VS

MIGHTY TOOTH

INVISIBLE STRAINS

GOOD MORNING!Dr. Ram

DENTAL CARIES- An irreversible microbial process….

Dr. Ram

•INTRODUCTION

•DEFINITION

•REMINERALISATION AND DEMINERALISATION

•CLASSIFICATION OF DENTAL CARIES

•ZONES OF ENAMEL CARIES

•ZONES OF DENTAL CARIES

•MICROBIOLOGY OF THE DENTAL CARIES

•THEORIES OF DENTAL CARIES

CONTENTS

I’M READY…

Dr. Ram

•IMMUNOLOGY OF DENTAL CARIES

•GENERAL CLINICAL FEATURES

•DIAGNOSIS

•CARIES ACTIVITY TESTS

•MANAGEMENT AND TREATMENT

•RECENT UPDATES

WHERE I’M I NOW?

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• COMMON REASON FOR TOOTH LOSS.

•Disease of Civilization- Due to habits & Diet.

•TRANSMISSIBLE DISEASE.

•WINDOW OF INFECTIONMATERNAL CARIES LEVEL

DIETARY SUCROSE LEVELS

INTRODUCTION

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Simple caries can …

? nextDr. Ram

DEFINITION OF DENTAL CARIESDEFINITION OF DENTAL CARIES

MISTAKE?? Dr. Ram

•REMINERALISATION AND DEMINERALISATION OF DENTAL CARIES

PLAQUE FORMATION ( NATURAL , PHYSIOLOGICAL PROCESS)

BACTERIA----------CARBOHYDRATES---------SUCROSE----------PH-BELOW -5DEMINERALISATION

REMINERALISATION

Saliva neutralizes the acid, ph increased and minerals may be gained.

Dr. Ram

Dr. Ram

The cumulative process of de and remineralisation leads to net loss of minerals.

DENTAL CARIES

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CLASSIFICATION

OF DENTAL CARIES

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Dr. Ram

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Dr. Ram

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Pit & Fissure Caries

Bluish Discoloration

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Proximal caries

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CERVICAL CARIES

crescent shaped

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Secondary / Recurrent Caries

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ETIOLOGY OF DENTAL CARIESETIOLOGY OF DENTAL CARIES

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Factors responsible for carbohydrates to be cariogenic

1.Physical nature- Sticky, solid carbohydrates, REFINED.

2. Chemical nature- glucose, galactose, sucrose, lactose &

starch.

3. Route of intake- tube/IV line don’t contribute to caries

4. Clearance rate- salivation causes less caries & vice versa

5. Frequency of intake- INTAKE, caries incidence is

more

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Other components of diet

Primitive man – unrefined, fibrous diet which cleaned teeth automatically, caries’ incidence

Modern man – soft diet with refined sugars, caries’ incidence

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Fat & proteins taken with sugars prevent attachment of

carbohydrates to tooth surface

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PLAQUE AND

MICROBIES OF DENTAL CARIES

And their types

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ACQUIRED PELLICLE

1st layer of glycoprotein deposited on teeth 30 mins after brushing.

Doesn’t contain micro-orgs, but gets colonized with bacteria-forming plaque.

Derived from saliva.

Dr. Ram

PLAQUE AND TYPES– Is a white, tenacious substance/deposit on tooth

surface which contains glycoproteins derived from saliva.

– Also contains, micro-orgs, desquamated epithelial cells, Ca, Ph, etc

– Causes dental caries & periodontal disease

– Formed from structure called “acquired pellicle”Dr. Ram

•Acidogenic bacteria-dental caries

•Proteolytic bacteria-periodontal disease

BACTERIA

Pioneer / primary bacteria – initiate caries

S.mutans (smooth surface caries)Lactobacillus acidophilus (pit & fissure caries)Actinomyces (root surface caries)

Invaders / secondary bacteria

Staphylococcus, VeillonellaeDr. Ram

•MICROBIOLOGY OF THE DENTAL CARIES

•STREPTOCOCCOUS

•ACTINOMYCES

•LACTOBACILLI

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S.m, S.sangLacto.Actinomyce.

Sm, S salivaries

A. vActi. NS.MS.sang

LA. SPACT. SPFILAMENTOUS ROD SHAPED

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S.MUTANS

•Most common, smooth surface caries producing orgBoth acidogenic & aciduric.

•Attachment to tooth by Glucans dextrans synthesis from dietary sucrose by polymerization.

•Synthesized by enzyme present in mutans’ cell wall – Glycosyl transferase.( GT)

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sucrose stored by mutans, released when required to cause caries.

•Mutans thickness of plaque – hampers diffusion of salivary bi-carbonates into plaque, risk of caries.

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Stephan’s curve

Critical pH – 5.5Resting pH in caries active ppl – 5.8In caries immune ppl – 6.5

Graph showing behavior of pH in caries active & immune ppl, after a 10% glucose rinse

SALIVA

IMMUNE

ACTIVE

CARBOHYDRATE DIET

Dr. Ram

SALIVAFlow rate: FR, caries & vice versa

Buffering capacity: BC, caries & vice versa

Amount of salivary secretion: , then caries

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COMPONENTS OF SALIVA

•Bicarbonates (salivary buffers), diffuse into plaque, acid

•Anti-bacterials like lactoferrin, lysosome, thiocynate, etc, present in saliva.

•Ig A in saliva, prevents attachment of bacteria on tooth surface Ions Ca, P help in remineralization.

•Salivary urea & bicarbonate rate of glycolysis I.e, glucose metabolism is faster, so, contact time of teeth with carbohydrates is reduced

Dr. Ram

THEORIES OF DENTAL CARIES

1) EARLY THEORIES: WORMS

2) ENDOGENOUS THEORY

- HUMORAL- VITAL- STAGNATION

3) EXOGENOUS THEORIES

-CHEMICAL THEORY-PARASITIC/SEPTIC THEORY-CHEMICO-PARASITIC THEORY ( MILLER’S/ ACIDOGENIC) THEORY-PROTEOLYTIC THEOTY-PROTEOLYTIC CHELATION THEORY-COMBINED ACIDIOGENIC AND PROTEOLYTIC THEORY

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OTHER THEORIES-SULFATES THEORY

-COMPLEXING AND PHOSPHORYLATING THEORY

-SUCROSE CHELATING THEORY

-AUTOIMMUNE THEORY

-GENETIC THEORY

-CELLULOSE THEORY

-CARIES SURVILLENCE THEORY

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• ACIDOGENIC THEORY– Miller 1890, most accepted.

– “Acids formed due to the fermentation of dietary carbohydrates by oral bacteria leads to progressive decalcification of tooth structure with subsequent disintegration of organic matrix”

– He isolated micro-orgs from his experiments & stated that many were involved in the carious process.

TOOTH

PLAQUE

BACTERIA

SUGAR

ACIDS

TOOTH DECAY

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– 4 important factors which can influence process of tooth destruction in process of dental caries

• Dietary carbohydrates, micro-organisms, acid, plaque.

Dr. Ram

Dr. Ram

PELLICLE FORMATION

COLONIZATION OF S. MUTANS AFTER 0-4 HRS

4-24 HRS MANY MICROBIAL COLONIES ARE FORMED WITH IN IT.

PLAQUE FORMATION

S.MUTANTS DOMINATION

CONVERSION OF CARBOHYDRATES INTO SUGARS ( SUCROSE)

RELEASE OF ACID (LACTIC ACID )Dr. Ram

• LIMITATIONS

– Did not explain sub-surface demineralization

– Failed to justify rampant caries

– Did not explain caries in impacted tooth

Dr. Ram

Proteolytic theory

• “ Formation of DC is essentially a proteolytic process. Bacteria present produce hydrolytic substances/enzymes & cause proteolysis leading to dissolution of organic substances”

• His view micro-orgs don’t cause decalcification but dissolution of organic substances present in the tooth. Micro orgs entered enamel through enamel lamellae & caused dissolution.

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• Limitations – The carious lesion couldn’t be reproduced in vitro by

the proteolytic mechanism.

– Proteolytic bacteria are very uncommon in the oral

cavity.

– This theory cant explain the role of sucrose, pH and

fluoride in DC

Dr. Ram

Proteolytic Chelation theory

• Chelate formation- citrate, lactate

• During DC, proteolytic breakdown of organic portion of enamel matrix takes place first.

• Following this, chelating agent is formed by combination of proteolytic breakdown products, acquired pellicle, food debris, etc.– Ex of chelating agent: citrate, lactate, etc

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•Even this theory failed to explain about sugar

or acid production

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Autoimmune theory

• Few odontoblast cells at specific sites within pulp of specific teeth are damaged by autoimmune mechanism

• Due to this the defense capacity & integrity of of enamel and dentin in those specific areas are compromised and act as potential sites for caries development in future

Dr. Ram

DENTAL CARIES

•ZONES OF ENAMEL CARIES

•ZONES OF DENTAL CARIES

Dr. Ram

•ZONES OF ENAMEL CARIES

E

NA

ME

L

-ZONE- 1

-ZONE-2

-ZONE-4

-ZONE-5

TRANSLUCENT ZONE

DARK ZONE

BODY OF THE LESION

SURFACE ZONEDr. Ram

ENAMEL CARIES ( PIT AND FISSURE)

1

23

4

.

Inner most zoneAdvancing end

Birefringence – polarised light

Max demineralised area

40 microns thickness

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SMOOTH SURFACE CARIESDr. Ram

Dr. Ram

Dr. Ram

•ZONES OF DENTINAL CARIES

Enamel

DEJ

Dentin

E-D- ACIDS- DEMINERALIZATION

ZONE-1- Fatty degeneration (T D F)

ZONE-2- Dentinal sclerosis

ZONE-3- Demineralization

ZONE-4- Bacterial invasion/ Turbid Dentin

ZONE-5- Decomposed dentin

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DECALCIFIED STRUCTURE OF DENTAL CARIES

5

4

3DEMINERLIZED ZONE (WITHOUT BACTERIAL INVASION)

ROSARY BEAD APPEARENCE

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Liquefaction Foci-Dentinal caries

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ZONE-2- DENTINAL SCLEROSIS

ZONE- 1- (F D T D F)

•ADVANCING END NEAR PULPAL SURFACE

•DEPOSITION OF FAT GLOBULES AT THE ODONTOBLASTIC PROCESS

ZONE-1- Fatty degeneration (T D F)

ZONE-2- Dentinal sclerosis

ZONE-3- Demineralization

ZONE-4- Bacterial invasion

ZONE-5- Decomposed dentin

Dr. Ram

Dr. Ram

Expansion & Fusion Of Tubules-Liquefaction Foci

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Transverse Clefts

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Caries in Dentinal Tubules

Dr. Ram

Dr. Ram

Bacteria wins the battle!

Thank you!Dr. Ram