An infectious microbial

disease that begins as

demineralization of
inorganic portion of tooth,
followed by destruction of
organic portions, leading
to cavity formation

ASYMPTOMATIC until it reaches advanced

stage.

Worm theory

Humour
theory

Parasitic
theory

Vital theory

Chemical
theory

Acidogenic
theory

Proteolytic
theory

Proteolysischelation
theory

Sucrosechelation
theory

Microorganism

Substrate

Host

Time

Cariogenic bacteria + cariogenic diet + plaque

Acid production
Subsurface demineralization
Continuous sucrose consumption

Initial lesion
Repeated attack of cariogenic challenge

Progression of carious lesion

More of mineral loss

Destruction of organic matrix

Cavitation

However
This progress can be arrested at any stage of
development due to

SALIVA
Calcium &
Phosphate
Fluoride
Ammonia

Comparison between solubility product (Ksp) and

ion product (Ip)
Ip > Ksp, saliva is saturated with Ca & P, promote
remineralisation

Formation of fluoroapatite crystal

Retard plaque formation

Neutralize acid in oral cavity

SALIVA
Bicarbonate

Diffuse across plaque and neutralise acid underneath

it

Antibacterial
substance

Lysozyme
Lactoperoxidase
Lactoferrin
IgA

Quantity and
viscosity

Remove food debris and bacteria from oral cavity

Spread of caries

ENAMEL CARIES
Surface
layer
Body of
lesion
Dark zone

Translucent zone
Pits & fissure caries

Smooth surface caries

From

ENAMEL

caries can spread to

DENTIN via

DENTINAL CARIES
Zone of decomposed dentin

Zone of bacterial invasion

Zone of decalcification

Sclerotic zone
Zone of fatty
degeneration
of Tomes fibre

Inflammation of pulp
The stage where caries is associated with toothache

It may be reversible or irreversible (pain persists when

stimulus is removed.
Reversible pulpitis may be treated with restoration while
irreversible pulpitis is indicated for RCT or extraction
Further progression of dental caries without treatment may
lead to periapical lesion.

Streptococcus mutans
Lactobacillus sp.
Actinomyces sp.
Other: S. salivarius, S. sanguis, Veilonella sp.
etc

Initiation of caries is associated with S. mutans

Because it can attach to tooth surface by 2 mechanisms:
1. Sucrose-independent adsorption through specific
extracellular proteins on its fimbriae
2. Sucrose-dependent mechanisms it converts sucrose
to sticky extracellular polysaccharide (glucan)
It is also:
1. Can produce lactic acid from sugar substrates
2. Can resist aciduric & acidogenic environment due to
phosphoenolpyruvate-phosphotransferase mechanism
3. Can produce intracellular polysaccharide (reservoir)

While progression of caries is associated with Lactobacillus

sp.

Type of caries

Microorganisms

Pits & Fissures

S. mutans
S. sanguis
Lactobacillus sp.
Actinomyces sp.

Smooth surface

S. mutans
S. salivarius

Root surface

A. viscosus
A. naeslundii
S. mutans
S. sanguis

Deep dentinal caries

Lactobacilli sp.
A. naeslundii
Other filamentous rods

PERIODIC SURVEYS OF ADULTS & ITS

FINDINGS

Caries Prevalence
90.3%, with female(91.4 %) > male (88.9%)
Rural (90.9%) > urban (89.9%)
Chinese (92.6 %) > Ibans (92.1%) > Malays
(90.9%) >Bumiputeras (89.3%) Indians/Pakistani
(82.5%).
Almost similar in all 3 education level, Level 1
89.7, Level 2 88.8%, Level 3 91.1%.

Caries prevalence by age group

Caries Severity
Measured using the DMFX(T) index.
Mean
Age Group

DMFX

15 - 19

0.66
(0.04)

0.29
(0.06)

1.63
(0.06)

0.27
(0.03)

2.85
(0.10)

35 - 44

1.03
(0.03)

7.77
(0.20)

2.11
(0.10)

1.20
(0.07)

12.11
(0.21)

65 - 74

0.41
(0.04)

21.17
(0.50)

0.25
(0.05)

1.36
(0.11)

23.20
(0.46)

0.85
(0.02)

7.87
(0.15)

1.68
(0.05)

0.94
(0.03)

11.34
(0.15)

Total

Mean D,M,F and X components of DMFX Per Subject by

Index Age Group, 2000

 Mean DMFX was:

higher for female(12.4) than male(10.0).
Higher for rural population(12.1) than urban
population(10.8).
Highest in Chinese(13.2), simlar in Malays and
Ibans(11.3) and lowest in Kadazans(6.3).
Higher in Level 3 subjects(13.5), while Level 1
and 2 subjects exhibit almost similar mean
DMFX of 7.5 and 7.7 respectively.

INTERNATIONAL DATA
Since 1990, continued change in global pattern
of oral diseases.
Dental caries found to increasein developing
countries, while in developed countries the
caries situation seems to be stable or on
decline.
Summarised that preventive measures,
especially flouride from a variety of sources,
have brought about the decline in developed
countries.

 WHO Oral Health Country/Area Profile Programme

for various age groups has archived invaluable date
on oral health status.
A comparison of dental caries data in the 1990s
between Malaysia and other countries is shown.

IMPACTS OF ORAL CONDITION

Oral health related quality of life

Disruption of daily activities

 Socialisation

Disruption of daily activities

Utilization of oral Health services

Utilisation of oral health services 2000

Last dental check-up and reasons for

last dental check up
Rank

1
2
3
4
5
6
7
8

Reason

Something wrong
Part of the school dental programme
Thought it was time
Part of a series of treament
Antenatal programme
Referral
Reinders
Other reasons

Percentage

44.5
18.5
13.3
11.4
2.8
2.4
0.6
6.6

 Male and female did not differ in reasons.

Urban population were more likely to seek care
because it was time as compared to rural
population, which sought care more because
something is wrong or as part of the antenatal
programme.
The more highly educated population were more
likely to seek care because of reasons such as it
was time, a reminder from the dentist, or other
reason.
Lower education level population were more
likely to seek treatment as part of the school
programme or only when they sensedthat
something was wrong.

 Amongst the various age groups, the main

reason for the last dental check-up were
invariably something is wrong except for the
15-19 age group whom treatment were mostly
related to school dental programme.
The 20-24 and 25-29 age groups have the
highest proportions that sought treatment
because the thought it was time for
examination/cleaning.

Reasons for not seeking treatment

within the last 2 years
Rank

Reason

Percentage

1
2
3
4
5
6
7
8
9
10
11
12
13
14

No problem
Problem not serious
Too busy
No teeth/ False teeth
Fear treatment
Other reason
Expected problem to go away
Location too far
Bad experience
Physical problems
Cannot afford
Did not want to spend money
Required appointment
Dentist would not give appointment

61.7
10.7
9.5
6.6
5.0
2.4
1.3
0.8
0.6
0.5
0.3
0.2
0.2
0.1

Facility Used

In radiotherapy patients, rampant caries occur

due to decrease in salivary flow.
Prevention at earliest level should be done to
control the caries. Extraction of tooth in
radiotherapy patients may lead to

Dental visit every 3 months

Measure stimulated salivary flow every 3 months

Reinforce the importance of avoiding sweet drinks & snacks

Use of saliva substitute

Daily 0.05% Sodium Fluoride mouthrinse

1% chlorhexidine gel in custom made tray for 5 mins, every night

*sodium lauryl sulphate*

Avoid smoking, alcohol & caffeine-based drinks

MANAGING CARIES IN GERIATRIC

PATIENTS

 In elderly, caries often progresses slowly along

the CEJ resulting in root caries.
This is due to exposed root surface, poor oral
hygiene, reduced salivary flow and high sugar
diet.
May cause sensitivity and pain
May progress and eventually affect the vitality of
the tooth.

 Management
Effective brushing using flouride toothpaste.
Use of dental floss and interdental sticks to
clean between teeth.
Reduce sugar intake.
Regular dental check-up.

Managing caries in diabetic

patients

Effect of diabetes on dental caries rate?

since most diabetic
patients limit their
intake of fermentable
carbohydrate less
cariogenic diet

associated with
xerostomia and
increased gingival
crevicular fluid
glucose level

Caries management consideration

Preoperative

Intraoperative

Diabetic
Emergency

Postoperative

Preoperative
Medical history
- ask pt about recent blood glucose level
- frequency of hypoglycemic episodes
- antidiabetic medications, dosage and time of administration

Scheduling of visit
- should receive dental treatment in the morning (higher cortisol
level)
- pt under insulin therapy avoid period of peak insulin activity

 Diet
- ensure patient has eaten normally and take medications as usual
- if patient skip meals but has taken insulin as usual increased risk
for hypoglycemia

Blood glucose monitoring

- Check the pretreatment blood glucose level using glucometer
- Lowblood glucose level (<70 mg/dl) give oral carb before
treatment
- Significantly high blood pressure refer to clinician

Glycated haemoglobin values

- <8% - good glycemic control, >10% indicate poor control

Intraoperative
Adequate control and stress reduction
- Anesthesia- reduces pain and minimize endogenous
epinephrine release
- Conscious sedation for extremely anxious patient

Diabetic emergency
Terminate dental treatment
Administer 15g of fast acting oral carbohydrates glucose
tablets, sugar, candy, soft drinks, juice
Measure blood glucose level to confirm determine if
repeated carbohydrate dosing is needed
If patient unable to swallow/ unconcious
give 25-30 ml of a 50% dextrose
solution i.v or 1 mg of glucagon
i.v./i.m./s.c.
Hyperglycemic crisis usually have
prolonged onset lower risk in dental
practice

Postoperative
Patient with uncontrolled diabetes have greater risk of getting
infection give antibiotic
If normal dietary intake is affected modify insulin or oral
antidiabetic medication dosage (consult physician)
Avoid prescribing aspirin salicylates can increase insulin
secretion and sensitivity - hypoglycemia

Caries Preventive Methods

Dietary
measures
Elimination

Modifying
microflora

nidus of
bacteria

Caries
Preventive
Method
Modifying
tooth
surface

Plaque
disruption

Stimulating
saliva flow

Dietary measures
Decreased frequency of meals
- only eat during mealtimes
- to decrease number, duration and intensity of acid attack
- limit to 4 meals per day reduces the retention period of sugar and
number of drops in pH

Eliminate sticky, sugar containing products with

prolonged sugar clearance times

 Use of sugar substitute

- xylitol, sorbitol, saccharin and aspartame
- Regular use of xylitol reduce number of
S. mutans in saliva and plaque

Protective food elements

Phosphate (cereals) :
prevent loss of phosphorus from enamel during demineralization
Helps in remineralization
Inhibit bacterial growth

- Fats :
Reduce the cariogenicity of different foods
Some fatty acids have antimicrobial effect

Cheese :
Reduce level of cariogenic bacteria
Increases flow of saliva and its buffering capacity
Provides organic phosphates for remineralization

Snackings
Choose less sticky snack and fast clearing
No snacks in between meals
Brush the teeth immediately after eating
Example of safe snacks?

Modifying microflora
Achieved by intensive antimicrobial treatment
that is capable to:
- Inhibit bacterial colonization-adhesion
- Affect plaque growth-metabolic activity

Characteristics of ideal antimicrobial

treatment:
- Not interfering in other biological process
- Harmless to mucosa
- Low toxicity

Plaque disruption
Brushing

 Flossing

 Mouthwash

Modifying tooth surface

Systemically administered fluoride
- Drinking water, salt, milk, tablets, lozenges, chewing gum,
drops.
- Optimal fluoride level : 1 ppm of fluoride

Topically applied fluoride

- Self-care : toothpaste, mouthwash
- Potential resevoirs plaque, gingiva, tongue, cheeks, under the
tongue, buccal sulcus

- Professionally applied : fluoride paints, gels, varnish, GIC,

prophylaxis pastes

Stimulating saliva flow

Function of saliva
- Protect the tooth surface continuously by a film of salivary
mucins and proline-rich glycoprotein
- Pellicle protein and proline rich protein promote
remineralization by attracting calcium ions
- Pellicle proteins, phosphate and calcium ions in saliva help to
retard demineralization
- Salivary proteins prevent adherence of oral m/organisms to
enamel pellicle and inhibit their growth
- Salivary bicarbonate buffer system rapid neutralization of
acids

How to increase salivary flow?

Sugarless fluoride chewing gums directly after meal for 1520 minutes
Fluoride or xylitol lozenges
Chewing gum containing chlorhexidine prolong fluoride
clearance, provide chemical plaque control after acid attack
Artificial saliva containing sodium fluoride gel/spray

Elimination of nidus for bacteria

Pit and fissure sealant
- On the basis of predicted caries risk and anatomy of fissure
- Erupting molars sealed as early as possible

Correction of defective restoration