Dental caries

From Wikipedia, the free encyclopedia

Dental caries, also known as tooth decay or dental cavities, are holes that damage the structure of teeth.[1] The occurrence of dental caries is globally widespread, and the disease can lead to pain, tooth loss, infection, and, in severe cases, death. n estimated !"# of schoolchildren worldwide and most adults have e$perienced dental caries, with the disease being more severe in sian and %atin merican countries and least in frican countries.[&] 'n the (nited )tates, dental caries is the most common chronic childhood disease* at least five times more common than asthma.[+] 't is the most important cause of tooth loss in children.[,] The number of cases has decreased in some developed countries, and the decrease is usually attributed to increasingly better oral hygiene practices and preventive measures such as fluoride e$posure.[-] .onetheless, places which have seen an overall decrease of dental caries continue to have a disparity in the distribution of the disease.[/] 'n children aged - to 10, 1"# of dental caries resides in &-# of the population.
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Contents
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1 Types of dental caries

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1.1 2eneral description of caries 1.& 3it and fissure caries 1.+ )mooth4surface caries 1., 5ther types of caries

& )igns and symptoms + 6iagnosis of caries , 7auses

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,.1 Teeth ,.& 8acteria ,.+ Fermentable carbohydrates ,., Time

- Treatment / 3revention

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/.1 5ral hygiene /.& 6ietary modification /.+ 5ther preventive measures

0 9eferences 1 :$ternal links

! )ee also

Types of dental caries

7aries are classified based on location. 2enerally, there are two different types of caries; caries found on smooth surfaces and caries found in pit and fissures.[1]. The location, initiation, and progression of smooth4 surface caries differs from pit and fissure caries.

General description of caries

7arious lesions are described based on their location on a tooth<s surface. 7aries on a tooth<s surface that is nearest the cheeks or lips are called =facial caries=, and caries on surfaces facing the tongue are known as =lingual caries.= Facial caries are further subdivided into buccal >when found on the surfaces of posterior teeth nearest the cheeks? and labial >when found on the surfaces of anterior teeth nearest the lips?. %ingual caries may also be described as palatal, as the lingual surface of ma$illary teeth are beside the hard palate. 7aries near a tooth<s cervi$, which is the location where the crown of a tooth and its roots meet, are referred to as cervical caries. 5cclusal caries are caries found on the chewing surfaces of posterior teeth. 'ncisal caries are caries found on the chewing surfaces of anterior teeth. 7aries can also be described as =mesial= or =distal.= @esial signifies a location on a tooth closer to the median line of the face, which is located on a vertical a$is between the eyes, down the nose, and between the contact of the central incisors. %ocations on a tooth further away from the median line are described as distal.

Pit and fissure caries

3it and fissures are anatomic landmarks on a tooth where tooth enamel infolds to create an appearance of pits and fissures. Fissures are the grooves located on the occlusal >chewing? surfaces of posterior teeth and lingual surfaces of ma$illary anterior teeth. 3its are small, pinpoint depressions that are found at the ends or cross4sections of grooves.[!] 'n particular, buccal pits are found on the facial surface of molars. For all types of pits and fissures, the deep infolding of enamel makes oral hygiene along these surfaces difficult, making dental caries common in these areas. The occlusal surfaces of teeth represent 1&.-# of all tooth surfaces but are the location of over -"# of all dental caries.[1"] mong children, pit and fissure caries represent !"# of all dental caries. [11] 3it and fissure caries can sometimes be difficult to detect. s the decay progresses, caries in enamel nearest the surface of the tooth spreads gradually deeper. 5nce the caries reaches the dentin at the dentino4enamel Aunction, the decay Buickly spreads laterally. The decay follows a triangle pattern, which points to the tooth<s pulp. This pattern of decay is typically described as two triangles with their bases overlapping each other at the dentino4enamel Aunction.
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Smooth-surface caries
There are three types of smooth4surface caries. 3ro$imal caries, also called interpro$imal caries, are caries that form on the smooth surfaces between adAacent teeth. 9oot caries are caries that form on the root surfaces of teeth. The third type of smoth4surface caries is caries on any other smooth4surface of a tooth.

'n this radiograph, the dark spots in the adAacent teeth show pro$imal caries.

3ro$imal caries are the most difficult type of caries to detect.[1&] FreBuently, this type of caries cannot be detected visually or manually with a dental e$plorer. 3ro$imal caries form cervically >toward the roots of a tooth? Aust under the contact between two teeth. s a result, radiographs are needed for early discovery of pro$imal caries.[1+] 9oot caries, which are sometimes described as a catagory of smooth4surfaces caries, are the third most common type of caries and usually occur when the root surfaces have been e$posed due to gingival recession. When the gingiva is healthy, root caries is unlikely to develop because the root surfaces are not as accessible to bacterial plaBue. The root surface is more vulnerable to the demeraliCation process than enamel because cementum begins to demineraliCe at /.0 pD, which is higher than enamel<s critical pD.[1,] 9egardless, it is easier to arrest the progression of root caries than enamel caries because roots have a greater reuptake of fluoride compared to enamel. 9oot caries are most likely to be found on facial surfaces, then interpro$imal surfaces, then lingual surfaces. @andibular molars are the most common location to find root caries, followed by mandibular premolars, ma$illary anteriors, ma$illary posteriors, and mandibular anteriors. %esions on other smooth surfaces of teeth are also possible. )ince these occur in all smooth surface areas of enamel e$cept for interpro$imal areas, these types of caries are easily detected and are associated with high levels of plaBue and diets promoting caries formation.[1&]

Other types of caries

'n some instances, caries are described in other ways that might better depict the state of dental health of a person<s teeth. =9ecurrent caries= describes caries that recur at a location, while =incipient caries= describes decay at a location that has not e$perienced decay previously. =8aby bottle caries,= =early childhood caries,= or =baby bottle tooth decay= is a pattern of decay found in young children with their deciduous >baby? teeth. The teeth most likely affected are the ma$illary anterior teeth, but all teeth can be affected. [1-] The name for this type of caries comes from the fact that the decay usually is a result of allowing children to fall asleep with sweetened liBuids in their bottles or feeding children sweetened liBuids multiple times during the day. nother pattern of decay is =rampant caries,= which signifies advanced or severe decay on multiple surfaces of many teeth.[1/] 9ampant caries may be seen in individuals with $erostomia, poor oral hygiene, methamphetamine use, andEor large sugar intake.

Signs and symptoms

(ntil caries progresses, a person may not be aware of it.[10] The earliest sign of a carious lesion is the appearance of a chalky white spot on the surface of the tooth, indicating an area of demineraliCation of enamel. s the lesion continues to demineraliCe, it can turn brown but will eventually turn into a cavitation, a =cavity=. The process before this point is reversible, but once a cavity forms, the lost tooth structure cannot be regenerated. lesion which appears brown and shiny suggests dental caries was once present but the demineraliCation process has stopped, leaving a stain. brown spot which is dull in appearance is probably a sign of active caries. s the enamel and dentin are destroyed further, the cavitation becomes more noticable. The affected areas of the tooth change color and become soft to the touch. 5nce the decay passes through enamel, the dentinal tubules, which have passages to the nerve of the tooth, become e$posed and cause the tooth to hurt. The pain can be worsened by heat, cold, or sweet foods and drinks.[1] 6ental caries can also cause bad breath and foul tastes.[11] 'n highly progressed cases, infection can spread from the tooth to the surrounding soft tissues which may become life4threatening, as in the case with %udwig<s angina.[1!]

Diagnosis of caries

3rimary diagnosis involves inspection of all visible tooth surfaces using a good light source, dental mirror and e$plorer. 6ental radiographs, produced when F4rays are passed through the Aaw and picked up on film or digital sensor, may show dental caries before it is otherwise visible, particularly in the case of caries on interpro$imal >between the teeth? surfaces. %arge dental caries are often apparent to the naked eye, but smaller lesions can be difficult to identify. (ne$tensive dental caries was formerly found by searching for soft areas of tooth structure with a dental e$plorer. Gisual and tactile inspection along with radiographs are still employed freBuently among dentists, particularly for pit and fissure caries. [&"] )ome dental researchers have cautioned against the use of dental e$plorers to find caries. [1&] 'n cases where a small area of tooth has begun demineraliCing but has not yet cavitated, the pressure from the dental e$plorer could cause a cavitation. )ince the carious process is reversible before a cavitation is present, it may be possible to arrest the caries with fluoride to remineraliCe the tooth surface. When a cavitation is present, a restoration will be needed to replace the lost tooth structure. common techniBue used for the diagnosis of early >uncavitated? caries is the use of air blown across the suspect surface, which removes moisture, changing the optical properties of the demineralised enamel. This produces a white <halo< effect detectable to the naked eye. Fiberoptic transillumination, lasers and disclosing dyes have been recommended for use as an adAunct when diagnosing smaller carious lesions in pits and fissures of teeth.

Causes
There are four players in the formation of caries; a tooth surface >enamel or dentin?* cariogenic >or potentially caries4causing? bacteria* fermentable carbohydrates >such as sucrose?* and time.[&1] The caries process does not have an inevitable outcome, and different individuals will be susceptible to different degrees depending on the shape of their teeth, oral hygiene habits, and the buffering capacity of their saliva. 6ental caries can occur on any surface of a tooth that is e$posed to the oral cavity, but not the structures which are retained within the bone.[&&].

Teeth
Daving =soft teeth= is usually not the cause of caries, despite commonly held belief to the contrary. There are certain diseases and disorders, however, that affect teeth that can leave an individual at greater risk for caries. melogenesis imperfecta, which occurs between 1 in 011 and 1 in 1,,""" individuals, is a disease in which the enamel does not form fully or in insufficient amounts and can fall off a tooth.[&+] 6entinogenesis imperfecta is a similar disease. 'n both cases, teeth may be left more vulnerable to decay because the enamel is not as able to protect the tooth as it would in health.[&,] 'n most persons, disorders or diseases affecting teeth are not the primary cause of dental caries. .inety4si$ percent of tooth enamel is composed of minerals.[&-] These minerals, especially hydro$yapatite, will become soluble when e$posed to acidic environments. :namel begins to demineraliCe at a pD of -.-.[&/] 6entin and cementum are more susceptible to caries than enamel because they have lower mineral content.[&0] Thus, when root surfaces of teeth are e$posed from gingival recession or periodontal disease, caries can develop more readily. :ven in a healthy oral environment, the tooth is susceptible to dental caries. The anatomy of teeth may affect the likelihood of caries formation. 'n cases where the deep grooves of teeth are more numerous and e$aggerated, pit and fissure caries are more likely to develop. lso, caries are more likely to develop when food is trapped between teeth.

gram stain image of Streptococcus mutans. [edit]

Bacteria
The mouth contains a wide variety of bacteria, but only a few specific species of bacteria are believed to cause dental caries; Streptococcus mutans and Lactobacilli among them.[&1] 3articular for root caries, the most closely associated bacteria freBuently identified are Lactobacillus acidophilus, Actinomyces viscosus, Nocardia spp., and Streptococcus mutans. 8acteria collect around the teeth and gums in a sticky, creamy4 coloured mass called plaBue. )ome sites collect plaBue more commonly than others. The grooves on the biting surfaces of molar and premolar teeth provide microscopic retention, as does the point of contact between teeth. 3laBue may also collect along the gingiva. 'n addition, the edges of fillings or crowns can provide protection for bacteria, as can intraoral appliances such as orthodontic braces or removable partial dentures.

Fermentable carbohydrates
8acteria in a person<s mouth converts sugars >most commonly sucrose 4 or common sugar, glucose and fructose? into acids such as lactic acid through fermentation processes.[&!] 'f left in contact with the tooth, these acids cause demineraliCation, which is the dissolution of its mineral content. The process is dynamic, however, as remineraliCation can also occur if the acid is buffered >or <neutralised<? and suitable minerals are available in the mouth from saliva but also from preventative aids such as fluoride toothpaste, varnish or mouthwash.[+"] 7aries may be arrested at this stage. 'f sufficient acid is produced over a period of time to the favor of demineraliCation, caries will progress and may then result in so much mineral content being lost that the soft organic material left behind will disintegrate, forming a cavity or hole.

Time
The freBuency of which teeth are e$posed to cariogenic >acidic? environments affects the likelihood of caries development.[+1] fter meals or snacks containing sugars, the bacteria in the mouth metaboliCe them resulting in acids as by4products which decreases pD. s time progresses, the pD returns to normal due to the buffering capacity of saliva and the dissolved mineral content from tooth surfaces. 6uring every e$posure to the acidic environment, portions of the inorganic mineral content at the surface of teeth dissolves and can remain dissolved for & hours.[+&] )ince teeth are vulnerable during these periods of acidic environments, the development of dental caries relies greatly on the freBuency of these occurences. For e$ample, when sugars are eaten continuously throughout the day, the tooth is move vulnerable to caries for a longer period of time, and caries are more likely to develop than if teeth are e$posed less freBuently to these environments and proper oral hygiene is maintained. This is because the pD never returns to normal levels, thus the tooth surfaces cannot remineralise, or regain lost mineral content. The carious process can begin within days of a tooth erupting into the mouth if the diet is sufficiently rich in suitable carbohydrates, but may begin at any other time thereafter. The speed of the process is dependent on the interplay of the various factors described above but is believed to be slower since the introduction of fluoride.[++] 7ompared to coronal smooth surface caries, pro$imal caries progress Buicker and takes an

average of , years to pass through enamel in permanent teeth. 8ecause the cementum enveloping the root surface is not nearly as durable as the enamel encasing the crown, root caries tends to progress much more rapidly than decay on other surfaces. The progression and loss of mineraliCation on the root surface is &.times faster than caries in enamel. 'n very severe cases where oral hygiene is very poor and where the diet is very rich in fermentable carbohydrates, caries may cause cavitation within months of tooth eruption. This can occur, for e$ample, when children continuously drink sugary drinks from baby bottles. 5n the other hand, it may take years before the process results in a cavity being formed, if at all.

Treatment
6estroyed tooth structure does not fully regenerate, although remineraliCation of very small cavities may occur if dental hygiene is kept at optimal level.[1] For the small lesions, topical fluoride is sometimes used to encourage remineraliCation. For larger lesions, the progression of dental caries can be stopped by treatment. The goal of treatment is to preserve tooth structures and prevent further destruction of the tooth. 2enerally, early treatment is less painful and less e$pensive than treatment of e$tensive decay. nesthetics 44 local, nitrous o$ide >=laughing gas=?, or other prescription medications 44 may be reBuired in some cases to relieve pain during or following treatment or to relieve an$iety during treatment.[+,] dental handpiece is used to remove large portions of decayed material from a tooth. spoon is a dental instrument used to remove decay carefully and is sometimes employed when the decay in dentin reaches near the pulp.[+-] 5nce the decay is removed, the missing tooth structure reBuires a dental restoration of some sort to restore the tooth to function and esthetics. 9estorative material include dental amalgam, composite resin, porcelain, and gold.[+/] 7omposite resin and porcelain can be made to match the color of a patient<s natural teeth and are thus used more freBuently when esthetics are a concern. )ince composite restorations are not as strong as dental amalgam and gold, some dentists consider them as the only advisable restoration for posterior areas where chewing forces are great.[+0] When the decay is too e$tensive, there may not be enough tooth structure remaining to allow a restorative material to be placed within the tooth. Thus, a crown may be needed. This restoration appears similar to a cap and is fitted over the remainder of the natural crown of the tooth. 7rowns are often made of gold, porcelain, or porcelain fused to metal. 'n certain cases, root canal therapy may be necessary for the restoration of a tooth.[+1] 9oot canal therapy, also called =endodontic therapy=, is recommended if the pulp in a tooth dies from infection by decay4 causing bacteria or from trauma. 6uring a root canal, the pulp of the tooth, including the nerve and vascular tissues, is removed along with decayed portions of the tooth. The canals are instrumented with endodontic files to clean and shape them, and they are then usually filled with a rubber4like material called gutta percha.[+!] The tooth is filled and a crown can be placed. (pon completion of a root canal, the tooth is now non4vital, as it is devoid of any living tissue. n e$traction can also serve as treatment for dental caries. The removal of the decayed tooth is performed if the tooth is too far destroyed from the decay process to effectively restore the tooth. :$tractions are sometimes considered if the tooth lacks an opposing tooth or will probably cause further problems in the future, as may be the case for wisdom teeth.[,"] :$tractions may also be preferred by patients unable or unwilling to undergo the e$pense or difficulties in restoring the tooth.

Prevention Oral hygiene

3ersonal hygiene care consists of proper brushing and flossing daily. [,1] The purpose of oral hygiene is to minimiCe any etiologic agents of disease in the mouth. The primary focus of brushing and flossing is to remove and prevent the formation of plaBue. 3laBue consists mostly of bacteria. [,&] s the amount of bacterial plaBue increases, the tooth is more vulnerable to dental caries. toothbrush can be used to remove plaBue on most surfaces of the teeth e$cept for areas between teeth. When used correctly, dental floss removes plaBue from areas which could otherwise develop pro$imal caries. 3rofessional hygiene care consists of regular dental e$aminations and cleanings. )ometimes, complete plaBue removal is difficult, and a dentist or dental hygienist may be needed. long with oral hygiene, radiographs may be taken at dental visits to detect possible dental caries development in high risk areas of the mouth.

Dietary modification
For dental health, the freBuency of sugar intake is more important than the amount of sugar consumed.[,+] 'n the presence of sugar and other carbohydrates, bacteria in the mouth produce acids which can demineraliCe enamel, dentin, and cementum. The more freBuently teeth are e$posed to this environment, the more likely it is that dental caries will occur. Therefore, it is recommended to minimiCe snacking, which creates a constant supply of nutrition for acid4creating bacteria in the mouth, to prevent dental caries. lso, chewy and sticky foods >such as dried fruit or candy? are more likely to adhere to teeth longer and consBuently are best eaten as part of a meal. 'f possible, brushing the teeth after meals is recommended. For children, the merican 6ental ssociation and the :uropean cademy of 3aediatric 6entistry recommend to limit the freBuency of drinks with sugar and to not give baby bottles to infants during sleep. [,,] [,-] 'n addition, it has also been found that milk or certain kinds of cheese like cheddar can help counter tooth decay if eaten soon after having eaten foods potentially harmful for teeth. lso, chewing gum containing $ylitol, wood sugar, is widely used to protect teeth in some countries, being especially popular in the Finnish candy industry.[citation needed] 'ts effect on reducing plaBue is believed to be based on bacteria not being able to utiliCe it like other sugars.[,/] 7hewing and stimulation of flavour receptors on the tongue are also known to increase the production and release of saliva, which contains natural buffers to prevent the lowering of pD in the mouth to the point where enamel may become demineralised. [,0]

7ommon dentistry trays used to deliver fluoride. [edit]

Other preventive measures

The use of dental sealants is a good means of prevention. )ealants are thin plastic4like coating applied to the chewing surfaces of the molars. This coating prevents the accumulation of plaBue in the deep grooves and thus prevents the formation of pit and fissure caries, the most common for of dental caries. )ealants are

usually applied on the teeth of children, shortly after the molars erupt. 5lder people may also benefit from the use of tooth sealants, but usually their dental history and likelihood of caries formation are taken into consideration. Fluoride therapy is often recommended to protect against dental caries. 't has been demonstrated that water fluoridation and fluoride supplements decrease the incidence of dental caries. Fluoride helps prevent dental decay by binding to the hydro$yapatite crystals in enamel. [,1] The incorporated fluoride makes enamel more resistant to demineraliCation and, thus, resistant to decay. [,!] Topical fluoride is also recommended to protect the surface of the teeth. This may include a fluoride toothpaste or mouthwash. @any dentists include application of topical fluoride solutions as part of routine visits. Furthermore, recent research shows that low intensity laser radiation of argon4ion lasers may prevent the susceptibility for enamel caries and white spot lesions. lso, there is current active research to find a vaccine for dental caries, but no effective vaccine has been created yet.