DENTAL CARIES

Etiology, Clinical Characteristics,

Risk Assessment, and
Management

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What is Dental Caries?

•  Dental caries is a multifactorial,

transmissible, infectious oral
disease.
•  Caused primarily by the complex
interaction of cariogenic oral
flora (biofilm) with fermentable
dietary carbohyrates on the
tooth surface over time.
•  Product of disequilibrium
between demineralization and
remineralization processes.

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Keyes-Jordan Diagram

Modified from Selwitz et al

Interaction of Aetiological Factors

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The Caries Balance

Modified from Featherstone JDB

 Clinical Characteristics of Lesion
Hydrated Desiccated Surface Surface
Texture Hardness
Normal Translucent Translucent Smooth Hard
enamel
Hypocalcified Opaque Opaque Smooth Hard
enamel
Noncavitated Translucent Opaque Smooth Softened
caries
Active caries Opaque Opaque Cavitated Very soft
Inactive Opaque, dark Opaque, dark Roughened Hard
caries

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 Caries Risk Assessment
Myths
Diagnosis of caries should be
based upon the detection of
cavity
Placement of restoration is
primary effective method of
treatment of caries
There is one treatment regime
that can be applies to all
individuals
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Facts
Diagnosis involves recognition
changes between significant
factors such as bacterial
infection and multifactorial
diseases rather than simply
noting cavities
Treatment of caries requires
behavioural modification to
rectify changes.
Treatment must be specific for
the condition that exist in the
individual’s mouth
 In order to manage caries effectively
there must be clear understanding
of:
1.  All factors contributing to the
development of caries
2.  Accurate diagnosis of abberant
factors
3.  Detection and assessment of
active lesions

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Traffic Light system
Risk Assessment Model
•  The first element of this system.
•  It builds on the existing risk
assessment models as well as
including patient motivation and
lifestyle activities.
•  Risk factors, scores a red light
(high), yellow light (moderate) or
a green light (low).

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 Risk Factors used in the TL-M model
Saliva Diet Fluoride Oral Modifying
biofilm factors
Ability of minor Number of Past and Differential Past and
salivary gland sugar current staining current dental
to produce exposures per exposure status
saliva day
Consistency of Number of acid Composition Past and
unstimulated exposures per current medical
salive day status
pH of Compliance
unstimulated
saliva
Stimulated Lifestyle
salivary flow
rate
Buffering Sosioeconomic
capacity of status
stimulated
saliva

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 The Matrix
•  The second element of TL-M
model.
•  Design as a means of assessing
the patient’s present disease
status and attitude to maintaining
their own dental health.
•  Attitude scored as a, b, c.
•  Disease scored as 1, 2, 3.

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 ATTITUDE DISEASE STATUS
(a) Self-motivated (1)  No apparent disease, no
treatment required at this
time but there may/may
not be restorations of past
(b) Dentally aware (2) Controlled disease, there
may be treatment required
for functional reasons
(c) Unmotivated (3) Active disease, new
lesions or disease activity
around existing restorations

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Clinical Application of TL-M

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Risk Assessment for Individual

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 Classification of Dental Caries
GV Black ICDAS New Cavity
(Caries Severity) (Mount & Hume)
Class I 0 Site 1
Class II 1 Site 2
Class III 2 Site 3
Class IV 3 Size 0
Class V 4 Size 1
Class VI 5 Size 2
(modification)
6 Size 3

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G.V. Black’s Classification of Caries
•  Standard method used in identification of carious
lesions according to its location on the tooth
surface.
•  Originally devised 5 classifications, but a sixth
was later added.

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 Class I Lesions

All pit and fissure restorations, involving:

•  Occlusal surfaces of molars and premolars
•  Occlusal two thirds of the buccal and lingual
surfaces of molars
•  Lingual surfaces of anterior teeth

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 Class II Lesions

Involve the proximal surfaces (mesial and

distal) of posterior teeth, with access
established from the occlusal tooth surface.

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 Class III Lesions

Involve the proximal surfaces of anterior

teeth, which may or may not involve the lingual
or palatal extension but DO NOT involve the
incisal line angle.

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 Class IV Lesions

Involve all proximal surfaces of anterior teeth,

which also involve the incisal line angle.

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 Class V Lesions

Involve the cervical third of all teeth, including

the proximal surface of posterior teeth where the
marginal ridge is not include in the cavity
preparation (exclude the pit and fissure).

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 Class VI Lesions

Involve the incisal edges of all anterior teeth

and the cusp tips of all posterior teeth.

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International Caries Detection and Assessment System
(ICDAS)

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First Digit (Restoration and Sealant Codes)
Code Description
0 Not sealed or restored
1 Partial sealant
2 Full sealant
3 Tooth-colored restoration
4 Amalgam restoration
5 Stainless steel crown
6 Porcelain, gold, PFM crown or veneer
7 Defective restoration
8 Temporary restoration

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 Second Digit (Caries Severity Codes)

Code Description

0 No evidence of caries after 5 sec air drying

1 Opacity/discoloration is visible at pit/fissure after prolonged

air drying
2 Distinct visual change in enamel visible when wet

3 Localized enamel breakdown, visible when wet

4 Underlying dark shadow from dentine

5 Distinct cavity with visible dentine

6 Extensive (>half surface) distinct cavity with visible

dentine

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A New Cavity Classification by G.J
Mount & W.R. Hume

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Lesions of The Exposed Tooth Surface

Site 1 Site 2 Site 3

•  Pits, fissures, Approximal •  Cervical one
and enamel enamel in relation third of the
defects on to areas in contact crown
occlusal with adjacent •  Gingival
surfaces of teeth recession
posterior teeth •  The exposed
•  Other smooth root
surfaces

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 Size 0 Size 1 Size 2 Size 3 Size 4
•  The •  Minimal •  Moderate •  Enlarged •  Extensive
earliest surface involveme beyond caries or
lesion cavitation nt of moderate bulk loss
•  Initial •  Some dentine •  Remaining of tooth
stages of form of •  The tooth structure
deminerali restoration remaining structure
zation require to tooth is is
•  Not restore sufficiently weakened
require the strong to •  Cusp or
further smooth support incisal
treatment surface restoration edge are
splits

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MINIMUM INTERVENTION
IN DENTISTRY

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What is MID?

•  Modern medical approach to the

management of caries.
•  Utilizing caries risk assessment.
•  Focusing in the early prevention
and interception of disease.
•  Principles: recognition, reduction,
regeneration, and repair.

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Recognition

•  Identify and assess any potential

caries risk factors.
•  Lifestyles analysis, saliva testing,
plaque diagnostic tests.

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Reduction

•  Eliminate or minimize caries risk

factors.
•  Altering fluid balance, reducing
intake of dietary cariogenic food.
•  Increasing the pH of oral
environment.

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Regeneration

•  To arrest and reverse incipient

lesions.
•  Regenerating enamel sub-surface
lesions.
•  Arresting root surface lesions.
•  Using topical agents including
fluorides and casein
phosphopeptides-amorphous
calcium phosphates (CPP-ACP)

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Repair

•  Cavitation is present, need surgical

intervention (restoration).
•  Maintain the tooth by using
conservative approaches to caries
removal.
•  Used bioactive materials to restore
the tooth and promote internal
healing dentine.

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