Cariology DEN 228 PDF

CARIOLOGY DEN 228 MARIA REGINA D. MALANA, DMD, MMPHA INTRODUCTION TO CARIOLOGY Definition of Dental Caries History of Dental Caries Theories of Dental Caries Contributing Factors and Components DENTAL CARIES 3 DENTAL CARIES 1. An infectious microbiolog...

CARIOLOGY DEN 228 MARIA REGINA D. MALANA, DMD, MMPHA INTRODUCTION TO CARIOLOGY Definition of Dental Caries History of Dental Caries Theories of Dental Caries Contributing Factors and Components DENTAL CARIES 3 DENTAL CARIES 1. An infectious microbiologic disease of the teeth that results in localized dissolution and destruction of calcified tissues. (Sturdevant) 2. Ubiquitous process defined as the result of a localized chemical dissolution of the tooth surface caused by acid production by the biofilm exposed frequently to sugar. (Fejerskov et al.) 4  TERMINOLOGY Caries diagnosis The clinical judgement integrating available information, including the detection and assessment of caries signs (lesions) to determine presence of the disease. Caries activity Concept that reflects the mineral balance, in terms of net mineral loss, net mineral gain, or stasis over time 5  Active Caries Implies caries initiation/progression Inactive caries Implies caries arrest/regression Prognosis of Caries Expected course of dental caries 6  TERMINOLOGY Caries Free Implies no detectable signs of dental caries. Cavity free - Implies no detected cavities in dentine. - Thorough clinical examination may reveal the presence of non-cavitated and/or micro-cavitated carious lesions. 7  TERMINOLOGY Caries care/management/control Actions taken to interfere with mineral loss at all stages of the caries disease Non-operative interventions/treatments -topical fluoride Operative interventions/treatments -removal of a certain portion of the tooth (restoration) 8  TERMINOLOGY Caries prevention - Inhibition of caries initiation/primary prevention. - Primary, together with secondary and tertiary prevention, comprising non-operative and operative treatments. Cariogenic Substances or microorganism capable of promoting dental caries. Examples: candies, carbs, s.mutans 9  TERMINOLOGY Cariostatic Substances or procedures capable of arresting dental caries. Examples: fluoride, chlorhexidine Dental biofilm Is a consortium of microorganisms (organic & inorganic materials derived from saliva, gingival crevicular fluid, and bacterial products) that stick to a tooth surface. 10 TERMINOLOGY Dental plaque Is a clinical term used commonly when referring to the dental biofilm. Caries Lesion Clinical manifestation of caries disease. 11  TERMINOLOGY Non-cavitated Initial caries lesion development, before cavitation occurs characterized by a change in color, glossiness or surface structure as a result of demineralization Cavitated - Denotes a loss of surface integrity - Refers to the total loss of enamel and exposure of the underlying dentin - Cavitation denotes the inability to biologically replace the loss of hard 12 tissue.  HISTORY OF DENTAL CARIES 13  HISTORY Paleozoic fishes (570-250 million years), Mesozoic herbivores dinosaurs (245-265 million years) Prehominines of the Eocene (60-25 million years) Miocenic (25-5 million years) Pliocenic (5-1.6 million years) Pleistocenic animals (1.6-0.01 million years) Caries also detected in bears and other wild animals and it is common in domestic animals. 14 HISTORY A Sumerian text from 5000 BC describes a “tooth worm” as the cause of caries. 15 HISTORY Earliest theory was the “tooth worm theory” (ancient Chinese in 2500 BC,) a tooth worm as the cause of dental caries. 16  HISTORY Hippocrates (460–357 BC) proclaimed that disease was due to natural causes and should be treated by means of human reason In 350 BC Aristotle observed figs and sweets caused tooth decay In 12th century, caries was described as holes in the teeth or cavities. 17  HISTORY Bronze Age and Iron Age - Low caries - Sugar cane in the Western world in 11th century, increase in caries prevalence. Middle Ages Caries incidence increased and affected around 20% of teeth in populations whose food was cooked and included carbohydrates. 18  HISTORY Pierre Fauchard, known as the father of modern dentistry, was one of the first to proclaim the idea of caries and sugars. W.D. Miller found (1890s) that acid producing bacteria inhabits the mouth and acid dissolved tooth structures. - With G.V. Black and J.L. Williams, who researched plaque and basis for explanation of the etiology of caries. 19  HISTORY Fernando E. Rodriguez Vargas found also several strains of lactobacilli in 1921. Streptococcus mutans were found by Killian Clarke in 1924 in London for which he believed that they were the cause of caries but remained unproven. Cause of caries only in late 1960s after the experiments on hamsters of Keyes and Fitzgerald in 1950s. 20 HISTORY Caries increase tendency seems constant during the second half of the 19th century and the first half of the 20th century, worldwide. Preventive policies had considerable effects only at second half of 20th century. 21 HISTORY: TOOTHPASTE 3000 to 5000 BC Ancient Egyptians Dental cream Powdered ashes Oxen hooves Burnt egg shells Pumice Myrrh 22 HISTORY: TOOTHPASTE 1873: The first commercially produced toothpaste was launched and sold in a jar. 1892: Dr. Washington Sheffield is the first person to put toothpaste in a collapsable tube similar to the one we have today. 1914: Fluoride added to toothpaste 23 HISTORY: TOOTHBRUSH France and England were major manufacturers of toothbrushes in 19th century. - Regular tooth brushing was not a widespread practice until after the second half of 19th century. 24  THEORIES OF DENTAL CARIES 25 THEORIES OF DENTAL CARIES THE LEGEND OF WORMS (5000 BC) - Earliest reference to tooth decay from ancient Sumerian text. - Caries are caused by worms –cause of toothache 26  THEORIES OF DENTAL CARIES EARLY STUDIES French physician, Pierre Fauchard (father of modern dentistry) was one of the first people to cite sugar as the possible cause of caries. In the 1890s, W.D. Miller, the (world’s first oral microbiologist), said he believed bacteria in the mouth could dissolve tooth structures. Miller and dental pioneers G.V. Black and J.L. Williams researched plaque and investigated the causes of dental caries. 27  THEORIES OF DENTAL CARIES ENDOGENOUS THEORY: HUMORAL THEORY (Greek) The relative proportion of the four-elemental fluid of the body determines the person’s physical and mental constitution. Four elemental fluids in the body: blood, phlegm, black bile, and yellow bile which correspond to four humors-sanguine, phlegmatic, melancholic, and choleric, respectively. Any imbalance in these humors causes disease including caries. 28  THEORIES OF DENTAL CARIES ENDOGENOUS THEORY: VITAL THEORY (Hippocrates, Celsus, Galen and Avicenna) A vital theory of tooth decay was advanced towards the end of the 18th century which postulated that tooth decay originated like bone gangrene, from within the tooth itself. Physicians of the Middle Ages - Teeth are the integral part of the body. (Celsus, Galen) 29  THEORIES OF DENTAL CARIES EXOGENOUS THEORY: CHEMICAL (ACID) THEORY (Parmly and Robertson, 1819) - Caries starts on the enamel surface, where food putrified and acquired sufficient dissolving power. - Inorganic acid (such as sulfuric, nitric, and citric acids formed by decomposition of food in saliva) - Corrosion. 30  THEORIES OF DENTAL CARIES EXOGENOUS THEORY: PARASITIC (SEPTIC) THEORY (Erdl and Ficinus,1843) - Dubos (1954) postulated that microorganisms can have toxic and destructive effects on tissue. - Early microscopic observation of scrapings from teeth and of the carious lesions by Antoni - Van Leeuwenhoek (1632-1723) indicated that microorganisms were associated with the carious process. 31  THEORIES OF DENTAL CARIES EXOGENOUS THEORY: PARASITIC (SEPTIC) THEORY (Erdl and Ficinus,1843) - Erdl described filamentous organisms in the membrane removed from teeth. - Ficinus (1847) attributed dental caries to ‘DENTICOLAE’ for decay related microorganisms. 32  THEORIES OF DENTAL CARIES EXOGENOUS THEORY: CHEMICO-PARASITIC (ACIDOGENIC) THEORY (Miller, 1889) - Dental decay is a chemico-parasitic process consists of two (2) stages: decalcification or softening of the tissues and dissolution of the softened residue. - Blend of two previous theories: - Acids produced from microorganisms of the mouth - Acid derived from the fermentation of starches & sugar lodged in the retaining center of the teeth 33  THEORIES OF DENTAL CARIES EXOGENOUS THEORY: CHEMICO-PARASITIC (ACIDOGENIC) THEORY (Miller, 1889) Limitations Did not explain sub-surface demineralization Failed to justify rampant caries Did not explain caries in impacted tooth Phenomenon of arrested caries is not explained Smooth surface caries is not accounted in this theory 34  THEORIES OF DENTAL CARIES EXOGENOUS THEORY: PROTEOLYTIC THEORY (Gottlieb, 1941) - Proposed that organic & protein elements were the initial pathway of invasion by microorganisms. - Gottlieb (1944) stated that instead of decalcification of inorganic part, the initial action was due to the proteolytic enzymes attacking the lamellae, rod sheaths, tufts & walls of tubules i.e. organic component. 35  THEORIES OF DENTAL CARIES EXOGENOUS THEORY: PROTEOLYTIC THEORY (Gottlieb, 1941) - Pathways for microorganism invasion through: the enamel, enamel lamellae, enamel rod sheaths - Drawbacks of this theory: No sufficient evidences to the claim that the initial attack on enamel is proteolytic; In experimental studies caries occurs even in the absence of proteolytic microorganisms. 36  THEORIES OF DENTAL CARIES EXOGENOUS THEORY: PROTEOLYSIS-CHELATION THEORY (SCHATZ ET AL, 1955) Simultaneous microbial degradation of the organic components (hence, proteolysis) and the dissolution of the minerals of the tooth by the chelation. Chelate results from combining an inorganic metal ion with at least two electron-rich functional groups in a single organic molecule. 37  THEORIES OF DENTAL CARIES EXOGENOUS THEORY: PROTEOLYSIS-CHELATION THEORY (SCHATZ ET AL, 1955) - It considers dental caries to be bacterial destruction where the initial attack is essentially on the organic components of enamel. - The breakdown products of this organic matter have chelating properties and thereby dissolve the minerals in enamel. 38  THEORIES OF DENTAL CARIES EXOGENOUS THEORY: SUCROSE-CHELATION THEORY (Eggers-Lura 1967) - Eggers – Lura (1967) proposed that sucrose itself can cause dissolution of enamel by forming an ionized calcium saccharate. - Calcium saccharates and calcium complexing intermediaries requires inorganic phosphate which is subsequently removed from the enamel by phosphorylating enzymes. 39  THEORIES OF CARIES FORMATION In 1924, Clark isolated streptococci from human carious lesions, and named Streptococcus mutans. In 1960, Keyes showed that ‘caries-free’ hamsters develop dental caries only when caged together with ‘caries-active’ hamsters – Infectious and transmissible. 40 THEORIES OF CARIES FORMATION The bacteria previously referred to as S. mutans are seven distinct species now called mutans streptococci (MS). MS are the principal etiological agents of dental caries. 41  CURRENT CONCEPT OF DENTAL CARIES The most widely accepted theory to date continues to be the Acidogenic Theory (Chemico-Parasitic Theory) put forth by Miller with recent addition. Dental caries is a multifactorial disease with interplay of factors: host microbial flora substrate time 42 CONTRIBUTING FACTORS AND COMPONENTS DENTAL CARIES 43  FACTORS IN CARIES FORMATION 4 Co-independent Factors Microorganisms Host Substrate Time 44 HOST FACTORS AND COMPONENTS: MICROFLORA Show selectivity on the tooth surface they prefer Streptococcus mutans plays a vital role Lactic acid formers which easily colonize on tooth surface 45 HOST FACTORS AND COMPONENTS: DENTAL PLAQUE Adherent deposit of bacteria and their products which form on all tooth surface. 46 HOST FACTORS AND COMPONENTS: BIOFILM Biofilm formation is a process Microorganisms irreversibly attach to and grow on a surface. Produce extracellular polymers that facilitate attachment and matrix formation. 47 HOST FACTORS AND COMPONENTS: BIOFILM Microorganism in biofilm show distinct characteristics to survive under difficult situations. Protection of bacteria Trapping nutrients Favourable conditions for different bacterial species Exchange of genetic material between different species 48 HOST FACTORS AND COMPONENTS: BIOFILM Protection of bacteria Many bacteria produce polysaccharide. Polysaccharide covers the communities and create favorable environment. Protects bacteria from environmental factors like ultraviolet radiation and toxins. 49 HOST FACTORS AND COMPONENTS: BIOFILM Trapping nutrient Degrade large nutrient molecule that single microorganism can effectively degrade Favorable condition Organized internal compartments for distribution of nutrient, pH, O2, metabolic products as well as bacterial species. Different microniche to develop diverse bacterial 50 species growth in biofilm. HOST FACTORS AND COMPONENTS: BIOFILM Exchange of genetic material between different species of bacteria Help in evolution of new microbes 51 ORAL STREPTOCOCCI S. mutans Does not colonize the mouth of infants prior to the eruption of teeth Disappears from the mouth following the extraction of all teeth Active involvement in dental caries formation Found in plaques over incipient lesions involving pits and fissures or smooth tooth surfaces 52 ORAL STREPTOCOCCI S. sanguinis S. salivarus 53 HOST FACTORS AND COMPONENTS Tooth Factors Structure and composition Morphologic characteristics Position 54 HOST FACTORS AND COMPONENTS Structure and Composition of Teeth 1. Fluoride 2. Disturbances in formation or calcification of dental tissues 55 1. FLUORIDE When the pH drops below 5.5, the biofilm fluid becomes undersaturated with phosphate and enamel dissolves to restore balance. When fluoride is present, fluoroapatite is incorporated into demineralized enamel and subsequent demineralization is inhibited. 56 2. DISTURBANCES IN FORMATION OR CALCIFICATION OF DENTAL TISSUES Secondary importance in dental caries. The rate of caries progression may be influenced, but caries initiation is affected only to a very little extent 57 FACTORS IN CARIES FORMATION Morphologic Characteristics of Tooth Presence of deep, narrow occlusal fissures or buccal or lingual pits. 58 MOST SUSCEPTIBLE PERMANENT TEETH TO CARIES Mandibular first molars Maxillary first molars Mandibular and maxillary second molars The mandibular incisors and canines are least likely to develop lesions 59 SURFACE OF TEETH PRONE TO DECAY Mandibular first molars Maxillary first molars Occlusal Occlusal Buccal Mesial Mesial Palatal Distal Buccal Lingual Distal 60 POSITION Misaligned Out of position Rotated 61 SALIVA FACTOR 62 SALIVA FACTOR Composition of Saliva Important natural defense mechanism against dissolution of teeth Fluoride Calcium Phosphate 63 SALIVA FACTOR pH of saliva o 5.5 pH or lower May lead to dissolution of inorganic substances of dental tissues. Buffer Capacity of saliva o Affects the dental caries process Bicarbonate in saliva can diffuse into the dental plaque to neutralize the acid formed from carbohydrate by the microorganisms. 64 SALIVA FACTOR Quantity of Saliva Lack in salivary flow- more prone to dental caries salivary gland aplasia Xerostomia - due to systemic conditions, drugs (antihistamine. Decongestant, etc), radiation therapy 65 SALIVA FACTOR Viscosity of Saliva Thick and ropy Watery 66 SALIVA FACTOR: ANTIBACTERIAL PROPERTIES OF SALIVA Lysozyme (N-acetylmuramide glycanohydrolassae)- can lyse many cariogenic and noncariogenic streptococci Lysozyme activity is significantly greater in a group of caries free preschool children than in a caries susceptible group Salivary Peroxidase System- inactivates many bacterial enzymes of the glycotic pathway and inhibit their growth by preventing cells from accumulating lysine and glutamic acid for essential growth. 67 SALIVA FACTOR: ANTIBACTERIAL PROPERTIES OF SALIVA Immunoglobulin - secretory IgA Experiments- found that these protects persons against dental caries 68 MEDICATION OR TREATMENT THAT AFFECTS SALIVARY FLOW Drugs can cause xerostomia. Diuretics, beta blockers, tricyclic antidepressants, Antihistamines, anticonvulsants and antipsychotics, oral morphine Greater likelihood of taking these drugs as patients age which explains the correlation of xerostomia with age. Radiotherapy 69 DIET AND NUTRITIONAL FACTORS Physical factors (quality of diet) Nature of carbohydrate content Local factors (carbohydrate, vitamin, fluoride content) 70 DIET AND NUTRITIONAL FACTORS Vitamins Vitamin A deficiency has definite effects on developing teeth Vitamin D- necessary for the normal development of the teeth, Malformation, particularly enamel hypoplasia Disturbance of Calcium and Phosphorus metabolism during tooth development- may lead to enamel hypoplasia and defects in dentin Vit K has an enzyme inhibiting action on CHO degradation cycle. Anticariogenic action. 71 SYSTEMIC FACTORS Heredity Pregnancy and lactation Systemic diseases 72 SUBSTRATE Oral Clearance (if food is retained or not in the mouth after eating) Oral hygiene (if after eating, food is actively removed with a sharp instrument such as toothpick) Eating frequency Consumption of carbohydrates Cariogenicity of consumed carbohydrates (sucrose is more cariogenic than glucose and fructose) 73 TIME Significant amount of time is needed for demineralization to lead to the development of carious lesions. 74 75 REFERENCES Sturdevant Dental Caries (Fejeskov) http://www.historyofdentistry.net/dentistry-history/history-of-dental-caries/ http://www.historyofdentistry.net/dentistry-history/history-of-dental-caries/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3227510/  LONG QUIZ NEXT MEETING! ACTIVITY NO. 2 On a yellow paper, answer the following questions: 1. Enumerate and explain the stages of Biofilm development. 2. Explain the following hypotheses on the role of bacteria in caries etiology: Specific plaque hypothesis Non-specific plaque hypothesis Ecological plaque hypothesis 3. What is the role of mutans streptococci, oral lactobacilli, and oral actinomyses in caries formation?