Prevention of Caries

PREVETION OF DENTAL CARIES

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INTRODUCTION

Dental caries is defined as a progressive irreversible microbial disease affecting the hard parts of tooth exposed to the oral environment, resulting in demineralization of the inorganic constituents and dissolution of the organic constituent, thereby leading to a cavity formation.

• The word caries derived from Latin meaning ‘rot’ or decay

• Similar to the Greek word ‘ker’ meaning death• The relationship between diet and dental caries

Bacterial enzymes + fermentable carbohydrates = acid,Acid + enamel = dental caries

CURRENT TRENDS IN CARIES INCIDENCE

• In developed countries, caries prevalence declined in last decade, causes are multifactorial. Eg: communal water fluoridation.

• In developing countries increase in caries prevalence, cause is increased use of refined carbohydrates.

CARIES SUSCEPTIBILITY JAW QUADRANTS

• Bilateral distribution between the right and left quadrant of both maxillary and mandibular arches.

• Maxillary teeth more susceptible than mandibular arch relate to gravity and saliva, with its buffering action, would tends to drain from upper teeth and collect around lower teeth.

CARIES SUSCEPTIBILITY OF INDIVIDUAL TEETH

• Upper and lower first molar 95%• Upper and lower second molar 75%• Upper second bicuspid 45%• Upper first bicuspid 35%• Lower second bicuspid 35%• Upper central and lateral incisor 30%• Upper cuspids and lower first bicuspid 10%• Lower central and lateral incisor 3%• Lower cuspids 3%• Teeth farthest back in the mouth are more frequently carious.• Caries susceptibility of individual tooth surface

occlusal > mesial > buccal > lingual

ECONOMIC IMPLICATION OF DENTAL CARIES

Factors changing the economic implication of treatment of dental caries :-

• Economic status of population• Increasing educational status• Growing number of dental graduates• Insurance programs• Commercial pressure• Governmental influences

CLASSIFICATION OF DENTAL CARIES

A) Black’s classificationCLASS I – cavities on the occlusal surface of premolars

and molars, on the occlusal two-third of the facial and lingual surface of molars, on lingual surface of maxillary incisors.

CLASS II – cavities on the proximal surface of posterior teeth

CLASS III - cavities on the proximal surface of anterior teeth that do not include the incisal angle

CLASS IV – cavities on the proximal surface of anterior teeth that include the incisal angle

CLASS V – cavities on the gingival third of the facial or lingual surface of all teeth

CLASS VI - cavities on the incisal edge of anterior teeth or occlusal cusp height of posterior teeth

B[1] According to location on individual teeth

- Pit and fissure caries- Smooth surface caries

B[2] According to the rapidity of the process- Acute dental caries- Chronic dental caries

B[3] - Primary caries (virgin)- Secondary caries (recurrent)

PIT AND FISSURE CARIES

- Pits and fissures with high steep walls & narrow base retention of food, debris, micro organisms fermentation acid production

- Caries appear brown/ black, feel soft

- Enamel bordering opaque bluish white

- Large carious lesion with a tiny point of opening

SMOOTH SURFACE CARIES- Preceded by formation of microbial/ dental

plaque- Begins just below contact point and appear in

early stages as faint white opacity of enamel (chalky spot) slightly roughened surrounding enamel bluish white as caries penetrate enamel

- Cervical carious lesion crescent shaped cavity (extend from areas opposite to the gingival crest occlusally to convexity of tooth surface)

ACUTE DENTAL CARIES- Rapid clinical course & early pulp involvement- Process rapid little time for deposition of

sec. dentin. Dentin stained a light yellow- Rampant caries, affecting deciduous dentition

nursing bottle caries- Commonly 4 maxillary incisors followed by

first molar and then cuspids- Absence of caries in mandibular incisors

distinguished from ordinary rampant caries

• CHRONIC DENTAL CARIES- Progress slowly and leads to involve pulp

much later- Sufficient time for both sclerosis deposition of

sec. dentin - Carious dentin stained deep brown.- cavity shallow with min. softening of dentin- Pain and undermining of enamel not a

common featureRECURRENT CARIES- Occurs in immediate vicinity of restoration- Poor adaptation of filling material

ARRESTED CARIES- Static or stationary caries- Exclusively in caries of occlusal surface- Large open cavity and lack of food

retention- Superficially retained and decalcified

dentin gradually burnished until it takes a brown stain, polished appearance and is hard EBURNATION OF DENTIN

- Caries on proximal surface of teeth adjacent approx. tooth extracted

THEORIES OF CARIES FORMATION

• Legend of the worm theory• Endogenous theories

Humoral theory Vital theory

• Exogenous theory Chemical (acid) theory Parasitic (septic) theory Miller’s chemicoparasitic theory – Acidogenic theory Proteolysis theory Proteolysis chelation theory Sucrose – chelation theory

• Other theories Auto immune theory Sulfatase theory

ETIOLOGIC FACTORS IN DENTAL CARIES

• Dental caries is a multifactorial disease in which there is an interplay of 3 principle factors.

I. The host ( teeth, saliva etc.) II. Micro flora III. Substrate (diet)• In addition the fourth factor, time

must be considered.

I. HOST FACTORSTooth• Composition• Morphologic characteristics• Position

Composition of toothEnamel:-- Inorganic : 96%- Organic + water : 4%Dentin:-- Organic matter +water :35%- Inorganic :65%Cementum:-- Inorganic : 45-50%- Organic +water : 50- 55%

Morphological characteristics of the tooth• Feature predisposed to the development of

dental caries is presence of deep narrow occlusal fissure/ buccal and lingual pits

Tooth position• Which are malaligned, out of position, rotated

or otherwise not normally situated, may be difficult to clean and tend to favor the accumulation of food and debris which subsequently lead to dental caries

Saliva

• Composition

• PH

• Quantity

• Viscosity

• Antibacterial factors

Composition of salivaInorganic:-

Positive ions:- Ca, Mg, K, Negative ions:- CO2, Cl, F, PO4,

thiocynateOrganic:-

Carbohydrates : glucoseLipids : cholesterol, lecithinNitrogen : non- protein ammonia,

nitrites & amino acids protein globulin, mucin, total

proteinMiscellaneous : peroxidesEnzymes : carbohydrases, proteases,

oxidases

PH of saliva• Determined by bicarbonate concentration• PH increases with flow rate, normal PH 7.8• Sialin is an argenine peptide described PH

rise factor, present in salivaQuantity of saliva• Normal quantity 700-800 ml per day• In case of salivary gland aplasia and

xerostomia in which salivary flow may entirely lacking, resulting in rampant dental caries

Viscosity of saliva• Thick, mucinous saliva increases the dental

caries

Antibacterial properties of saliva

Lactoperoxidase• They participate in killing of microorganisms

by catalyzing the H2O2 mediated oxidation of a variety of substances in the microbes

• Utilizing thiocynate ions in saliva peroxidation generate highly reactive chemical compound that bond and inactivate general intracellular microbial enzyme system, as well as microbial surface compound.

Lysozyme• Small, highly positive enzyme that catalyze

the degradation of negatively charged peptidoglycan matrix of microbial cell wall

Lactoferin• Fe binding basic protein found in saliva with mol. wt.

near 80,000. • Tends to bind & link the amount of the free Fe which

is essential for microbial growthIgA• Immunoglobulin in saliva• Inhibit adherence and prevent colonization of

microbial on tooth and mucosal surfacesOther salivary components with protective functionProline rich protein• Mucus and glycoprotein• Because of their high proline content, there are rigid

collagen like molecules designed to form a pseudo membranous layer in the hard and soft oral surfaces as well as on the oral flora.

Aromatic rich protein• Statherin• It causes remineralization

Other host factors

Age

• Dental caries decreases as age increases

• Root caries are common in elders

• Gingival recession cemental exposure (improper brushing)

Socioeconomic status

• High low chance

• Low more chance

II. MICROFLORA

• Strep. mutans early carious lesions of enamel• Lactobacilli dentinal caries• Actinomyces root caries

Role of microorganisms in dental caries

• Prerequisite for dental caries initiation

• A single type of microbe is capable of inducing dental caries

• Ability to produce acid prerequisite for caries induction

• Streptococcus strains are capable of inducing caries

• Organisms vary greatly in their ability to induce caries

Role of dental plaque• soft, non mineralized, bacterial deposit

which forms on a teeth that are not adequately cleaned

• Complex metabolically interconned highly organized bacteria/ ecosystem

• Important component of dental plaque is acquired pellicle just prior or concomitantly with bacterial colonization and may facilitate plaque formation

• Microbial in dental plaque streptococci actinomycetes veillonella

• Strep. mutans chief etiological agent of dental caries

III. DIET• Increase in carbohydrate increase carious activity• Risk of caries is greater if the sugar is consumed in a

form that will be retained on the surface of the teeth• Risk of sugar increasing caries activity if it is consumed

between meals• Increasing caries activity varies widely between

individuals• Upon withdrawal of the sugar rich foods the increased

caries activity rapidly disappears• Carious lesion may continue to appear desperate to

avoidance of refined sugar and maximum restriction on natural sugars dietary carbohydrates

• High concentration sugar in solution and its prolonged retention on the tooth surface leads to increased caries activity

• Clearance time of the sugar correlates closely with caries activity

THE CARIES PROCESS• Caries of enamel

smooth surface caries pit and fissure caries

• Caries of dentin• Caries of cementum

SMOOTH SURFACE CARIES

• Earliest manifestation is the appearance of an area of decalcification, beneath dental plaque with a smooth chalky white area

• Loss of interprismatic substance with increase in prominence and roughening of ends of enamel rods

• Accentuation of incremental striae of retzius• As this process advances and involves deeper

layer of enamel it forms a cone shaped lesion with apex towards DEJ and base towards surface of teeth

PIT AND FISSURE CARIES• Because pit and fissure provides more depth

increased food stagnation with bacterial decomposition• Here caries follow direction of enamel rods and forms a

cone shaped lesion with apex at outer surface and base towards DEJ

Different zones present in lesion areZone 1: translucent zone

Advancing front of enamel lesion, not always presentZone 2: dark zone

Referred as positive zone formed as a result of demineralization

Zone 3: body of lesion Area of greatest mineralization

Zone 4: surface zone Appears relatively unaffected

CARIES OF DENTIN

• Initial penetration of dentin by caries may result in dentinal sclerosis

• This is a reaction of vital dentinal tubules and a vital pulp, in which results in calcification of dentinal tubules, that tend to seal them off against further penetration by microorganisms

• The different zones which are present in carious dentin are (beginning pulpally at advancing edge of lesion)

Zone 1 : zone of fatty degeneration of Tome’s fibresZone 2 : zone of degeneration Zone 3 : zone of decalcificationZone 4 : zone of bacterial invasion of decalcified but intact

dentinZone 5 : zone of decomposed dentin

ROOT CARIES

• Defined as soft progressive lesion that is found anywhere on root surface that has lost connective tissue attachment and exposed to oral environment

• Microorganisms involved in root caries are filamentous

• Microorganisms invade cementum, along sharpey’s fibres

INDICES USED TO ASSESSMENT OF DENTAL CARIES

1. DMFT index2. DMFS index3. DEF index4. Stone’s index5. Caries severity index

Diagnosis of caries1. Identification of subsurface demineralization

(inspection/ palpation, radiographs)2. Bacterial testing (caries activity testing)3. Assessment of environment conditions like salivary

PH, flow and buffering

METHODS OF CARIES CONTROL

• There are various levels for prevention of dental caries

these include

1. Primary prevention

2. Secondary prevention

3. Tertiary prevention

levels of prevention

Primary prevention Secondary prevention

Tertiary prevention

Preventive services

Health promotion Specific protection

Early diagnosis and prompt treatment

Disability limitation

Rehabilitation

Services provided by the individual

Diet planning, demand for preventive services, periodic visit to dental office

Appropriate use of fluoride, ingestion of fluoridated water, use of fluoridated dentifrices

Self examination and referral, utilization of dental services

Utilization of dental services Utilization of

dental services

Services provided by community

Dental health education programs, promotion of lobby efforts

Comm. or school water fluoridation, school fluoride mouth rinse program, school fluoride tablet program, school sealant program

Periodic screening and referral, provision of dental services

provision of dental services

provision of dental services

Services provided by the dental profession

Patient education, plaque control program, diet counseling, recall, reinforcement, caries activity tests

Topical application of fluoride, supplements/ rinse preparation, pit and fissure sealants

Complete exam, prompt treatment of incipient lesions, preventive resin restoration, pulp capping

Complex restorative dentistry

Removable and fixed prosthodontic minor tooth movement, implants

METHODS TO CONTROL CARIES

1. Chemical measures

2. Nutritional measures

3. Mechanical measures

1. CHEMICAL MEASURESA vast number of chemical substances have been proposed for the purpose of controlling dental caries

Ideal properties:• It should be safe for intraoral use• Must be able to penetrate dense microbial plaque• Agent used for topical application should not be

systematically toxic if swallowed accidentally• Should not produce local tissue irritation• Should be rapidly bactericidal as contact time is less• Should possess degree of specificity • Should be destroyed or inactivated by GIT• Should have an acceptable taste• Medically important antibiotics should not be used

Chemical measures include:

I. Substances which alter tooth surface or tooth structure

II. Substances which interfere with carbohydrate degradation through enzymatic alteration

III. Substances which interfere with bacterial growth and metabolism

I. SUBSTANCES WHICH ALTER TOOTH SURFACE/ TOOTH

STRUCTURE• Chemicals falling into this categories

includea. Fluorides

b. Iodides

c. Bisbiguanides

d. Silver nitrates

e. Zinc chloride and potassium ferrocyanates

Fluoride• Most widely used and promising chemical in

this category• Fluorides have been administrated

principally in two waysa. Systemic application

eg:- School water fluoridation, community water fluoridation, milk fluoridation, self fluoridation

b. Topical applicationeg:- Sodium fluoride, aciduated phosphate fluoride, stannous fluoride

• A fluoride concentration of 1 ppm in drinking water is associated with a marked decrease in dental caries

• Other methods of using fluorides areAs dietary supplementation of fluorideFluoride dentifricesFluoride in mouth washes/ rinsesFluoride incorporated in chewing gums and dental floss

Rinse Concentration

PH Application

Aqueous NaF

0.2% 7 Once a wk/ once every 2 wk

Aqueous NaF

0.5% 7 Once daily

Aqueous APF

0.02%` 4 Once daily

• Rinses for caries reduction

The effect of fluoride influencing its anticaries actions are:-

• Interference in enzymatic process of bacteria

• Direct bactericidal action• Reduction of plaque formation• Enhancement of enamel remineralization• Stimulation of formation of large appetite

crystal• Lowers the solubility of enamel

Iodine• Used as a antibactericidal mouth

rinses• Kills microorganisms immediately • Disadvantages : metallic taste, stain

metallic or composite restorationsBisbiguanides• The two most common commercially available bisbiguanides are:

a) Chlorohexidineb) Alexidine

• These are potential anticaries agents• They are bactericidal• Have both hydrophobic and

hydrophilic constituents and possess a net +ve charge – adsorbs –vely charged membrane surface and damage to the membrane by breaking permeability barrier

• Disadvantages1. Stains teeth and dorsum of tongue

2. Evidence of bacterial resistance

3. Bitter taste

4. Mucosal irritation and desquamation

5. Allergic reaction

Silver nitrate, zinc chloride and potassium ferrocyante

- seal off the enamel caries invasion pathway by getting impregnated to the enamel

II. SUBSTANCES WHICH INTERFERE WITH CARBOHYDRATE DEGRADATION THROUGH ENZYMATIC ALTERATIONS

• Includes:-1. Vitamin K2. Sarcoside

Vitamin K- Vit. K was found to prevent acid formation in

incubated mixtures of glucose and saliva Sarcoside- Sodium-N-lauryl sarcosinate & sodium

dehydroacetate were promising enzyme inhibitors or antienzymes. They have the ability to reduce the solubility of powdered enamel

III. SUBSTANCES WHICH INTERFERE WITH BACTERIAL GROWTH AND

METABOLISMIncludes:-

• Urea and ammonium compounds

• Chlorophyll

• Nitrofurans

• Antibiotics

• Caries vaccines

Urea and ammonium compounds• Potential anticariogenic agents.• Urea degradation by urease ammonium

neutralize acids • They are cationic antiseptic and surface

active agents• More active against GPB.• Mechanism of action:- +vely charged

molecules reacts with –vely charged cell membrane phophates and thereby disrupts the cell wall structure microorganisms.Eg:- benzathonium chloride, benzalleonium chloride, cetylpyredinium chloride

Chlorophyll• Water soluble form of chlorophyll is capable

of preventing or reducing the PH fall in carbohydrate

• Saliva mixture invitro chlorophyll is bactriostatic

Nitrofurans• These compounds have been found to exert

bactriostatic and bactriocidal action• Act on both aerobic and anaerobic

microorganisms• Eg:- furacin 0.2% cream

Antibiotics• Penicillin:- as an anticariogenic compound, act on cell

wall synthesisdisadvantage: resistance

• Erythromycin:- act on bacterial protein synthesisDisadvantage: diarrhoea and resistance

• Kanamycin:- act on bacterial protein synthesis. It reduced S. Mutans and S. Sanguis population in plaqueDisadvantage: nephrotoxicity and ototoxicity

• Others:- spiramycin, tetrcycline, tyrothricin, vancomycin

Caries vaccine• Caries vaccine dates back to a period, when

lactobacilli were thought to be of paramount of importance. Oral administration of S. Mutan vaccine leads to accelerated clearance S. mutans from mouth.

NUTRITIONAL MEASURES

The chief nutritional measures advocated for the control of dental caries is restriction of refined carbohydrate intake.

Other measures include- Avoiding sugar that

retains of teeth surface- Avoiding sugar in

between meals- Eating of phosphated

diets

Phosphated dietPhosphates are anticariogenic sodiummeta phosphate appear to be

most effective. Phosphate exhibit their cariogenic action via local factors like:-

1. Reduction of enamel solubility2. Buffering effect in neutralizing salivary plaque3. Rendering fats, carbohydrates and proteins which are less

cariogenic4. Interference with enzymatic process on enamel surface to

increase host resistance5. Decrease in bacterial adhesion 6. Interference with enzymatic process on enamel surface to

increase host resistance7. Interference with synthesis of extra cellular polysaccharide

formation8. Maintenance or increase of plaque calcium and phosphorous

level.• Other inhibitors like pyridoxine, fat, tannic acid, xanthines,

constituents of cocoa butter are believed to have caries protective factors. Nutritional or dietary means of caries control is impossible to achieve on basis of mass prevention program

MECHANICAL MEASURES

• This refers to procedures specifically designed for and aimed at removal of plaque from tooth surface methods for cleaning tooth mechanically are:

1. Prophylaxis by dentist2. Tooth brushing3. Mouth rinsing4. Use of dental floss or tooth picks5. Incorporation of detergents foods in

diet6. Pit and fissure sealants

Dental prophylaxis• Careful polishing of roughened

smooth surface and correction of faulty restoration decreases the formation of bacterial plaque and there by reducing the development of new carious lesion

Tooth brushingTypes of tooth brushing- Manual - Powered- Sonic and ultrasonic- IonicADA specification for a tooth brush- 1- 1.25 inches length- 5/16 – 3/8 inches in width- 2 – 4 rows of bristles- 5-12 tufts per row

Mouth rinsing• Use of mouth wash for the benefit of its action in loosening

food debris from teeth has been suggested to be of value as caries control measures.

Dental floss• Dental flossing is effective in removing plaque and

dislodge the irritating matter that is real source of disease.• Used in type I gingival embrasuresIt is available in: - Multifilament – twisted / non twisted- Bounded / unbounded- Thick / thin- Waxed / non waxedOral irrigators- Use of flushing devices- Irrigation devices composed of a built in pump and a

reservoir- It can also be used to deliver antimicrobial agents

Detergent foods• Fibrous food in diet prevent lodging of food in pit and

fissure and acts as detergentChewing gum• Chewing gum tend to prevent caries by mechanical

cleaning actionPit and fissure sealants• A sealant is a dental resin that is firmly bounded to

enamel surface and isolates pit and fissure from caries producing conditions in oral environment

• Types:1st generation – ultraviolet light activated2nd generation – chemical activated3rd generation – visible light activated4th generation – fluoride containing

• Examples of pit and fissure sealants

alphadent

helioseal F

helioseal

Seal – rite

baritone L3

concise white sealant

concise light cure white seal

CONCLUSION

Dental caries is an irreversible process. It is a disease of modern man and its manifestation persist throughout life. There are various methods of control and prevention of disease. It is always better to prevent disease. Once occurred it has to be controlled as it has dangerous sequale.

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