Caries and Prevention PDF

Caries and Prevention What is Caries? Dental caries (also known as tooth decay or dental cavities) is the most common noncommunicable disease worldwide. It is a bacterial infectious disease that can be characterized by a progressive demineralization process that affects the mineralized dental tissu...

Caries and Prevention What is Caries? Dental caries (also known as tooth decay or dental cavities) is the most common noncommunicable disease worldwide. It is a bacterial infectious disease that can be characterized by a progressive demineralization process that affects the mineralized dental tissues. It is the main cause of tooth loss among the population  What is Intial Caries? Appearance: white spots or opaque areas on the enamel surface, indicating mineral loss beneath the surface. In some cases, lesions may appear brownish or yellow if staining from foods or beverages occurs. Location: Often found on the smooth surfaces of teeth, along the gumline, in pits and fissures on the occlusal (chewing) surfaces, or between teeth where plaque accumulates. What is Intial Caries? Reversibility: can be remineralized and reversed with proper oral hygiene, fluoride treatments, and dietary adjustments. Remineralization therapies, such as fluoride toothpaste, fluoride varnishes, and calcium phosphate-based products, can help rebuild the mineral content of the enamel. Diagnosis: Diagnosed visually or through diagnostic tools like transillumination and laser fluorescence. Initial caries may also be detected with radiographs if the lesion is interproximal.  01 Risk Factors  Risk Factors Local Systemic 1. Oral environment 1. Radiotherapy risk factors 2. Diabetes mellitus 2. Personal Behavior 3. Sjogren’s syndrome  Oral Environmental Risk Factors Past caries experience is a significant 1. Previous Caries predictor of future dental decay. Baseline Caries Prevalence 2. Salivary Higher levels of S. mutans bacteria in saliva are strongly correlated with S.Mutans Level increased caries risk Lower plaque pH is a well-established risk 3. Plaque PH factor for caries, as it creates an acidic environment conducive to tooth decay. Developmental enamel defects significantly 4. Enamel Defects increase caries risk, particularly in early childhood.  Personal Behavior Risk Factors high sugar intake and frequent 1. Diet snacking, is a well-established risk factor for caries. Poor oral hygiene was directly linked to 2. Oral Hygiene high caries risk, periodontal disease and tooth loss. The oral health, socio-economic status, and 3. Family habits of parents significantly influence a child’s caries risk. Behavior low socio-economic status. Exhibit poor oral health or high levels of S. mutans bacteria. Engage in behaviors like smoking,  Systemic Risk Factors Radiotherapy to the head and neck, especially targeting 1. Radiotherapy salivary glands and dental hard tissues, significantly increases caries risk. 2. Diabetes Both Type 1 and Type 2 diabetes are linked to higher caries risk Mellitus 3. Sjogren an autoimmune disorder, causes high Syndrome caries risk due to chronic hyposalivation.  02 Preventive Factors  Preventive Factors Local Systemic 1. Saliva 1. Systemic Fluoride 2. Fluoride 2. Probiotics 3. Chewing gum 4. Dental Sealant  Local Factors 1. Saliva Saliva with high pH, flow rate, and buffering capacity helps protect against caries by neutralizing acids produced by cariogenic bacteria. Contains antibacterial compounds like lysozyme and lactoferrin, which further shield teeth from decay. Mouth rinses, toothpaste, or topical 2. Fluoride applications, significantly reduce caries incidence.  Local Factors 3. Chewing sugar-free gum, especially xylitol- containing gum, reduces S. mutans levels gum in saliva, decreasing caries risk by limiting the bacteria’s ability to thrive. Offer effective protection against occlusal 4. Dental Sealant caries, reducing caries risk by up to 85%. Act as a physical barrier, preventing bacteria from penetrating tooth surfaces, particularly in deep grooves of molars.  Systemic Factors 1. Probiotics Probiotic supplements lower caries risk by reducing S. mutans levels and preventing biofilm formation. 2. Water shown to significantly reduce the incidence Fluoridation of dental caries. Fluorude Supplement??  03 Role of Saliva Role of Saliva Saliva plays a crucial role in defending against dental caries through four primary mechanisms: diluting and eliminating sugars and other substances, buffer capacity, balancing demineralization and remineralization, and antimicrobial action. Role of Saliva 1. Diluting and Eliminating Sugars and Other Substances Sugar Clearance: Saliva helps to remove dietary sugars and microorganisms from the mouth, especially after carbohydrate ingestion when sugar concentration in saliva spikes. Flow and Volume: When carbohydrates are consumed, initial salivary flow is low, causing sugar to concentrate in the saliva and stimulating increased salivary flow to clear sugars. Role of Saliva 1. Diluting and Eliminating Sugars and Other Substances Speed of Clearance: Saliva flow from glands quickly dilutes sugars and acids, particularly near salivary duct openings. However, clearance varies across different areas, being slower in less accessible areas like mid-interproximal spaces where pH recovery is also delayed. pH Recovery: After sugar intake, the pH decreases due to acid production by plaque bacteria. Stephan’s curve shows that pH recovery depends on the speed of saliva clearance, which is lower in hard-to-reach areas, leaving these areas more prone to decay. Role of Saliva 2. Buffer Capacity Acid Neutralization: Saliva neutralizes acids in dental plaque through buffer mechanisms involving bicarbonate, phosphate, and protein systems. Bicarbonate Buffer: Effective when salivary flow is stimulated, reducing acidity. Phosphate Buffer: Dominates at lower flow rates, maintaining pH by releasing phosphates to counteract acidity when the pH drops below 5.5. Protein Systems: Proteins like histatins and sialin help control pH, supplemented by metabolic products from bacteria. Selective Action: Buffering is stronger on tooth surfaces with thinner plaque layers, while heavily coated or interproximal surfaces have reduced buffering. Role of Saliva 3. Balance Between Demineralization and Remineralization Mineral Saturation: Both saliva and plaque fluid are supersaturated with calcium, phosphate, and hydroxyl ions, essential for enamel stability. Fluoride: Fluoride from sources like toothpaste enhances remineralization, creating a barrier against demineralization. Mineral-Binding Proteins: Proteins such as statherins, histatins, and proline-rich proteins bind to enamel, stabilizing calcium and phosphate ions to prevent unwanted precipitation and maintain enamel integrity. Dynamic Balance: Caries begins when acid-producing bacteria lower the pH, leading to enamel demineralization. Saliva helps counteract this by providing ions that promote remineralization, maintaining a delicate balance with demineralization. Role of Saliva 4. Antimicrobial Action Oral Microbiota Balance: Saliva maintains microbial equilibrium in the mouth, essential for controlling caries. Antimicrobial Proteins: Saliva contains proteins like lysozyme, lactoferrin, peroxidases, and agglutinins that have antimicrobial properties. They help reduce bacterial growth and biofilm formation. Secretory Immunoglobulins: Immunoglobulins (IgA, IgG, IgM) and histidine-based proteins further protect by inhibiting bacterial adhesion and metabolism, reducing the bacterial load on tooth surfaces. Formation of Pellicle: Some proteins also form the acquired pellicle, a protein layer on teeth that provides a physical barrier against bacterial adherence.  04 Stephan’s Curve Stephan’s Curve describes the pH changes within A dental plaque following sugar exposure. D B Resting Phase (A) Represents the baseline or fasting pH of plaque that has not been exposed to sugars for 12 hours or more. C Plaque in caries-active individuals tends to have a lower resting pH (more acidic) than plaque on cavity-free teeth. Observations by Stephan suggest that plaque in the upper jaw is generally more acidogenic than that in the lower jaw. Stephan’s Curve A Initial Decline (B) D B Following sugar intake, plaque pH drops sharply as bacteria metabolize sugars into acids. Carbohydrates within plaque, both C ingested and internally stored, are broken down into sugars that bacteria convert to acids, Stephan’s Curve A Critical pH Phase (C) D B plaque pH remains below the critical pH of 5.5, the threshold at which demineralization of enamel occurs. C The duration of time that pH remains below this level is critical in caries development, as prolonged acid exposure weakens enamel. Stephan’s Curve A Recovery Phase (D) D B The pH gradually returns to its resting level as saliva buffers the acids, though the rate and extent of recovery vary. C Faster recovery is observed on surfaces easily reached by saliva, while harder-to-reach areas (e.g., interproximal spaces) recover more slowly, posing a higher caries risk.  05 Caries Risk Assessment  Caries Risk Assessment (CRA) Tools designed to evaluate an individual’s risk of developing dental caries. They can be divided into single- factor and multiple-factor tools, depending on the number of parameters they assess. Only one parameter of caries risk, simple but less Single comprehensive than multiple-factor tools. They do not Factor provide management recommendations. Multiple more complex, combining patient history and clinical findings to provide a comprehensive risk assessment. They Factor are further divided into form-based and algorithm-based tools.  Single Factor Tools Salivary Bacteria-Level Test Measures the level of cariogenic bacteria, especially S. mutans, in saliva. Examples include the Saliva-Check mutans kit and Caries Risk Test, showing sensitivity and specificity rates from 88-90% in some studies, though specificity varies. Salivary Property Test Assesses salivary pH, flow rate, and buffering capacity. High pH is generally associated with lower caries risk, but results vary, with some studies finding limited reliability in predicting caries risk based solely on salivary properties.  Single Factor Tools Salivary Immunoglobulin Level Examines levels of immunoglobulins in saliva, though evidence on its accuracy as a caries risk indicator is mixed, with studies showing both positive and inconclusive results. Plaque pH Test Determines plaque pH using kits like the Plaque- check pH kit; shows a 72% sensitivity and 55% specificity. Some tests, like Cariview and Dentocult SM®, indicate a stronger correlation between plaque pH and caries risk.  Multiple Factor Tools Form-Based CRA Tools American Academy of Pediatric Dentistry Caries Risk Assessment Tool (AAPD-CAT) Separate forms for children (0-5 years) and older patients (6+ years), available online. Factors include social, behavioral, medical, and clinical indicators (e.g., visible plaque, fluoride use, white spot lesions). High sensitivity but low specificity reported, especially in children under 6. American Dental Association Caries Risk Assessment Tool (ADA-CAT) Provides forms for different age groups, considering conditions like fluoride exposure and dietary habits.  Multiple Factor Tools Form-Based CRA Tools Caries Management by Risk Assessment (CAMBRA) assesses health and lifestyle factors against protective factors. Used widely with visual feedback to aid patient behavior, though accuracy varies between studies. International Caries Classification and Management System (ICCMS ) and CariesCare International (CCI) System The ICCMS includes a “4D” protocol—Determining risk, Detecting lesions, Deciding treatment, and Doing intervention. This tool provides structured guidance but lacks evidence for accuracy in preventing caries.  Multiple Factor Tools Algorithm-Based CRA Tools Cariogram Software that presents a graphical prediction of caries risk based on factors like diet, caries history, and saliva properties. Accuracy studies show varied results, with some studies reporting moderate sensitivity and specificity, but results are inconsistent.  06 Caries Indices DMFT/dmft Index (Decayed, Missing, Filled Teeth) Purpose: Measures caries prevalence and severity in permanent (DMFT) and primary (dmft) teeth. Components: D/d: Number of decayed teeth. M/m: Number of missing teeth due to caries. F/f: Number of filled teeth. Application: Used worldwide to quantify caries in populations and evaluate public health interventions. DMFS/dmfs Index (Decayed, Missing, Filled Surfaces) Purpose: Similar to DMFT, but measures caries on the individual tooth surfaces rather than entire teeth. Components: Each tooth surface (e.g., occlusal, buccal) is assessed separately. Application: Provides a more detailed view of caries activity, especially in research studies. ICDAS (International Caries Detection and Assessment System) Purpose: A clinical scoring system for identifying caries severity and lesion progression at different stages. Components: Scores range from 0 (sound) to 6 (extensive decay into dentin). Application: Useful for detecting early caries lesions and monitoring disease progression in both clinical and research settings Root Caries Index (RCI) Purpose: Evaluates caries specifically on the root surfaces of teeth, which is common in older adults. Components: Counts of decayed and filled root surfaces, divided by the total number of exposed root surfaces. Application: Used primarily for assessing caries risk in older populations.  01 Enamel De/Re mineralization Demineralization This process involves the loss of mineral ions from hydroxyapatite (HA) crystals in hard tissues like enamel, dentin, and bone, leading to sensitivity and potential cavity formation if enamel integrity is compromised. Remineralization Occurs when mineral ions are reabsorbed into the Hydroxyapatite lattice, repairing demineralized crystals. Saliva plays a crucial role in promoting remineralization by supplying calcium and phosphate ions.  02 Detection Caries Detection and Diagnosis 1. Visual Inspection 2. Tactile Examination 3. Radiographic Diagnosis 4. Light Based Caries Detection 5. Electric Based Detection Methods 6. Ultrasound Caries Detection and Diagnosis Visual Inspection Must use a definite criteria unreliable alone 1. International Caries Detection and Assessment System ICDAS can prove to be a useful and reliable system in detecting early lesions Unreliable in monitiring Caries Detection and Diagnosis 2. Caries Detection Dye stain collagen in less mineralized dentin but do not specifically stain bacteria or identify the infection areas. This means they highlight demineralized areas with more organic material, regardless of bacterial presence. RISKS: Potential for Over-Removal of Sound Dentin Irreversible Staining and Aesthetic Concerns Caries Detection and Diagnosis Tactile Examination The dental explorer and dental floss have been used.  Caries Detection and Diagnosis Radiographic Examination The caries attenuates less radiation than intact tooth surface. So the area receives more exposure thus appears darker on film. Interproximal> Occlusal> Buccal> Lingual > Cemental Conventional vs Digital Caries Detection and Diagnosis Light Based Caries Detection 1. Fluorescence-Aided Caries Excavation (FACE) 2. Fiber-Optic Transillumination (FOTI) 3. Quantitative Light-Induced Fluorescence (QLF) 4. Laser fluorescence (DIAGNOdent) 5. Photothermal Radiometry and Modulated Luminescence (The Canary System)  Caries Detection and Diagnosis Fiber-Optic Transillumination (FOTI) Transillumination: Transmits light through dental tissues to help in diagnosing caries and other conditions. Applications: Besides caries detection, FOTI is used for identifying developmental defects (e.g., fluorosis), locating root canal orifices, and detecting fractures or cracks in teeth. Advantages over Radiographs: FOTI has high specificity and sensitivity, often comparable to or better than radiographs, and does not expose patients to radiation.  Caries Detection and Diagnosis Fiber-Optic Transillumination (FOTI) Light Transmission Differences: Healthy dental tissue and pathological conditions (e.g., caries, calculus) have different light transmission indices: Caries: Appears as a shadow within the tooth due to its lower light transmission index. Calculus: Shows as a darker area on the tooth surface.  03 Prevention Prevention Early Screening is required from infacy, childhood, adolescence to adulthood. As previously discussed prevention can be applied through: 1. Community 2. Professional care 3. Individual Care  04 Remineralization Remedies Requirements of an ideal remineralization material Diffuses into the subsurface or delivers calcium and phosphate into the subsurface Does not deliver an excess of calcium Does not favor calculus formation Works at an acidic pH Works in xerostomic patients Boosts the remineralizing properties of saliva Classification of Remineralization Agents Fluorides Non-fluoride remineralizing agents Alpha tricalcium phosphate (TCP) and beta TCP (β-TCP) Amorphous calcium phosphate CPP–ACP Sodium calcium phosphosilicate (bioactive glass) Xylitol Dicalcium phosphate dehydrate (DCPD) Nanoparticles for remineralization Calcium fluoride nanoparticles Calcium phosphate-based nanomaterials. NanoHAP particles ACP nanoparticles Nanobioactive glass materials Classification of Remineralization Agents Fluoride Mechanisms: Inhibits demineralization by forming acid-resistant fluorapatite crystals. Enhances remineralization by attracting calcium and phosphate ions. Reduces cariogenic bacterial activity by disrupting metabolic pathways. Retains on dental tissues, helping to sustain its protective effects. Fluoride Dentifrices: Common forms include sodium fluoride, stannous fluoride, and sodium monofluorophosphate. Dentifrices with 1400+ ppm fluoride show significant enamel protection. Classification of Remineralization Agents Amorphous Calcium Phosphate (ACP): Serves as a precursor to bioapatite; facilitates sustained calcium and phosphate release, supporting enamel repair. CPP–ACP (Casein Phosphopeptide–Amorphous Calcium Phosphate): Stabilizes calcium and phosphate ions to increase plaque calcium levels; found in products like MI Paste. Minimal Invasive Dentistry Icon resin infiltration is a minimally invasive treatment for initial caries, designed to stop the progression of early carious lesions and improve the appearance of white spot lesions without drilling or removing healthy tooth structure. Icon resin infiltration is particularly effective for treating smooth surface lesions (such as white spots on visible enamel) and interproximal caries (between teeth). THANK YOU