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An infectious microbialdisease that begins as

demineralization of

inorganic portion of tooth,

followed by destruction of

organic portions, leadingto cavity formation

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ASYMPTOMATICuntil it reaches advancedstage.

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WormtheoryHumour

theory

Parasitic

theory

Vital theoryChemical

theory

Acidogenic

theory

Proteolytic

theory

Proteolysis-

chelation

theory

Sucrose-

chelation

theory

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Time

Microorganism

HostSubstrate

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Cavitation

Progression of carious lesion

Initial lesion

Subsurface demineralization

Acid production

Cariogenic bacteria + cariogenic diet + plaque

Continuoussucrose consumption

Repeated attack of cariogenic challenge

Destruction of organic matrixMore of mineral loss

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However

This progress can be arrested at any stage of

development due to

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SALIVA Comparison between solubility product (Ksp) and

ion product (Ip)

Ip > Ksp, saliva is saturated with Ca & P, promoteremineralisation

Calcium &

Phosphate

Formation of fluoroapatite crystalFluoride

Retard plaque formation

Neutralize acid in oral cavityAmmonia

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SALIVA

Diffuse across plaque and neutralise acid underneathitBicarbonate

Lysozyme

Lactoperoxidase

Lactoferrin

IgA

Antibacterial

substance

Remove food debris and bacteria from oral cavityQuantity and

viscosity

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Spread of caries

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Surfacelayer

Body of

lesion

Dark zone

Translucent zone

ENAMEL CARIES

Pits & fissure caries

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Smooth surface caries

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From ENAMEL

caries can spread to DENTINvia

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DENTINAL CARIES

Zone of decomposed dentin

Zone of bacterial invasion

Zone of decalcification

Sclerotic zone

Zone of fatty

degeneration

of Tomes fibre

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Inflammation of pulp

The stage where caries is associated with toothache

It may be reversibleorirreversible(pain persists whenstimulus is removed.

Reversible pulpitis may be treated with restorationwhileirreversible pulpitis is indicated for RCTor extraction

Further progression of dental caries without treatment maylead to periapical lesion.

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Streptococcus mutans

Lactobacillus sp.

Actinomyces sp.

Other: S. salivarius, S. sanguis, Veilonella sp.

etc

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Initiation of caries is associated with S. mutans

Because it can attach to tooth surface by 2 mechanisms:

1. Sucrose-independent adsorptionthrough specificextracellular proteins on its fimbriae

2. Sucrose-dependent mechanismsit converts sucroseto sticky extracellular polysaccharide (glucan)

It is also:

1. Can produce lactic acid from sugar substrates

2. Can resist aciduric & acidogenic environment due tophosphoenolpyruvate-phosphotransferase mechanism

3. Can produce intracellular polysaccharide (reservoir)

While progression of caries is associated with Lactobacillussp.

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Type of caries Microorganisms

Pits & Fissures S. mutans

S. sanguisLactobacillus sp.

Actinomyces sp.

Smooth surface S. mutans

S. salivarius

Root surface A. viscosus

A. naeslundii

S. mutans

S. sanguis

Deep dentinal caries Lactobacilli sp.

A. naeslundii

Other filamentous rods

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PERIODIC SURVEYS OF ADULTS & ITS

FINDINGS

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Caries Prevalence

90.3%, with female(91.4 %) > male (88.9%) Rural (90.9%) > urban (89.9%)

Chinese (92.6 %) > Ibans (92.1%) > Malays

(90.9%) >Bumiputeras (89.3%) Indians/Pakistani(82.5%).

Almost similar in all 3 education level, Level 1

89.7, Level 2 88.8%, Level 3 91.1%.

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Caries prevalence by age group

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Caries Severity

Measured using the DMFX(T) index.

Age Group

Mean

D M F X DMFX

15 - 19 0.66

(0.04)

0.29

(0.06)

1.63

(0.06)

0.27

(0.03)

2.85

(0.10)

35 - 44 1.03

(0.03)

7.77

(0.20)

2.11

(0.10)

1.20

(0.07)

12.11

(0.21)

65 - 74 0.41

(0.04)

21.17

(0.50)

0.25

(0.05)

1.36

(0.11)

23.20

(0.46)

Total

0.85

(0.02)

7.87

(0.15)

1.68

(0.05)

0.94

(0.03)

11.34

(0.15)

Mean D,M,F and X components of DMFX Per Subject byIndex Age Group, 2000

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Mean DMFX was:

higher for female(12.4) than male(10.0).

Higher for rural population(12.1) than urban

population(10.8).

Highest in Chinese(13.2), simlar in Malays and

Ibans(11.3) and lowest in Kadazans(6.3).

Higher in Level 3 subjects(13.5), while Level 1

and 2 subjects exhibit almost similar mean

DMFX of 7.5 and 7.7 respectively.

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INTERNATIONAL DATA

Since 1990, continued change in global patternof oral diseases.

Dental caries found to increasein developing

countries, while in developed countries thecaries situation seems to be stable or ondecline.

Summarised that preventive measures,

especially flouride from a variety of sources,have brought about the decline in developedcountries.

WHO Oral Health Country/Area Profile Programme

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WHO Oral Health Country/Area Profile Programme

for various age groups has archived invaluable date

on oral health status.

A comparison of dental caries data in the 1990s

between Malaysia and other countries is shown.

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IMPACTS OF ORAL CONDITION

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Oral health related quality of life

Disruption of daily activities

Socialisation

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Socialisation

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Disruption of daily activities

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Utilization of oral Health services

Utili ti f l h lth i 2000

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Utilisation of oral health services 2000

Last dental check up and reasons for

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Last dental check-up and reasons for

last dental check up

Rank Reason Percentage1

2

3

4

5

67

8

Something wrong

Part of the school dental programme

Thought it was time

Part of a series of treament

Antenatal programme

ReferralReinders

Other reasons

44.5

18.5

13.3

11.4

2.8

2.40.6

6.6

Male and female did not differ in reasons.

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Urban population were more likely to seek carebecause it was time as compared to rural

population, which sought care more becausesomething is wrong or as part of the antenatalprogramme.

The more highly educated population were morelikely to seek care because of reasons such as itwas time, a reminder from the dentist, or otherreason.

Lower education level population were morelikely to seek treatment as part of the schoolprogramme or only when they sensedthatsomething was wrong.

A t th i th i

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Amongst the various age groups, the main

reason for the last dental check-up were

invariably something is wrong except for the

15-19 age group whom treatment were mostly

related to school dental programme.

The 20-24 and 25-29 age groups have the

highest proportions that sought treatment

because the thought it was time for

examination/cleaning.

Reasons for not seeking treatment

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Reasons for not seeking treatment

within the last 2 years

Rank Reason Percentage

1

2

3

45

6

7

8

9

10

11

12

13

14

No problem

Problem not serious

Too busy

No teeth/ False teethFear treatment

Other reason

Expected problem to go away

Location too far

Bad experience

Physical problems

Cannot afford

Did not want to spend money

Required appointment

Dentist would not give appointment

61.7

10.7

9.5

6.65.0

2.4

1.3

0.8

0.6

0.5

0.3

0.2

0.2

0.1

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Facility Used

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In radiotherapy patients, rampant caries occur

due to decrease in salivary flow.

Prevention at earliest level should be done to

control the caries. Extraction of tooth inradiotherapy patients may lead to

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Avoid smoking, alcohol & caffeine-based drinks

1% chlorhexidine gel in custom made tray for 5 mins, every night

Daily 0.05% Sodium Fluoride mouthrinse

Use of saliva substitute

Reinforce the importance of avoiding sweet drinks & snacks

Measure stimulated salivary flow every 3 months

Dental visit every 3 months

*sodium lauryl sulphate*

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MANAGING CARIES IN GERIATRICPATIENTS

In elderly, caries often progresses slowly along

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the CEJ resulting in root caries.

This is due to exposed root surface, poor oral

hygiene, reduced salivary flow and high sugar

diet.

May cause sensitivity and pain

May progress and eventually affect the vitality of

the tooth.

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Management

Effective brushing using flouride toothpaste.

Use of dental floss and interdental sticks toclean between teeth.

Reduce sugar intake.

Regular dental check-up.

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Managing caries in diabetic

patients

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Effect of diabetes on dental caries rate?

since most diabeticpatients limit their

intake of fermentablecarbohydrateless

cariogenic diet

associated withxerostomia and

increased gingivalcrevicular fluidglucose level

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Caries management consideration

Preoperative IntraoperativeDiabetic

EmergencyPostoperative

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Preoperative

Medical history

- ask pt about recent blood glucose level

- frequency of hypoglycemic episodes

- antidiabetic medications, dosage and time of administration

Scheduling of visit

- should receive dental treatment in the morning (higher cortisol

level)

- pt under insulin therapyavoid period of peak insulin activity

Di t

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Diet

- ensure patient has eaten normally and take medications as usual

- if patient skip meals but has taken insulin as usualincreased riskfor hypoglycemia

Blood glucose monitoring

- Check the pretreatment blood glucose level using glucometer

- Lowblood glucose level (

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Intraoperative

Adequate control and stress reduction

- Anesthesia- reduces pain and minimize endogenous

epinephrine release

- Conscious sedation for extremely anxious patient

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Diabetic emergency

Terminate dental treatment

Administer 15g of fast acting oral carbohydratesglucosetablets, sugar, candy, soft drinks, juice

Measure blood glucose level to confirmdetermine if

repeated carbohydrate dosing is needed If patient unable to swallow/ unconcious

give 25-30 ml of a 50% dextrose

solution i.vor 1 mg of glucagon

i.v./i.m./s.c. Hyperglycemic crisis usually have

prolonged onsetlower risk in dental

practice

Postoperative

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Postoperative

Patient with uncontrolled diabetes have greater risk of gettinginfectiongive antibiotic

If normal dietary intake is affectedmodify insulin or oral

antidiabetic medication dosage (consult physician)

Avoid prescribing aspirinsalicylates can increase insulinsecretion and sensitivity - hypoglycemia

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Caries Preventive Methods

Di

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Caries

PreventiveMethod

Dietarymeasures

Modifyingmicroflora

Plaquedisruption

Stimulatingsaliva flow

Modifyingtooth

surface

Eliminationnidus ofbacteria

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Dietary measures

Decreased frequency of meals- only eat during mealtimes

- to decrease number, duration and intensity of acid attack

- limit to 4 meals per dayreduces the retention period of sugar and

number of drops in pH

Eliminate sticky, sugar containing products with

prolonged sugar clearance times

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Use of sugar substitute

- xylitol, sorbitol, saccharin and aspartame

- Regular use of xylitolreduce number of

S. mutans in saliva and plaque

Protective food elements- Phosphate (cereals) :

prevent loss of phosphorus from enamel during demineralization

Helps in remineralization

Inhibit bacterial growth

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- Fats :

Reduce the cariogenicity of different foods

Some fatty acids have antimicrobial effect

- Cheese :

Reduce level of cariogenic bacteria

Increases flow of saliva and its buffering capacity

Provides organic phosphates for remineralization

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Snackings

- Choose less sticky snack and fast clearing

- No snacks in between meals- Brush the teeth immediately after eating

- Example of safe snacks?

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Modifying microflora

Achieved by intensive antimicrobial treatment

that is capable to:

- Inhibit bacterial colonization-adhesion

- Affect plaque growth-metabolic activity

Characteristics of ideal antimicrobial

treatment:- Not interfering in other biological process

- Harmless to mucosa

- Low toxicity

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Plaque disruption

Brushing

Fl i

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Flossing

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Mouthwash

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Modifying tooth surface

Systemically administered fluoride- Drinking water, salt, milk, tablets, lozenges, chewing gum,

drops.

- Optimal fluoride level : 1 ppm of fluoride

Topically applied fluoride

- Self-care : toothpaste, mouthwash

- Potential resevoirsplaque, gingiva, tongue, cheeks, under the

tongue, buccal sulcus

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- Professionally applied : fluoride paints, gels, varnish, GIC,

prophylaxis pastes

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Stimulating saliva flow

Function of saliva- Protect the tooth surface continuously by a film of salivary

mucins and proline-rich glycoprotein

- Pellicle protein and proline rich protein promote

remineralization by attracting calcium ions

- Pellicle proteins, phosphate and calcium ions in saliva help to

retard demineralization

- Salivary proteins prevent adherence of oral m/organisms to

enamel pellicle and inhibit their growth

- Salivary bicarbonate buffer systemrapid neutralization of

acids

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How to increase salivary flow?

Sugarless fluoride chewing gumsdirectly after meal for 15-

20 minutes

Fluoride or xylitol lozenges

Chewing gum containing chlorhexidineprolong fluoride

clearance, provide chemical plaque control after acid attack

Artificial saliva containing sodium fluoridegel/spray

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Elimination of nidus for bacteria

Pit and fissure sealant- On the basis of predicted caries risk and anatomy of fissure

- Erupting molars sealed as early as possible

Correction of defective restoration

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