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Introduction
The process of enamel caries begins when acidogenic bacteria (such as streptococci and
lactobacilli) are exposed to glucose/sucrose in the dental biofilm. There are more than one
type of bacteria involved in the initiation and progression of enamel caries such as mutans
streptococci and non-mutans streptococci. These bacteria take in the sucrose and in turn
produce acids, resulting in a increase in concentration of hydroxyl ions, thus decreasing the
pH. The pH rapidly decreases from a resting pH of 7.0 to a pH of less than 5.0 within the
biofilm fluid and along the interface between the biofilm and enamel surface. When the
critical pH (about pH 5.5) is reached, demineralization of the enamel begins.
Formation of Enamel caries
Enamel is a unique hard tissue that is 95% mineralized (minimal protein content). It is a
cellular and non-vital (cannot repair itself)tissue, but at the same time, it is permeable
(water and small molecules) and always in a dynamic chemical equilibrium with the oral
environment.
Enamel caries is primarily a chemical process that is a result of an increase in proportions of
aciduric and acidogenic bacteria, especially mutans streptococci (eg. S. mutans and S.
sobrinus) and lactobacilli have been proven clinically to be responsible for most caries
formation as they are able to demineralize the enamel through the rapid metabolic activity
of utilizing sugars to produce acids. The acid produced provides a low pH which allows an
optimal environment for the aciduric bacteria to proliferate. [Marsh PD, 2006]
The pH of a tooth surface is highly dependent on three factors:
sites with large amount of dental plaque,
easily fermentable/metabolized carbohydrate sources and
low rates of diffusion of substrates and metabolites into and out of the plaque
are the susceptible to caries. This explains why pits and fissures have the highest
occurrence for enamel caries. Studies have shown a strong correlation between plaque
levels of mutans streptococci and caries at these sites. The deepest parts of these surfaces
are also often not accessible to toothbrushes, resulting in high availability of
substrate(carbohydrates) for the respective bacteria, leading to more production of acid,
thus further demineralization. However, recent studies have shown that mutans
streptococci were only minor components of plaque at these carious sites and these sites
had relatively high levels of lactobacilli, suggesting that lactobacilli might be responsible
for the demineralization.
*Additional research results have shown that mutans streptococci have a strong
relationship with initial caries formation, and lactobacilli were strongly associated with sites
that required restoration.
When there is a drastic change in oral environment (eg. reduced salivary flow rates),
rampant caries might occur. Further studies involving patients undergoing radiation
treatment have shown a large increase in the proportions of mutans streptococci and
lactobacilli in plaque and saliva. Large percentage of data collected have shown a strong
positive association between increased levels of mutans streptococci and
lactobacilli. [Fejerskov O. & Kidd E., 2008]
Bacteria involved in caries formation
1. Mutans streptococci (MS)
Evidence of presence of mutans streptococci:
Mutans streptococci is a group of bacteria that is commonly found at cavitated caries
lesions and have been proven to cause caries formation in animals that have a sucrose-rich
diet. It is able to synthesis water-insoluble glucan that makes the tooth surface more
susceptible to bacteria adhesion. [Hamada S, Slade HD, 1980]
Characteristics of mutans streptococci:
Mutans streptococci are non-mobile, catalase-negative, gram-positive cocci and form
short/medium chains. They are capable of rapid transport and fermentation of dietary
carbohydrates into lactic, formic, acetic and proprionic acids. These bacteria can undergo
both extracellular and intracellular polysaccharide synthesis even under adverse
environmental stress. However, the two most important characteristics of mutans
streptococci that closely relates it to the formation of caries is that it
is acidogenic (produce organic acid) and aciduric (can survive in acidic environments).
Action of mutans streptococci:
Mutans streptococci rapidly synthesize insoluble polysaccharides from sucrose. They
colonize on tooth surfaces and they are homo-fermentative lactic acid formers. When
excess sugar is available, streptococci are able to store these sugar as intracellular
polysaccharides (IPS) which can then be used as an energy source in between meals to
produce acid [Hamilton, 1976; Van Houte et al., 1970]
*Both non-mutans streptococci and mutans streptococci metabolize sugar to produce
acid. [Langlais RP, et al, 1994]
Other theories regarding mutans streptococci and other bacteria involved in caries
formation:
Studies have shown that the presence of high concentrations of mutans streptococci does
not necessarily equate to white lesion formation on tooth surface, and certain caries can
form even without a trace of mutan streptococci present [Nyvad, 1993].
Caries can be initiated by non-mutans streptococci (non-MS) and Actinomyces [van Houte et
al., 1996; Sansone et al., 1993]