Dental Caries 476v1r

DENTAL CARIES 1

NORMAL TOOTH

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TYPES OF TOOTH LOSS Loss of tooth substance in different ways: • Microbial tooth loss (dental caries) • Non microbial tooth loss (attrition, abrasion and erosion)

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Definition • According to Sturdevants “Dental caries is an infectious microbiologic disease of the teeth that results in localized dissolution and destruction of the calcified tissues ”. • According to Shafers “the microbial disease of the calcified tissues of teeth, characterized by demineralization of the inorganic portion and destruction of organic substance of the tooth ”. • According to WHO “caries is defined as a localized post eruptive, pathological process of external origin involving softening of the hard tooth tissue and proceeding to the formation of a cavity ”.

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CLASSIFICATION On basis of occurrence as a new or on previously attacked surface : (1) Primary Caries-is the original carious lesion of the tooth . (2) Secondary Caries / Recurrent caries - occurs at the junction of a restoration & under it

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ON BASIS OF LOCATION PIT &FISSURE CARIES Form in the regions of pits and fissures usually resulting from imperfect coalescence of the developmental lobes. Diagrammatically caries may be represented as two cones ,base to base, with the apex of the enamel cone at the point of origin and the apex of the dentin cone directed toward the pulp.

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Smooth surface caries • Occurs on habitually unclean surfaces usually covered by plaque • Picture as a cone with its base on the enamel surface and the apex at DEJ • Lateral spread along the DEJ occurs in the same manner as in pit & fissure caries • Apex of the cone of caries in the enamel s the base of the cone of caries in dentin.

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ROOT SURFACE CARIES • Occur on the tooth root that has been both exposed to the oral environment and habitually covered with plaque. • Usually more rapid than other forms of caries, and thus should be detected and treated early.

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ON THE BASIS OF RAPIDITY OF PROCESS • Acute Caries - also called as rampant caries, is when the disease is rapid in damaging the tooth. It is usually in the form of many, soft, light colored lesions in a mouth & is infectious. • Chronic (slow or arrested) caries -chronic caries is slow or it may be arrested following several active phases. The slow rate results from periods when demineralized tooth structure is almost remineralized.

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• The slow rate allows time for extrinsic pigmentation. An arrested enamel lesion is brown to black , hard and due to fluoride may be more caries resistant than contiguous unaffected enamel. An arrested dentinal lesion is open dark and hard and this dentin is termed as Eburnated dentin / sclerotic dentin.

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ON BASIS OF PROGRESSION OF CARIES • Forward Caries – is wherever caries cone in enamel is larger or at least is the same size as that in dentin • Backward Caries- when the spread of caries along the DEJ exceeds the caries in contiguous enamel ,caries extend into this enamel from the junction and is termed backward caries

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On the basis of Extent • INCIPIENT CARIES (REVERSIBLE) –is the first evidence of caries activity in the enamel. The lesion appears opaque white when air dried, & will seem to disappear if wetted. This lesion of demineralized enamel has not extended to the DEJ,& the enamel surface is fairly hard and still intact. The lesion can be remineralised

• CAVITATED CARIES (NONREVERSIBLE) –The enamel surface is broken & usually the lesion has advanced into dentin. Usually remineralisation is not possible. 12

G.V.BLACKS CLASSIFICATION • Class I cavities- All pit and fissure cavities i.e.cavities on occlusal surface of premolars and molars,cavities on occlusal two thirds of the facial and lingual surfaces of molars,cavities on lingual surface of maxillary incisors. • Class II cavities- Cavities on the surface of proximal surfaces of posterior teeth. • Class III cavities - On the proximal surfaces of anterior teeth that do not involve the incisal angle. • Class IV cavities- On the proximal surfaces of anterior teeth that do involve the incisal edge. • Class V cavities- On the gingival third of the facial or lingual surfaces of all teeth. • Class VI cavities- On the incisal edge of anterior teeth or occlusal cusp heights of posterior teeth. 13

FACTORS INVOLVED IN THE CARIOUS PROCESS • 1. Microflora: acidogenic bacteria that colonize the tooth surface. • 2 Host: quantity and quality of saliva, the quality of tooth etc. • 3. Diet: intake of fermentable carbohydrates, especially sucrose, but also starch. • 4. Time: total exposure time to inorganic acids produced by the bacteria of the dental plaque.

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PREDOMINANT SPECIES Enamel Caries - S Mutans Dentin Caries - S Mutans &Lactobacillus Root Caries - Actinomyces species . Actinomyces odontologica, Actinomyces naeslundii

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HOST The two main host factors are: (A) Saliva (B) Tooth

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SALIVA Saliva is the primary means by which the host exerts control over its oral flora. The modifying factors can be defined as ;  Composition  Quantity  Viscosity  Antibacterial Properties  Buffering Capacity of Saliva

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Composition Inorganic • Calcium and phosphate contents present in saliva are inversely related to caries. • Fluoride is also inversely related to caries. Organic • Ammonia reduces plaque formation and neutralize acid. • Urea gets hydrolyzed to ammonium carbonate by urease, thus increases the neutralizing power of the saliva. • Amylase/Ptyalin a substance responsible for the degradation of starches.

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Quantity • Adults produce 1 to 1.5 L of saliva a flushing effect of the salivary flow microorganisms not adherent to an oral Therefore, an inverse relationship salivary flow rate and caries exist.

day. The removes surface. between

• High flow rate increases buffering capacity of saliva and thus inhibits caries. • Decreased salivary secretion in which salivary flow may be entirely lacking may result in rampant dental caries. 19

Viscosity High caries incidence is associated with thick mucinous saliva. Viscosity of the saliva is due to mucin content derived from the submandibular, sublingual glands.

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Antibacterial Properties • Lysozyme - In the presence of sodium lauryl sulfate , can lyse many cariogenic and non cariogenic streptococci. • Lactoperoxidase • Immunoglobulins (mainly IgA) • Lactoferrin

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Buffering Capacity of Saliva • • • • •

A Buffer is a solution that tends to maintain constant pH. In saliva chief buffers are: Bicarbonate – Carbonic acid. Phosphate Ammonia Urea Statherin

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TOOTH Tooth is one of the major modifying factors of the carious process which can be described as: Tooth Morphology Tooth Composition Tooth Position

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Tooth Morphology • Enamel hypoplasia predisposes to the development of dental caries. More severe the tooth is affected, the more extensive will be the caries. • Presence of deep, narrow occlusal fissures or buccal or lingual pits predisposes to the development of caries. Such fissures tend to trap food, bacteria and debris. Food impaction and bacterial stagnation leads to caries. 24

Types of Fissures 1. V type – wide at the top and gradually narrowing towards the bottom (34%) 2. U type – almost the same width from top to bottom (14%) 3. I type – an extremely narrow slit (19%) 4. IK type- hourglass extremely narrow slit associated with a higher space at the bottom (26%) 5.Inverted Y type – bifurcating at the bottom

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Tooth Composition • • • • •

Surface enamel is more resistant to caries than subsurface enamel as ; highly mineralized accumulate greater quantities of fluoride, zinc, lead lower in CO2, dissolves at a slower rate in acids contains less water more organic material than subsurface enamel. These factors constitute to caries resistance and are partly responsible for slower disintegration of surface enamel than of underlying enamel in initial carious lesions.

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DIET The main dietary factors effecting carious process are: Type of Carbohydrate Physical Nature of Carbohydrate Frequency of Consumption Other Dietary Factors

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CARIES RISK ASSESSMENT • The process of caries diagnosis involves both risk assessment and the application of diagnostic criteria to determine the disease state. • Risk assessment primarily intends to identify the individuals who are prone to the disease. • To properly prescribe and determine appropriate preventive and therapeutic strategies, the dentist must consider the patient's overall risk status in the context of the current level of understanding of both disease progression and management options.

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• Historically dentists have relied on their knowledge of the disease process in combination with their experiences and intuition to estimate the risk levels for their patients. • PATIENT’S HISTORY. • CLINICAL EXAMINATION. • NUTRITIONAL ANALYSES. • SALIVARY ANALYSES. • RADIOGRAPHIC ASSESSMENT

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Caries Diagnosis

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Visual Examination: under clean and dry conditions using good illumination n    Brownish discoloration of pits and fissures n    Opacity beneath pits and fissures or marginal ridges n    Frank cavitation of the tooth surface. Problem: discoloration of the pits & fissures may be mistaken for the presence of caries. Magnifying lens: enhances Visual examination

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Tactile Evidence of Caries: Explorer and dental floss curved explorers are used for examination of occlusal pits and fissures interproximal explorers are used to detect proximal caries. Tactile findings suggestive of caries: • Softness at the base of a pit or fissure and discontinuity of enamel surface • Binding or catch of the explorer tip • Cavitation at the base of pit or fissure.    

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Disadvantages: 1. May transmit cariogenic bacteria from one site to another. 2.May produce irreversible traumatic defects in potentially remineralizable enamel. 3. May not be able to add any information to the visual examination. 4. Mechanical binding of an explorer tip in a fissure may not be because of caries but because of other causes like: a. Shape of the fissure. b. Sharpness of an explorer. c. Force of application.

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Dental Floss: when sawed through the areas between teeth, if it frays or shreds then it is a sign for proximal caries. overhanging restorations on the proximal side also give the same features. Tooth separation can be achieved using wedges or mechanical separator. Once the proximal surface is accessible, visual examination and gentle probing may help in diagnosis of the carious lesion. 36

Conventional Radiographs: presents a 2-D picture of a 3-D object. • intraoral periapical • bitewing radiographs (bitewing radiographs have more diagnostic value) Advantages: • Non-invasive method • Disclose sites inaccessible to other diagnostic methods • Permanent record for monitoring progress or arrest of the carious lesion. 37

Problems encountered with radiographic methods are: 1. 2. 3. 4.

5. 6. 7.

Overlapping of approximal s. False diagnosis due to overestimation of lesion depth, due to change in angulations. Radiolucency may be because of caries or resorption or any other defect i.e. wear, etc. A superficial demineralization in the buccal & lingual surfaces may be imaged on the radiograph as an approximal carious lesion. Fracture of one lingual cusp may appear as radiolucent approximal cavity. Tilt of maxillary lateral incisors appears as caries on the mesial side of lateral incisors. Cervical burnout may mimic cervical caries.

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Proximal caries susceptible zone

caries

Approximately 50 % demineralization is required for radiographic detection of a lesion. As seen in the occlusal view, above right, the thickness of the tooth buccolingually masks the carious lesion when it is small. The actual depth of penetration of a carious lesion is deeper clinically than radiographically. 39

Cervical Burnout Cervical burnout is an apparent radiolucency found just below the CE junction on the root due to anatomical variation (concave root formation posteriorly) or a gap between the enamel and bone covering the root (anteriorly).

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Posterior cervical burnout The invagination of the proximal root surfaces allow more x-rays to through this area, resulting in a more radiolucent appearance on the radiograph. X-rays directed at a different angle usually through more tooth structure and the radiolucency disappears.

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Radiolucency seen at left (arrow) disappears on periapical film of same tooth. This is cervical burnout. 42

Anterior cervical burnout. The space between the enamel and the bone overlying the tooth will appear more radiolucent than either the enamel or the bonetooth combination.

bone level

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Cervical burnout in the anterior region due to gap between enamel (red arrows) and alveolar bone over root (blue arrows).

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RADIOVISIOGRAPHY • Introduced in 1989 in dentistry. • Principle- Digital, filmless technique that is based on image acquisition from CCD(Charged Coupled Device). • CCD- semiconductor made of metal oxides coated with x-ray sensitive phosphorus, is electrically connected to the computer. • The Digital Image Receptor(DIR) is placed in the mouth. • Once the image has been captured by the CCD, it can be stored in the computer memory for processing & viewing.

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Advantages• Instant image, no dark room, Consistent image. • Eliminates hazards of film development. • Image can be magnified, contrast & density can be enhanced. • Capable of teletransmission. • Disadvantages • Cost. • Life expectancy of CCD is not fixed.

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FIBRE OPTIC TRANS ILLUMINATION • FOTI was detection.

initially

designed

for

proximal

caries

• Works under the principle that since an area of carious lesion has a lowered index of light transmission, an area of caries appears as a darkened shadow. Advantage : • No hazards , lesion not diagnosed by radiographs can be diagnosed. Disadvantage : • Subject to inter and intra observer variation. 47

The major problem being low sensitivity.

• When a narrow beam of bright light is directed across the areas of between approximal surfaces, the disruption of crystal structure occurs in demineralization area which deflects the light beam and produces shadows. • This decrease of transmission is interpreted by the observer.

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DIGITAL FIBREOPTIC TRANS ILLUMINATION

• The human eyes are replaced by CCD intraoral camera to capture the image and instantly project in the monitor.

• The receptor with photocells converts photon energy to electrical energy – transmitted to a video processor-converted into colour value and displayed on video monitor.

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• Can detect incipient & recurrent caries very early. • Overcomes the shortcomings of FOTI. • Both specificity and sensitivity are high DISADVANTAGE • Difficult to distinguish between deep fissure, stain & dental caries.

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QUANTITATIVE LASER FLUORESCENCE (QLF) •LF method measures the fluorescence of the tooth that is induced after light irradiation to discriminate between carious and sound enamel. •Uses laser light at/near 488 nm to quantify tooth demineralization. •To quantify the mineral loss, the device was improvised with a CCD camera and computerization. 51

• Enamel and dentin have a certain fluorescence that is called as auto- fluorescence. • Tooth is exposed with a broad beam of blue light from an argon laser. • Demineralized enamel will result in a reduction of fluorescence with respect to surrounding enamel. • The demineralized enamel appears dark and this can be recorded on a photographic film or measured by a computer. • This difference in fluorescent intensities enables the degree of demineralization to be quantified.

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• Best suited for diagnosis of early enamel lesions on accessible smooth surfaces. • Can also be used to detect occlusal pit & fissure caries. DISADVANTAGES • Can only discern enamel demineralization • Cannot differentiate between caries, hypoplasia & calculus. • Had better sensitivity but poor specifity than visual examination alone. • Can be affected by the wet or dry state of the fissue.

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DIAGNODENT

• A variant of QLF system.

• Portable diode laser with a fiberoptic probe designed for commercial use. • Uses red laser light (665nm wavelength). • Caries-induced changes fluoresce in red colour due to the presence of the bacterial by-product. • Diagnodent device can detect the deep lesions with bacteria and not the superficial lesions where bacterial fluorophores are absent.

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• The unit gives an adjustable sound and a digital numeric readout (0-99). • The more intense the fluorescence, the more is the destruction. • Values : 5-25 initial lesions in Enamel 25-35 initial dentinal caries > 35 advanced dentinal lesion.

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• A recent modification of Diagnodent is the Diagnodent pen, which has a tip of 0.4 mm.

• Thus it facilitates easy placement in the approximal areas for the detection of an incipient proximal lesion. 58

CARIES DETECTOR DYES • Dyes can visualize a subject from its routine background or if several objects have a similar appearance, colouring by a dye can may discriminate between them and allow identification. • Are an adjunct in caries detection & removal. • Various dyes have been used for staining the porous caries lesion to enhance the contrast between the carious region and the surrounding enamel. • The observation in caries diagnosis is qualitative.

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Dyes for detection of carious • Procion dyes stain enamel lesions but the staining enamel becomes irreversible as the dye reacts with the • •

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nitrogen & hydroxyl groups of enamel. Calcien dye makes a complex with calcium and remains bound to the lesion. Fluorsescent dye like ZygloZL-22 has been used invitro which is not suitable in vivo. The dye is made visible by UV illumination. Use of dye in enamel lesions cannot be used clinically yet. Allow lesions to be visualized at an early stage & allow remineralization process to be carried out at an early.

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Dyes for detection of carious • In 1972, 0.5% basic fuchsin in propylene glycol was dentin developed. • Because of its potential carcinogenicity, replaced by acid red solution. • Intended to enhance complete removal of infected dentin. • Stains the demineralized collagen of infected dentin.

• 1% Acid red & Methylene blue are used now.

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Why??

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CARIES PREVENTION

• The change in food habits from raw, fibrous or minimally processed to increasingly processed and sugary foodstuffs the diet pattern is shifting towards more cariogenic. • Cost in of money, time and health is high.

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• Dental caries and periodontal disease have historically been considered the most important global oral health burdens.

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Sequelae of untreated Dental Caries

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• During the past few decades, changes have been observed not only in the prevalence of dental caries, but also in the distribution and pattern of the disease in the population • Global elderly population is growing. i.e. Life expectancy has gone up. • More people are keeping their teeth into their later years of life wear and caries

• Caries is a major problem in children, as well as adults, and we need an improved approach to prevention and therapy

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When a caries lesion is detected, three courses of action are available to the clinician: • Monitor the condition • Choose non-invasive (early) intervention, the aim of which is to prevent progression of the lesion • Choose operative intervention, i.e. remove the carious tooth substance and restore it with a filling.

Should aim • To asses the caries risk • To increase tooth resistance • To modify diet • To combat the microbial agent • To deliver anticaries measures to the public

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Anti Caries Campaign

SERVICE S

ON

Individua Diet, l Checkups

SECONDA RY PREVENTI EARLY ON DIAGNOSIS

C & PROMPT PROTEC TREATMEN TIO-N T

TERTIARY PREVENTION DISABILI REHABILI TY TAT-ION LIMITATI ON 68

LEVELS PRIMARY OF PREVENTION PREVENTI PREVENT HEALTH ON IVE PROMOTI SPECIFI

Oral Self Utilization Utilization hygiene, examination of of Fluorides utilization of services services services

Communi Education, Fluoridat ty programs ion , school sealant program s

Screening provision of dental services

Provision of dental services

Provision of dental services

Dental Education, Topical professio plaque applicati nal control on program, fluorides,

Examn, prompt treatment, preventive

Complex RPD/FPD restorativ implants e tt, pulpotom

• Attempts to prevent caries attack have been reported through history e.g. • Application of silver nitrate by Miller in 1905 in order to plug the fissures • Hyatt in 1923 gave prophylactic odontomy • The methods of control of caries can be classified into three general types: • Chemical measures • Nutritional measures • Mechanical measures

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Caries Control methods

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Mechanical Measures for Dental Caries Prevention • Self • Toothbrushing • Flossing • Including Fibrous/ Detergent Food in diet

• Dentist • Prophylaxis [ scaling and root planing] • Pit and fissure sealants

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Chemical Measures of Caries Prevention

• Restriction of Sucrose rich diet • Anticariogenic / Cariostatic foodstuffs

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Nutritional Measures for Dental Caries Prevention

Conclusion • Changes in caries patterns in developed countries will dramatically affect the nature of operative dentistry practiced in the near future • Little is known about the caries risk in adults, particularly with regard to root caries, except that the risk increases with age. It is expected that the prevalence of root caries will increase over the next several decades. • The emphasis should be on understanding and controlling the carious process rather than spending huge amounts of money to correct the disability arising out of dental caries.

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• Caries is a global health burden

– Kauffman

THANK YOU

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“The supreme ideal of dental profession should be to eliminate the necessity for its own existence”