Dental Caries in theChild and Adolescent

Chapter 10

Mc Donald 2010

Presented by Dr.Ali Vafaei

Assistant professor of pediatric dentistry

• Dental caries is the single most common chronic childhood disease.

• 5X asthma + 7X hay fever.

ETIOLOGY OF DENTAL CARIES

• infectious and communicable disease • multiple factors influence the initiation and

progression:• Host (tooth in the oral environment)

• Dietary substrate• Aciduric bacteria.

• The saliva (also considered a host component)

• The substrate + bacteria biofilm (plaque) that adheres to the tooth surface.

• The critical pH for dissolution of enamel has been shown to be about 5.5.

• Once the process reaches dentin, dissolution can occur at a considerably higher pH.

• Dental caries is a preventable disease.

• typically begins in enamel and progresses slowly in the early stages of the process.

• Cavitation of the tooth structure is quite a late stage of the disease.

• Prior to cavitation, the progress of the disease may be arrested and/or reversed if a favorable oral environment can be achieved.

• Even after cavitation occurs, if the pulp is not yet involved and if the cavitated area is open enough to be self-cleansing ("plaque-free"), the caries process can halt and become an "arrested lesion

• Arrested lesions:

much coronal destruction

remaining exposed dentin is hard and usually very dark

no evidence of pulpal damage

the patient has no pain

Orland study• dental caries will not occur in the absence of

microorganisms.• Animals maintained in a germ-free environment

did not develop caries even when fed a high-carbohydrate diet.

• microorganisms can produce enough acid to decalcify tooth structure:Aciduric streptococci, lactobacilli, diphtheroids,

yeasts, staphylococci, and certain strains of sarcinae.

Loesche

• He concluded that the evidence suggests that S. mutans, possibly Streptococcus sobrinus, and lactobacilli are human odontopathogens.

• He stated that aciduricity appears to be the most consistent attribute of S. mutans and is associated with its cariogenicity

Wan et al

• They found S. mutans colonization in infants as young as 3 months, and over 50% of the predentate infants were infected by 6 months of age.

• By 24 months of age, 84% of the children harbored the bacteria.

window of infectivity

• between 19 and 33 months of age during which most children acquire the cariogenic organisms.

• The mother was the most common source of transmission of the bacteria to the child.

• Because the outer surface of enamel is far more resistant to demineralization by acid than is the deeper portion of enamel, the greatest amount of demineralization occurs 10 to 15 µm beneath the enamel surface .

• The continuation of this process results in the formation of an incipient subsurface enamel lesion that is first observed clinically as a so-called white spot.

White spot

• Remineralization of incipient subsurface lesions may occur as long as the surface layer of the enamel remains intact.

• The time required for remineralization is determined by:

• age of the plaque,

• the nature of the carbohydrate consumed

• presence or absence of fluoride.

Example

• in the presence of dental plaque that has developed for 12 hours or less, the enamel demineralization resulting from a single exposure to sucrose will be remineralized by saliva within about 10 minutes.

• plaque that is 48 or more hours old

Remineralization period : 4hours

Fluoride role

• enhance the rate of remineralization of enamel by saliva

• formation of a fluorhydroxyapatite

• Increases the resistance of the remineralized enamel to future attack by acids.

• antimicrobial effects

CARIES PREVALENCE INPRESCHOOL CHILDREN

• Children in the middle and middle- low socioeconomic groups showed a trend toward higher caries frequencies.

• Age rate

• 84% of the children who were caries free in the primary dentition remained caries free in the mixed dentition.

• Children with pit and fissure caries in the primary dentition were more likely to develop smooth-surface caries of primary teeth than the caries-free children.

• Children with faciolingual decay (nursing caries) were at the highest risk of any group for developing additional carious lesions.

RAMPANT DENTAL CARIES

• widespread, rapidly burrowing type of caries, resulting in early involvement of the pulp and affecting those teeth usually regarded as immune to ordinary decay.

• sudden onset

• imbalance of the oral environment

• Young teenagers seem to be particularly susceptible to rampant caries

emotional disturbances may be a causative factor in some cases of rampant caries.

emotional disturbance

unusual craving for sweets

+

Antidepressant drug induced xerostomia

EARLY CHILDHOOD CARIESECC

• AAPD:

Presence of one or more decayed (noncavitated or cavitated), missing (due to caries), or filled tooth surfaces in any primary tooth in a child 71 months of age or younger.

Any sign of smooth-surface caries in children younger than 3 years is indicative of severe early childhood caries (S.ECC).

SECC PATTERN

• Maxillary A + B• Mandibular C• Maxillary and mandibular D• The mandibular incisors are usually unaffected.

parent should start brushing the child's teeth as soon as they erupt and should

discontinue nursing as soon as the child can drink from a cup—at approximately 12

months of age.

ADDITIONAL FACTORS KNOWNTO INFLUENCE DENTAL CARIES

SALIVA

• Any patient with a salivary deficiency, from any cause, is at higher risk for caries activity.

• Many properties of saliva have been investigated to learn their possible role in the caries process:

salivary PHthe acid-neutralizing powerthe calcium, fluoride, and phosphorus

content.rate of flow and the viscosity of saliva

Parasympathetic Stimulation

profuse and watery saliva

Sympathetic stimulation

thick, mucinous juice

parotid gland

Stimulation of the parasympathetic fibers

profuse, watery secretion

stimulation of the sympathetic fibers

no secretion

Salivary Deficiency

• When the quantity is only moderately reduced, the oral structures may appear normal.

• A pronounced reduction or complete absence of saliva, however, will result in a septic mouth with rampant caries

reasons for a reduction of saliva

• psychologic or emotional disturbance

• Mumps

• Immune disorders, such as Sjogren syndrome

• genetic conditions, such as hypohidrotic ED

• oncology patients receive head and neck or total body irradiation and …

Viscosity of Saliva

• viscosity of saliva is related to the rate of dental decay.

• Both thick, ropy saliva and thin, watery saliva have been blamed for rampant dental caries.

• Patients with thick, ropy saliva invariably had poor oral hygiene.

• We have observed that children who consume excessive amounts of carbohydrates often have not only a sparse flow but also a viscous saliva.

• Reduction of refined sugar intake may be effective in some patients.

Other causes for tooth decay

• SOCIOECONOMIC STATUS:

economically poor children are at high risk for dental caries.

• ANATOMIC CHARACTERISTICS OF THE TEETH

• ARRANGEMENT OF THE TEETH IN THE ARCH

• PRESENCE OF DENTAL APPLIANCES AND RESTORATIONS:

S. mutans levels were significantly elevated during active treatment.

When samples were taken 6 to 15 weeks into the retention phase of treatment, however, the microbial levels were found to have decreased significantly to levels comparable to those of untreated children.

• HEREDITARY FACTORS:

most authors agree that genetic influences on dental caries are relatively minor in comparison with the overall effect of environmental factors.

The fact that children acquire their dietary habits, oral hygiene habits, and oral microflora from their parents makes dental caries more an environmental than a hereditary disease.

EARLY DETECTION OF DISEASEACTIVITY

• Because the reversal of the caries process depends on an intact surface layer of the lesion and the typical use of the dental explorer to probe the suspicious areas often results in the rupture of the surface layer covering early lesions, the use of the dental explorer to probe enamel is no longer recommended.

INFRARED LASER FLUORESCENCE

(DIAGNOdent)

• Detection and quantification of dental caries of occlusal and smooth surfaces.

• The emitted fluorescence is collected at the probe tip, transmitted through ascending fibers, and processed and presented on a display window as an integer between 0 and 99.

• Increased fluorescence reflects carious tooth substance, particularly for numerical values higher than about 20.

• What material is responsible for the fluorescence is still under investigation, but it appears to be bacterial metabolites, particularly the porphyrins

• DIAGNOdent readings show a very good correlation with histologic evidence of caries but not with the depth of the lesions into dentin

• readings are influenced by several variables, including:

the degree of dehydration of the lesion the presence of dental plaque

the presence of various types of stain in occlusal fissures.

• The DIAGNOdent instrument appears to be particularly useful for confirming the presence of occlusal caries.

Infra red and red fluorescence(Midwest Caries ID)

• Use both Red (660nm) and Infrared (880nm) fluorescence.

• Use on all surfaces of tooth

• The inclusion of the red light permits observations related to light-scattering properties associated with loss of tooth structure.

• Infrared light induces florescence from bacterial porphyrins and related exogenous materials that may be present in pits and fissures, dental plaque or cavitated carious lesion.

This combination instrument appears to be more useful for detecting so-called

hidden occlusal caries

Important note!

There is no indication that either the Diagnodent nor Midwest

careis ID is capable of detecting noncavitated lesions confined to

the outer half of enamel

DIGITAL IMAGING FIBER-OPTICTRANS-ILLUMINATION (DIFOTI)

• Use transillumination to identify lesions located on the interproximal surfaces of the anterior teeth.

• practitioners were able to detect more proximal lesions with FOTI than with a visual examination with or without the use of radiographs.

• not able to determine the depth of lesions.

QUANTITATIVE LIGHT FLUORESCENCE(QLF)

• Detect early carious lesions and to accurately monitor either lesion progression or regression.(F2 effect evaluation)

• the QLF instrument detected 5 to 10 times more early lesions than conventional detection methods.

• Particularly useful for examination of occlusal pits and fissures

• gave reproducible results.

Thanks