DENTAL CARIES

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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 4
a cavity .
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 contacts
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.
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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.
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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. 18
Quantity
Adults produce 1 to 1.5 L of saliva a day. The
flushing effect of the salivary flow removes
microorganisms not adherent to an oral surface.
Therefore, an inverse relationship between
salivary flow rate and caries exist.

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.
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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.

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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.
2828
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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.

PATIENTS 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 contact
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.

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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.
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Problems encountered with radiographic methods
are:

1. Overlapping of approximal contacts.

2. False diagnosis due to overestimation of lesion depth,
due to change in angulations.
3. Radiolucency may be because of caries or resorption or
any other defect i.e. wear, etc.
4. A superficial demineralization in the buccal & lingual
surfaces may be imaged on the radiograph as an
approximal carious lesion.
5. Fracture of one lingual cusp may appear as radiolucent
approximal cavity.
6. Tilt of maxillary lateral incisors appears as caries on the
mesial side of lateral incisors.
7. Cervical burnout may mimic cervical caries. 38
 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.

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 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 pass through this area, resulting in a
more radiolucent appearance on the radiograph.
X-rays directed at a different angle usually pass
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.

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 Anterior cervical burnout. The space between the
enamel and the bone overlying the tooth will appear
more radiolucent than either the enamel or the bone-
tooth 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 &
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viewing.
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 initially designed for proximal caries
detection.

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.
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The major problem being low sensitivity.
 When a narrow beam of
bright light is directed
across the areas of contact
between approximal
surfaces, the disruption of
crystal structure occurs in
demineralization area
which deflects the light
beam and produces
shadows.

This decrease of
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transmission is interpreted
by the observer.
 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.

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 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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53
 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 56
lesion.
57
 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.
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 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. 59

Dyes for detection of carious
enamel
Procion dyes stain enamel lesions but the staining
becomes irreversible as the dye reacts with the
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. 60
Dyes for detection of carious
dentin
In 1972, 0.5% basic fuchsin in propylene glycol was
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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CARIES PREVENTION

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Why??
 Dental caries and periodontal disease have

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historically been considered the most important
global oral health burdens.

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 terms of money, time and health is

high.
Sequelae of untreated Dental
Caries

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 65
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
When a caries lesion is detected, three courses of

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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.

Caries is a major problem in children, as well as adults,

and we need an improved approach to prevention and
therapy
 Anti Caries
Campaign

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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
LEVELS PRIMARY SECONDA TERTIARY
OF PREVENTION RY PREVENTION
PREVENTI PREVENTI
PREVENT HEALTH EARLY DISABILI REHABILI
ON
IVE PROMOTI SPECIFI
ON
DIAGNOSIS TY TAT-ION
SERVICE ON C & PROMPT LIMITATI

68
S PROTEC TREATMEN ON
TIO-N T
Individua Diet, Oral Self Utilization Utilization
l Checkups hygiene, examination of of
Fluorides utilization of services services
services
Communi Education, Fluoridat Screening Provision Provision
ty programs ion , provision of of dental of dental
school dental services services
sealant services
program
s
Dental Education, Topical Examn, Complex RPD/FPD
professio plaque applicati prompt restorativ implants
nal control on treatment, e tt,
program, fluorides, preventive pulpotom
 Caries Control methods
Attempts to prevent caries attack have been

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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
Mechanical Measures for
Dental Caries Prevention

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Self
Toothbrushing
Flossing
Including Fibrous/ Detergent Food in diet
Dentist
Prophylaxis [ scaling and root planing]
Pit and fissure sealants
Chemical Measures of Caries Prevention

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 Nutritional Measures for
Dental Caries Prevention
Restriction of Sucrose rich diet

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Anticariogenic / Cariostatic foodstuffs
Conclusion
Caries is a global health burden

Changes in caries patterns in developed countries will

dramatically affect the nature of operative dentistry

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

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Kauffman

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