dental caries ,recent advances,prevention,treatment

dental caries

1. DENTAL CARIES GUIDED BY DR.LAVANYA NEELIMA READER DEPARTMENT OF CONSERVATIVE DENTISTRY AND ENDODONTICS PRESENTED BY DR.P.LIKHITHA 1 ST MDS DEPARTMENT OF CONSERVATIVE DENTISTRY AND ENDODONTICS

2. CONTENTS Introduction Definition History Epidemiology Classification Etiology Pathophysiology of caries

3. Histopathology Diagnosis Caries risk assessment tools Prevention Treatment Conclusion References

4. INTRODUCTION Caries -Dry rot (Latin) Dental caries and periodontal disease - most common chronic diseases in the world. Prevalence Modern times »» Dietary changes. 

5. Dental caries is a disease which damages the structures of teeth .   If left untreated, the  disease can lead to  pain, infection and tooth loss.  Today, it remains one of the most common bacterial diseases throughout the world.

6. DEFINITION Dental caries is defined as the chemical dissolution of the calcium salts, first of the enamel then of the dentin by lactic acid . - GV Black Dental caries is defined as irreversible microbial disease of the calcified tissues of the teeth characterized by demineralization of the inorganic portion and destruction of organic substance of the tooth . - Shafer

7. Dental caries is an infectious microbiologic disease of the teeth that results in localized dissolution and destruction of calcified tissues. - Sturdevant Dental caries is defined as localized post eruptive pathological process of external origin involving softening of hard tooth tissue and proceeding to formation of cavity. – WHO

8. HISTORY Archaeological evidence shows that dental caries is an ancient disease dating far into  prehistory.   Skulls  dating from a million years ago through the  neolithic  period show signs of caries. The increase of caries during the neolithic period may be attributed to the increase of plant foods containing carbohydrates .  A wooden bow drill available in the neolithic period would have been able to make a hole in a tooth to relieve an  abscess in 5½ minutes.

9. The beginning of rice cultivation in South  Asia  is also believed to have caused an increase in caries . A Sumerian text from 5000 BC describes a "tooth worm" as the cause of caries. Evidence of this belief has also been found in India, Egypt, Japan, and  China. In Pakistan, teeth dating from around 5500 BC to 7000 BC show nearly perfect holes from primitive dental drills.

10. The Greco-Roman civilization, in addition to the Egyptian, had treatments for pain resulting from caries . Pierre Fauchard , known as the father of modern dentistry, was one of the first to reject the idea that worms caused tooth decay and noted that sugar was detrimental to the teeth and  gingiva. In 1850, another sharp increase in the prevalence of caries occurred and is believed to be a result of widespread diet changes .

11. Prior to this time, cervical caries was the most frequent type of caries, but increased availability of sugar cane, refined flour, bread, and sweetened tea corresponded with a greater number of pit and fissure caries.

12. In the 1890s, W.D. Miller conducted a series of studies that led him to propose an explanation for dental caries that was influential for current theories . He found that bacteria inhabited the mouth and that they produced acids which dissolved tooth structures when in the presence of fermentable carbohydrates .  

13. EPIDEMIOLOGY An estimated 90% of schoolchildren worldwide and most adults have experienced caries.  In the United States, dental caries is the most common  chronic childhood disease, being at least five times more common than  asthma.  It is the primary pathological cause of tooth loss in children. Between 29% and 59% of adults over the age of fifty experience caries .

14. CLASSIFICATION Based on treatment and restorative design (GV Black):  

15. Sturdevant Classification Based on Location Primary caries Secondary caries Based on Extent Incipient caries (Reversible ) Cavitated caries (Irreversible) Based on Rate Acute caries Chronic caries

16. Based on origin : Pit and fissure caries Smooth surface caries Forward caries Backward caries Residual caries Root surface caries

17. According to Dental Clinics of North America: a . Acc. to tooth type : • Deciduous (A-T) • Permanent (1–32) b . Acc. to anatomic site: • Pit and fissure • Smooth surface • Root surface c . Acc. to tissue affected: • Enamel • Dentin • Pulp d . Others : • Primary, secondary • Nursing caries • Radiation caries • Rampant caries

18. Classification by GJ Mount

19. Root caries classification by Billings : Grade I (incipient) Grade II (shallow) Grade III (cavitation) Grade IV (pulpal)

20. ICDAS(International Caries Detection and Assessment System)

21. ETIOLOGY Early concepts : The legend of worms Endogenous theories ( Humoral and Vital theory) Chemical theory Parasitic theory The acidogenic theory/ Miller’s chemico -parasitic theory The proteolytic theory The proteolysis - chelation theory Sucrose chelation theory Levines theory

22. The legend of worms: Earliest reference to tooth decay - Sumerian text (5000 BC) According to concept of that time, the cause of caries was thought to be invasion of ‘worms’ into teeth. Treatment for worms - Few drops of oil of vitriol ( sulphuric acid) onto the tooth.

23. Endogenous theories : Humoral theory - Dental caries was produced due to imbalance between humours of body. Vital theory - Tooth decay originated like a bone gangrene from within the tooth itself.

24. Chemical theory : Roberston , 1835 – Acid formed by fermentation of food particles caused tooth decay .

25. Parasitic theory: Fincus (1847) – Attributed dental caries to denticolae , the generic term for decay related to micro- organisms.

26. Miller’s chemico – parasitic theory ( Acidogenic theory),1882: 1 ) • Decalcification of enamel and dentin (preliminary stage) 2) • Dissolution of softened residue (subsequent stage )” 3 factors essential in caries process: • Oral micro-organisms • Carbohydrate substrate • Acid

27. The Proteolytic theory: Gottlieb (1944 ), Diamond & Applebaum (1946): Caries is essentially a proteolytic process. Acid formation accompanied proteolysis .

28. The Proteolysis – Chelation theory Schatz et al (1955): Simultaneous microbial degradation of organic components (proteolysis) and the dissolution of the minerals of the tooth by the process known as chelation. The proteolysis – chelation theory resolves the argument as to weather the initial attack of dental caries is on the organic/ inorganic portion of enamel by stating that both may be attacked simultaneously . .

29. The Sucrose – Chelation theory : Egglers-Lura (1967): Sucrose itself, and not the acid derived from it, can cause dissolution of enamel by forming an ionized calcium sacharrate . However, reinvestigations failed to confirm this

30. Levine’s theory : Levine (1977) hypothesized ‘see-saw’ mechanism in which there is movement of minerals from saliva/ plaque to enamel and vice versa. The mechanism emphasized that the demineralization and remineralization of enamel is a continuous process. .

31. Current concepts of dental caries : Dental caries is a multifactorial disease with interplay of 3 primary factors: • Host • Microbial flora • Substrate A fourth concept, time was added with better understanding of the disease.

32. PATHOPHYSIOLOGY

33. HISTOPATHOLOGY ENAMEL CARIES PIT AND FISSURE CARIES SMOOTH SURFACE CARIES

34. DENTINAL CARIES

35. DIAGNOSIS Patient history Visual examination Tactile examination Radiographic examination Tooth separation Dental floss/tape Fiberoptic transillumination Xeroradiography

36. Digital radiographic methods Digital subtraction radiography Digital fibre -optic transillumination (DIFOTI ) Dyes for detection of caries

37. Endoscopic filtered fluorescence method Quantitative laser fluorescence ( DIAGNODENT) Ultrasonic imaging Optical coherence tomography

38. Terahertz pulse imaging Cariescan

39. CARIES RISK ASSESSMENT TOOLS AAPD (The American Academy of Pediatric Dentistry ) Caries – Risk Assessment Tool Cariogram CAMBRA ( Caries Management By Risk Assessment)

40. PREVENTION Measures to improve oral hygiene Diet modifications Salivary stimulants Fluorides Pit and fissure sealants Current methods of caries prevention

41. Measures to improve oral hygiene Plaque control is vital to caries prevention 1. Tooth brushes – • Medium/Soft brush with a small head is usually recommended. • Brushes can be manual or powered. • S hould be replaced every 3 months/sooner depending on bristle fraying.

42. Tooth brushing methods: • Modified Bass method • Charter’s method • Fones / Circular method • Sulcular method • Sulcular method is most effective in plaque removal • Bristles are held at 45º angle to tooth surface and vibrated into gingival sulcus and embrasure. • Lingual aspect of anterior teeth – brush is held at 45º to occlusal plane

43. 2. Interdental cleaning aids – • Dental floss/tape • Wooden sticks • Interdental brushes • Single tufted brushes

44. 3. Dentifrices 4. Disclosing agents 5. Professional tooth cleaning measures 6. Chemical agents

45. Diet modifications: • Reduce frequency and amount of sugary foods and drinks. • Recommend diet high in proteins. • Avoid snacks in-between meals . Food with anticariogenic effects: • Milk • Cheese • Fibrous foods, raw vegetables • Sugar substitutes and artificial sweeteners

46. Salivary stimulants • Saliva has antibacterial, buffering and flushing actions. • In patients with xerostomia risk of caries is more. • For these patients, salivary stimulants such as xylitol gums, paraffin waxes or salivary substitutes can be advised .

47. Fluorides Systemic fluorides Topical fluoride Professionally applied Fluoride solutions Fluoride gels Fluoride varnishes Self applied Dentifrices Mouthrinses

48. Pit and fissure sealants Glass ionomer sealants Resin sealants Functions: Mechanically fill pits & fissures Prevent cariogenic bacteria Arrest incipient lesions

49. Current methods of caries prevention Lasers – Lasers can be effectively absorbed and rapidly transformed into heat to form a ceramic like surface resistant to caries attack. 2. Genetic modalities – attempts have been made to create strains of S.mutans that lack lactate dehydrogenase responsible for production of lactic acid.

50. 3. Caries vaccines – saliva and gingival fluid are capable of producing effective immune response against oral microorganisms. Caries vaccine is based on specific surface antigens of S.mutans . 4 . Passive immunization – monoclonal antibodies have been prepared that can prevent adhesion of S.mutans to tooth surfaces.

51. TREATMENT 1 . Hypocalcified enamel/White spot lesion : Treatment is elective, esthetic needs, repair defects. Follow up after 1 year 2. Early enamel lesions/Incipient lesion : Seal defective pits and fissure or by enameloplasty . Evaluate after 3 months .

52. 3. Active caries / cavitated lesions: Shallow depth – Restoration indicated. Evaluation after 3-6 months Deep lesions: Excavation of caries – no pulpal exposure –pulp protection agents and restoration. Pinpoint pulpal exposure – Calcium hydroxide placed over exposed area. Temporary restoration. Evaluate pulpal response after 3-6 weeks and restore. Arrested caries – no active cavitation. Treatment elective – for esthetics. Restore defects and follow up after 1 year.

53. 4.Nursing bottle caries: Habit Breaking. Restoration with fluoride-releasing cements. In severe cases restoring after extraction with a prosthesis. Prophylactic Varnish application on unaffected teeth. Instilling good oral hygiene measures in your kids.

54. 5.Radiation Caries:

55. Rampant caries: R emoving the diseased portion of the tooth, then placing a filling to strengthen the tooth. If too much of the tooth loss occurs due to rampant decay, then the dentist may choose to place a crown on the tooth to protect it.

56. CONCLUSION Dental caries still remains the most commonly encountered clinical problem. Research efforts must be continued in understanding the caries process to maximize the efforts towards prevention and treatment . Patient education and motivation in prevention and treatment of caries should be stressed as it plays a key role in current treatment practices.

57. REFERENCES  Sturdevant’s Art and Science of Operative dentistry, Fifth edition  Shafer’s textbook of oral pathology, seventh edition  Textbook of operative dentistry, Vimal.K.Sikri . Fourth edition  Principles and practice of operative dentistry – Geralt.T.Charbeneau , Third edition  The science and practice of caries prevention, The Journal of American Dental Association.  Dental caries vaccine : An overview, Indian journal of dental sciences.

58. THANK YOU