths – no fluorescence in
visible range (633 nm)
• Hibst and Gall , 1998
• red light (638–655 nm)-induced fluorescence
• KaVo DIAGNOdent (KaVo, Biberach, Diagnodent
pen
Germany),
• laser-based instrument for detection and quantification
of dental caries on smooth & occlusal surfaces.
• 655 nm red laser light and 1 mW peak power
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• 0 and 99 and adjustable sound
• Readings (Tam & McComb, J Can Dent Assoc, 2001):
• 5-25: initial lesions
• 25-35:early dentinal caries
• > 35: advanced dentinal caries
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Chairside Investigations:
•Cariostat
•Oratest
•Dentocult
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International Caries Detection and Assessment System (ICDAS) Coordinating Committee, 2009. 87
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PREVENTIVE
MEASURES
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PARADIGM SHIFT
Caries risk assessment
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Levels of prevention
Tertiary
Secondary
Primary
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PRIMARY PREVENTION
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SUGAR SUBSTITUES
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Xylitol
• Frequency – 3 times a day.
Caries prevention
• Turku 1975- 90% reduced
Lynch H, Milgrom P. Xylitol and dental caries: An overview for clinicians, J Calif Dent Assoc, 2003;31(3):205-9.
Sorbitol
• Less effective than
xylitol.
• Blocks transmission
of mutans
streptococci from
mother to child.
• Laxative at high
doses.
• Slack et al 1964- 48%
reduction
Burt AB. The use of sorbitol and xylitol sweetened chewing gum in caries control, JADA, 2006;137:190-197
MINIMAL
INTERVENTION
DENTISTRY
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REMINERALISING
AGENTS
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Jingarwar MM, Bajwa NK, Pathak A. Minimal Intervention Dentistry – A new frontier in clinical dentistry, Journal of clinical102and
diagnostic research, 2014;8(7):4-8
NOVAMIN
•Jingarwar MM, Bajwa NK,

Pathak A. Minimal
Intervention Dentistry – A
new frontier in clinical
dentistry, Journal of clinical
and diagnostic research,
2014;8(7):4-8
104
Tricalcium phosphate:
Nano hydroxyapatite:
Enamelon:
MINIMAL
INTERVENTION
TECHNIQUES
Chemo mechanical Caries Removal (CMCR)
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Carisolv
•Jingarwar MM, Bajwa NK, Pathak A. Minimal

Intervention Dentistry – A new frontier in clinical
dentistry, Journal of clinical and diagnostic
research, 2014;8(7):4-8
111
Papacarie
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Air abrasion
Ultrasonic instrumentation
lasers
Conclusion
Caries management efforts must be directed not at the tooth level
(traditional or surgical treatment) but at the total-patient level
(medical model of treatment).
Restorative treatment does not cure the caries process.
Instead, identifying and eliminating the causative factors for caries

must be the primary focus, in addition to the restorative repair of
damage caused by caries.
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References:
• Newbrun E. Cariology, 3rd edition, Quintessence Pub. Co, Chicago; 1989: 4-35.
• Machiulskiene et al. Terminology of Dental Caries and Dental Caries Management: Consensus report of a workshop
organised by ORCA and Cariology research group of IADR, Caries Research, 2020;54:7-14.
• Fejerskov, O, and Anders Thylstrup. Textbook of Clinical Cariology Ed. by Anders Thylstrup; Ole Fejerskov.
Copenhagen: Munksgaard, 1996.
• Shafer, William G, Maynard K. Hine, and Barnet M. Levy. A Textbook of Oral Pathology. 7th Edition, Elsevier
Publications, Philadelphia: Saunders; 2012.
• Stephan MR. Intra-Oral Hydrogen-Ion concentrations associated with dental caries activity. J Dent Res, 1944; 257-70.
• Usha C, Satyanarayanan R. Dental caries – A complete changeover (Part I), J Conserv Dent., 2009; 12(2): 46-54
• Dean AJ, Jones JE, Vinson LA. McDonald & Avery’s Dentistry for the child and adolescent. 10 th Edition, 2016,
Elsevier Inc, USA; 303-327.
• Ritter A, Boushell LW, Walter R. Sturdevant’s Art and Science of Operative Dentistry, 7 th Edition, Elsevier
Publications, 2019.
118
References:
• Usha C, Satyanarayanan R. Dental caries – A complete changeover (Part II), J Conserv Dent., 2009; 12(3):
87-100.
• Islam B, Khan SN, Khan AU. Dental caries: From infection to prevention, Med Sci Monit, 2007;
13(11):196-203.
• Smith DJ. Dental caries vaccines: Prospects and concerns, Crit Rev Oral Biol Med 2002; 13(4):335-249.
• Houte JV. Role of micro-organisms in caries etiology. J Dent Res 1994, 73(3):672-681.
• Femiano F, Femiano R, Femiano L, Jamilian A, Rullo R, Perillo L. Dentin caries progression and the role of
metalloproteinases: an update, Eur J Pediatr Dent 2016;17(3):243-247.
• Jingarwar MM, Bajwa NK, Pathak A. Minimal Intervention Dentistry – A new frontier in clinical dentistry,
Journal of clinical and diagnostic research, 2014;8(7):4-8
• International Caries Detection and Assessment System (ICDAS) Coordinating Committee.
119
References:
• Scheie AA:Mechanismof denta plaqueformation. Adv Dent Res.1994;8:246-53.
• Harper DS, Loesche WJ. Growth & tolerance of human dental plaque bacteria. Arch Oral Biol.1984;29:843-8.
• Trahan L. Xylitol- a review of its action on mutans streptococci & dental plaque—its clinical significance. Int
Dent J.1995;45:77-92.
• Marrquis RE. Oxygen metabolism, oxidative stress & acid-base physiology of dental plaque biofilms. I Ind
Microbiol,1995;15:198-207.
• Mount GJ, Hume WR. A new cavity classification, Australian Dental Journal, 1988;43(3):153-9
• Lynch H, Milgrom P. Xylitol and dental caries: An overview for clinicians, J Calif Dent Assoc,
2003;31(3):205-9.
120
ACKNOWLEDGEMENT
Dr. HIMANSHU AERAN
DIRECTOR PRINCIPAL
PROFESSOR AND HEAD
DEPARTMENT OF PROSTHODONTICS
AND CROWN & BRIDGE
121
Dr. AVANTIKA TULI Dr. ANSHDEEP SINGH
PROFESSOR & HEAD READER
DEPARTMENT OF DEPARTMENT OF
PEDIATRIC AND CONSERVATIVE DENTISTRY
PREVENTIVE DENTISTRY AND ENDODONTICS
122
Dr. AMRINDER TULI
PROFESSOR AND HEAD
DEPARTMENT OF PERIODONTICS
Dr. VARUN KUMAR

PROFESSOR
DEPARTMENT OF PROSTHODONTICS
AND CROWN & BRIDGE
123
Dr. S. KARPAGAVALLI
PROFESSOR AND HEAD
DEPARTMENT OF ORAL MEDICINE
AND RADIOLOGY
DR. TARUN KUMAR

PROFESSOR
DEPARTMENT OF ORTHODONTICS
124
Dr. AVANTIKA TULI
PROFESSOR AND HEAD
DEPARTMENT OF PEDIATRIC
AND PREVENTIVE DENTISTRY
Dr. KULWANT RAI

READER
DEPARTMENT OF CONSERVATIVE DENTISTRY
AND ENDODONTICS
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1

Dr. AVANTIKA TULI Dr. ANSHDEEP SINGH

Latin : caries = rot or decay

It is akin to Greek word Ker for death.

Dental caries or tooth decay is a pathological process of localized destruction of

Newbrun E. Cariology, 3rd edition, Quintessence Pub. Co, Chicago; 1989: 4-35

by ORCA and Cariology research group of IADR, Caries Research, 2020;54:7-14.

by ORCA and Cariology research group of IADR, Caries Research, 2020;54:7-14.

by ORCA and Cariology research group of IADR, Caries Research, 2020;54:7-14.

Ganesh A, Muthu MS et al, 2019, systematic review on

• Earliest reference to tooth decay & tooth pain came from

“ Dental decay is a chemo-parasitic process consisting

• Schatz et al (1955): Simultaneous microbial degradation of organic components

(proteolysis) & dissolution of minerals of tooth (chelation)

Caries – multifactorial disease

A fourth factor time is considered

KEYE’S RINGS (1962)

•Stephan MR. Intra-Oral Hydrogen-Ion concentrations

Frequent eating - Acid

Movement of minerals Levine proposed that the

If in a given interval of time,

Enamel Early childhood

Philadelphia: Saunders; 2012.

•Mount GJ, Hume WR. A

• Thus diagnosis / detection done using:

Shift paradigm “ Restoration to Conservation”

11-12-06 Caries detection & diagnosis 66

Increase in porosity of tissue (enamel or dentine)

Higher fluid content than sound tissue

Difference detected by electrical measurement by decreased electrical

Can detect Discriminate b/w Detection of Particularly

Position the hand piece

11-12-06 Caries detection & diagnosis 79

• Bejelkhagen & Sundstrom (1981)

Omnii InspektorPro QLF

• Silver nitrate, Methyl red, Alizarin stain

• Lack of evidence for use of dyes to detect underlying dentinal

• 1985, Sundstrom et al.

•Jingarwar MM, Bajwa NK,

•Jingarwar MM, Bajwa NK, Pathak A. Minimal

Restorative treatment does not cure the caries process.

Instead, identifying and eliminating the causative factors for caries

Dr. VARUN KUMAR

DR. TARUN KUMAR

Dr. KULWANT RAI

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