EPIDEMIOLOGY AND RECENT CONCEPTS IN DENTAL CARIES

PRESENTED BY OMANAKUTTAN KR

CONTENTS INTRODUCTION DEFINITION PATTERN AND TRENDS GLOBAL AND INDIAN SCENARIO FACTORS INVOLVED RECENT CONCEPTS - DIAGNOSIS - PREVENTION - MANAGEMENT

DEFINITION EPIDEMIOLOGY

The study of the distribution and the determinants of health related states and events in specified population and the application of this study to control health problems ( John Last 1988.)

EPIDEMIOLOGIST A person who defines the frequency and severity of health problems in relation to such factors like age, sex, geography, nutrition, diet etc

RELEVANCE OF EPIDEMIOLOGICAL STUDIES ???

2 terms are of utmost importance in epidemiology

INCIDENCE and Point PREVELANCE Period

DURATION OF DISEASE AND INCIDENCE /PREVALANCE

……RELATION

KEYS TRIAD 1960

MODIFIED KEYS TRIAD (NEWBURNS) 1983

Dental Caries is an oral disease of pandemic proportion and to measure its extend and severity accurately is impossible

The closest we can assess these parameters are by epidemiological

studies that target a population which can then be generalized.

LOW CARIES INCIDENCE EXISTED IN ANCIENT MAN

LOW CARIES INCIDENCE IN THE ANCIENT MAN IS DUE TO DIET WHICH WAS :

Comparatively low in carbohydrates.

Natural (unrefined) diet.

PATTERN OF ANCIENT DENTAL CARIES

• The pattern of ancient caries was mostly cervical or root caries

PATTERN OF ANCIENT DENTAL CARIES

in the 17th century a new pattern emerged…… lesion begins in fissured surfaces and develops later on proximal surfaces.

• This pattern took place in the industrialized nations as a result of the increased use of sucrose as sugars became more available.

CURRENT GLOBAL DISTRIBUTION

During most of the 20th

century, dental cariespattern was :I. High prevalence in developed

countries & higher socioeconomic group.

II. Low prevalence in developing countries with less economic development.

Caries was referred to as “a disease of civilization.”

High level of consumption of refined carbohydrates in developed

countries

Diet low in fermentable carbohydrates in developing countries

surviving on farming lower level of cariogenic bacteria.

Explanation of this pattern is :

BY THE LATE 20TH CENTURY, CARIES PATTERN WAS CHANGING IN TWO WAYS:

1- Sharp rising in caries prevalence and severity in most developing countries especially urban areas.

2- Marked reduction among children & young adults in developed countries.

M0LLER et al.1999

The decline of caries is attributed to:

Use of fluoridated tooth paste. (Brathall et al.1996)

Fluoridation of water supplies.

The use of fissure sealants.

Implementation of preventive programs

better access to dental care

better living conditions.

GLOBAL DISTRIBUTION

Upward trend of caries in many developing countries is related to:

The absence of widespread caries preventive strategy.

Increasing consumption of sugar containing products.

Moeller et al 1999

GLOBAL SCENARIO AND CURRENT TRENDS Dental caries is still a major health problem in most industrialized countries, affecting

60-90% of school children Substantial decrease in caries prevalence in the last decades in western countries

In developing and underdeveloped countries, prevalence of caries seems to be increasing

REASONS FOR THIS CHANGE…. Increase in dental man power along with an upswing in dental health education,

more demand for dental care have resulted in decrease in dental caries experience.

INDIAN TRENDS

Caries experience is high in all age groups

percentage of subjects with caries increased as age advanced.

The percentage of subjects with caries range from about 52% in primary dentition 85% in permanent teeth in older adults(65-74 years).

Root caries prevalence was 4.5% among the 35-44 years individuals and 5.5% among the 65-74 years individuals. Prevalence of root caries was higher in rural areas than in urban areas. B S Shivakumar et.al 2002

HOST FACTORS1) Saliva Composition pH Quantity Viscosity Antibacterial factors.2) Race and ethnic groups3) Age4) Gender 5) Hereditary6) Emotional disturbances.

MORPHOLOGIC CHARACTERISTICS OF TOOTH

PREDISPOSING FACTORS:-

1.Presence of deep, narrow, occlusal fissures or buccal and lingual pits.

2. Alteration of tooth structure by disturbance in formation or in calcification

TOOTH POSITIONTeeth which are malaligned, rotated or out of position

SALIVAThe fact that teeth are in constant contact with and bathed in saliva would suggest that this factor could profoundly influence the state of oral health of a person.

One of the most important function of saliva is its role in removal of micro flora & food debris from the mouth

The distribution pattern of dental caries closely follows that of plaque. Thus, the sites in the mouth which are most prone to caries are those where plaque accumulates.

DISTRIBUTION PATTERN OF CARIES

SALIVARY PH Determined mainly by the Bicarbonate concentration Salivary pH increases with flow rate Salivary buffers increase pH of saliva in the oral cavity.

Decrease pH favors caries

RACE OR ETHINC GROUPSCertain races has high degree of resistance to caries.These beliefs have faded as evidence suggests that these differences are more due to environmental factors than inherent racial attributes

Russel et al.1986

Cariesincidence

Age in years

1 6 17 22 50

AGE

GENDERhigher caries experience in girls than boys

Root caries is more prevalent in males

Increased susceptibility may be due to:1. Early eruption of teeth in females

2. Increased fondness towards sweets among girls3. Due to hormonal changes

Kaste et al 1986

FAMILIAL HEREDITY

“ GOOD OR BAD TEETH RUN IN THE FAMILY”Family studies have shown that offsprings have the same score as parents

Mansbridge (1987) found a greater resemblance in dmf score between identical twins or fraternal twins than unrelated pair of children

EMOTIONAL DISTURBANCESPeriods of stress have been associated with high caries incidence

Schizophrenics have reduced caries activity which may be attributed to increased salivation and higher pH of saliva

SOCIOECONOMIC STATUS It is difficult to correlate caries pattern with socioeconomic status due to its complexity

low SES groups have more number of decayed & missing teeth but less number of filled teeth and vice versa in high SES group

MICRO FLORAMutans Streptococcus – initiation of smooth surface caries

Lactobacillus - Initiation of pit and fissure caries, progression of smooth surface caries

Actinomyces - Root caries

1. The fissures in the occlusal surfaces of molars.

2. The proximal areas.

3. The marginal area between the tooth and the gingiva.

SUSCEPTIBILITY OF DIFFERENT TEETH

According to the pioneering Hagerstown studies (1937), the rank order of susceptibility of teeth to caries is listed as follows:

Mandibular 1st & 2nd molars

Max. 1st & 2nd molars Mand. 2nd,max. 1st & 2nd premolars

max. central & lateral incisors.

Max. canines & mand. 1st premolars

Mand. Central& lateral Incisors & canines.

1

2

3

4

5 Hagerstown studies (1937)

CARIES SUSCEPTIBILITY OF INDIVIDUAL TEETHUpper and Lower first molars - 95%

Upper and Lower second molars – 75%

Upper second bicuspids -45%

Upper first bicuspids – 35%

Lower second bicuspids -35%

Upper central and lateral incisors – 30%Upper cuspids and lower first

bicuspids – 10%Lower central and

lateral incisors – 3%Lower cuspids –

3% RUTHERFORD 1978

CARIES SUSCEPTIBILITY OF INDIVIDUAL TOOTH SURFACE

OCCLUSAL

MESIAL

BUCCAL

LINGUAL

RECENT CONCEPTS IN DENTAL CARIES

Scientific advances in cariology have led to the understanding that

dental caries is a chronic, dietomicrobial , site-specific disease caused by a shift from protective factors favoring tooth remineralization to destructive factors leading to demineralization. JADA 2009;140(9 suppl):25S-34S.

From antient times there has been multiple theories involving the

initiation of dental caries

THEORIES OF DENTAL CARIES

THEORIES Legend of Worm Humoral Theory Chemical Theory Vital Theory Parasitic Theory Acidogenic Theory Proteolytic Theory Proteolytic Chelation Theory

DIAGNOSIS – RECENT CONCEPT

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WHAT IS DIAGNOSIS?

Defined as utilization of scientific knowledge for identifying a disease process and to differentiate it from other disease process.

CARIES DIAGNOSIS

IMPORTANCE OF DIAGNOSISTo identify etiological factors

Determine nature of the disease involved

To determine treatment planning

To access prognosis 45

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ADVANCES IN VISUAL METHODINTERNATIONAL and CARIES DETECTION ASSESSMENT

SYSTEM (ICDAS)

Created in 2002 based on visual examination aided by a WHO PROBE

2 digit system (x-y)Scoring system of 0,1,2,3,4,5,6 with respective criterias

NYVAD’S SYSTEM

For activity assessment of non cavitated and cavitated lesions

Scores of 0,1,2,3,4,5,6,7,8,9 assigned

CLASSIFIES A LESION AS ACTIVE OR INACTIVE

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ADVANCES IN X RAYS:Xeroradiography

Digital radiography

Computer aided radiography

Digital subtraction radiography

Tuned aperture computed tomography

XERO RADIOGRAPHY Technique simulates that of photo-copying Image recorded on aluminium plate with a layer of

selenium particles

Xerographic films to record the images produced by X-rays

These are a given a uniform electrostatic charge

X-rays-passes through film-causes the discharge of particles producing a latent image-converted in a processing unit.

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Advantages-

-edge enhancement -less radiation -economical

Disadvantages -

electrical charge may cause discomfort to patients exposure time varies with thickness of film process of development cannot be delayed more than 15min 54

DIGITAL IMAGINGPrinciple: works on a CCD which is electronically connected

to computer

CCD-is a semi-conductor made of metal oxide silicon coated with x-ray sensitive photons

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Advantage no dark room processing greater exposure latitude reduced radiation dose capability of teletransmission image manipulation ability to enlarge specific area

Disadvantage high cost of the system life expectancy is not fixed

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Digital radiography

Direct: Indirect

DIGITAL IMAGINGVariety of multiple well established digitalsensors are available

1. Charge couple device based sensors (CCD)

2. Complimentary metal oxide semiconductors (CMOS)

3. Photo stimulable phosphor plates (PSP)

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Charge-Coupled device:CCD

Egs: Durr Vista Ray Trophy RVG, Sens-A-Ray, Visualix/Vixa

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DIGORA SYSTEM

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According to Kantor et al ( J. Dent. Aug 2005) who compared the conventional radiography with digital radiography and found no statistically significant difference in diagnosis of proximal caries

COMPUTER AIDED RADIORAPHY

Assessment and recording of lesion size Trophy 97 system

DIGITAL SUBSTRACTION RADIOGRAPHY

Principle:Optimally, all unchanged anatomical background structures will cancel, and unchanged areas will be displayed in a neutral grey shade in the subtraction image.

Areas with mineral loss appear in darker shades of grey, and areas of gain appear lighter than the background.

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TUNED APERTURE COMPUTED TOMOGRAPHY

It constructs radiographic slices, cross sections, through teeth-viewed for radiolucencies

Images brought to a 3D image- known as pseudohologram

Used in early caries and recurrent caries detection

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ADDITIONAL DIAGNOSTIC METHODS:

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Based on light:

DIFOTI- DIGITAL FIBRE OPTIC TRANSILLUMINATION

Quantitative laser light fluorescence

Diagnodent

FLUORESCENCE

A phenomenon by which the wavelength of the emitted light is changed into a larger wavelength as it travels back.

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Omnii InspektorPro QLF

QUANTITATIVE LASER/LIGHT FLUORESCENCE

Bejelkhagen & Sundstrom (1981) Mechanism

Argon laser-488 nmXenon arc lamp – 370 nm

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Argon laser:Tooth appears yellow-green

Demineralized areas-dark

ADVANTAGES: Incipient lesions – 25 μm Monitor changes in lesionRed fluorescence-plaque, leaky margins

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LIMITATIONS:

• On accessible smooth surfaces only• Cant discriminate between enamel & dentin

lesions• Cant differentiate between decay , hypoplasia

Diagnodent

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Readings (Tam & McComb, J Can Dent Assoc, 2001)

5-25: initial lesions 25-35:early dentinal caries 35: advanced dentinal caries

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FIBRE OPTIC TRANSILLUMINATION

Principle: decayed matter scatter light more strongly

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ELECTRICAL CONDUCTANCE MEASUREMENTS (ECM)

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Indications: Pit and fissure

caries Failure of fissure

sealants

False +ve results: Immature teeth Cracks in enamel

MANAGEMENT AND PREVENTION – RECENT CONCEPTS

Demineralization-Remineralization cycle

Demineralization -Remineralization cycle (Mount & Hume

2005)

PREVENTION- RECENT CONCEPTS

CARIES MANAGEMENT BY RISK ASSESSMENT (CAMBRA)

CARIOGRAM

TOOTH MOUSSE (CCP-ACP)

CAMBRABuilt on the understanding that dental caries is a dynamic disease

Determines and deals with multiple factors that cause the expression of

the disease and helps take corrective actions

An evidence based approach for prevention of dental caries

THE CARIES BALANCE/IMBALANCE MODEL

A visual representation of the multifactorial nature of the disease

Risk of demineralization can be assessed by weighing all the disease

indicators and risk factors against protective factors

CARIES RISK ASSESSMENT

CARIOGRAMA graphical illustration of the caries risk profile of an individual.

Includes factors directly and indirectly involved in biochemical

events on the tooth surface

ILLUSTRATES AN OVERALL RISK SCENARIO

DATA NEEDEDCARIES EXPERIENCERELATED DISEASEDIET- CONTENTS AND FREQUENCYPLAQUE LEVELMUTANS STREPTOCOCCIFLUORIDE EXPOSURESALIVA SECRETIONSALIVARY BUFFER TEST

CARIOGRAM MODEL

CASEIN PHOSPHOPEPTIDE AMORPHOUS CALCIUM PHOSPHATE COMPLEXES - CPP-ACPBIOACTIVE PEPTIDE

HAS SPECIFIC PHOSPHORYLATED ELEMENTS CAPABLE OF CALCIUM BINDING

STABILIZES CALCIUM PHOSPHATE AS AMORPHOUS CALCIUM PHOSPHATE

CPP + ACP

SUPERSATURATION

MANAGEMENT - RECENT CONCEPTSCALCIUM SODIUM PHOSPHOSILICATE (BIOACTIVE GLASS) – NOVAMIN

AIR ABRASION

POLYMER CUTTING INSTRUMENTS

CALCIUM SODIUM PHOSPHOSILICATE (BIOACTIVE GLASS) – NOVAMIN

A ceramic material used for remineralization

Combines with water to release calcium, phosphorous , sodium , and silicon

ions and results in hydrocarbonate crystal formation (HCA)

ions

DENTINAL TUBULE OCCLUSION USING NOVAMIN

AIR ABRASION

PSEUDO MECHANICAL, NON- ROTARY METHOD OF CUTTING AND TISSUE

REMOVAL

PRINCIPLE ACTION IS OF END CUTTING TYPE

DESSICATED ABRASIVE PARTICLES ASSIST CUTTING

POLYMER CUTTING INSTRUMENTS

DIFFERENTIATE BETWEEN DECAYED AND HEALTHY DENTINE

REMOVES CARIOUS DENTINE NOT SOUND DENTINE

DESIGN IS BASED ON THE DIFFERENTIAL HARDNESS OF TOOTH TISSUE

DOESN’T EXPOSE VITAL ODONTOBLASTS AND HENCE LIMITED PATIENT DISCOMFORT

SINGLE USE DISPOSABLE BURS

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