is a multifactorial, transmissible, infectious oral disease caused primarily by the complex interaction of cariogenic oral flora (biofilm) with fermentable dietary carbohydrates on the tooth surface over time.

Cariogenic bacteria in the biofilm

metabolize refined carbohydrates for

energy

produce organic acid byproducts

lower the pH in the biofilm

drives calcium and phosphate from the tooth to the biofilm

Demineralization

the pH in the biofilmreturns to neutral

and the concentration of the

mineral is super saturates compared

to the tooth

mineral can then be added back to

partially demineralized

enamel

remenineralization

Saliva: Nature’s Anticaries Agent

Bacterial Clearance Buffer

Capacity

Direct Antibacterial

Activity

Remineralization

Clinical sites for caires initiation

it has a comparatively rapid

progression

it is often asymptomatic,

it is closer to the pulp

it is more difficult to restore

Progression of Caries Lesions

With in enamel

With in dentin

white spots of noncavitated caries from developmental

white spot (hypocalcification of

enamel)

Noncavitated (white spot) caries partially or totally disappears

visually when the enamel is

hydrated(wet)

hypocalcifiedenamel is

affected less by drying and wetting .

Infected dentin

• outer carious dentin,the zone of bacterial invasion

• The dentin in this zone does not self-repair

Affected dentine

Normal dentine

• The deepest area , No bacteria are present in the tubules

Although it is very important to detect caries lesions. It is critical to remember that clinicians treat the entire patient and not just individual teeth and caries lesions. because dental caries is a multi-factorial medical disease process, and the caries lesions are the expression of that disease process involving the patient as a whole.

is defined as an environmental, behavioral, or biologic factor that directly increases the probability that a disease will occur and, the absence or removal of which reduces the possibility of disease. but once the disease occurs, removal of a risk factor may not always result in the disease process being halt .

High risk

At risk

Medium

low risk

are existing signs of the disease process.

They are examples of what is happening with the patient’s current state of oral health, not how disease occurred.

• the biomechanical excision of caries lesions and the restoration of the resultant tooth preparation to form and function with a restorative material.

• dealing only with the end result of the disease and not addressing its etiology for each individual patient was not successful in controlling the caries disease process.

1)This process provides an individualized evaluation of a patient’s pathologic factors and protective factors and assesses the patient’s risk for developing future disease.

2)manages the caries disease process using a medical model.

3)The risk assessment is then used to develop an individualized evidence-based caries management plan that would involve all aspects of nonsurgical therapeutics and dental surgical interventions.

4)Both risk assessment and patient-centered interventions are based on the concept of caries balance.

The caries balance model is based on minimizing pathologic factors while maximizing protective factors to attain a balance that favors no disease occurring, or health.

5) Risk assessments are important in determining the frequency of re care visits and the treatment protocols for follow-up visits.

6)Restorative decisions in terms of material used and cavity preparation design are also influenced by the information gathered in the risk assessments.

7) The systematic use of risk assessment profiles is essential in uncovering risk factors that are present before expression of the disease. This information can be useful in the prevention of caries lesions in patients who have risk factors present but no disease expression and then experience a lifestyle change that adds additional risk factors.

8) Risk assessments lead to better treatment outcomes for patients.

Because inactive lesions may remineralize and

not require operative intervention. By

(1) a positive shift in protective factors, (2)change in oral hygiene,

(3) reduction of negative risk factors,

Social status and economic status are not directly involved in the disease process ,but are important because they affect the expression and management of the caries disease they have implications on the necessary compliance and behavioral changes that can decrease risk for caries in patients.

These are predictive at the population level but are generally inaccurate at the individual level.

Dietary Analysis

Sugar intake in the form of fermentable carbohydrates and increased frequency of intake are conditions that increase risk for caries.

1)by providing energy to the acidogenic and aciduric bacteria

2) influencing the pH of the biofilm to support cariogenic bacteria.

Dental Clinical Analysis (Dental

Exam)

The dental examination determines risk indicators more than risk factors. This is also important as many of the indicators are directly related to the current caries activity. The indicators and current caries activity drive the decision making process for the type of intervention that the clinician would prescribe.

Bacterial Biofilm Analysis

Use of supplemental tests to analyze the bacterial component of the biofilm can help determine the patient’s risk level.

the measurement of adenosine tri phosphate (ATP) activity of the biofilm bacteria as a surrogate measure of caries activity.

Risk Considerations for Children

Under 6 Years Old:-

risk factors and indicators for this age group include:

• presence of active caries in the primary caregiver in the past year;

• feeding on demand past 1 year of age;• bedtime bottle or sippy cup with anything other

than water; • no supervised brushing; and • severe enamel hypoplasia.

Caries Management and Protocols or

Strategies for Prevention

Caries risk assessment is only effective if used in conjunction with a corresponding caries management program.

are designed to limit tooth demineralization caused by cariogenic bacteria, preventing cavitated lesions. These methods include:-

• (1) limiting pathogen growth and altering metabolism,

• (2) increasing the resistance of the tooth surface to demineralization, and

• (3) increasing biofilm pH.

factors that may have an

impact on the

prevention of caries:-

General health

diet

Oral hygiene

Antimicrobial Agents

Calcium and

Phosphate Compounds

RestorationsSealants

Probiotics

Function of Saliva

immunization

Fluoride Exposure

Early signs of increased risk include: increased plaque biofilm; puffy, bleeding gingiva ; dry mouth with red, glossy mucosa; and demineralization of teeth.

Caries activity is most strongly stimulated by the frequency, rather than the quantity of sucrose ingested.

Evidence of new caries activity in adolescent and adult patients indicates the need for dietary counseling. The goals of dietary counseling should be to identify the sources of sucrose and acidic foods in the diet and to reduce the frequency of ingestion of both.

• Rampant caries that is present primarily on inter proximal surfaces may point more to diet as the main causative factor, whereas rampant caries in the cervical and inter proximal areas may point to diet and hygiene as the causative factors.

• For high-risk patients, a formal diet analysis should routinely be undertaken to identify cariogenic foods and beverages that are frequently ingested.

• This analysis should be conducted over a 4-day period with 2 of the days surveyed being weekend days.

•

• Biofilm-free tooth surfaces do not decay. Daily removal of plaque biofilm by dental flossing, tooth brushing, and rinsing is the best patient based measure for preventing caries and periodontal disease.

• Mechanical plaque biofilm disorganization by brushing and flossing has the advantage of not eliminating the normal oral flora.

• Fluoride in trace amounts increases the resistance of tooth structure to demineralization and is particularly important for caries prevention

• The availability of fluoride to reduce caries risk is thought to be primarily achieved by fluoridated community water systems but also may occur from fluoride in the diet, toothpastes, mouth rinses, and professional topical applications.

(1)the presence of fluoride ion greatly enhances the precipitation of fluorapatite from calcium and phosphate ions present in saliva into tooth structure .

(2) non cavitated caries lesions are remineralizedby the same process.

(3)fluoride has antimicrobial activity.

• The clinician’s goal is to choose the most effective combination for each patient. This choice must be based on the patient’s age, caries experience, general health, and oral hygiene.

• Children with developing permanent teeth benefit most from (??)

Pumicing of teeth (professional prophylaxis) can remove a considerable amount of the fluoride-rich surface layer of enamel and can

be counterproductive.

• Varnishes provide a high uptake of the fluoride ion into enamel

• For patients with a high risk of caries, fluoride varnish should be applied every 3 months.

• For moderate-risk patients, application every 6 months is indicated.

• Fluoride varnish is not needed for low risk patients.

The main disadvantage of fluoride varnish is that a temporary change in tooth color may occur.

Immunization

Several prototypes have been tested in animals, but at this time, neither the safety nor efficacy of such vaccines has been demonstrated in humans.

Even if an anti-caries vaccine were developed, some concerns remain, which may affect its widespread use.

(1)the potential adverse effects of a vaccine must be identified. The concerns about a possible cross-reaction with human heart tissue remain.

(2) its cost must be compared with that of public water fluoridation, which is inexpensive and already effective at reducing caries.

Function of Saliva

Saliva is nature’s first line of defense against dental caries.

• Saliva works by diluting acid produced in plaque biofilm, washing the acid away (swallowing), buffering the produced acid , and assisting in remineralization, and by forming a pellicle

When attempting to improve salivary flow rates

• a consultation with the patient’s physician may be in order.

• Prescribing salivary stimulants can be very beneficial in patients with functioning salivary glands but who have xerostomia because of medications.

• chewing sugar-free candies or mints several times a day and the use of xylitol chewing gum.

A variety of antimicrobial agents are available to help prevent caries .In rare cases, antibiotics might be considered, but the systemic effects must be considered.

(1)The traditional approach is the use of chlorhexidine (CHX) mouthwash, varnish, or both, along with prescription fluoride toothpaste.

(2)The other approach is to use a twice-daily mouth rinse containing sodium hypo chlorite and xylitol .

have the potential to remineralize tooth structure. ACP is a reactive and soluble calcium phosphate compound that releases calcium and phosphate ions to convert it to apatite and re mineralize the enamel when it comes in contact with saliva.

• The fundamental concept is to inoculate the oral cavity with bacteria that will compete with cariogenic bacteria and eventually replace them.

• Obviously, the probiotic bacteria must not produce significant adverse effects.

• It has been speculated that for the probioticmicroorganisms to gain dominance, existing pathogens must first be eliminated.

extremely low-viscosity resin sealants

for the infiltration of white-spot caries

lesions on smooth surfaces.

•

(1) sealants mechanically fill pits and fissures with an acid-resistant resin.

(2) acts as a mechanical barrier against bacterial accumulation.

(3) sealants make cleaning of pits and fissures easier by tooth brushing and mastication.

The status of a patient’s existing restorations may have an important bearing on the outcome of preventive measures and caries treatment (HOW)

refers to an operative procedure in which multiple teeth with acute threatening caries are treated quickly by:-

(1) removing the infected tooth structure,

(2) medicating the pulp, if necessary,

(3) restoring the defect(s) with a temporary material.

(1) the caries is extensive enough that adverse pulpalsequelae are likely to occur soon,

(2) the goal of treatment is to remove the nidus of caries infection in the patient’s mouth,

(3) a tooth has extensive carious involvement that cannot or should not be permanently restored.

(4) during an operative procedure when a tooth is unexpectedly found to have extensive caries.

(5) to avoid possible sequelae such as toothache, root canal therapy, or more complex ultimate restorations.

• 1)Anaesthesia

• (2) operating site must be isolated.

• (3)The primary objective of the caries-control tooth procedure is to provide adequate visual and mechanical access to facilitate the removal of infected dentin.

• (4)Retaining unsupported enamel is permissible in caries-control procedures

• (5)Retaining sound portions of old restorative material

(6) the identification and removal of caries depends primarily on the dentist’s interpretation of tactile stimuli.

• Effective caries removal can be accomplished with

• (1) hand instrumentation using spoon excavators,

• (2) a slow-speed handpiece with a large round bur, or

• (3) a high-speed handpiece using a round bur operated just above stall-out speed (low speed).

Amount of caries removed?

• Usually, all softened, infected dentin is removed during caries-control procedures.

• In asymptomatic teeth that have deep lesions (in which complete excavation of softened dentin is anticipated to produce pulpal exposure), softened, affected dentin nearest the pulp may be left.

7)If the pulp is penetrated by an instrument during the operative procedure, a decision must be made whether to proceed with root canal therapy or do a direct pulp capping.

(8)A deep caries excavation close to the pulp, which may result in either an undetected pulpalexposure or a visible pulpal exposure, should be covered with a calcium hydroxide liner ,If used, the calcium hydroxide liner should always be covered with a glass ionomer or resin modified glass ionomer liner before the tooth is restored.

(9)Deep excavations not encroaching on the pulp should be covered with a glass-ionomer material and then restored with either a definitive or a temporary restorative material. Alternatively, a reinforced glass ionomer material can be used for caries-control restorations, which eliminates the need for liners or bases in cases where no pulp exposure has occurred.

Some controversy exists concerning

the medication material to place over

deeply excavated areas

The selection of a caries-

control restorative

material depends on:-

the amount of missing

tooth structure

Significant portions of

the proximal or occlusal

surfaces are missing

Amalgumrestoration

Lessed amount of tooth

structure is missing

Weaker restorative

material

the expected length of service

anticipated for this

temporary restoration

long interval is anticipated between

the caries-control procedure and the

permanentAmalgum

restoration

.lesser time is between

them

Weaker retorationmaterial

Precise anatomic form is unnecessary for temporary restorations. Proper proximal contacts and contours should be established

Also, a condensation technique that exerts less pressure (i.e., using a spherical amalgam) reduces the chance of pulpal perforation.

Risk factors for root caries include the following:

1. Gingival recession

2. Poor oral hygiene

3. Cariogenic diet

4. Presence of multiple restorations or multiple missing teeth

5. Existing caries

6. Xerogenic medications

7. Compromised salivary flow rates

The protocol for the prevention of

root caries

try to improve salivary flow

rates and increase the

buffering capacity.

to attempt to re mineralize non cavitated

lesions and prevent new lesions from developing

reduce the quantity and numbers of

exposures of ingested refined carbohydrates

try to reduce the numbers

of cariogenic

bacteria (S. mutans) in

the oral cavity.

Restore all root caries

lesions with a

fluoride releasing material.

use of powered toothbru

shes

Many root caries lesions occur in locations that make them difficult, if not impossible, to restore. The dental profession has a strong track record of prevention, and it is clear that with root caries, prevention is much better than restoration.