Dental Caries

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CONTENTS

INTRODUCTION

                 Dental caries is the most prevalent chronic disease affecting the human race. In many ways   it can be considered a disease of modern times as the occurrence of caries seems to be much higher in the last few generations. It is said that once it occurs the scars persists throughout life even though the lesion is treated.

      It affects persons of both sexes, in all races, all socioeconomic strata and in every age group, though some people may be more prone to it than others. Systemic complications such as, subacute bacterial endocarditis   have also been associated with dental caries.

         Therefore it is mandatory for the clinician to understand the magnitude of this problem and the risk factors in the community to plan suitable preventive measures.

          The word CARIES is derived from the Latin word meaning  rot or decay .

DEFINITION OF CARIES

              DENTAL CARIES is an irreversible microbial disease affecting the hard tissues of the tooth causing demineralization of inorganic portion and destruction of organic portion which further leads to cavitations

THEORIES OF DENTAL CARIES

            Many theories have evolved through years of investigation and observation for etiology of caries

  

EARLY THEORIES

·        The Worm Theory

·        Humoral Theory

·        Vital theory

·        Chemical Theory

·        Parasitic Theory

MODERN THEORY

·        Acidogenic theory

·        Proteolytic Theory

·        Proteolytic- Chelation theory

·        Sucrose Chelation Theory

·        Genetic Theory

·        Autoimmune Theory

ACIDOGENIC  THEORY

           Introduced by Miller

      THEORY: Caries is caused by acid produced by microorganism of mouth.

            Dental decay is chemo parasitic process consisting of two stages:

·        Decalcification of  enamel and dentin

·        Dissolution of softened residue  acids resulting in primary decalcification is produced by fermentation of starches and sugar from the retaining centers of teeth

PROTEOLYTIC  THEORY

       THEORY: Organic or Protein element of tooth as initial pathways of invasion by microorganisms

·     Enamel lamella is the pathways for organism in the progress of dental caries

·     Drawback : No satisfactory evidence to support the    claim that the initial attack in enamel is proteolysis

PROTEOLYTIC- CHELATION THEORY

THEORY : Simultaneous microbial degradation of  organic components and the dissolution of minerals of tooth by process known as chelation

Chelation : A process involving the complexing of a metallic ions to a substance through  a covalent bond which results in a highly stable, poorly dissociated or weakly ionized compound

Effect of chelation : Independent of PH of medium . That removal of metallic ions such as calcium from a biological calcium phosphate system may occur at neutral or even alkaline PH

SUCROSE - CHELATION THEORY

THEORY : Calcium saccharate and calcium complexing intermediates require inorganic phosphate , which is subsequently removed from the enamel by phosphorylating enzymes

ETIOLOGY OF DENTAL CARIES

Dental caries is multifactoriaL . It requires the presence of                                   

§    Susceptible host                                              

§   Cariogenic micro flora                                      

§  Diet favouring caries

ETIOLOGIC FACTORS

1.     Host

2.     Microflora

3.     Substrate

HOST FACTORS

TOOTH

–  Composition

–  Morphological characteristics

–  Arch form

– Presence of dental appliance and restorations

SALIVA

–  pH

–  Quantity

–  Viscosity

–  Antibacterial factor

ROLE  OF  TOOTH 

Anatomical  characteristic of  teeth

·        The only morphologic feature which conceivably  might predispose to the development of caries is the presence of deep, narrow occlusal fissures or buccal or lingual pits.

·        The palatal pits  of  maxillary molar and buccal pits on mandibular molar and the  palatal pits  on maxillary incisor are very vulnerable for the development of caries

·        As attrition advances , inclined planes become flattened , providing less opportunity for entrapment of food debris.

Arch   form

·        Crowding and overlapping of teeth increasing the risk of caries due to the presence of area of stagnation for accumulation of plaque risk and there area  are difficult to clean

Presence of dental  appliance and restoration

·        All these encouraged the   retention of food debris and   plaque .

·        It observed that patient with moderate caries activity in the past have experienced increased caries activity following placement  of prosthesis

Composition  of  the  teeth

       Surface zone of enamel is more resistant to caries compared to the inner layer due to the presence of :

·        Dicalcium phosphate dihydrate and fluroapatite

·        Increased minerals and less organic matter

·        Decreased water content

·        Increased fluoride, chloride, zinc, lead and iron

·        Decreased carbonate and magnesium

·         

ROLE OF SALIVA

Composition of saliva

·        There seems to be existing direct relationship between Caries prevalence and salivary amylase, urea, ammonia, PH etc

·        Saliva of caries immune person exhibit increased ammonia content which helps in neutralizing acids

·        Amylolytic activity of Ptyalin also helps in decreasing caries  chance

·        Decreased salivary flow is associated with increase caries activity

·        Xerostomia associated with cervical caries similar to rampant caries

·        Increase in bacterial flora with decrease in salivary flow rate

·        Physiological  Xerostomia occur during sleep, so it is important to brush the teeth before sleeping

Salivary buffers

·        Chief buffer system in saliva is bicarbonates

·        Carbonic acid and phosphates are  certain extent

ROLE OF BACTERIA

·        Normal flora of the oral cavity contains abundance of bacteria which derive their energy by the chemical process of fermentation

·        Mainly the bacteria are Streptococcus Mutans, and streptococcus sobrinus collectively known mutans streptococci(MS)

·        The ability to produce caries is a prerequisite for caries induction

Microbiology

1.     Bacteria involved :

•      Streptococci  e.g.  mutans, sobrinus

•      Lactobacilli   e.g.  acidophilus

     2.  Possibly associated bacteria :

•      Streptococci  e.g.  mitis

•      Actinomyces  e.g. viscosus

ROLE OF PLAQUE:

·        Plaque is an  adhesive layer which deposits on the surface of the tooth and has colonies of bacteria

·        Dental plaque contain in the order of 10^8 organisms per mg wet wt.

·        Plaque tends to stick to the surface of the teeth and in this helps in the localization of acid

ROLE OF DIET

1.     Nature of diet

2.     Roughage food- reduces caries incidence

3.     Soft sticky food- increases caries incidence

4.     Carbohydrate content

•      Easily fermentable carbohydrate-increased caries incidence

•      Raw carbohydrate-reduced caries incidence

 ROLE OF CARBOHYDRATES:

§  Fermentable carbohydrates are  the most important cause of causing dental caries.

§  Increase in the intake of refined carbohydrates are directly proportional in causing the dental caries

§  Different studies have been done in order to know the role of carbohydrates in causing the dental caries.

CLASSIFICATION OF CARIES

CRITERIA OF CLASSIFICATION

·         Location

·        Rate of progression

·         Based on nature of attack

·         G.V. Black’s classification

ACCORDING TO LOCATION

Pit or Fissure Caries

         

Smooth surface caries

                            

PIT AND FISSURE CARIES

Caries which  affecting :

·        Occlusal surface of molars and premolars

·        Buccal and lingual surface of molars

·       Lingual surface of maxillary incisors

 Pits  are  fissures are more prone to caries  due to

·        High steep walls & narrow bases

·        Enamel in extreme depth is often very thin or even absent

·        Resulting in “Exposure of Dentine”

·        Deep narrow pits and fissures favour retention of food debris and microorganisms

CLINICAL APPEARANCE

            Early carious lesion may appear brown or black

PROGRESSION

 Caries extend laterally at DEJ without fracturing away overhanging enamel.

SMOOTH SURFACE CARIES

                               

·        Proximal surfaces of teeth

·        Gingival third of buccal and lingual surfaces.

CERVICAL CARIES

                                            

·        Buccal, Labial or Lingual surfaces

·        Crescent shaped

·        Always an open cavity

ROOT SURFACE CARIES

        Root surface is more rough so more prone to plaque accumulation. Cementum covering root surface is thin SO little resistance to caries attack

ACCORDING TO RATE OF PROGRESSION

1.     Acute Dental Caries

2.     Chronic Dental Caries

ACUTE DENTAL CARIES

·        Runs a rapid clinical course

·        Result in early pulp involvement

·        Occur most frequently in children and young adults  because  Dentinal tubules are large and open.

·        No sclerosis.

                                         

NURSING BOTTLE CARIES

           Also known as Nursing caries / Baby bottle syndrome  /Bottle mouth syndrome

                                              

ETIOLOGY:

·        Prolonged use of Nursing bottle containing milk or formula

·        Breast feeding

·        Sugar or honey sweetened pacifiers

Habitual use of one of above after 1 year of age as an AID for sleeping at night .

RADIATION CARIES

·        Result of receiving radiation treatment to the head and neck region for cancer

·        Caries develop as a result of “Xerostomia”

·        Caries completely encircling the neck of tooth

·        Amputation of crown may occur due to this type of lesion

                                         

CHRONIC DENTAL CARIES

·        Progress slowly

·        Involve the pulp much later

·        Most common in adults

·        Stained deep brown

·        Entrance of lesion is invariably larger than acute caries

      Pain is not a common feature , because  slow progression allows sufficient time for:

·        Sclerosis of dentinal tubules

·        Deposition of secondary dentine

ACCORDING TO NATURE OF ATTACK

1.     Primary (virgin) caries

2.     Secondary (recurrent) caries

3.     Arrested caries

PRIMARY CARIES

        Any new carious lesion on tooth surface

SECONDARY (RECURRENT) CARIES

·        Occurs in immediate vicinity of the original restoration

·        Poor adaptation of the filling material to cavity resulting in “LEAKY MARGINS”

·        Favors retention of debris

·        Bacteria and substrate enter through leaky margins easily                                 

                   

ARRESTED CARIES

                                 

                                                

·        Static or stationary

·        Does not show any tendency towards further progression  large open cavity so lack of food retention

·        Formation of a self cleansing area.

ACCORDING TO G.V.BLACK’S CLASSIFICATION

CLASS I

·      Occlusal Pits and fissure of molars and pre molars

·      Occlusal surface of M and P.M

·      Occlusal 2/3 of facial and lingual surface of M and lingual surface of anteriors

CLASS II

         Proximal surface of posteriors

CLASS III

          Proximal surface of anteriors not including incisal edge

CLASS IV

          Proximal surface of anteriors including incisal edge

CLASS V

          Gingival third of facial and lingual surfaces of all teeth

CLASS VI

           Cusp tips

ACCORDING TOWORLD HEALTH ORGANISATION SYSTEM

  Shape and depth  of caries lesion is scored on a four point scale

1.     D1- clinically detectable enamel lesions with intact non cavitated surfaces

2.     D2- clinically detectable cavities limited to enamel

3.     D3-clinically detectable cavities in dentin

4.     D4-Lesions extending to pulp

Shape of the lesion is triangular with the apex towards the pulp and the base towards the enamel.

·              Zone 1:  Zone of Fatty Degeneration of Tome’s Fibers,(next to pulp).

·              Zone 2:  Zone of dentinal sclerosis,

·              Zone 3:  Zone of decalcification of dentin

·              Zone 4:  Zone of bacterial invasion

·              Zone 5:  Zone of decomposed dentin due to acids and enzymes.

                  DIAGNOSIS  OF CARIES

METHODS OF DIAGNOSIS OF CARIES

1.     .Visual examination

2.      Tactile examination

3.      Radiographs

4.      Fiber optic trasillumination

5.      Optical methods

6.      Ultrasonics

7.      Dyes

VISUAL EXAMINATION

·        Slight change in enamel translucency after air drying

·        Opacity or discoloration

·        Local enamel breakdown

·        Cavitation in enamel exposing dentin

                                         

TACTILE EXAMINATION

·        Detected tactilely as  softness or binding of the explorer tip

·        Binding of the tip can also be due to non carious causes such as shape of the fissure, sharpness of the explorer, force of application etc.

RADIOGRAPHS

·        Due to demineralization affected area of tooth becomes more radiolucent than unaffected portions

·        Most commonly used are IOPA and bite wing radiographs

·        readily assessed visually or tactilely

                                               

FIBER OPTIC TRANSILLUMINATION

     The principle is that there is a difference in the index of light transmission in decayed and sound tooth .  As tooth decay has low index of light transmission the area of decay appears darkened shadow

                                             

DIFOTI (Digitally imaged FOTI)

       Visually observed images are captured using a digital charged couple  device camera and sent to computer for analysis

                                           

DIAGNODENT

   LASER FLUORESCENT SYSTEM

·        It has a range of values from -9 to 99

·        -9 being the healthiest

·        It has a diode laser fluorescent device which emits light at 655nm.

·        A second fiber optic bundle receives reflected fluorescent light beam

·        The changes caused by demineralization are assigned a numerical value and is displayed on the monitor

Cut-off limit for DIAGNODENT

·        -9 TO 13  NO CARIES

·        14 TO 20 ENAMEL CARIES and preventive care advised

·        21 to 30 dentin caries and preventive or operative care advised

·        >30 operative care advised

ULTRASONICS

·        Use of sound waves for detection of caries

·        The velocity of sound waves on enamel is 3,143,121m/s

·        All sites with visible Cavitation and dentinal radiolucencies produces echoes with a higher amplitude

DYES

·        ENAMEL CARIES : Calcein, zygloZL22                                                                  

·        DENTIN CARIES  :  Fuschin, acid red, 9 amino acridine

                                 

SPECTRA FLUORESCENCE                                                                            \

                                     

TREATMENT OF DENTALCARIES

PREVENTIVE MEASURES

·        Caries begins as a subsurface lesion which can be rematerialized as long as the surface remains intact.

·        Supersaturated salivary calcium and phosphates in the presence of fluoride can slowly rematerialize dematerialized enamel.

·        Rematerialized enamel is more resistant to subsequent demineralization than original intact enamel

MEASURES TO IMPROVE ORAL HYGIENE

         The effect of oral hygiene/plaque control on caries activity is controversial. Oral hygiene is much less important than diet, but complete plaque removal daily will reduce caries on exposed tooth surface

INTERDENTAL CLEANING AIDS

Proximal surfaces and areas where teeth are malaligned requires additional cleaning aids like dental floss, wooden sticks, interdental brushes, single tufted brushes

                                                  

MOUTH WASHES

Various anti-microbial mouthwashes will reduce certain cariogenic microorganisms, but may also interfere with the normal oral flora and allow overgrowth of undesirable organisms.

       For example, Chlorohexidine Gluconate mouthwashes may reduce Strep. Mutans counts, but will not reach organisms in deep lesions. Deep lesions should therefore be eliminated with caries control restorations before instituting anti-microbial therapy.

DIET MODIFICATION

·        Reduce the frequency and  amount of sugary foods and drinks

·        Avoid snacks in between meals

·        Recommend diets high in proteins instead of sugar rich sweets and sticky foods

FOODS WITH ANTICARIOGENIC EFFECTS

·        Milk- casein and calcium phosphate prevents demineralization of enamel

·        CHEESE- casein phosphopeptides makes it anticariogenic

·        fibrous foods- contains polyphenols, phytates etc.

SUGAR SUBSTITUTES

·        SORBITOL,XYLITOL have an anticariogenic effect

·        Xylitol prevents S.mutans from binding to sucrose

·        Increase the concentration of amino acids and ammonia and neutralize acids

·        Increases salivary flow

FLUORIDES

·        F ions in the oral cavity precipitates fluorapatite into tooth structure and makes enamel more resistant to caries attack

·        Helps in mineralization of hypo mineralized areas

·        Interferes with bacterial enzymatic process of carbohydrate metabolism

·        If ingested during tooth development it makes tooth slightly smaller with shallow fissures and decreases cusp heights

PIT AND FISSURE SEALANTS

·        It fills pits and fissures thereby preventing bacteria like S.mutans from occupying their habitat

·        Arrest incipient carious lesions

·        Enable pits and fissures to be easily cleaned by brushing

CARIES VACCINE

·        Saliva and gingival fluids are capable of producing effective immune response against micro organisms.

·        This led to the development of  caries vaccines based on specific surface antigens of S.mutans.

·        Genetically modified organisms

·        Attempts are made to create strains of S.mutans that lack lactate dehydrogenase enzyme

·        Another  attempt to produce micro organisms capable of destroying S.mutans. One such organisms is LACTOBACILLUS   ZEAE

MANAGEMENT OF CARIES

TREATMENT PLANNING FOR RESTORATIVE DENTISTRY

·        Early elimination of all dentinal caries is very important in eliminating the source of Strep. Mutans.

·        Caries control restorations may be necessary to accomplish this quickly.

TYPES OF LESIONS AND CHOICE OF TREATMENT

SMOOTH SURFACE INCIPIENT CARIES:

       Remineralize with clinical topical fluoride applications and home application of fluoride by various means ; toothpaste, rinses, brush-on gels, custom tray-applied gels, etc.

STICKY PITS AND FISSURES:

        Pit and fissure sealants

STICKY PITS AND FISSURES WITH INCIPIENT CARIES

·        Preventive resin/sealants (Remove caries, place composite in the cavity and cover all with sealant)

·        Definitive amalgam restorations

SMALL AND MODERATE LESIONS

            Definitive amalgam, composite or glass ionomer restorations

DEEP LESION:

           Caries control restorations with ZnO-eugenol, glass ionomer or amalgam, and the definitive restorations after caries activity has decreased

ROOT CARIES:

·        Fluoride applications      

·        Glass ionomer restoration

·        Caries control restoration

CARIES CONTROL RESTORATION

         The restoration protects the pulp against further insult and promotes healing of the lesion by remineralization of affected dentin and stimulation of reparative dentin.

CARIES CONTROL RESTORATION

Restorative materials used for caries control restoration.

·        CaOH is bacteriocidal and stimulates reparative dentin

·        Reinforced Zinc Oxide-eugenol is obtundant, reducing pain and sensitivity; it is bacteriocidal to organisms deep in the cavity, and it seals margins well for several months, preventing ingress of nutrients to the organisms. Strength is fair.

·        Glass ionomer-bonds to tooth structure for improved retention, it release fluoride which reduces organisms and promotes remineralization, has good marginal seal, fair strength, and is esthetically pleasing.

·        Amalgam has excellent strength, maintains occlusal and proximal relationships, fair marginal seal, best for long term temporary

·        Indirect pulp capping is often done in conjunction with caries control restorations.

1.     Pulp must show radiographic and clinical signs and symptoms of vitality.

2.     All caries is removed at the periphery, establishing a sound DEJ.

·        Indirect pulp capping is often done in conjunction with caries control restorations.

1.     All infected dentin is excavated with large round burs and excavators, being careful not to expose the pulp. Basic fuchsine effectively identifies infected dentin.

2.     A small amount of firm caries (affected dentin) is left over sites of potential exposure.

3.     After 6-8 weeks the entire restoration is removed, any remaining INTRODUCTION

                 Dental caries is the most prevalent chronic disease affecting the human race. In many ways   it can be considered a disease of modern times as the occurrence of caries seems to be much higher in the last few generations. It is said that once it occurs the scars persists throughout life even though the lesion is treated.

      It affects persons of both sexes, in all races, all socioeconomic strata and in every age group, though some people may be more prone to it than others. Systemic complications such as, subacute bacterial endocarditis   have also been associated with dental caries.

         Therefore it is mandatory for the clinician to understand the magnitude of this problem and the risk factors in the community to plan suitable preventive measures.

          The word CARIES is derived from the Latin word meaning  rot or decay .

DEFINITION OF CARIES

              DENTAL CARIES is an irreversible microbial disease affecting the hard tissues of the tooth causing demineralization of inorganic portion and destruction of organic portion which further leads to cavitations

THEORIES OF DENTAL CARIES

            Many theories have evolved through years of investigation and observation for etiology of caries

  

EARLY THEORIES

·        The Worm Theory

·        Humoral Theory

·        Vital theory

·        Chemical Theory

·        Parasitic Theory

MODERN THEORY

·        Acidogenic theory

·        Proteolytic Theory

·        Proteolytic- Chelation theory

·        Sucrose Chelation Theory

·        Genetic Theory

·        Autoimmune Theory

ACIDOGENIC  THEORY

           Introduced by Miller

      THEORY: Caries is caused by acid produced by microorganism of mouth.

            Dental decay is chemo parasitic process consisting of two stages:

·        Decalcification of  enamel and dentin

·        Dissolution of softened residue  acids resulting in primary decalcification is produced by fermentation of starches and sugar from the retaining centers of teeth

PROTEOLYTIC  THEORY

       THEORY: Organic or Protein element of tooth as initial pathways of invasion by microorganisms

·     Enamel lamella is the pathways for organism in the progress of dental caries

·     Drawback : No satisfactory evidence to support the    claim that the initial attack in enamel is proteolysis

PROTEOLYTIC- CHELATION THEORY

THEORY : Simultaneous microbial degradation of  organic components and the dissolution of minerals of tooth by process known as chelation

Chelation : A process involving the complexing of a metallic ions to a substance through  a covalent bond which results in a highly stable, poorly dissociated or weakly ionized compound

Effect of chelation : Independent of PH of medium . That removal of metallic ions such as calcium from a biological calcium phosphate system may occur at neutral or even alkaline PH

SUCROSE - CHELATION THEORY

THEORY : Calcium saccharate and calcium complexing intermediates require inorganic phosphate , which is subsequently removed from the enamel by phosphorylating enzymes

ETIOLOGY OF DENTAL CARIES

Dental caries is multifactoriaL . It requires the presence of                                   

§    Susceptible host                                              

§   Cariogenic micro flora                                      

§  Diet favouring caries

ETIOLOGIC FACTORS

1.     Host

2.     Microflora

3.     Substrate

HOST FACTORS

TOOTH

–  Composition

–  Morphological characteristics

–  Arch form

– Presence of dental appliance and restorations

SALIVA

–  pH

–  Quantity

–  Viscosity

–  Antibacterial factor

ROLE  OF  TOOTH 

Anatomical  characteristic of  teeth

·        The only morphologic feature which conceivably  might predispose to the development of caries is the presence of deep, narrow occlusal fissures or buccal or lingual pits.

·        The palatal pits  of  maxillary molar and buccal pits on mandibular molar and the  palatal pits  on maxillary incisor are very vulnerable for the development of caries

·        As attrition advances , inclined planes become flattened , providing less opportunity for entrapment of food debris.

Arch   form

·        Crowding and overlapping of teeth increasing the risk of caries due to the presence of area of stagnation for accumulation of plaque risk and there area  are difficult to clean

Presence of dental  appliance and restoration

·        All these encouraged the   retention of food debris and   plaque .

·        It observed that patient with moderate caries activity in the past have experienced increased caries activity following placement  of prosthesis

Composition  of  the  teeth

       Surface zone of enamel is more resistant to caries compared to the inner layer due to the presence of :

·        Dicalcium phosphate dihydrate and fluroapatite

·        Increased minerals and less organic matter

·        Decreased water content

·        Increased fluoride, chloride, zinc, lead and iron

·        Decreased carbonate and magnesium

·         

ROLE OF SALIVA

Composition of saliva

·        There seems to be existing direct relationship between Caries prevalence and salivary amylase, urea, ammonia, PH etc

·        Saliva of caries immune person exhibit increased ammonia content which helps in neutralizing acids

·        Amylolytic activity of Ptyalin also helps in decreasing caries  chance

·        Decreased salivary flow is associated with increase caries activity

·        Xerostomia associated with cervical caries similar to rampant caries

·        Increase in bacterial flora with decrease in salivary flow rate

·        Physiological  Xerostomia occur during sleep, so it is important to brush the teeth before sleeping

Salivary buffers

·        Chief buffer system in saliva is bicarbonates

·        Carbonic acid and phosphates are  certain extent

ROLE OF BACTERIA

·        Normal flora of the oral cavity contains abundance of bacteria which derive their energy by the chemical process of fermentation

·        Mainly the bacteria are Streptococcus Mutans, and streptococcus sobrinus collectively known mutans streptococci(MS)

·        The ability to produce caries is a prerequisite for caries induction

Microbiology

1.     Bacteria involved :

•      Streptococci  e.g.  mutans, sobrinus

•      Lactobacilli   e.g.  acidophilus

     2.  Possibly associated bacteria :

•      Streptococci  e.g.  mitis

•      Actinomyces  e.g. viscosus

ROLE OF PLAQUE:

·        Plaque is an  adhesive layer which deposits on the surface of the tooth and has colonies of bacteria

·        Dental plaque contain in the order of 10^8 organisms per mg wet wt.

·        Plaque tends to stick to the surface of the teeth and in this helps in the localization of acid

ROLE OF DIET

1.     Nature of diet

2.     Roughage food- reduces caries incidence

3.     Soft sticky food- increases caries incidence

4.     Carbohydrate content

•      Easily fermentable carbohydrate-increased caries incidence

•      Raw carbohydrate-reduced caries incidence

 ROLE OF CARBOHYDRATES:

§  Fermentable carbohydrates are  the most important cause of causing dental caries.

§  Increase in the intake of refined carbohydrates are directly proportional in causing the dental caries

§  Different studies have been done in order to know the role of carbohydrates in causing the dental caries.

CLASSIFICATION OF CARIES

CRITERIA OF CLASSIFICATION

·         Location

·        Rate of progression

·         Based on nature of attack

·         G.V. Black’s classification

ACCORDING TO LOCATION

Pit or Fissure Caries

         

Smooth surface caries

                            

PIT AND FISSURE CARIES

Caries which  affecting :

·        Occlusal surface of molars and premolars

·        Buccal and lingual surface of molars

·       Lingual surface of maxillary incisors

 Pits  are  fissures are more prone to caries  due to

·        High steep walls & narrow bases

·        Enamel in extreme depth is often very thin or even absent

·        Resulting in “Exposure of Dentine”

·        Deep narrow pits and fissures favour retention of food debris and microorganisms

CLINICAL APPEARANCE

            Early carious lesion may appear brown or black

PROGRESSION

 Caries extend laterally at DEJ without fracturing away overhanging enamel.

SMOOTH SURFACE CARIES

                               

·        Proximal surfaces of teeth

·        Gingival third of buccal and lingual surfaces.

CERVICAL CARIES

                                            

·        Buccal, Labial or Lingual surfaces

·        Crescent shaped

·        Always an open cavity

ROOT SURFACE CARIES

        Root surface is more rough so more prone to plaque accumulation. Cementum covering root surface is thin SO little resistance to caries attack

ACCORDING TO RATE OF PROGRESSION

1.     Acute Dental Caries

2.     Chronic Dental Caries

ACUTE DENTAL CARIES

·        Runs a rapid clinical course

·        Result in early pulp involvement

·        Occur most frequently in children and young adults  because  Dentinal tubules are large and open.

·        No sclerosis.

                                         

NURSING BOTTLE CARIES

           Also known as Nursing caries / Baby bottle syndrome  /Bottle mouth syndrome

                                              

ETIOLOGY:

·        Prolonged use of Nursing bottle containing milk or formula

·        Breast feeding

·        Sugar or honey sweetened pacifiers

Habitual use of one of above after 1 year of age as an AID for sleeping at night .

RADIATION CARIES

·        Result of receiving radiation treatment to the head and neck region for cancer

·        Caries develop as a result of “Xerostomia”

·        Caries completely encircling the neck of tooth

·        Amputation of crown may occur due to this type of lesion

                                         

CHRONIC DENTAL CARIES

·        Progress slowly

·        Involve the pulp much later

·        Most common in adults

·        Stained deep brown

·        Entrance of lesion is invariably larger than acute caries

      Pain is not a common feature , because  slow progression allows sufficient time for:

·        Sclerosis of dentinal tubules

·        Deposition of secondary dentine

ACCORDING TO NATURE OF ATTACK

1.     Primary (virgin) caries

2.     Secondary (recurrent) caries

3.     Arrested caries

PRIMARY CARIES

        Any new carious lesion on tooth surface

SECONDARY (RECURRENT) CARIES

·        Occurs in immediate vicinity of the original restoration

·        Poor adaptation of the filling material to cavity resulting in “LEAKY MARGINS”

·        Favors retention of debris

·        Bacteria and substrate enter through leaky margins easily                                 

                   

ARRESTED CARIES

                                 

                                                

·        Static or stationary

·        Does not show any tendency towards further progression  large open cavity so lack of food retention

·        Formation of a self cleansing area.

ACCORDING TO G.V.BLACK’S CLASSIFICATION

CLASS I

·      Occlusal Pits and fissure of molars and pre molars

·      Occlusal surface of M and P.M

·      Occlusal 2/3 of facial and lingual surface of M and lingual surface of anteriors

CLASS II

         Proximal surface of posteriors

CLASS III

          Proximal surface of anteriors not including incisal edge

CLASS IV

          Proximal surface of anteriors including incisal edge

CLASS V

          Gingival third of facial and lingual surfaces of all teeth

CLASS VI

           Cusp tips

ACCORDING TOWORLD HEALTH ORGANISATION SYSTEM

  Shape and depth  of caries lesion is scored on a four point scale

1.     D1- clinically detectable enamel lesions with intact non cavitated surfaces

2.     D2- clinically detectable cavities limited to enamel

3.     D3-clinically detectable cavities in dentin

4.     D4-Lesions extending to pulp

Shape of the lesion is triangular with the apex towards the pulp and the base towards the enamel.

·              Zone 1:  Zone of Fatty Degeneration of Tome’s Fibers,(next to pulp).

·              Zone 2:  Zone of dentinal sclerosis,

·              Zone 3:  Zone of decalcification of dentin

·              Zone 4:  Zone of bacterial invasion

·              Zone 5:  Zone of decomposed dentin due to acids and enzymes.

                  DIAGNOSIS  OF CARIES

METHODS OF DIAGNOSIS OF CARIES

1.     .Visual examination

2.      Tactile examination

3.      Radiographs

4.      Fiber optic trasillumination

5.      Optical methods

6.      Ultrasonics

7.      Dyes

VISUAL EXAMINATION

·        Slight change in enamel translucency after air drying

·        Opacity or discoloration

·        Local enamel breakdown

·        Cavitation in enamel exposing dentin

                                         

TACTILE EXAMINATION

·        Detected tactilely as  softness or binding of the explorer tip

·        Binding of the tip can also be due to non carious causes such as shape of the fissure, sharpness of the explorer, force of application etc.

RADIOGRAPHS

·        Due to demineralization affected area of tooth becomes more radiolucent than unaffected portions

·        Most commonly used are IOPA and bite wing radiographs

·        readily assessed visually or tactilely

                                               

FIBER OPTIC TRANSILLUMINATION

     The principle is that there is a difference in the index of light transmission in decayed and sound tooth .  As tooth decay has low index of light transmission the area of decay appears darkened shadow

                                             

DIFOTI (Digitally imaged FOTI)

       Visually observed images are captured using a digital charged couple  device camera and sent to computer for analysis

                                           

DIAGNODENT

   LASER FLUORESCENT SYSTEM

·        It has a range of values from -9 to 99

·        -9 being the healthiest

·        It has a diode laser fluorescent device which emits light at 655nm.

·        A second fiber optic bundle receives reflected fluorescent light beam

·        The changes caused by demineralization are assigned a numerical value and is displayed on the monitor

Cut-off limit for DIAGNODENT

·        -9 TO 13  NO CARIES

·        14 TO 20 ENAMEL CARIES and preventive care advised

·        21 to 30 dentin caries and preventive or operative care advised

·        >30 operative care advised

ULTRASONICS

·        Use of sound waves for detection of caries

·        The velocity of sound waves on enamel is 3,143,121m/s

·        All sites with visible Cavitation and dentinal radiolucencies produces echoes with a higher amplitude

DYES

·        ENAMEL CARIES : Calcein, zygloZL22                                                                  

·        DENTIN CARIES  :  Fuschin, acid red, 9 amino acridine

                                 

SPECTRA FLUORESCENCE                                                                            \

                                     

TREATMENT OF DENTALCARIES

PREVENTIVE MEASURES

·        Caries begins as a subsurface lesion which can be rematerialized as long as the surface remains intact.

·        Supersaturated salivary calcium and phosphates in the presence of fluoride can slowly rematerialize dematerialized enamel.

·        Rematerialized enamel is more resistant to subsequent demineralization than original intact enamel

MEASURES TO IMPROVE ORAL HYGIENE

         The effect of oral hygiene/plaque control on caries activity is controversial. Oral hygiene is much less important than diet, but complete plaque removal daily will reduce caries on exposed tooth surface

INTERDENTAL CLEANING AIDS

Proximal surfaces and areas where teeth are malaligned requires additional cleaning aids like dental floss, wooden sticks, interdental brushes, single tufted brushes

                                                  

MOUTH WASHES

Various anti-microbial mouthwashes will reduce certain cariogenic microorganisms, but may also interfere with the normal oral flora and allow overgrowth of undesirable organisms.

       For example, Chlorohexidine Gluconate mouthwashes may reduce Strep. Mutans counts, but will not reach organisms in deep lesions. Deep lesions should therefore be eliminated with caries control restorations before instituting anti-microbial therapy.

DIET MODIFICATION

·        Reduce the frequency and  amount of sugary foods and drinks

·        Avoid snacks in between meals

·        Recommend diets high in proteins instead of sugar rich sweets and sticky foods

FOODS WITH ANTICARIOGENIC EFFECTS

·        Milk- casein and calcium phosphate prevents demineralization of enamel

·        CHEESE- casein phosphopeptides makes it anticariogenic

·        fibrous foods- contains polyphenols, phytates etc.

SUGAR SUBSTITUTES

·        SORBITOL,XYLITOL have an anticariogenic effect

·        Xylitol prevents S.mutans from binding to sucrose

·        Increase the concentration of amino acids and ammonia and neutralize acids

·        Increases salivary flow

FLUORIDES

·        F ions in the oral cavity precipitates fluorapatite into tooth structure and makes enamel more resistant to caries attack

·        Helps in mineralization of hypo mineralized areas

·        Interferes with bacterial enzymatic process of carbohydrate metabolism

·        If ingested during tooth development it makes tooth slightly smaller with shallow fissures and decreases cusp heights

PIT AND FISSURE SEALANTS

·        It fills pits and fissures thereby preventing bacteria like S.mutans from occupying their habitat

·        Arrest incipient carious lesions

·        Enable pits and fissures to be easily cleaned by brushing

CARIES VACCINE

·        Saliva and gingival fluids are capable of producing effective immune response against micro organisms.

·        This led to the development of  caries vaccines based on specific surface antigens of S.mutans.

·        Genetically modified organisms

·        Attempts are made to create strains of S.mutans that lack lactate dehydrogenase enzyme

·        Another  attempt to produce micro organisms capable of destroying S.mutans. One such organisms is LACTOBACILLUS   ZEAE

MANAGEMENT OF CARIES

TREATMENT PLANNING FOR RESTORATIVE DENTISTRY

·        Early elimination of all dentinal caries is very important in eliminating the source of Strep. Mutans.

·        Caries control restorations may be necessary to accomplish this quickly.

TYPES OF LESIONS AND CHOICE OF TREATMENT

SMOOTH SURFACE INCIPIENT CARIES:

       Remineralize with clinical topical fluoride applications and home application of fluoride by various means ; toothpaste, rinses, brush-on gels, custom tray-applied gels, etc.

STICKY PITS AND FISSURES:

        Pit and fissure sealants

STICKY PITS AND FISSURES WITH INCIPIENT CARIES

·        Preventive resin/sealants (Remove caries, place composite in the cavity and cover all with sealant)

·        Definitive amalgam restorations

SMALL AND MODERATE LESIONS

            Definitive amalgam, composite or glass ionomer restorations

DEEP LESION:

           Caries control restorations with ZnO-eugenol, glass ionomer or amalgam, and the definitive restorations after caries activity has decreased

ROOT CARIES:

·        Fluoride applications      

·        Glass ionomer restoration

·        Caries control restoration

CARIES CONTROL RESTORATION

         The restoration protects the pulp against further insult and promotes healing of the lesion by remineralization of affected dentin and stimulation of reparative dentin.

CARIES CONTROL RESTORATION

Restorative materials used for caries control restoration.

·        CaOH is bacteriocidal and stimulates reparative dentin

·        Reinforced Zinc Oxide-eugenol is obtundant, reducing pain and sensitivity; it is bacteriocidal to organisms deep in the cavity, and it seals margins well for several months, preventing ingress of nutrients to the organisms. Strength is fair.

·        Glass ionomer-bonds to tooth structure for improved retention, it release fluoride which reduces organisms and promotes remineralization, has good marginal seal, fair strength, and is esthetically pleasing.

·        Amalgam has excellent strength, maintains occlusal and proximal relationships, fair marginal seal, best for long term temporary

·        Indirect pulp capping is often done in conjunction with caries control restorations.

1.     Pulp must show radiographic and clinical signs and symptoms of vitality.

2.     All caries is removed at the periphery, establishing a sound DEJ.

·        Indirect pulp capping is often done in conjunction with caries control restorations.

1.     All infected dentin is excavated with large round burs and excavators, being careful not to expose the pulp. Basic fuchsine effectively identifies infected dentin.

2.     A small amount of firm caries (affected dentin) is left over sites of potential exposure.

3.     After 6-8 weeks the entire restoration is removed, any remaining caries is removed and a definitive restoration is planned.

                           

CONCLUSION

           Since dental caries is a highly prevalent disease , control of dental caries concern for all people . The ideal control measures for dental caries must have immediate , high and lasting effectiveness.

 

  REFERENCE

1.    SHAFER            : TEXTBOOK OF ORAL PATHOLOGY.

2.    ANIL GHOM     : TEXTBOOK OF ORAL MEDICINE.caries is removed and a definitive restoration is planned.

                           

CONCLUSION

           Since dental caries is a highly prevalent disease , control of dental caries concern for all people . The ideal control measures for dental caries must have immediate , high and lasting effectiveness.

 

  REFERENCE

1.    SHAFER            : TEXTBOOK OF ORAL PATHOLOGY.

2.    ANIL GHOM     : TEXTBOOK OF ORAL MEDICINE.