DENTAL CARIES

Prepared by: Dr. Rea Corpuz

Dental Caries
progressive initially subsurface demineralization of teeth by bacterial acid one of the most common of all diseases major cause of loss of teeth

Dental Caries
may be considered a disease of modern civilization

since prehistoric man rarely suffered from this form of tooth

Dental Caries
biological process of tooth decay with mutifactorial etiology microbial disease of calcified tissues of teeth characterized by demineralization of inorganic portion destruction of organic substance of tooth

Etiology of Dental Caries

generally agreed to be complex problem complicated by many indirect factors obscure the direct cause or causes

Etiology of Dental Caries

Possible interventions Reduce intake of cariogenic sugars Particularly sucrose Diet Bacteria Possible interventions Reduce Strep. mutans numbers by: Reduction in sugar intake Active or passive immunization Possible interventions Time Susceptible Water + other types of Surface Fluoridation (Host) Prevention during posteruptive maturation Fissure sealing Properly contured restorations

Caries

Possible interventions
Avoid frequent sucrose intake (snacking)

Stimulate salivary flow + sugar clearance

Etiology of Dental Caries

Plaque Acidogenic Bacteria

Enzymes

Food

Acids

Tooth

Carious Lesions

Etiology of Dental Caries

Old Theories Exogenous Theories

(1) Legend of worm (2) Chemical Theory (3) Parasitic or Septic Theory

Etiology of Dental Caries

Old Theories Endogenous Theories

(1) Humoral Theory (2) Vital Theory

Etiology of Dental Caries

New Theories (1) Acidogenic Theory (2) Proteolytic Theory (3) Proteolysis-chelation Theory

Old Theories (Exogenous Theory)

(1) Legend of Worm 5000 BC

ancient Sumerian text

obtained from Mesopotamian area caused by worm that drank blood of teeth fed on roots of jaws

Old Theories (Exogenous Theory)

(2) Chemical Theory 1819

proposed by Parmly
unidentified chemical agent responsible for caries

Old Theories (Exogenous Theory)

(2) Chemical Theory stated that caries began on enamel surface where food putrefied acquired sufficient dissolving power to produce disease chemically

Old Theories (Exogenous Theory)

(3) Parasitic or Septic Theory 1843 proposed by Erdl filamentous parasite in plaque he termed as Denticolae responsible for dental caries

Old Theories (Endogenous Theory)

(1) Humoral Theory 4 humors of body blood phelgm black bile yellow bile any change in relative proportion of these elements causes disease

Old Theories (Endogenous Theory)

(2) Vital Theory 18 century

tooth decay originated like bone gangrene, from within the tooth itself

NewTheories Old Theories (Exogenous Theory)

(1) Acidogenic/Chemoparasitic Theory 1890

WD Miller
dental decay is a chemoparasitic process consisting of 2 stages decalcification of enamel results in total destruction

NewTheories Old Theories (Exogenous Theory)

(1) Acidogenic/Chemoparasitic Theory decalcification of dentin as a preliminary stage followed by dissolution of softened residue

NewTheories Old Theories (Exogenous Theory)

(1) Acidogenic/Chemoparasitic Theory following factors cause decay: (1) Role of carbohydrates (2) Role of microorganisms (3) Role of acids (4) Role of dental plaque

(1)Acidogenic/ Old Theories Chemoparasitic Theory

(1) Role of carbohydrates food substances act as substrate for microorganisms of dental plaque various carbohydrates have been examined for cariogenic potential

(1)Acidogenic/ Old Theories Chemoparasitic Theory

(1) Role of carbohydrates cariogenicity of carbohydrate varies with: (1) frequency of ingestion (2) physical form (3) chemical composition (4) route of administration (5) presence of other food constituents

(1)Acidogenic/ Old Theories Chemoparasitic Theory

(1) Role of carbohydrates (1) frequency of ingestion

taken repeatedly in between two major meals

provides constant supply of carbohydrate to plaque bacteria for fermentation + production of acids

(1)Acidogenic/ Old Theories Chemoparasitic Theory

(1) Role of carbohydrates (2) physical form

sticky
solid carbohydrates

(1)Acidogenic/ Old Theories Chemoparasitic Theory

(1) Role of carbohydrates (3) chemical composition

in the form of glucose, sucrose + fructose due to low molecular weight rapidly diffuse into plaque
make themselves easily available for fermentation by plaque bacteria

(1)Acidogenic/ Chemoparasitic Theory

(1) Role of carbohydrates (4) Route of administration

oral intake of sticky food

(1)Acidogenic/ Chemoparasitic Theory

(1) Role of carbohydrates (5) Presence of other food constituents refined pure carbohydrates more caries producing

(1)Acidogenic/ Chemoparasitic Theory

(2) Role of microorganisms caused by acid resulting from action of microorganisms on carbohydrates

(1)Acidogenic/ Chemoparasitic Theory

(2) Role of microorganisms
Initiation of Dental Caries Streptococci S. mutans S. milleri S. mitior S. sanguis S. salivaris Lactobacilli L. acidophillus L. casei Progression of Dental Caries Streptococcal species: Streptoccal species in deep dentinal caries and root caries

Lactobacilli in dentin L. acidophillus L. casei

Actinomycoses A. viscosus A. naeslundii

Actinomycoses A. Israeli A. odontolyticus

(1)Acidogenic/ Chemoparasitic Theory

(2) Role of microorganisms S. mutans has been proved for the initiation of caries

(1)Acidogenic/ Chemoparasitic Theory

(3) Role of acids play most important role in pathogenesis of dental caries pH 5.5 is called critical pH below this pH demineralization of tooth substance begins

(1)Acidogenic/ Chemoparasitic Theory

(4) Role of Dental Plaque found on uncleaned tooth surfaces appear as tenacious, thin film may accumulate within 24-48 hours

NewTheories Old Theories (Exogenous Theory)

(2) Proteolytic Theory proteolysis of the organic components of tooth as an initial process than actual demineralization + dissolution of inorganic substances

NewTheories Old Theories (Exogenous Theory)

(2) Proteolytic Theory proposed that enamel lamellae or rod sheath (proteins) may be lysed which means proteolysis as first event in further progression of bacterial invasion + demineralization carious lesions

NewTheories Old Theories (Exogenous Theory)

(3) Proteolysis Chelation Theory suggests that caries is caused by simultaneous events of proteolysis + chelation proteolysis destruction of organic portion of tooth by proteolytic microorganisms

NewTheories Old Theories (Exogenous Theory)

(3) Proteolysis Chelation Theory chelation

removal of calcium by forming soluble chelates

oral bacteria attack organic component of enamel (proteolysis) breakdown products have chelating ability and this dissolves tooth minerals

Old Theories Classification

(1) Depending on nature of attack (2) Depending on progression of caries (3) Depending on surfaces involved (4) Based on direction of attack (5) Based on number of surfaces involved

Old Theories Classification

(6) GV Black Classification based on treatment and restoration design

(7) Based on location of lesion

(8) Based on tissue involved

OldNature (1) Theories of Attack

Primary Caries incipient; initial

first attack on tooth surface

Secondary Caries recurrent occurs on margins or walls of existing restorations

OldProgression (2) Theories of Caries

Acute rapidly invading process

involves several teeth

lesions are soft + light colored

OldProgression (2) Theories of Caries

Acute usually pulp is involved at early stage Rampant caries Nursing bottle caries Radiation caries

OldProgression (2) Theories of Caries

Chronic lesions are long standing

fewer in number

OldSurfaces (3) Theoriesinvolved

Pit and fissure Smooth surface caries

OldDirection (4) Theoriesof caries attack

Forward Caries proceeds from enamel to dentin lesion is triangle in shaped with base of triangle at enamel surface + apex towards dentin in pits + fissures base is at DEJ + apex is in the pit

OldDirection (4) Theoriesof caries attack

Backward Caries proceeds from DEJ towards enamel surface also triangle shaped with base at DEJ + apex towards enamel surface

OldNumber (5) Theories of Surfaces involved

Simple only one surface is involved by caries Compound 2 surfaces are involved Complex more than 3 surfaces involved

OldGV (6) Theories Black Classification

Class I begin in pits, fissures + defective grooves seen in occlusal surface occlusal two-thirds of molars lingual pits of incisors

OldGV (6) Theories Black Classification

Class II lesions seen on proximal aspects of molars + premolars

OldGV (6) Theories Black Classification

Class III lesions involving proximal aspects of incisors do not involve or necessitate removal of incisal edge

OldGV (6) Theories Black Classification

Class IV lesions involving proximal aspects of incisors involve or require removal of incisal edge

OldGV (6) Theories Black Classification

Class V lesions present on gingival third of all teeth

OldGV (6) Theories Black Classification

Class VI lesions found on incisal edges + cusp tips

OldLocation (7) Theoriesof the lesion

Pit and Fissure caries Occlusal Buccal or lingual pit Smooth surface caries Proximal Buccal or Lingual surface Root caries

OldTissue (8) Theories involved

Enamel Caries Dentinal Caries

Cemental Caries

Classification
Senile Caries caries associated with aging almost exclusively seen on root surface Residual Caries not removed during restorative procedure

Clinical Features: Smooth Surface Caries

Interproximal Caries opaque chalky region (white spot) some cases yellow or brown pigment area spots are generally located on outer surface of enamel between contact point + height of free gingival margin

Clinical Features: Smooth Surface Caries

Interproximal Caries as caries penetrates enamel, enamel surrounding the lesion assumes bluish white appearance usally apparent as laterally spreading caries at DEJ

Clinical Features: Smooth Surface Caries

Interproximal Caries common for proximal caries to extend both bucally + lingually

Cervical, Buccal, Lingual or Palatal Caries

Clinical Features: usually extends from area opposite gingival crest occlusally to convexity of tooth surface extends laterally towards proximal surfaces

Cervical, Buccal, Lingual or Palatal Caries

Clinical Features: usually occurs on cervical area typical cervical lesion is a crescent shaped cavity beginning as slightly roughened chalky area gradually becomes excavated

Pit and Fissure Caries

Clinical Features: appears brown or black

feel slightly soft

catch a fine explorer point

Pit and Fissure Caries

Clinical Features: enamel bordering the pit and fissure may appear opaque bluish white as it becomes undermined

Pit and Fissure Caries

Clinical Features: lateral spread of caries at DEJ as well as penetration into dentin along dentinal tubules may be extensive without fracturing away overhanging enamel there may be large carious lesion with only a tiny point of opening

Root Caries
also known as cemental caries involves both dentin + cementum in number of people exhibiting gingival recession with clinical exposure of cemental surface

Root Caries
Clinical Features: slowly progressing chronic lesion usually found in mandibular molar area + premolar region gingival recession is associated with root surface caries

Recurrent Caries
occurs immediately adjacent to restoration may be caused by inadequate extension of restoration was not able to excavate or removed well original carious lesion

Recurrent Caries
Clinical Features: restoration with poor margins permitted leakage + entrance of both bacteria + substrate

Nursing Bottle Caries

Etiology: due to nursing bottle containing milk or milk formula, fruit juice or sweetened water

sometimes it occurs due to sugar or honey-sweetened pacifier

Nursing Bottle Caries

Pathogenesis: child is put on bed at afternoon nap time or at night with nursing bottle containing milk or a sugar containing beverage milk or sweetened liquid becomes pooled around maxillary anterior teeth

Nursing Bottle Caries

Pathogenesis: carbohydrate containing liquid provide an excellent culture medium for acidogenic microorganisms

Nursing Bottle Caries

Clinical Feature: prolonged feeding beyond usual time may result in early + rampant caries early carious involvement of maxillary anterior, maxillary + mandibular 1st permanent molars, mandibular canines

Nursing Bottle Caries

Clinical Feature: carious process is so severe that only root stumps remain

Nursing Bottle Caries

Prevention: parent should start brushing the child teeth as soon as they erupt in oral cavity

discontinue bottle feeding as soon as child can drink from a cup, at approximately 12-15 months of age

Rampant Caries
suddenly appearing widespread

resulting in early involvement of pulp

Rampant Caries
Etiology: may be due to nutritional deficiency malnutrition emotional disturbances

Rampant Caries
Clinical Features: occurs in children with poor dietary habits extensive inter-proximal + smooth surface caries

Rampant Caries
Management: extensive dental care

parent education

Arrested Caries
Clinical Features: both deciduous + permanent are affected large open cavities brown-stained polished appearance + hard

Prevention/Management of Dental Caries

Restorative Treatment

Tooth Brushing
Mouth Rinsing Dental Floss Topical Fluoride Application (Pedo Patients) Pit and Fissure Sealants

References: Books
Cawson, R.A: Cawsons Essentials of Oral Oral Pathology and Oral Medicine, 8th Edition (page 40) Ghom, Ali & Mhaske, Shubhangi: Textbook of Oral Pathology (pages 401-419) Shafer, et al: A textbook of Oral Pathology, 3rd Edition (pages 369,394, 407)