J Bagh College Dentistry

Vol. 22(2), 2010

Severity of dental caries

Severity of dental caries in relation to salivary parameters and inorganic compositions among a group of 22-23 years old adults in Baghdad city
Wejdan M. Al-Obaidi B.D.S. (1) Wesal A. Al-Obaidi B.D.S., M.Sc. (2)

ABSTRACT
Background: Dental caries is a wide spread chronic multifactorial disease. The secretion rate and quality of saliva are important factors not only in caries development but also for remineralization. The aim of this study was to measure the severity of dental caries among a group of 22-23 years old adults in relation to salivary flow rate, calcium and phosphate ions in unstimulated and stimulated saliva. Materials and methods: Unstimulated saliva was collected from one hundred healthy adults (males and females) first then the stimulated saliva with one hour interval. The sample was divided into three groups (mild, moderate and severe) according to (DMFS). Salivary flow rates were estimated as ml/min. Calcium ions were assessed using Atomic Absorption Spectrophotometer, while inorganic phosphate ions concentration were determined by MolybdenumVanadate method using Ulteaviolet visible spectrophotometer. Results: Highly significant difference of unstimulated salivary flow rate means was found among DMFS caries severity groups, recording highest mean in mild group with non significant correlations with DMFS. In relation to stimulated flow rate, significant difference was seen among DMFS severity groups, recording the highest mean within mild group and highly significant negative correlations with DMFS. Unstimulated salivary calcium showed highly significant differences among DMFS severity groups, where the highest means were in the severe group and recorded highly significant correlations with DMFS, while phosphate recording non significant differences among DMFS severity groups and non significant negative correlation with DMFS. In stimulated saliva, calcium showed highest mean values with highly significant differences in severe DMFS caries severity groups with highly significant correlation with DMFS, while phosphorus had significant highest mean within severe DMFS group and recorded non significant correlation with DMFS. Conclusions: The study showed the importance of stimulated salivary flow rate in reducing dental caries severity. Keywords: Dental caries, salivary flow rate, salivary calcium, salivary phosphate. (J Bagh Coll Dentistry 2010;22(2):118122).

INTRODUCTION
Dental caries is one of the most prevalent infectious diseases of man; it begins soon after the eruption of the teeth and can affects different surfaces at different ages (1). It involves the demineralization of the dental hard tissues by organic acids and ranges from initial lesions that confined to enamel then to dentinal lesions; which may ultimately exposed the pulp(2). Dental caries is a chronic complex disease; resulting from an imbalance between multiple risk factors and protective factors (3) in addition to interplay of three principles factors: host, microflora and substrate over the time (4,5). Saliva is the body's natural defense for the oral cavity. It plays a key role in lubrication, digestion, tissue repair, taste, dilution and cleansing effect, immunological protection and dental remineralization(6-8).

(1) M.Sc. student, Department of Pedodontic and Preventive Dentistry, Dental College, University of Baghdad. (2) Assistant professor, Department of Pedodontic and Preventive Dentistry, Dental College, University of Baghdad.

At present, saliva represents an increasingly useful auxiliary mean of diagnosis. Some researchers have made use of sialometry and sialochemistry to diagnose systemic illness, monitoring general health and as an indication of diseases risks; creating a close relation between oral and systemic health (9,10). It is generally accepted that saliva is of paramount importance for the maintenance of oral health. This is based on numerous studies that reporting functional lose in persons who lack the ability to produce adequate volumes of saliva(11-13). A chronically low salivary flow rate has been found to be a strongest salivary indicator for an increasing the risk for developing caries(14,15). Saliva can also influence caries processes through its composition; the main factors that controlling the stability of hydroxyapatite crystals are calcium, phosphate, fluoride and salivary pH(16,17). Many Iraqi studies have been done to investigate the relation between saliva and dental caries; some studied some of salivary constituents in relation to rampant caries in children (18,19), others studied salivary parameters and compositions in relation to dental caries in diseased persons (20-22). While some other studies

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assessed the relation of some of salivary constituents to caries severity in healthy persons in stimulated saliva only (23-25).While no previous Iraqi study available had been done to investigate the effect of both unstimulated and stimulated salivary parameters and inorganic composition in relation to dental caries severity in healthy adults. For this reason this study was conducted.

RESULTS
One hundred patients were participated in this study; the age was 22-23 years old. The sample was divided into three groups (mild, moderate and severe according to caries severity (DMFS) as shown in Table 1.

Table 1: Caries severity according to DMFS

Groups No. Caries severity DMFS values Mild 1-8 First 33 Moderate 9-16 Second 33 Severe ! 17 Third 34

MATERIALS AND METHODS

A total sample of one hundred persons was selected from 22-23 years old patients who attended College of Dentistry, University of Baghdad. The collection of resting (unstimulated saliva) was done in the morning between 9-12 Am, at least one hour after breakfast. Patient was asked to sit on an ordinary chair and in a relax position; the head and neck were bent and the arms were rested on the thigh or knees. Immediately before the test begins, patient was asked to swallow any residual saliva that may be present in mouth. Resting whole saliva was collected in sterile screwed tubes for 10 minutes by expectoration (26). After the foam was disappeared, salivary volume was estimated by using graduated cylinder, and then salivary flow rate was expressed as milliliter per minute (ml/ min). Dental examination was done after collection of whole unstimulated saliva. The dental examination was done using the criteria of WHO (27). Stimulated saliva was collected from the patient after 1 hour from collection of unstimulated saliva. Each patient was asked to chew a piece of Arabic gum (0.35- 0.4) gm for 1 minute, then removed all saliva by expectoration, after that chewing was continued for another 3 minutes with the same piece of chewing gum and saliva was collected in a sterile screwed tubes during this period(26). After that measuring volume and flow rate were done as for unstimulated saliva. All salivary samples were centrifuged at 3000 r.p.m for 10 minutes then the clear supernatants were separated by micropipette and stored in ( 200C) in a deep freeze for biochemical analysis within maximum period of three weeks. Biochemical analysis for salivary calcium was done by using Atomic Absorption Spectrophotometer, while inorganic phosphate concentration was determined by MolybdenumVanadate method a UV-visible Spectrophotometer. Analysis of variance (ANOVA) and correlation coefficient were used for statistical analysis, which were accepted when P value was less than 0.05 as the limit of significance and when P value was less than 0.01,they were regarded as highly significant.

Table 2: Caries severity (DMFS) and salivary flow rate of unstimulated and stimulated saliva
Unstimulated Stimulated flow rate flow rate Grade No. (ml/min) (ml/min) Mean SD Mean SD 33 0.34 0.22 1.63 0.78 Mild 0.46 Moderate 33 0.24 0.16 1.11 0.43 Severe 34 0.24 0.11 1.05 F = 9.61** * F = 3.16 P < 0.01 ANOVA P < 0.05 Correlation coefficient
*

r = - 0.19 P > 0.05 n = 100

**

r = - 0.33** P < 0.01 n = 100

Significant

Highly significant

Table 2 showed caries severity (DMFS) and unstimulated and stimulated salivary flow rate. For unstimulated saliva, ANOVA test revealed a significant difference for salivary flow rate. By using LSD test, the significant differences in means were found between (mild moderate) groups and (mild-severe) groups, for both the mean differences = 0.09, P< 0.05. The results showed non significant weak negative correlations between DMFS with unstimulated flow rate. For stimulated salivary flow rate, it was highly significant. LSD test for flow rate showed that the significant differences were between mildmoderate (mean difference = 0.05, P < 0.05) and mild-severe groups (mean difference = 0.56, P < 0.01). It was found that the correlation coefficient between flow rate and DMFS was negative weak highly significant.

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Table 3: Caries severity (DMFS) and inorganic compositions of unstimulated saliva

Grade NO. 33 Mild Moderate 33 Severe 34 ANOVA Correlation coeffecient Calcium# Phosphorus# Mean SD Mean SD 1.16 0.25 5.08 1.51 1.34 0.41 4.76 1.61 1.55 0.37 4.85 1.14 F= 9.99** N.S P < 0.01 r= 0.33 r = - 0.12 P < 0.01** P > 0.05 n = 100 n = 100

(mean difference= -0.45, P<0.01), moderatesevere (mean difference= -0.22, P<0.01). While for phosphorus, the only significant difference was found between mild and severe groups (mean difference= -0.66, P<0.05). Correlation coefficients between DMFS and salivary calcium was weak positive highly significant, while for phosphorus it was not significant ( P> 0.05).

DISCUSSION
It is generally accepted that salivary secretion and components are important for dental health and any changes may compromise the integrity of soft and hard tissues in the oral cavity (7,28,29). Unstimulated and mechanically stimulated whole saliva (with 1 hour interval) were collected under standardized conditions; including time of day the samples were collected and duration of stimulation (for stimulated saliva)(30). In this study, unstimulated flow rate range from (0.24 0.34) ml/min, for stimulated saliva, it was (1.021.63) ml/min, both were within normal ranges. Unstimulated salivary flow recorded significant highest mean in mild caries DMFS group. Unstimulated flow rate also showed inverse but not significant correlations with DMFS, these findings were in agreement with some studies (31,32) who found a non significant, inverse correlation between unstimulated flow rate and DMFS. Farsi (33) studied the relation of unstimulated flow rate to DMFS caries severity and found non significant difference among three caries groups. The results were in disagreement with Bardow et al (34) and Dodds (35) who found a significant association with DMFS. Regarding stimulated salivary flow rate, significant highest mean was recorded in mild DMFS grouyp. Inverse highly significant correlations were also seen between DMFS and stimulated salivary flow. This explain the importance of stimulated flow rate in the dilution and cleansing effect, which helps to remove non-adherent bacteria, cellular and food debris and eliminate excess carbohydrates and consequently retard dental plaque formation (13,36). The results was in agreement with many studies (23,32,37,38) and in disagreement with others (33,39). The other important salivary variables in relation to dental caries are its constituents; Saliva composed mainly of water plus inorganic ions and organic substances (17). High concentration of calcium and phosphate in saliva guarantee the ionic exchanges that directed towards the tooth surfaces and resulting in post-eruptive maturation. Remineralization of a carious tooth before cavitation is then possible, mainly due to the availability of calcium and phosphate in the oral

# Expressed in mMol/L ** Highly significant

Table 3 shows that mean values for unstimulated salivary calcium was highest in the third group (severe) while for phosphorus, the first group (mild) had the highest mean. Results showed highly significant differences among dental caries severity groups regarding salivary calcium; in contrast to phosphorus which was not significant (P>0.05). LSD test showed that for calcium; there were significant differences among all groups, mild-moderate (mean difference= 0.18, P<0.05), mild-severe (mean difference= 0.38, P<0.01) and moderate-severe (mean difference= -0.20, P<0.05). Correlation coefficients were found to be weak positive highly significant between DMFS and salivary calcium. For salivary phosphorus, the relation was negative weak non significant (P > 0.05).

Table 4: Caries severity (DMFS) and inorganic compositions of stimulated saliva

Grade No. 33 Mild Moderate 33 Severe 34 ANOVA Correlation coefficient Calcium# Phosphorus# Mean SD Mean SD 1.06 0.15 3.39 0.89 1.29 0.32 3.62 1.17 1.52 0.35 4.06 1.19 F =20.41** F = 3.25* P < 0.01 P < 0.05 r= 0.37** r= 0.80 P <0.01 P> 0.05 n=100 n=100

# Expressed in mMol/L * Significant, **Highly significant

For stimulated saliva, results showed that the highest means of calcium and phosphorus were found in the third group as shown in Table 4. Significant differences were found among caries severity groups regarding salivary calcium and phosphorus. When used LSD, for salivary calcium highly significant differences among all caries severity groups were recorded, mild-moderate (mean difference= - 0.23, P<0.01), mild-severe

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fluid (30). In this study, unstimulated salivary calcium showed significantly highest mean in severe DMFS group with positive significant correlations with DMFS. This result was in disagreement with Cornejo et al (40) who found a non significant difference among DMFS caries severity groups and a non significant correlation between DMFS and unstimulated salivary calcium. Calcium in stimulated saliva also showed the same results in relation to DMFS; in contrast to Lenander-Lumikari et al (29) who found a negative not significant correlation with DMFS. Sulaiman (23) found that mean value of calcium in stimulated saliva was significantly higher in low caries experience group. The findings of this study demonstrated that both unstimulated and stimulated salivary calcium were increased with increasing caries severity, which may be attributed to increase demineralization of hydroxyapatite crystals of the teeth and increase calcium concentration in the surrounding fluid (saliva and dental plaque) (41). In addition to that, calcium ion is essential for bridging microbial adhesion and facilitates bacterial agglutination (42). Relations of unstimulated and stimulated salivary phosphorus to the severity of dental caries were also studied, there was a non significant difference among mean values of unstimuled salivary phosphorus, in spite of recording the highest mean in mild DMFS caries group. In addition to that, salivary phosphate showed inverse not significant correlations with DMFS, which is in agreement with Gandhy and Damle (43). The negative correlation of unstimulated salivary phosphate with dental caries may be due to its cariostatic action and its role as a buffer and in remineralization of the teeth (44). In addition to that, phosphate can probably interfere with the adherence of pellicle and plaque bacteria to the enamel surface and also can inhibit bacterial growth (45). Phosphate in stimulated saliva revealed a significant highest mean in severe DMFS caries group. Positive not significant correlations were recorded with DMFS. This is in disagreement with Sulaiman (23) who found that the low DMFS caries group had the highest phosphorus level.

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