1 Histopathology of The Developing Caries Lesion Gary &ildebrandt. //0.

10 2ni3ersity of 1innesota 0chool of /entistry Smooth Surface Caries Etiology of Caries Lesion Causative Factors Presence of caries pathogens (MS, LB) Frequent or prolonged exposure to fermentable carbohydrates Potentiating Factors Low fluoride exposure level Inadequate salivary flow !"#"$%&'(%"$ )*"#%+E*'(%"$ -E.%$E*'#%&'(%"$ *E.%$E*'#%&'(%"$ E*'-%!'(%"$ /0))*E//%"$ !! ! !!! !" !'1%('(%"$ SU#CLINICAL !#%$%!'# enamel dentin gingiva plaque 2ram staine< =la?@e on enamel s@rface DE cocciF E !lamento@sF scattere< G formsH IJKK

2 Lesion Initiation MS present in low numbers in plaque (carrier state) Frequent sugar supply gives MS competitive advantage ECP helps adhere them .rmly to tooth surface Metabolism of sugar to acid byproducts lowers pH Few organisms can survive in low pH (aciduric) MS proportions increase This lowers the pH further and decreases the number of competing organisms Once the pH low enough (critical pH, 5.0-5.5) tooth mineral begins dissolving Mineral loss follows down the grain of the enamel rods incipient caries cariogenic plaque lesion high proportions of mutans streptococci visible as white spot not visible on radiographs created by frequent or prolonged exposure to fermentable carbohydrates MS concentrated at plaque tooth interface ECPs maintain tight attachment & decrease permeability salivary buffers lowest pH at plaque-tooth interface mineral lost from hydroxyapatite crystals saliva remineralizes surface first fluoroapatite near tooth surface less soluble in acid tiny hydrogen ion penetrates deeply microradiograph of ground section of incipient lesion X36 intact surface layer incremental growth lines striae of Retzius incipient caries lesions incipient caries lesion at contact area

3 VIPEHOLM STUDY Gustafsson et al., Acta Odontol Scand 1954; 11:232. 24-toffee (f) Caramel Sucrose 8-toffee Control Mean DMFT 11 13 15 17 19 21 1946 1947 1948 1949 1950 1951 at meals at & between meals N=436 Stephan Curve (pH at plaque-tooth interface by time after sugar) A. rapid pH drop indicates sugar instantaneously converted to acids--overwhelming salivary buffers B. persistence of low pH (plateau) due to catabolism of ICP --can be >60 minutes C. gradual return to resting pH due to diffusion, dilution, & buffering of acid Demin/Remin Cycling Saliva dilutes & buffers acid & contains concentrated calcium & phosphate ions When sugar present, net demineralization rapidly occurs Between sugar episodes, remineralization slowly occurs If remin periods exceed demin periods, subsurface lesion will mineralize & arrest If demin periods exceed remin periods, cavitation will occur Demin periods exceed remin periods when sugar is frequent or prolonged mineral content of lesion sugar sugar sugar mineral content of lesion sugar sugar sugar sugar sugar sugar demin remin Mineral loss follows down the grain of the enamel rods

Leads to characteristic cone shape pointing at dentin For this reason, debriding procedures alone will not prevent decay MS too small to be removed by brushing & flossing courtesy of Dr. Jorge Perdigao

4 body of lesion dark zone translucent zone intact surface visible on PBWs as E1 lesion Translucent zone: advancing lesion front, large pores Dark zone: small & large pores, small pores may be remineralizing large pores Body of the lesion: enough mineral loss to be visible radiographically Intact surface zone: F catalyzed precipitation of Ca & PO4 from subsurface dissolution & saliva Cone shape demonstrates in.uence of enamel rod direction X22 interglobular dentin primary dentin ground section incipient caries lesion ground section X36 incremental growth lines striae of Retzius dark zone translucent zone incipient caries lesion A E1 lesion con.ned to outer half of enamel slowly progressing lesions go through more demin/remin cycles leading to dark shallow lesions rapidly progressing lesions go through fewer demin/remin cycles leading to lighter-colored, more aggressive lesions

5 decomposed dentin decalcified dentin bacteria in tubules sclerosed dentin dead tracts visible on PBWs as E2 lesion !"#$%& '()*+#% ,-./ (0"12 &(%*+% )0"+(' 1('+#% +%*0)* '$"30)( &()#45#'(& &(%*+% +%3()*(& &(%*+% 6#&2/#3 (%04(1 1('+#% ')1("#*+) &(%*+% &(0& *"0)*' !"#$%& '()*+#% ,-./ (0"12 &(%*+% )0"+(' 1('+#% (%04(1/7 &(%*+% 1('+#%/0"( )#%+)01 5#+%*+%! *#80"& 5$15 ! "#$%&'()* +&,-.&'$(*/)$(**&+ .,%0$)0$&*,1&% Dentinal Lesion decay progresses slowly through enamel & quickly through dentin enamel is 99% mineral, whereas dentin is a living tissue with 30% organic content salivary buffers are more potent at the enamel surface than deeper in the dentin dentinal lesion is more isolated from the diluting effects of the saliva in dentinal lesion low pH is more steady this selects more strongly for aciduric organisms (LB) low pH demineralizes dentin & denatures collagen (gelatin)

proteolytic organisms increase in prominence &(4+%("01+90*+#%/'#3*(%'/&(%*+%/7/(%10"!('/*$6$1(' // ,.::/ 5+#%(("+%!/60)*("+0/(%*("/*$6$1('/7/"(5"#&$)( (0);/*$6$1(/)#%*0+%'/0/60)*("+01/4+)"#<)#1#%2 // ="04 '*0+%

6 bacteria begin to spread laterally from the dentinal tubules X220 demineralization continues, softening intertubular dentin Gram stain infected tubule with localized destruction of surrounding intertubular matrix forming micro-cavities X220 invasion and destruction of dentin is not uniform demineralization of matrix occurs unevenly X355 larger micro-cavities form in tubules as surrounding dentin softens and distorts .lling with breakdown products of the dentin matrix & proliferating bacteria X90 transverse clefts open up perpendicular to dentinal tubules probably following incremental growth lines macroscopically dentin becomes leathery pieces are easily pealed away by an explorer & .ll with breakdown products & bacteria X220 increasing proteolytic bacteria activity tears the demineralized matrix apart extensive areas of tissue breakdown form Gram stain X220 until .nally only traces of recognizable dentin tissue remain saprophytic micro-organisms help complete destruction Gram stain

7 X13 4) surface zone of decomposed dentin 3) decalci.ed matrix with bacteria in tubules 2) zone of sclerotic dentin where mineral .lls tubules & optical distinction between tubules & matrix lost 1) dead tracts: tubules containing degenerating odontoblastic processes ground section dentin caries lesion oral cavity pulp X36 the pulp responds as soon as the lesion enters the dentin pulp dentin infected tubules in.ammation: diffuse lymphocyte in.ltrate visible on PBWs as D1 lesion DEJ is weak point exploited by pathogens destruction spreads laterally at DEJ this effectively uncouples the enamel and dentin breakdown in surface integrity linked to lesion reaching DEJ X13 ground section caries lesion extending into dentin decomposed dentin infected dentin sclerotic dentin

dead tracts dead tracts cavitated lesion at contact area enamel lesion contact area cavitation enamel becomes brittle when decoupled from dentin this is why a prepared cavity should contain no stain at DEJ lateral spread of lesion at DEJ leads to unsupported enamel peripheral to cavity

8 cavitated lesion C cavitated lesion spreading radiolucency at DEJ E2 D1 D2 D1 D3

9 X13 the pulp responds as soon as the lesion enters the dentin secondary dentin forms beneath affected tubules ground section dentin caries lesion oral cavity pulp secondary dentin dead tracts decomposed dentin note peeling surface clinical cavity ground section X90 primary dentin secondary (reparative) dentin advanced caries lesion bacteria penetrated full thickness of dentin & into tubules of secondary dentin Pit & Fissure Caries dentin enamel fissure plaque stained material in fissure lumen must be differentiated from dental caries stained .ssures

10 active plaque acid production salivary buffers & dilution protective sugars do not diffuse this far through fissure plug where in the fissure does the caries lesion begin? incipient fissure caries is not clinically detectable ? THE STICK OR CATCH the fissure brings surface of tooth closer to DEJ it does not take long for the lesion to reach dentin because of enamel rod direction, lesion develops cone shape pointing toward surface of tooth Cone shape demonstrates in.uence of enamel rod direction X36 ground section incipient .ssure caries lesion translucent zone intact surface body of lesion dark zone

11 on contact with dentin lesion spreads laterally, undermining adjacent enamel X65 ground section cavitated .ssure caries lesion softened unsupported enamel caves in forming cavitated caries lesion X13 ground section cavitated .ssure caries lesion sound dentin carious dentin note narrow cavity ori.ce this is often the .rst clinically detectable stage of .ssure caries ENAMEL DENTIN shadow transmitted through translucent enamel caries spreads laterally at DEJ cavitated lesion in .ssure cavitated lesion in pit Caries Removal Carious Dentin Removal Exercise

12 identify carious and sound tooth tissue remove infected tooth tissue establish sound dentoenamel junction develop surgical precision in what amount of caries affected tissue must be removed and what should be alowed to remain Objectives Surgical removal of infected dentin Accepted Terminology excavating carious dentin removing carious dentin Jargon chasing caries removing caries caries removal HUMAN TISSUE BIOHAZARD FACE MASK SAFETY GLASSES SURGICAL GLOVES SAFEGUARD AGAINST SKIN PUNCTURE OR LACERATION DISPOSE OF TEETH IN BIOHAZARD CONTAINER CHOOSE THE LARGEST CARIES LESION YOU CAN FIND INCIPIENT LESIONS WILL NOT DO HAVE BENCH INSTRUCTOR APPROVE CHOICE MOUNT IN SMALL AMOUNT OF PLASTER TO SIMPLIFY HANDLING #245 bur highspeed light touch

13 unsupported enamel !n health, enamel is !rmly attached to the underlying dentin 4nsupported enamel is not bac7ed up by dentin !t hangs out from the perimeter of the cavity and is easily chipped a:ay deminerali/ed enamel opa;ue, soft, chal7y 0arious dentin soft, mushy, gummy, leathery, tac7y deminerali/ed enamel opa;ue, soft, chal7y 0arious dentin soft, mushy, gummy, leathery, tac7y deminerali/ed enamel opa;ue, soft, chal7y stained DEJ sound DEJ

14 largest round bur lowspeed light touch !"#$%"&'(!)$*+&,"-.),$/-&.$&+$*-,&,"-.)!"#$%"&'(!)$*+&,"-.),$/-&.$&+$*-,&,"-.)- carious dentin +$0.1&#*+231 4*##31 5"(.2"!31&.('63 !"#$%"&'(!)$*+&,"-.),$/-&.$&+$*-,&,"-.)sound dentin 2(!,1&45(++75)6" carious dentin +$0.1&#*+231 4*##31 5"(.2"!31&.('63 !"#$%"&'(!)$*+&,"-.),$/-&.$&+$*-,&,"-.)sound dentin 2(!,1&45(++75)6" carious dentin +$0.1&#*+231 4*##31 5"(.2"!31&.('63 '$5$!&$0&,"-.)*-!"5)(85"&)-,)'(.$! 3st 4nd 5rd last !"#$%"&'(!)$*+&,"-.)9"!)92"!(553&!!+. (,:('"-.&.$&;<= "+.(85)+2&+$*-,&,"-.))-&'$-'"-.!)'&9(.."!">'(%(.)-4&'5$+"+.&.$&9*59&5(+.

15 !ud$in$ dentin soundness ,it- e./0orer 23 use 0i$-t /en $ras/ 53 $ent06 7o8e ti/ 0atera006 93 sense dra$ on ti/ ne8er /o:e ti/ into dentin !"#$%&'() '()&*#!+&,-&./--&".&!+01$&0$%&#$!#22"/+-%&-$0*-3 !"#$%&'() !"#$%&%-$+1$ !"#$%&%-$+1$&1!&40/%&5&630!!78 $"+&$-9-!!0/137&!41$7&"/&!+01$:./-!"#$%&'() !"#$%&%-$+1$ !-9"$%0/7 %-$+1$ 30!+&90/1"#!&%-$+1$&/-*";-%&1!&";-/&2#32&4"/$ *07&,-&1$+-$+1"$0337&3-!!&+4"/"#64&+"&2/-;-$+&-<2"!#/-