Epidemiology of dental caries

definition, factors for dental caries, studies, classification of caries, levels of prevention

1. GOOD MORNING 8/20/2016 1

2. EPIDEMIOLOGY OF DENTAL CARIES Presented by:- Dr. Amrita Rastogi SEMINAR DEPARTMENT OF PUBLIC HEALTH DENTISTRY 8/20/2016 2

3. Contents Introduction Definition of Epidemiology and Dental Caries Caries in Prehistoric Man 3000-750 BC Global scenario and Indian scenario Epidemiological studies Theories of Caries Etiology Epidemiological factors of Dental Caries 8/20/2016 3

4. Contents 8/20/2016 4 Classic Dietary Studies Classification of dental caries Reasons for caries decline and rise Levels of prevention of dental caries Conclusion References

5. INTRODUCTION 1,2 The word caries is derived from Latin word meaning “rot” or decay. Dental caries is an infectious microbiological disease that results in localized dissolution and destruction of calcified structures of the teeth. Dental caries may be considered as a disease of modern civilization, since prehistoric man was rarely affected from dental caries . 8/20/2016 5

6. In 1980, Miller gave the chemoparasitic theory for dental caries. Then, there was no reason to look beyond the oral cavity for the causes of dental caries. Dental research since that day has provided so many factors which seemed to influence the occurrence of caries. So, instead of finding ‘a cause’ of dental caries, the concept of ‘multifactorial disease’ become more acceptable. 8/20/2016 6

7. EPIDEMIOLOGY 1 “Epidemiology can be defined as the study of the distribution and determinants of health related states or events in specified population and the application of this study to control the health problems.” John Last 1988. 8/20/2016 7

8. DENTAL CARIES 2 Dental caries is defined as a irreversible, microbial disease of the calcified tissues of the teeth, characterized by demineralization of the inorganic portion and destruction of the organic substance of the tooth, which often leads to cavitations. 8/20/2016 8

9. Caries in Prehistoric Man 3000-750 BC 3 Since teeth can survive in dry burial sites for thousand of years and since no caries like lesions have been produced in cadavers, reliable data on occurrence of dental caries in ancient population are available. There is no evidence of dental caries in the relatively few teeth found in skull fragments of our earliest known direct ancestors, the Pithecanthropus 8/20/2016 9

10. Anthropologic studies of Von Lenhossek revealed that the dolichocephalic skulls of men from preneolithic periods (12,000BC) did not exhibit dental caries, but brachycephalic skulls of the neolithic period (12,000-30,000 BC) contained carious teeth. 8/20/2016 10

11. Global scenario 1,3 Dental caries is still a major health problem in most industrialized countries, affecting 60-90% of school children & vast majority of adults. . It is the most prevalent oral disease in several Asian and Latin American countries, while it appears to be less common and less severe in most African countries. The WHO records a Global DMFT of 1.61 for 12 year old in 2004, a reduction of 0.13 as compared to a DMFT of 1.74 in the year 2001. 8/20/2016 11

12. Various studies conducted in different countries at different time periods have given evidence that a substantial decrease in caries prevalence in the last decade has been found among western countries whereas in case of developing and underdeveloped countries, prevalence of caries seems to be increasing. 8/20/2016 12

13. 8/20/2016 13 WHO Regions DMFT AFRO 1.15 AMRO 2.79 EMRO 1.58 EURO 2.57 SEARO 1.12 WPRO 1.48 Global average (among 188 countries) 1.61

14. Indian scenario 1,3 WHO reported a DMFT score of 3.94 for India. In India, data from the National Oral health Survey (2002-2003) states that in children aged 12 years, the caries prevalence was 53.8% and the mean DMFT was 1.8 whereas it was 80.2% and 5.4 in the 35-44 year age group. In the 65-74 year age group, the prevalence was 85% and mean DMFT was 14.9. 8/20/2016 14

15. Epidemiological studies 1,4 8/20/2016 15 Day and Tandon (1940) conducted a survey among 756 subjects aged between 5-18 years in Lahore, and the point prevalence of caries was reported as 94.04%. Chaudhary and Chawla (1957) conducted a survey of 2900 school children of 5-16 years old in Lucknow . They found the dmft as 11.1 and DMFT to 1.9.

16. 8/20/2016 16 Ludwig (1960) carried out a survey among school children and found that children in the age group of 3-5 years had an average of 0.9 deft. Dorothy et al (1969) carried a survey of oral health of preschool children in Israel and this revealed high caries rate among children and attributed to increase in sugar consumption. Onisi and Shinohara (1976) in their survey of 1172 children in age group of 13 years in Japan found that mean DMFT score 7.5, and this was higher in female than in males.

17. 8/20/2016 17 Enwonwn (1981) noticed that with a rapid socioeconomic development and drastic changes in traditional dietary habits, dental caries, which was extremely low in the African countries in the past, is now posing serious dental health problems. A study conducted by Mahesh P. and Joseph T. in 5-12 years school going children in Chennai city , according to this dental caries correlated with malocclusion .

18. 8/20/2016 18 In 2007, a post-war survey conducted by Ahmed NAM, Astrom AN and Bergen NS in12-year old school children from Baghdad, Iraq. according to this the low prevalence of caries among children by increasing awareness and promoting oral health care strategies.

19. 8/20/2016 19 In 2015, the caries prevalence and experience among 5, 12 and 15 years age group children from all the reviewed articles from 1999-2014 was 48.11%, 43.34% and 62.02% respectively. Region wise distribution of dental caries in the past 15 years (1999-2014) shows more prevalent in the Northernern region among all the index age groups with maximum prevalence (76.06 %) among 15 year age group . 5

20. Theories of Caries Etiology 2,4,6 The etiology of dental caries is a complex problem. There is no universally accepted opinion of the etiology of dental caries. Early theories of caries:- The legend of Worm:- In the past, dental caries was thought to be caused by living worms inside the tooth structure. B. Endogenous theories:- Humoral theory- According to which an imbalance between the humors of body caused tooth decay. 8/20/2016 20

21. Vital theory:- According to which tooth decay originated from within the tooth itself, like a bone gangrene. C . Exogenous Theories:- Chemical (acid) theory:- On the basis of findings of Robertson (1835), this theory proposed that tooth decay was caused by the fermentation of food particles around the teeth. 8/20/2016 21

22. Parasitic (septic) theory:- This was the first theory that related microorganisms with caries on a causative basis (by ERDLE, 1843)Accordingly, it was proposed that even though caries starts purely as a chemical process but microorganisms continued the disintegration in both enamel and dentin. 8/20/2016 22

23. 8/20/2016 23 Miller's chemico -parasitic theory(the acidogenic theory):- Proposed by Willoughby D Miller. This theory is a blend of both chemical and parasitic theory proposed earlier. According to this theory, dental caries is a chemico -parasitic process consisting of 2 stages: first, decalcification of enamel and dentin (preliminary stage) second, dissolution of the softened residue (later stage) and the acid causing primary decalcification is produced by the fermentation of starches and sugar from the retained corners of teeth.

24. 8/20/2016 24 Hence Miller advocated an essential role of 3 factors in the caries process: the oral microorganisms, the carbohydrate substrate, and the acid. Even though, at that time, this theory couldn’t explain 1) predilection of specific sites on a tooth 2) initiation of smooth surface caries 3) why some populations are caries free 4) the phenomenon of arrested caries. This theory is still considered as the backbone of current knowledge and understanding of the etiology of dental caries.

25. 8/20/2016 25 The Proteolytic theory:- By Gottlieb and Gottlieb. According to this theory, the organic or protein elements of tooth (not the inorganic constituents of enamel ) are the initial pathways of invasion by microorganisms; And, caries is essentially a proteolytic process , in which the microorganisms invade the organic pathways and destroy them while advancing through them by forming acids. Hence certain structures of enamel having high organic material composition, like enamel lamellae and enamel rod sheaths, could serve as a pathway for microorganism invasion through the enamel .

26. 8/20/2016 26 Drawbacks of this theory 1)It couldn’t provide sufficient evidences to support the claim that the initial attack on enamel is proteolytic ; 2)also experimental studies have shown the occurrence of caries even in the absence of proteolytic microorganisms However , this theory is still helpful in explaining the progression of a more advanced carious lesion.

27. 8/20/2016 27 Proteolysis Chelation theory:- This theory proposed b y  Schatz   et al. implies a simultaneous microbial  degradation of the organic components (hence, proteolysis), and the dissolution of the minerals of the tooth by the process of chelation . According to the proteolytic-chelation theory, dental caries results from an initial bacterial and enzymatic proteolytic action on the organic matter of enamel without preliminary demineralization.

28. 8/20/2016 28 Such action, the theory suggests, produces an initial caries lesion and the release of a variety of complexing agents, such as amino acids, polyphosphates and organic acids. The complexing agents then dissolve the crystalline appetite.

29. Epidemiological factors of Dental Caries 8/20/2016 29 Dental caries is a multifactorial disease in which there is an interaction between three principle factors :-

30. 8/20/2016 30 In addition, a fourth factor “time”, is also considered. This concept is shown in the “Keyes diagram”. All the factors must be present and must interact with each other for dental caries to develop. HOST AGENT ENVIRONMENT TIME TIME TIME DENTAL CARIES

31. A susceptible host tissue 8/20/2016 31 A person or other animal, including birds and arthropods that affords subsistence or lodgment to an infectious agent under natural condition. In case of dental caries, host is the tooth itself.

32. Tooth structure 8/20/2016 32 COMPOSITION ENAMEL DENTIN CEMENTUM ORGANIC SUBSTANCE & WATER 4% 35% 50-55% INORGANIC SUBSTANCE 96% 65% 45-50%

33. Morphologic characteristics of tooth 8/20/2016 33 PREDISPOSING FACTORS:- 1.Presence of deep, narrow, occlusal fissures or buccal and lingual pits. 2. Alteration of tooth structure by disturbance in formation or in calcification

34. 8/20/2016 34 Tooth position Teeth which are malaligned , rotated or out of position may be difficult to clean and tends to favor the accumulation of food and debris . This, in susceptible persons, would be sufficient to cause caries in tooth.

35. Variation in caries within the Mouth 8/20/2016 35 It is grouped under three main parts:- Observation on types of caries, according to tooth surface attacked. Observation upon the frequency with which the different teeth in the mouth are attacked. Observation upon bilateral symmetry.

36. CARIES SUSCEPTIBILITY OF INDIVIDUAL TOOTH SURFACE 8/20/2016 36

37. Caries susceptibility of individual teeth 8/20/2016 37

38. CARIES SUSCEPTIBILITY OF INDIVIDUAL QUADRANTS 8/20/2016 38 Many investigators have shown that caries exhibit a bilateral distribution between right and left quadrants on both maxillary and mandibular arches. Scott (1944) found bilateral caries in 95% of a group of 300 persons whose dental radiographs were studied. Healey and Cheyne (1943) studying caries activity in the University of Minnesota students reported that 44.4% and 47.5% of the maxillary teeth were involved in men and women respectively, compared to 33.1% and 34.4% of the mandibular teeth in respective gender. It may relate to gravity and the fact that saliva, with it’s buffering action would tend to drain from the upper teeth and collect around the lower teeth

39. OTHER HOST FACTORS 8/20/2016 39 1 ) Saliva Composition pH Quantity Viscosity Antibacterial factors. 2) Race and ethnic groups 3) Age 4) Gender 5) Hereditary 6) Emotional disturbances. 7) Nutrition 8) Socio-economic Status

40. Saliva 8/20/2016 40 The fact that teeth are in constant contact with and bathed in saliva would suggest that this factor could profoundly influence the state of oral health of a person. One of the most important function of saliva is its role in removal of micro flora & food debris from the mouth

41. 8/20/2016 41 CONSTITUENTS INORGANIC CONSTITUENTS ORGANIC CONSTTIUENTS Positive ions Carbohydrates - Glucose Calcium, Hydrogen, Magnesium, Potassium Lipids – Cholesterol, lecithin Negative ions Nitrogen – non protein Ammonia, Urea Carbon dioxide, Carbonate, Chloride, Fluoride & Phosphates Nitrogen – protein Globulin, Mucin Peroxides enzymes

42. 8/20/2016 42 Quantity of saliva Normal: 700-800 ml/day salivary gland Aplasia and Xerostomia where salivary flow is reduced results in rampant dental caries. High Caries Incidence Is Associated With Thick Mucinous Saliva . Viscosity of saliva:

43. 8/20/2016 43 Antibacterial properties of saliva: Lactoperoxidase Lysozyme Lactoferrin IgA Other salivary components with protective function Proline rich proteins- mucin and glycoprotein

44. 8/20/2016 44 SALIVARY pH Determined mainly by the Bicarbonate concentration Salivary pH increases with flow rate Salivary buffers increase pH of saliva in the oral cavity. Decrease pH favors caries

45. 8/20/2016 45 Stephan curve:- Acidogenic bacteria in dental plaque rapidly metabolize fermentable carbohydrates producing acidic end products.  In the mouth, these changes over time in response to a challenge (usually a cariogenic food) are known as Stephan responses or Stephan curves.  The pH of dental plaque under resting conditions (i.e., when no food or drink has been consumed), is fairly constant.  Differences do exist, however, between individuals and in different sites within an individual .

46. 8/20/2016 46 Under resting conditions, pH of plaque is constant, 6.9-7.2. Following exposure to sugars the pH drops very rapidly(in few minutes) to its lowest level(5.5-5.2 – critical pH) and at this pH, the tooth surface is at risk. During the critical period, the tooth mineral dissolves to buffer further acid at lower pH in the plaque – enamel interface and also result in mineral loss.

47. 8/20/2016 47 The Stephan Curve Adapted from: Stephan RM, Miller BF. A quantitative method for evaluating physical and chemical agents which modify production of acids in bacterial plaques on human teeth. J Dent Res. 1943;22;45-51.

48. 8/20/2016 48 Repeated fall of pH over a period of time leads to more and more mineral loss from the tooth surface and ultimately it presents in unfavorable way resulting in initiation of dental caries Later slowly it returns to its original value over a period of 30-60 minutes, approximately .

49. RACE OR ETHINC GROUPS 8/20/2016 49 Certain races enjoy high degree of resistance to caries. These beliefs have faded as evidence suggests that these differences are more due to environmental factors than inherent racial attributes

50. 8/20/2016 50 Non-European races such as African and Asian enjoyed freedom from caries than Europeans. Moreover, certain groups, once thought to be resistant to caries became susceptible when they moved area with different cultural and dietary pattern.

51. Age 8/20/2016 51 Previously caries was considered “essentially a disease of childhood” but it shows 3 peaks: at ages of 4-8 years, 11-19 years, and 55-65 years. With the advent of better preventive measures like use of fluorides, maintenance of oral hygiene, etc, more and more younger people are reaching adulthood with many caries free surfaces, and hence caries is becoming a ‘disease of lifetime ’.

52. 8/20/2016 52 Maximum caries activity is noticed among children and later root caries prevalence will be more in elderly people .

53. Gender 8/20/2016 53 Many studies have shown higher caries experience in girls than boys during childhood period & also later at adolescence period. Increased susceptibility may be due to: Early eruption of teeth in females Morphological difference in teeth Increased fondness towards sweets among girls Due to hormonal changes Root caries is more prevalent in males

54. 8/20/2016 54 Several epidemiological studies have shown a consistent, higher caries experience in permanent teeth of females as compared to males of the same chronological age in spite of a higher average level of oral hygiene in girls. This was shown by the results of the survey of the US department of Health and Human service { Brunelle and Carlos, 1982}

55. 8/20/2016 55 Observation by Carlos and Gittelshon {1 965 } support the observation that eruption time explains the most, but not all, of the age specific prevalence difference between boys & girls . Even after the adjustment for eruption times the caries rate for the first and second molars were consistently higher in females.

56. FAMILIAL HEREDITY 8/20/2016 56 “ GOOD OR BAD TEETH RUN IN THE FAMILY” Family studies have shown that offspring have the same score as parents and this happens due to transmission of dietary and oral hygiene habits through family. Mansbridge found a greater resemblance between identical twins or fraternal twins than unrelated pair of children.

57. 8/20/2016 57 In a study of identical twins the dominance of hereditary factor should reveal a more closely related caries pattern than would be found in fraternal twins. Such studies indicate that concordance for caries sites in monozygotic twins is much higher than in dizygotic twin pairs. The studies suggest that genetically determined factors such as tooth morphology and occlusion, may play a significant role in determining caries rate .

58. EMOTIONAL DISTURBANCES 8/20/2016 58 Periods of stress have been associated with high caries incidence. Schizophrenics have reduced caries activity which may be attributed to increased salivation and higher pH of saliva.

59. NUTRITION 8/20/2016 59 Nutrition can be called a host factor to the extend that the individual selects specific foods from the array available to him/her. Under nutrition is associated with hypoplasia of enamel, salivary gland atropy , reduced salivary flow rate leading to high susceptibility to dental caries. Under nutrition results in delayed shedding of primary teeth and delayed eruption.

60. SOCIOECONOMIC STATUS 8/20/2016 60 It is difficult to correlate caries pattern with socioeconomic status due to its complexity. It is noticed that low SES groups have more number of decayed & missing teeth but less number of filled teeth and vice versa in high SES group. Good economic status and social pressure in the direction of good appearances are both strong factors in creating demand for dental treatme nt .

61. Agents 8/20/2016 61 Agent- A substance living or non living or a force tangible or intangible, the excessive presence or lack of which may initiate disease process. The classical germ –free animal studies of Orland et al(1954), firmly established principal evidence that had been debated for more than a century that dental caries is a bacterial infection .

62. 8/20/2016 62 Mutans Streptococcus – initiation of smooth surface caries Lactobacillus - Initiation of pit and fissure caries, progression of smooth surface caries Actinomyces - Root caries

63. 8/20/2016 63 Role of dental plaque:- Dental plaque is a complex, metabolically interconnected, highly organized, bacterial ecosystem. It is a structure of vital significance of the carious lesion. An important component of dental plaque is acquired pellicle, which forms just prior to or with bacterial colonization and may facilitate plaque formation .

64. A suitable local substrate 8/20/2016 64 The role of diet and nutritional factors deserves special consideration. The physical properties of food may be significant by affecting food retention, food clearance, solubility and oral hygiene. Various factors that considered among the properties of diet:-

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66. Classic Dietary Studies 8/20/2016 66 5year investigation 436 adult inmates in a mental institution at the Vipeholm hospital near Sweden. The institutional diet was nutritious but contained little sugar with no provision for between meal snacks. VIPEHOLM STUDY Gustaffson et al 1954

67. 8/20/2016 67 7 Experimental groups GROUP INTERVENTION CONTROL Usual diet SUCROSE 300g of sucrose in solution, 75g in last 2 years BREAD 345 g of sweet bread = 50g of sugar daily CHOCOLATE 65g of milk chocolate daily between meals for last 2 years CARAMEL 22 caramels = 70g of sugar in 4 proportions between meals 8 TOFFEE 8 sticky toffee = 60g of sugar daily for 3 years 24 TOFFEE 24 toffee = 120g of sugar for 18 months

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69. 8/20/2016 69 An increase in carbohydrate mainly sugar definitely increase caries activity. Risk of caries is greater if the sugar is sticky in nature. The caries activity is greatest, if the sugar is consumed between meals Increase in caries activity varies widely between individuals Upon withdrawal of the sugar rich foods, increase activity rapidly decrease and disappears A high concentration of sugar in solution and its prolonged retention on tooth surfaces leads to increase caries activity This study showed that the physical from of carbohydrate is much more important in Cariogenicity than the total amount of sugar ingested . Conclusions of the Vipeholm study

70. 8/20/2016 70 3 -14 years age children Hope wood house, Bowral , New south Wales Australia, 10 years. strictly institutional diet occasional serving of egg yolk Diet - vegetable in nature and largely raw. The absence of meat and a rigid restriction of refined carbohydrate The meals were supplemented by vitamin concentrates and an occasional serving of nuts and honey. The fluoride content of water and food was insignificant and no tea was consumed. HOPEWOOD HOUSE STUDY (SULLIVAN- 1958, HARRIS –1963)

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72. 8/20/2016 72 At the end of 10 years  13 years old had DMFT mean 1.6 /child General population  13 years old mean DMFT 10.7 53% children at the hope wood house  caries free 0.4% children of state children  caries free. Hope wood house children’s oral hygiene was poor, calculus + gingivitis more prevalent in 75% of children. Conclusion : In institutionalized children, at least dental caries can be reduced by carbohydrate restricted diet without the beneficial effects of fluoride and in the presence of unfavorable oral hygiene. RESULTS

73. 8/20/2016 73 Finland studies Aim : To Study the effects of the chronic consumption of sucrose, fructose and xylitol on dental caries. 2 year study of 125 young adults 125 young adults  Sucrose group – 35 people Fructose group – 38 people Xylitol group – 52 people TURKU SUGAR STUDIES ( Scheinin , Makinen et al 1975)

74. Conclusion 8/20/2016 74 After 2 years Sucrose group  increased Cariogenicity Fructose group  fructose as cariogenic as sucrose for first 1 year, less cariogenic at the end of 24 months. Xylitol group  dramatic reduction in the incidence of dental caries after 2 years Frequent chewing of xylitol gum in between meals produced anti- cariogenic effect. ‘Sucrose is arch criminal’

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76. PREVENTIVE DIETARY PROGRAMME 8/20/2016 76 1 . Exclude fermentable sugars from diet. 2. If child is fond of sweets, give them all at meal time, not between the meals. 3. Include vegetables and fruits, nuts (pea nuts) and cheese as basic diet (increases in salivation). 4. Avoid solid and sticky sugary foods. 5. Reduce the number of sugar exposures.

77. Diabetes and Dental caries 8/20/2016 77 The occurrence of dental caries in patients with diabetes mellitus has been studied, but no specific association has been identified. The relationship between dental caries and diabetes mellitus is complex. Children with type 1 diabetes often are given diets that restrict their intake of carbohydrate-rich, cariogenic foods, whereas children and adults with type 2 diabetes—which often is associated with obesity and intake of high-calorie and carbohydrate rich food—can be expected to have a greater exposure to cariogenic foods.

78. 8/20/2016 78 Furthermore, a reduction in salivary flow has been reported in people with diabetes who have neuropathy, and diminished salivary flow is a risk factor for dental caries. The literature presents no consistent pattern regarding the relationship of dental caries and Diabetes.

79. Environment 8/20/2016 79 All that which is external to the individual human host living or non-living and with which he is in constant interaction.

80. ENVIRONMENTAL FACTORS 8/20/2016 80 GEOGRAPHIC VARIATIONS Following geographic factors influence the parameters Sunshine Temperature Rainfall Fluoride level Total water hardness Trace elements Soil Relative humidity

81. Sunshine 8/20/2016 81 The high correlation leads to consideration of the mechanism relating sunshine to caries. Ultraviolet light from the sun is known for its ability to promote synthesis of vitamin D in skin tissue and thus reduce caries incidence.

82. Temperature 8/20/2016 82 Temperature varies with latitude and altitude. It acts to vary the caloric requirements and water intake of humans. One study by US department of agriculture showed that the consumption of baked foods and sugar to be higher in the north where temperatures are low. Hence lower the temperature, higher the caries prevalence.

83. Relative Humidity 8/20/2016 83 Humidity shows higher correlation with caries prevalence. Higher the humidity, more moisture in the atmosphere which block the UV rays and sunlight . Hence increased caries activity.

84. Rainfall 8/20/2016 84 Rainfall which leaches minerals from the soil and blocks sunlight. Though no latitude relation is evident, there is evident, there is regular decrease in rainfalls as one proceeds inshore. The mechanisms by which relative humidity and rainfall might be linked to dental caries, either together or separately.

85. Fluoride 8/20/2016 85 Fluoride is most common in deep-well waters, and deep wells are most common in inshore areas .

86. Water Hardness 8/20/2016 86 Water hardness is measured by the concentration of calcium carbonate. An inverse relation is seen between caries and water hardness

87. Trace elements 8/20/2016 87 A number of trace elements deserve attention, some found in water supplies but most found in greater concentration in common foodstuffs. Hadjimarkos has found marked increase in dental caries in areas where selenium was high both in water and foodstuffs.

88. 8/20/2016 88 Selenium is the first micronutrient element shown to be capable of increasing caries, particularly when consumed during the developmental period of the teeth and incorporated into their structure.

89. Soil 8/20/2016 89 Where populations depend largely on locally grown food products . Ludwig, Healy & Malthus noted marked difference in caries between the town of Napier and Hastings, New Zealand, without any environmental factor other than soil to account for it. Difference in diet, fluoride, climate and so forth were negligible. The soil of Napier, however, had higher pH, higher molybdenum, and the children there had lower caries. Soil is not likely to prove an important elements in program for the prevention of dental disease

90. Urbanization 8/20/2016 90 A study by WHO has showed higher caries score in urban areas where the consumption of refined food stuffs by urban community is observed

91. Nutrition 8/20/2016 91 Nutrition is an environmental factor as the influence of food available to the population.

92. Social Factor 8/20/2016 92 Social factors like economic status, social pressure, provision of good preventive measures etc. might create more demand for better dental care and leads to lesser caries prevalence

93. Industrial hazards 8/20/2016 93 Carbohydrate dust and acid fumes are both known to be deleterious to the teeth, the one promoting caries and other chemical erosion.

94. Classification of dental caries 8/20/2016 94 According to Black's Classification of Caries Lesions : Class I Caries affecting pits and fissures on occlusal third of molars and premolars, occlusal two thirds of molars and premolars, and Lingual part of anterior teeth. Class II Caries affecting proximal surfaces of molars  and premolars. Class III Caries affecting proximal surfaces of central incisors, lateral incisors and cuspids.

95. 8/20/2016 95 Class IV Caries affecting proximal including incisal edges of anterior teeth. Class V Caries affecting gingival 1/3 of facial or lingual surfaces of anterior or posterior teeth. Class VI (never described by Black, added later by others) Caries affecting cusp tips of molars, premolars, and cuspids.

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97. Various clinical classification system for caries- 8/20/2016 97 1- According to location Pit and fissure Smooth surface Root surface 2- According to clinical appearance Incipient Cavitations Gross destruction

98. 8/20/2016 98 3- According to rate of disease progression Acute Chronic Arrested Rampant 4- According to history Primary Secondary or recurrent

99. Reasons for caries decline and rise 8/20/2016 99 Common factors contributing to the decline of dental caries in developed countries- Fluoridation of water supplies Use of fluoride supplements Use of fluoride dentifrices Availability of dental resources Increased dental awareness

100. 8/20/2016 100 Changes in diagnostic criteria Widespread use of antibiotics Herd immunity Decrease in sugar consumption

101. 8/20/2016 101 Reasons for rise in dental caries in developing countries:- Increase in sugar consumption in underdeveloped countries Lack of dental resources Socio economic factor Lack of water fluoridation Lack of preventive dental health programes

102. Levels of prevention of dental caries 8/20/2016 102 LEVELS OF PREVENTION PRIMARY PREVENTION SECONDARY PREVENTION TERTIARY PREVENTION PREVENTIVE SERVICES HEALTH PROMOTION SPECIFIC PROTECTION EARLY DIAGNOSIS & PROMPT TREATMENT DISABILITY LIMITATION REHABILITATION Services provided by the individual Diet planning Demand for preventive services Periodic visits to dental clinic Appropriate use of fluoride Ingestion of fluoridated water Use of fluoridated dentifrices Oral hygiene practices Self examination & referral Utilization of dental services Utilization of dental services Utilization of dental services

103. Levels of prevention of dental caries 8/20/2016 103 LEVELS OF PREVENTION PRIMARY PREVENTION SECONDARY PREVENTION TERTIARY PREVENTION PREVENTIVE SERVICES HEALTH PROMOTION SPECIFIC PROTECTION EARLY DIAGNOSIS & PROMPT TREATMENT DISABILITY LIMITATION REHABILITATION Services provided by the community Dental health education programs Promotion of lobby efforts Community or school water fluoridation School fluoride mouth rinse program School sealant program Periodic screening & referral Provision of dental services Provision of dental services Provision of dental services

104. Levels of prevention of dental caries 8/20/2016 104 LEVELS OF PREVENTION PRIMARY PREVENTION SECONDARY PREVENTION TERTIARY PREVENTION PREVENTIVE SERVICES HEALTH PROMOTION SPECIFIC PROTECTION EARLY DIAGNOSIS & PROMPT TREATMENT DISABILITY LIMITATION REHABILITATION Services provided by professional Patient education Plaque control program Diet counseling Recall reinforcement Caries activity tests Topical application of fluorides Fluorides supplement Rinse preparation Pit & fissure sealant Complete examination Prompt treatment of incipient lesions Preventive resin restorations Simple restorative dentistry Pulp capping Complex restorative dentistry Pulpotomy RCT Extraction Removable & fixed prosthodontics Minor tooth movement implants

105. Conclusion 8/20/2016 105 Dental caries is still a considerable burden largely in developing world and to lesser extent in developed world. Nevertheless continuous & significant presence of dental caries in population and with its prime determinants is operating in relatively large number of populations. So further exploration using epidemiology as a tool will certainly throw a light in understanding and management of dental caries.

106. REFERENCES 8/20/2016 106 Peter S Essentials of Preventive and Community Dentistry 2014 5 th ed. Rajendran R, Sivapathasundharam B Shefer’s Textbook of oral pathology 2012. 7 th edition. Pg no. – 419-440 Hiremath SS Textbook of Preventive and Community Dentistry 2011 2 nd ed. Marya CM A Textbook of public health dentistry .2011 1 st edition : 98-111

107. 8/20/2016 107 5. Hansa Kundu , Basavaraj Patthi,Ashish Singla , Chandrashekar Jankiram , Swati Jain, and Khushboo Singh Dental Caries Scenario Among 5, 12 and 15-Year-old Children in India- A Retrospective Analysis J Clin Diagn Res. 2015 Jul; 9(7): ZE01–ZE05. 6.