Etiology, epidemiology and prevention of dental caries

INTRODUCTION
Latin word meaning rot or decay

progressive, irreversible, microbial disease
affecting the hard parts of the tooth exposed to
the oral environment, resulting in
demineralization of inorganic constituents and
dissolution of the organic constituents, thereby
leading to a cavity formation
CLASSIFICATION
Morphology - Anatomic site of lesion

Occlusal and smooth surface caries

Root (cementum) caries

Linear enamel caries (odontoclasia)
Primary dentition
Seen in the region of neonatal zone
Dynamics severity and rate of progression

Acute and chronic lesions

Rampant caries
A caries increment of 10 or more new carious
lesions over a year period

Incipient caries
Early white spot lesion
Recurrent caries
Develops at interface of restoration and
cavosurface of enamel

Radiation caries

Arrested caries
Eburnation of dentin
Seen in proximal surfaces - when
adjacent tooth is extracted
Chronology according to
age patterns

Nursing bottle caries /Early
childhood caries

Adolescent caries
Form of acute caries

The legend of the worm:
It was discovered on a clay tablet, excavated from an ancient city
within the Euphrates valley of the Mesopotamian era, which dates
from about 5000 BC.

In Japanese - mush-ha (mushi-room; ha-tooth), meaning hollow
tooth.

Chinese - chung choo. Use of acupuncture for treating caries

The early history of India, Egypt and the writing of Homer also
make reference to the worm as the cause of toothache.
Early theories and current concepts- in
etiology of dental caries
Endogenous Theories
1. Humoral theory:
dental caries is produced by internal action of acrid
and corroding humors (Galen, the ancient Greek
physician and philosopher)

Four elemental humors- blood, phlegm, black bile and
yellow bile

Hippocrates - referred to the accumulated debris
around teeth and to their corroding action

2. Vital theory:

tooth decay originated, like bone gangrene, from within
the tooth itself

internal resorption

presence of deep, undermining carious lesions with but
pin point surface involvement of a pit or fissure

Exogenous Theories
1. Chemical (Acid) theory:
Robertson in 1835

2. Parasitic (Septic) theory:
Antoni Van Leeuwenhoek (1632-1723) found
bacteria in scrapping from the tooth
1843, Erdl described filamentous parasites in the
membrane removed from teeth.
3. The acidogenic theory or Millers
chemicoparasitic theory:

Willoughby D. Miller, 1889

Essential features required to cause caries-
Microorganisms

Carbohydrate

Acid
chief acids formed - lactic, butyric, acetic, formic, succinic
and other acids.

Critique of chemicoparasitic theory:

was unable to explain the predilection of specific sites
on a tooth to dental caries

does not explain why some populations are caries free

phenomenon of arrested caries was not explained
4. The Proteolytic theory:

Gottileb (1947) proposed that microorganisms invade
the organic pathways (lamellae) of enamel and
initiate caries by proteolytic action

Limitations
Organic matter is around 0.2-2% in enamel

5. The proteolysis chelation theory:

Schatz et al (1955)

Chelate are compound that are able to bind metallic
ions and results in formation of a highly stable, poorly
dissociated or weakly ionized compound

initial bacterial and enzymatic proteolytic action on
the organic matter of enamel

release of a variety of complexing agents, such as
amino acids, polyphosphates and organic acids

the complexing agents then dissolve the crystalline
apatite

6. Sulfatase theory:
Pincus (1950)
bacterial sulfatase hydrolyzes the mucoitin
sulfate of enamel and the chondroitin sulfate
of dentin producing sulfuric acid that in turn
causes decalcifications of the dental tissues

7. Auto immune theory :
Burch and Jackson (1966)
Based on caries epidemiologic data genes
determine whether a tooth is at risk of caries
8. Sucrose chelation theory:
Eggers Lura (1967) - sucrose itself and not the acid
derived from it can cause dissolution of enamel by
forming unionized calcium saccharates.

inorganic phosphate is removed from the enamel by
phosphorylating enzymes.

CURRENT CONCEPTS
multifactorial

Primary Or Essential Factors in the etiology of
dental caries (Keyes, 1960)
A susceptible host tissue - the tooth
Microflora with a cariogenic potential, and
A suitable local substrate to meet the requirements of
the pathogenic flora
Caries tetralogy (Newbrun, 1982)
Primary mechanism of caries formation
Cariogenic bacterial plaque + Suitable local substrate
Organic acids

Organic acids (in plaque) + Tooth mineral
Loss of enamel

Demineralized tooth + Bacterial proteolytic enzymes
Cavitation
The Role of Dental Plaque
G.V. Black in 1899 described plaque and
regarded it as important factor in the carious
process.

Dental plaque - soft deposits that form the
biofilm adhering to the tooth surfaces or other
hard surfaces in the oral cavity including
removable and fixed restorations.

One gram of plaque (wet weight) contains approx. 2 x
10
11
bacteria

80% - water and 20% solids

Inorganic component
Ca, phosphate, F
F : 5-10ppm

Role of bacterial polymers
Helps in adhesion of bacteria to pellicle (extracellular)
Reservoir of fermentable substrates (intracellular)
E.g. glucan and fructan
Composition of dental plaque
Concept of critical pH
Stephan curve (1944)
Plaque fluid

Critical pH : 5.5
Properties of cariogenic plaque
Rate of sucrose consumption is high

Lactic acid formation is higher

Synthesis of more intracellular polysaccharides by bacteria

Higher levels of S. mutans
Caries as a specific microbial infection
Keyes (1960) dental caries is an infectious and
transmissible disease in experimental animals

Fitzgerald and Keyes isolated streptococci from
carious lesions

Streptococcus mutans main microorganism

Evidence from animal and human studies
Important points of studies on gnotobiotic animals
are : (Fitzgerald 1968, Keyes 1960)

Microorganisms are a prerequisite for caries initiation

A single type of organism (eg. enterococcus strain) is capable of
inducing caries.

The ability to produce acid is a prerequisite for caries induction but
not all acid-producing (acidogenic) organisms are cariogenic.

Streptococci's strains that are capable of inducing caries are also able
to synthesize extracellular dextrans or levans.

Organisms vary greatly in their capacity (virulence) to induce caries.
Essentiality of a local substrate
No effect of deficiency of vitamin D, calcium, vit.
A, protein or lipids

Carbohydrate mainly sucrose is main dietary
factor associated for caries formation


Dietary studies on controlled human populations
Hopewood house study (Sullivan& Harris, 1958)

New South Wales, Australia
Study period: 1947-1962
80 children
Low caries prevalence and severity
Diet was low in sugar and white flour products
The Vipeholm studies (Gustaffson et al, 1954)
In Vipeholm hospital, Lund, Sweden

From 1945-1953 on around 600 mentally retarded
patients

Main purpose: to investigate how caries activity is
influenced by
By the ingestion of non-sticky at meals refined
sugar
By the ingestion of sticky at meals sugar
By the ingestion of sticky between meals sugar
Groups:
Control
Sucrose - 300 gm of sucrose given in solution, but reduced to 75
gms during the last 2 years
Bread - 345 gm of sweet bread containing 50 gm of sugar was
given daily
Chocolate - 65 gm of milk chocolate daily between meals during
last 2 years
Caramel - 22 caramels 70 gm of sugar in 4 portions between
meals
Eight-toffee
24-toffee
Conclusions:
The risk of sugar increases caries activity if
Sugar consumed have strong tendency to be
retained on teeth
Consumed in between meals along with above
group

Increase duration of clearance of sugar from mouth
increase caries risk

Carious lesions may continue to appear in absence of
sugar-rich diet
Turku study (Scheinin and Makinen, 1975)

Turku , Finland

Aim : to find out cariogenicity of sucrose, fructose and
xylitol

125 subjects, 2 year duration

Lowest caries incidence in xylitol group

No significant difference in sucrose and fructose group
Hereditary Fructose Intolerance
Described by Froesch, 1959

Inborn error of fructose metabolism

Appearance of various symptoms on consumption
of diet containing fructose or cane sugar

Reduced caries experience (Marthler, 1967)
Conclusions
The cariogenicity of a dietary carbohydrates
varies with the frequency and time of ingestion,
physical form, chemical composition, and
presence of other food constituents.

The frequency of in between meal snacking plays
an important role in increasing the caries rate.


Sticky, solid carbohydrates are more caries
producing than those consumed as liquids.
Polysaccharides are less easily fermented by
plaque bacteria than mono and disaccharides

Meals high in fat, protein or salt reduce the oral
retentiveness of carbohydrates.


Host factors
TOOTH
Composition

Morphological characteristics

Position

SALIVA
Effect of hyposalivation or
xerostomia
Increase in caries incidence

Antibacterial properties
Lactoperoxidase
Lysozyme
Lactoferrin
IgA

Sialin
ENVIRONMENTAL FACTORS

Latitude (Sunshine) : Increase
latitude increase caries

Temperature

Relative humidity

Rainfall
Soil

Urbanization

Trace elements
Decrease in dental caries with
increasing Molybdenum, fluoride and
strontium concentration

Selenium - capable of increasing
caries
Epidemiology of dental caries
Demographic factors :
Sex : Females > males
Age
Three peak ages
Race or ethnic group

Familial and genetic patterns of caries
Parents with low caries experience- children also have
low caries risk
Studies on identical twins

Emotional disturbances


Caries susceptibility of Jaw quadrants
Maxillary >mandibular

Caries susceptibility of individual teeth
Upper and lower 1st molars
Upper and lower 2nd molars
Upper 2nd bicuspids
Upper 1st bicuspids and lower 2nd bicuspids
Upper central and lateral incisors
Upper cuspids and lower 1st bicuspids
Lower central and lateral incisors and lower cuspids

Caries susceptibility of individual tooth surfaces
occlusal surfaces are the most commonly affected,
followed by mesial, buccal and lingual surfaces in
descending order.

Buccal > lingual - Mand molars
Lingual > buccal - Max molars
Prevalence of dental
caries around world
Dental caries experience (DMFT) of 12-year-old worldwide [2002]
Dental caries experience (DMFT) of 35-44-year-olds worldwide [2002]
Dental caries experience (DMFT) of 12-year-old
according to WHO regional offices [2002]
Changing trends in prevalence of dental caries
India
Percent subjects with caries experience in
different age groups
Mean dmft/ DMFT:

Rural Urban
5 yrs 2.0 1.9
12 yrs 1.8 1.8
15 yrs 2.3 2.4
35-44yrs 5.5 5.0
65-74
yrs
14.9 14.7
Root caries
4% :35-44 yrs

5.5%: 65 -74yrs

High in rural than urban