1.PREVENTIVE AND COMMUNITY DENTISTRY I EPIDEMIOLOGY OF ORAL DISEASES: DENTAL CARIES Dr. Caroline Piske de A. Mohamed
Nov 15, 2015
1.PREVENTIVE AND COMMUNITY DENTISTRY I
EPIDEMIOLOGY OF ORAL DISEASES:
DENTAL CARIES
Dr. Caroline Piske de A. Mohamed
OBJECTIVES
Students should be able to explain and discuss:
1. Epidemiology of dental caries
2. How do you measure dental caries?
3. Epidemiology of dental caries A HISTORICAL PERSPECTIVE
4. Dental caries and disparities
5. Factors affecting the epidemiology of dental caries
6. RISK FACTORS AND INDICATORS
7. Nutrition and caries
8. DIET AND CARIES
9. Environmental factors that may affect caries
HOW DO YOU MEASURE DENTAL CARIES?
Dental caries is an universal disease affecting all
geographic regions, races, both the sexes
and all ages groups.
The prevalence of dental caries is generally
estimated at the ages of 5, 12, 15, 35 to 44 and
65 to 74 years for global monitoring of
trends and international comparisons.
The prevalence is expressed in terms of point
prevalence ( percentage of population affected
at any given point of time) as well as DMFT
index ( number of decayed, missing and filled
teeth in an individual and in a population)
MEASURING DENTAL CARIES
WHO oral health surveys manual means of DMF-
T Index:
Very low = 0.0 1.0
Low = 1.2 2.6
Medium = 2.7 4.4
High = 4.4 6.5
Very high = 6.5 or more
The levels of dental caries are high
in many countries and populations,
was it the same in ancient times?
EPIDEMIOLOGY OF DENTAL CARIES
A HISTORICAL PERSPECTIVE
Dental caries was very uncommon amongst
fossil hominids into the Paleolithic and
Mesolithic era. The incidence of caries was less
than 1%.
From the Australopithecines (over a million years
ago) to the Neolithic (since 10,000 years ago),
carious lesions have been found in almost
every population studied.
FROM HUNTERS TO CROPERS
MORE CARIES....
Several studies have shown an increase in
caries rate associated with the change from a
hunter-gatherer diet with meat and low
carbohydrate to a diet heavy with starch-
rich cereal.
With maize agriculture, the dominant pattern
was root surface caries or lesions at the
cemento-enamel junction initiated in
adulthood.
Where sugars have been introduced into the
diet, fissure and proximal surface cavities,
particularly in children, became dominant.
ANCIENT EGYPT
What do Egyptian dental patterns reveal
about their lives and how to they compare
to living populations today?
Dental caries were far less frequently seen
amongst ancient Egyptians and Nubians than in
today's populations. Two reasons are cited.
First, rapid wear literally wore away the
sites of pit and fissure cavities. Second, was
the lack of refined carbohydrates in their
diet.
Ancient Egyptians and Nubians rarely had the
dental crowding and abnormal molar
relationships that are observed throughout
the world today.
Many anthropologists and some orthodontists
suggest that vigorous chewing encourages
development of robust, full sized lower jaws
and some degree of wear minimized joint
pain and crowding that are prevalent
today.
In ancient Egypt, the greatest single problem was
attrition, specifically the wear of the occlusal and proximal surfaces.
The teeth were rapidly worn down throughout
life by the consumption of a course diet. This was true for both pharaohs and commoners.
In time, the wear became so extensive that
enamel and dentin were worn away, exposing the
pulp.
Painful chronic infection was the result. Dental
surgeons of that time would drain the abscesses
with the use of a hollow reed and had worked in
teeth restoration and prostheses..
High level of calculus accumulation were found
and tooth loss for periodontal disease was
moderately prevalent.
In European material, there is a gradual increase
from very low rates through the Paleolithic,
Neolithic, Bronze and Iron Age, to a rapid rise
through Medieval and modern times.
GOING TO MODERN TIMES AND DENTAL
CARIES AS AN ENDEMIC DISEASE
5th to 6th centuries: MODERATE caries
experience. More attrition, cervical & root caries.
16 th century: MODERN pattern ( fissures &
proximal surfaces caries), in HIGH-INCOME
nations. ( Sugar crop at colonies)
DENTAL CARIES AS AN ENDEMIC DISEASE
18 th century: dietary changes, increase in caries
prevalence until 70s.
The only break in this increase came during the mid 40s
and early 50s and this coincided with the reduced
availability of sucrose as a result of food rationing
imposed during the World War II.
19 th century: dental caries endemic disease.
NUMBER OF CARIOUS TEETH PER 100 TEETH
IN FOUR EUROPEAN POPULATIONS, ADAPTED
FROM KEAN, 1980
Increase in the number of caries is
related to the:
1. improvement of productivity (
industrialization),
2. the development of agriculture and
3. food processing industry and
4. increase of sugar intake amount.
ANCIENT X MODERN PEOPLE IN
RELATION TO DENTAL CARIES
Ancient people Modern people
Proximal caries Occlusal pit &
fissures caries
Poor production
tools and coarse
food
Industrialized
refined food
Low sugar
comsumption
High sugar
comsuption
EPIDEMIOLOGY OF DENTAL CARIES
GOING THROUGH THE 20S AND AFTER
II WORLD WAR
Most obvious reason: DIET
For most of the 20 th century dental caries:
Disease of the HIGH-INCOME countries
Low prevalence in poorer countries
By the late 20 century happened:
Sharply RISING caries in some LOW INCOME countries after world war ( 1939-1945) especially urban areas.
Significant caries reduction in HIGH-INCOME countries. Marked reduction among children and young adults eventhough caries remains the most common common chronic childhood disease.
Most data: DMFT
CHANGING TRENDS IN DENTAL CARIES [DMFT
OF 12 YR OLDS] IN DEVELOPED & DEVELOPING
COUNTRIES
WHAT WERE THE CAUSES
OF THE CHANGE OF
DENTAL CARIES PATTERN
IN THE LATE 20S IN
DEVELOPED AND
UNDEVELOPED
COUNTRIES?
THIS WAS ATTRIBUTED TO:
Dietary changes
Fluorides
Preventive programs
(better oral hygiene)
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NUMBERS....
Worldwide, approximately 2.43 billion people (36% of the population) have dental carries in their permanent teeth. In baby teeth it affects about 620 million people or 9% of the population.
The disease is most prevalent in Latin American countries, countries in the Middle East, and South Asia, and least prevalent in China.
Countries with good oral health programs decreased DMFT ( Brazil- Water fluoridation- Brazil Sorridente Oral Health Program)
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 dental caries.
Caries continues to affects millions of
adolescents and adults.
Almost 94% of dentate adults showed
evidence of coronal caries, and almost 23%
root caries.
The prevalence of caries in adults
increase with age.
DENTAL CARIES AND DISPARITIES
Developed countries (North America, Australia, Europe and Japan)......decreasing caries rate in children and increased number of retained teeth in older adults.
There are disparities in this situation (developed countries) for:
1. Developmentally disabled
2. Mentally retarded
3. Immigrant groups
4. Low socioeconomic group individuals
They present high levels of decay.
POLARIZATION
Dental caries, in those countries, are largely a disease
affecting the deprived section of the society.
In many communities 60 to 80% of dental caries is
occuring in 20 % of the population.
of all affected teeth are found in of the
population, constituting a small amount of people
with the greatest severity of decay - polarization.
SIGNIFICANT CARIES INDEX SIC FOR 12
YEAR OLD CHILDREN IN GERMANY
DENTAL CARIES, AN PANDEMIC DISEASE B.L. Edelstein (2006)
Because: 1. those who are affected by caries and have litlle or no
access to care number in the hundreds of millions,
2. reside on all continents and in most societies,
3. and experience significant consequences of pain and dysfunction that impair their most basic functions of eating, sleeping, speaking, being productive and enjoying general health as defined by the WHO.
FACTORS AFFECTING THE
EPIDEMIOLOGY OF DENTAL CARIES
Keyes triad ( carbohydrate (diet); bacteria ( dental
plaque); susceptible teeth( the host)
Modifying factors:
Saliva, immune system, time, socioeconomical
status, level of education, lifestyle behaviors,
and the use of fluorides.
The caries process can be described as loss of
mineral (demineralization) when the pH of
plaque drops below the critical value of 5.5.
Redisposition of mineral ( remineralization) occurs
when the pH of plaque rises.
The presence of fluoride reduces the critical pH by 0.5
pH units, thus exerting its protective effect.
Dr.Caroline Mohamed 33
HOST
Susceptibility of different teeth: 1. Mandibular first and second molar
2. Maxillary first and second molar
3. Mandibular second bicuspids, maxilar
first and second bicuspids, maxillary
central and lateral incisors.
4. Maxillary canines and mandibular first
bicuspid.
5. Mandibular central and lateral incisors,
mandibular canines.
DEVELOPMENT OF CARIES WITHIN THE
MOUTH/PERMANENT DENTITION
First lesions: pits and fissures soon
after eruption.
The rapid onset of pit and fissures caries is
expected because of the morphology of those
pits and fissures where food debris is retained,
and the enamel at the very depth of the fissures
is often very thin or even absent.
IN CONTRAST, CARIES OF
PROXIMAL SURFACES ARE
SELDOM CLINICALLY EVIDENT
UNTIL THE AFFECTED TOOTH
HAS BEEN ERUPTED FOR TWO
OR MORE YEARS.
CARIES OF CERVICAL
AREAS OF TOOTH
WHERE CEMENTUM
HAS BEEN EXPOSED
IS RELATED TO
PROGRESSIVE
CHANGE IN THE
FREE MARGIN OF
THE GINGIVA WHICH
INCREASE
SUSCEPTIBILITY TO
PLAQUE FORMATION.
I. DEMOGRAPHIC RISK FACTORS
1) AGE
Mean DMF scores increase with age.
The increase with age for children comes largely
from an increase in number of restored teeth.(
developed countries)
Developing countries ( high levels of D, low levels of
F). For the adult most of increase comes from
missing teeth.
THE RELATION OF AGE AND CARIES
In the past caries used to be considered a childhood
disease ( as most susceptible surfaces were usually
affected by the time the child reached adulthood).
NOW ( developed countries) younger people reach
adulthood with many surfaces free of caries, the
carious attack is spread out more throughout life.
Adults of ages can develop new coronal lesions, and
caries has to be viewed as a lifetime disease.
2) GENDER
Females usually demonstrate higher
DMF scores than males of the same
age.
WHY?
Women produce less saliva than do men,
reducing the removal of food residue from the
teeth, and during pregnancies the chemical
composition changes, reducing salivas antimicrobial capacity.
Food cravings, aversions (women crave high-
energy, sweet foods related to pregnancy and in
periodical hormonal changes).
Undeveloped countries women normally
have more pregnancies, less quality in
nutrition, more caries.
THE RELATION BW GENDER AND DENTAL CARIES
In children the different due to earlier eruption
of the teeth in girls.
In adults the treatment factor is more likely to
be affecting the differences.
In national surveys, males usually have more
untreated decayed surfaces (D), and females
have more restored teeth (F).
The females are not more susceptible to
caries than males, a combination of earlier
tooth eruption plus, habits, hormonal
changes and treatment factor is a more
likely explanation for the observed
difference.
WOMEN LOOK FOR TREATMENT MORE
THAN MEN.
3. RACE AND ETHNICITY
Old observations showed that non-European
races, such as those in Africa and India, enjoyed
a greater freedom from caries.
This global variation result more from
environment rather than racial factors.
Certain racial groups thought to be caries
resistant, quicly developed caries when
they migrate to areas with different culture
and dietary pattern.
THE RELATION BW RACE & ETHNICITY AND
DENTAL CARIES
In the past there were wide DMF difference
between whites and African-Americans ( W>AF),
although the latter usually had more decayed
teeth (D) as a result of lack to access to care.
Now there is little difference in the total DMFs,
although whites still had a higher filled (F)
component and lower scores for decayed
( D) and missing surfaces (M).
THE RELATION BW RACE & ETHNICITY AND
DENTAL CARIES
There are NO inherent differences in susceptibility to
dental caries bw different racial groups.
Socio-economic differences ( i. e. Differences in
education, self care practices, attitudes, value,
income, and access to health care ) appear to be far
more important.
4. SOCIO-ECONOMIC STATUS SES
SES is a broad measure of an individuals background in
terms of such factors as education, income, occupation
and attitude &values.
SES usually measured by the annual income or years of
education.
SES is inversely related to the status of
many diseases and to characteristics
though to affect health.
Lower SES groups had higher values of D and M,
lower for F.
THE RELATION BW SES AND DENTAL CARIES
Although fluoridation of water supplies reduces the
difference bw the social classes, it doesnt entirely
remove it.
The greatest reduction in caries experience
has been enjoyed by the upper social groups, where reduction is less in lower social groups.
When planning treatment programs, caries
experience expected to be more extensive and sever
among low SES population.
5) FAMILIAL AND GENETIC PATTERN
Familial tendencies ( bad teeth run in families) are seen by
many dentists and have been demonstrated by research.
Such tendencies may have genetic basis such as:
deep and narrow pits and fissures, and
special arch form ( crowding) and/or
salivary flow and composition
o or from bacterial transmission or continuing familial
dietary or behavioral traits.
THE RELATION BW FAMILIAL AND GENETIC PATTERN AND DENTAL CARIES
Intrafamilial transmission of cariogenic flora
especially from mother to infants is accepted as
primary way for cariogenic bacteria to
become established in children.
Studies with identical twins concluded that
whereas genetic factors could affect caries
experience to some extent, the environmental
variables were stronger.
WEB OF TRANSMISSION/
PARENTS EDUCATION
53
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II. RISK FACTORS AND INDICATORS THE AGENT
1) Bacterial infection
Dental caries is a bacterial disease, bacteria is
necessary for the disease to occur.
The most important bacteria involved are:
streptococos mutans and lactobacilli.
These bacteria are normally present in the oral
flora, so caries may be considered as an ecologic
imbalance rather than an exogenous infection.
Caries is described as a carbohydrate-modified
bacterial infectious disease, in which cariogenic diet
selectively favors cariogenic bacteria.
Because infection with cariogenic bacteria is
necessary condition for caries to occur, its considered as a
risk factor for caries.
2)NUTRITION AND CARIES Diet is the total oral intake of substances that provide nourishment and
energy.
Nutrition: refers to the absorption of nutrients.
Inadequate Calcium intake for a prolonged period;
Vitamin A, C and D deficiency,
Iodine,
fluoride,
protein-energy malnutrition ( inadequate intake of protein, calories and micronutrients)
have been associated to
delays in tooth eruption,
hypoplasia of the enamel,
atrophy of the salivary glands, and
impaired salivary antimicrobial activity;
conditions that determine a greater susceptibility to caries and are causative factors in hypoplasia.
A specific type of enamel hypoplasia of primary
teeth called linear enamel hypoplasia (LEH) is
common in some economically
underdeveloped countries.
In children, who have signs of severe
malnutrition (related to mal absorption,
gastrointestinal disease and infection that
may lead to hypocalcaemia), linear
hypoplasia was present in up to 73% of the
population.
VITAMIN D DEPENDENT RICKETS
The structural damage can testify to the period
in which the lack of nutrition occurred.
The rate of enamel hypoplasia in primary teeth of
children born prematurely is more than two fold (
2X) that of controls.
Caries is found in countries where malnutrition
during early childhood is common but where
there is later exposure to cariogenic food; the
malnutrition itself DOESNT produce dental
caries whithout the later cariogenic challenge.
Hypoplasia and pits on the surface of the
enamel correlate to a lack of vitamin A.
3) DIET AND CARIES
In contrast with nutrition dietary factors have a
clear influence on caries development.
The relation bw the intake of refined CHO, and
the prevalence and severity of caries is so strong
that sugars are clearly a major etiologic
factor in the causation of caries.
Although the evidence that consumption of
sugars is a major risk factor for caries, sugar
arent the only food sources likely to be
involved in the carious process.
Cooked or milled starches can be broken
down to low molecular weight carbohydrates
by the salivary amylase and thus act as a
substrate for cariogenic bacteria.
Large molecular weight CHO in uncooked or
lightly cooked wegetables are considered non-
cariogenic because little brekdown of these
foods occurs in the mouth.
THE VIPEHOLM STUDY
The Vipeholm Study was a study that dental researchers conducted on a group of mentally challenged residents of the Vipeholm Institution.
Dental researchers fed mentally handicapped people lots of sugar for the purpose of studying tooth decay. Unfortunately, many of these patients ended up losing their teeth to cavities.
Although the study is tragic and wouldn't be allowed to be done today due to ethics concerns, we learned a great deal about how foods cause cavities from this study.
The participants in the study were all fed the same basic diet. The participants were divided up into seven groups to compare how subtle changes in the timing and quantity of sugar consumption affected their dental health.
THREE KEY GROUPS IN THE VIPEHOLM
STUDY
There are three key groups in the Vipeholm study that helped us understand
more about how food affects the formation of a cavity on a tooth:
1 - One group ate the original diet with an extra 300 grams
of sugar dissolved in solution during their
meals. That's the equivalent of drinking about five bottles of coke per day during meals!
2 - Another group ate the basic diet with an extra 50
grams of sugar mixed into their bread that
they ate during mealtime.
3 - The last group ate the basic diet, in between meals,
this group also ate snacks of sugary toffee and
candy.
WHICH GROUP ENDED UP
GETTING THE MOST CAVITIES
AND LOSING THE MOST
TEETH?
The third group.
When the sugar was consumed in between
meals, it gave the bacteria more opportunities
throughout the day to form cavities on the
teeth.
http://www.medicinhistoriskasyd.se/SMHS_bilder/thumbnail
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VIPEHOLM STUDY,( 1952), CONCLUDED THAT:
1. Sugar consumption increase caries activity.
2. The risk of increased caries activity is greater if the sugar
is in a sticky form.
3. The risk is greater if taken bw the meals and sticky
form.
4. The increase in caries under uniform conditions shows
great individual variation.( 20 to 30% of the
patients didnt have any caries although they
consumed tofees bw meals)
5. The increase in caries disappears upon withdrawl of
sticky foodstuffs from the diet.
6. Caries can still occur in the absence of refined sugar,
natural sugars and total dietary CHO.
SUGAR CARIES RELATIONSHIP
Are all the caries free children not consuming
sugar or do other factors
have a major influence?
SUGAR CARIES RELATIONSHIP
Oral hygiene is an important co-variable in the
sugar caries relationship.
Consumption of sugars is not a major risk factor
for many children ( those who were caries free
and still ate a lot of sugar), but it is for these
who are still clearly susceptible to caries (
those presenting proximal caries)
The caries is a multifactorial disease, and
the caries risk is not always related to
sugar consumption.
ENVIRONMENTAL FACTORS THAT MAY
AFFECT CARIES
I) Climatological factors:
Sunshine, temperature, relative humidity.
Geographical disposition of developed and
underdevelopment countries in temperate and
tropical zones leads to this type of hypothesis.
Non-climatological factors:
1) Fluoride
The geologic formation as well as the distance from the sea coast affect the fluoride concentration in water supplies.
2) Total water hardness
It is measured in terms of calcium carbonate. There is inverse relationship bw caries and total water hardness.
3) Trace elements
They are elements found in water supplies and in common food. Such as Selenium which is a micronutrient element and it is capable of increasing caries particularly when consumed during the developmental period of teeth.
An overwhelming number of scientific studies
conclude that cavity levels are falling
worldwide even in countries which dont fluoridate water related possibly to good oral
hygiene habits, fluoridated toothpaste and
community OH programs.
To Fluoridate or not fluoridate,
thats the question
ACTIVITIES
Make a resume about: The Vipeholm Dental
Caries Study: recollections and reflections 50
years later.
How to find it:
The Vipeholm Dental Caries Study: recollections
and reflections 50 ...
www.researchgate.net/.../11439564_The_Vipehol
m_... -
Right side of page click VIEW
Read and make a 1 page resume.
THANK YOU