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)

file:///C:/Users/sony/Downloads/a01f01.gif

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

Dr.C

aro

line M

oh

am

ed

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

s.php?album=25&page=3

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