Cariology

COLLEGE OF DENTISTRY
DEPARTMENT OF RESTORATIVE DENTAL SCIENCE

OPERATIVE DENTISTRY DIVISION
CARIOLOGY
The Science of Dental Caries
By
:
The Staff Members of Operative

Dentistry Division
Department of Restorative Dental Science
College of Dentistry
Taibah University
KSA
Designed by Al-Wasifi, Y.A.
CARIOLOGY
OPERATIVE DENTISTRY, COLLEGE OF

DENTISTRY, TAIBAH UNIVERSITY, KSA
Intended Learning Outcomes (ILOs)

BY THE END OF THIS PRESENTATION, YOU
SHOULD BE ABLE TO:
1. Define dental caries.
2. Recognize participants of dental caries etiology.
3. List different theories explaining the incidence of dental
caries.
4. Clarify the rationale of dental caries ecology.
5. Clarify the rationale of adhesion to enamel and dentin.
6. List the different factors contributing for dental caries.
7. Classify different type of dental caries.
8. Recognize the role of fluoride in dental caries prevention.
9. List different methods of fluoride application.
10.Recognize the rationale of dental plaque control.
CARIOLOGY
11.List different methods
of
dental
plaque
control.
DEFINITIONS
&
INTRODUCTION
CARIOLOGY

DEFINITIONS & INTRODUCTION
Dental caries is a disease of

the calcified tissues of the
teeth,
characterized
by
demineralization
of
the
inorganic
portion
and
destruction of the organic
substance of the tooth.
CARIOLOGY

DEFINITIONS & INTRODUCTION

Dental caries is considered a disease of modern
civilization.
Extensive studies had been made of the incidence
of dental caries, in existing primitive races and it
was noted that the incidence was invariably less
than that in civilized man.
These studies indicate that modern civilization and
increased dental caries are constant in their
association and that primitive isolated tribes are
relatively caries resistant.
CARIOLOGY

DEFINITION & INTRODUCTION

Apart from age and the advance of civilization,
many other factors influence the prevalence and
incidence of dental caries in populations.
These include:
1. Dietary habits.
2. Race.
3. Geographical locations.
4. Sex.
5. Familial patterns.
6. Influence of treatment.
CARIOLOGY


Dental Caries is:
1. Site-specific: caries occurs in areas of food
stagnation where plaque can accumulate and
remain undisturbed.
2. Multifactorial: that involves the shift of the

balance between protective factors (that aid in
remineralization) and destructive factors (that
aid
in
demineralization)
to
favor
demineralization of the tooth structure over
time.
CARIOLOGY

Dental Caries is:

3. Dynamic:
a state of demineralization &

demineralization, but not necessarily continuous.
4. Disease process: Involves microorganisms.

5. Can be arrested at any point in time.
CARIOLOGY

ETIOLOGY OF DENTAL
CARIES
CARIOLOGY

ETIOLOGY OF DENTAL CARIES
The complete divorcement of dental practice from

studies of the pathology of dental caries, that existed in
the past, is an anomaly in science that should not
continue. It has the apparent tendency plainly to make
dentists mechanics only
CARIOLOGY
G.V. Black,
OPERATIVE DENTISTRY,
COLLEGE OF
1908DENTISTRY, TAIBAH UNIVERSITY, KSA
ACID
Organic
Inorganic
CARIOLOGY

AGENDA
a) ETIOLOGICAL
THEORIES
OF
DENTAL CARIES.
b) ECOLOGY OF DENTAL CARIES.
c) FACTORS
CONTRIBUTING
FOR
DENTAL CARIES.
d) DIFFUSION PHENOMENON.
CARIOLOGY

ETIOLOGICAL
THEORIES OF DENTAL
CARIES
CARIOLOGY

ETIOLOGICAL THEORIES
A complete explanation of how the dental caries

destroys the teeth has not yet been found.
Historically, it was thought to be due to:
1. Worm theory (7000 BC 1700s).
2. Vital theory (1700s): Inflammation within the
tooth that leads to necrosis, gangrene and finally
amputation of the tooth.
CARIOLOGY

Recently many theories were developed to explain

how caries destroys the tooth structure:
a) ACIDOGENIC THEORY.
b) PROTEOLYTIC THEORY.
c) PROTEOLYTIC
CHELATION
THEORY
CARIOLOGY

ETIOLOGIC THEORIES
A)
ACIDOGENIC THEORY
Assigned and proposed by Miller and also known as

Millers theory.
Cariogenic bacteria produce acid that decalcifies

the inorganic tooth structure.
The caries process continues by breakdown of the

organic cementing substance by numerous micro
organisms.
CARIOLOGY


c) PROTEOLYTIC
CHELATION
THEORY
CARIOLOGY

ETIOLOGIC THEORIES
B)
PROTEOLYTIC THEORY
Assigned and proposed by Gottlieb, et al.
Proteolytic micro organisms of the oral cavity have

the ability to invade the organic part of the tooth
structure
liberating
a
proteolytic
enzymes
(collagenase and keratinase enzymes) that destroy
the collagen matrix of the tooth structure.
The formed acid could then demineralize the

inorganic part.
CARIOLOGY


c) PROTEOLYTIC
CHELATION
THEORY
CARIOLOGY

ETIOLOGIC THEORIES
C)
PROTEOLYTIC CHELATION THEORY
Assigned and proposed by Schatz.
Liberated acids with the help of chelating agents

could demineralize the inorganic part.
Bacterial proteolytic enzymes destruct the organic

matrix.
CARIOLOGY

AGENDA
a) ETIOLOGICAL
THEORIES
OF
DENTAL CARIES.
c) FACTORS
CONTRIBUTING
FOR
DENTAL CARIES.
CARIOLOGY

ECOLOGY OF DENTAL
CARIES
CARIOLOGY

ECOLOGY OF DENTAL CARIES

A better understanding of dental caries can be obtained
by viewing dental disease as a consequence of an
ecological system.
Ecology: Is the science that studies interaction between
organisms and their environment.
Ecosystem: It is a circumscribed area occupied by biological

community, e.g. Oral cavity.
Habitat: Constitutes an area where food and shelter for

supporting different species of microorganisms
(organism location or address) e.g. Dental fissure.
So, the ecosystem is formed of different habitats.
CARIOLOGY

CARIOLOGY

Ecological niche: Organism profession, i.e. what it

does to survive.
For each habitat, a limited number of niches are

available to the oral flora.
St. Mutans is the microorganism of dental caries, so

if the niches are not available by any mean, St.
Mutans could be prevented from being established
leading to decrease in dental caries production.
CARIOLOGY

AGENDA
a) ETIOLOGICAL
THEORIES
OF
DENTAL CARIES.
c) FACTORS
CONTRIBUTING
FOR
DENTAL CARIES.
CARIOLOGY

FACTORS
CONTRIBUTING FOR
DENTAL CARIES
CARIOLOGY

FACTORS CONTRIBUTING FOR DENTAL CARIES
Some plaque bacteria are capable of fermenting a

suitable
dietary
carbohydrate
substrate
to
produce acid, causing the plaque pH to fall below 5
within 1 3 minutes.
Repeated falls in pH may result in the

demineralization of a susceptible site on a tooth
surface, thus initiating the carious process.
CARIOLOGY

CARIOLOGY


The
factors
contributing
to
this
process are:
I. Dental plaque.
II. Dietary carbohydrates.
III. Susceptibility of the tooth
surface.
IV. Time.
CARIOLOGY

FACTORS CONTRIBUTING
I. DENTAL PLAQUE
Definition:
Dental plaque is an adherent deposit of bacteria

and their products, which forms on all tooth
surfaces.
CARIOLOGY

I. DENTAL PLAQUE
Formation:
When a clean enamel surface is exposed to the
oral environment it becomes covered with an
amorphous organic film called the pellicle.
This
consists
mainly
of
a
glycoprotein
precipitated from saliva, which is very tenacious,
and can attract and help anchor specific types of
bacteria to the tooth structure.
A large proportion of these is a streptococcus but
only about 2% of these are mutans streptococci.
CARIOLOGY

I. DENTAL PLAQUE
Formation
(Cont.):
This is interesting because, these microorganisms

are particularly associated with initiation of the
carious process.
Within few days the plaque becomes thicker and
a mixture of different types of microorganisms
comprise the bacterial community.
Consequently, the flora of the plaque changes
from its initial predominantly coccal form to a
mixed flora consisting of cocci, rods and
filaments.
CARIOLOGY

I. DENTAL PLAQUE
Formation
(Cont.):
There are local variation in the micro-flora at

different sites on the tooth surface and these
differences
may
explain
why
some
sites
experience
a
high
caries
activity
while
neighboring sites in the same mouth remain
relatively free from clinically detectable caries.
CARIOLOGY

I. DENTAL PLAQUE
CARIOLOGY

I. DENTAL PLAQUE
CARIOLOGY

I. DENTAL PLAQUE
CARIOLOGY

I. DENTAL PLAQUE
Role of bacteria:
Mutans
streptococci
and
lactobacilli
are
cariogenic because they are able to produce acid
rapidly
from
fermentable
carbohydrates
(acidogenic).
They thrive under acid conditions (aciduric)
and are able to adhere to the tooth surface
because of their ability to synthesize sticky
extracellular polysaccharides from dietary sugars.
CARIOLOGY

I. DENTAL PLAQUE
Role of bacteria
(Cont.):
These
polysaccharides,
which
are
mainly
polymers of glucose, give the matrix of dental
plaque its gelatinous consistency.
Consequently, they help:
1. Bacteria to stick to each other and to the
tooth.
2. Thickening the layer of plaque.
3. Preventing saliva from neutralizing plaque
acid.
CARIOLOGY

I. DENTAL PLAQUE
Plaque Hypothesis:
There are two hypothesizes:
1. Non-specific plaque hypothesis considered

any plaque responsible for carious process and
daily mechanical plaque removal is important.
2. Specific
plaque
hypothesis
depend on
dental plaque not always cariogenic and there
are certain plaque that are colonized by specific
microorganisms responsible for dental caries.
CARIOLOGY


The
factors
contributing
to
this
process are:
I. Dental plaque.
surface.
IV. Time.
CARIOLOGY

II.
DIETARY CARBOHYDRATES
Carbohydrates provide the plaque bacteria with

the substrate for acid production and the
synthesis of extracellular polysaccharides.
However, carbohydrates
cariogenic.
While complex carbohydrates such as starch are

relatively harmless because they are not
completely digested in the mouth, the low
molecular weight carbohydrates (sugars) diffuse
readily into plaque and are metabolized quickly
by the bacteria.
CARIOLOGY
are
not
all
equally

II.
Thus many sugar containing foods and drinks
cause a rapid drop in the plaque pH to a level
which can cause demineralization of dental
enamel.
The plaque remains acid for some time, taking 30
60 minutes to return to its normal pH in the
region of 7.
The gradual return of pH to baseline values is a
result of acid diffusion out of the plaque and
buffers in the plaque and salivary film overlaying
it, exerting a neutralizing effect.
CARIOLOGY

II.
Repeated and frequent consumption of sugars
will keep plaque pH depressed and cause
demineralization of the teeth.
The synthesis of extracellular polysaccharides
from sucrose is more rapid than from glucose,
fructose and lactose.
Consequently, sucrose is the most cariogenic
sugar, although the other sugars are also
harmful.
Since sucrose is also the sugar eaten most
commonly, it is a very important cause of dental
caries.
CARIOLOGY

The
factors
contributing
to
this
process are:
I. Dental plaque.
surface.
IV. Time.
CARIOLOGY

III.
SUSCEPTIBILITY OF TOOTH SURFACE

Bacterial plaque is an essential precursor of
caries, and for this reason, sites on the tooth
surface which favor plaque retention and
stagnation are particularly prone to decay.
These sites are:
1. Enamel pits and fissures.
2. Approximal enamel smooth surfaces just
cervical to the contact point.
3. The enamel of the cervical margin of the tooth
just coronal to the gingival margin.
CARIOLOGY

III.
4. In patients where periodontal disease has

resulted in gingival recession, the area of
plaque stagnation is on the exposed root
surface.
5. The margins of restorations, particularly those
that are deficient or overhanging.
6. Tooth surfaces adjacent to dentures and
bridges, which increase the areas, where
stagnation can occur.
CARIOLOGY

III.
ENVIRONMENT OF THE
TOOTH
a) Saliva
CARIOLOGY
b) Fluoride

III.
A) SALIVA
Under normal conditions, the tooth is continually
bathed in saliva.
Since the susceptibility of the tooth to caries
depends to a large extent on its environment,
saliva has a considerable part to play.
It is capable of remineralizing the early carious
lesion because it is supersaturated with calcium
and phosphate ions.
This remineralizing capacity of saliva is enhanced
when the fluoride ions are present.
CARIOLOGY

III.
A) SALIVA
(CONT.)
When salivary flow is diminished or absent there is

increased food retention.
Since salivary buffering capacity has been lost, a
low pH environment is encouraged and persists
longer.
This is turn encourages aciduric bacteria, which
relish the acid conditions, and continues to
metabolize
carbohydrate
in
the
low
pH
environment.
CARIOLOGY

III.
B) FLUORIDE
The presence of optimum concentrations of
fluoride in the environment and in the dental
tissues exerts an anti-caries effect in several
ways.
The most important mechanism is probably its
ability to retard the rate of progression of the
lesion.
CARIOLOGY


The
factors
contributing
to
this
process are:
I. Dental plaque.
surface.
IV. Time.
CARIOLOGY

IV. TIME
The carious process consists of alternating

periods of destruction and repair, and the saliva
has the ability to delay progression of lesions.
Thus, when saliva is present, caries does not
destroy the tooth in days or weeks but rather in
months or years, or not at all.
CARIOLOGY

AGENDA
a) ETIOLOGICAL
THEORIES
OF
DENTAL CARIES.
c) FACTORS
CONTRIBUTING
FOR
DENTAL CARIES.
CARIOLOGY

DIFFUSION
PHENOMENON
CARIOLOGY

DIFFUSION PHENOMENON
Featherstone, et al, in 1980, formulated

the diffusion phenomenon to explain
the process of dental caries.
Diffusion phenomenon is based on the
acidogenic
theory but with slight
modification.
CARIOLOGY

The mechanism of dental caries according
Featherstone diffusion phenomenon is:
to
1. Organic acids as lactic acid are

carbohydrate metabolism in plaque.
by
formed
2. The acids will diffuse through the enamel due to

concentration gradient passing through the
acquired pellicle.
3. The diffusion will be firstly through the interprismatic area, and then the water filled areas of
the organic matrix.
CARIOLOGY

4. Acids will dissociate giving hydrogen and (-)ve

radicals which attack the apatite lattice of enamel
forming calcium and phosphorous complex.
5. According to concentration gradient calcium and
phosphorous will diffuse outwards in unionized
form giving rise to demineralization with
subsequent cavity formation
CARIOLOGY

Enamel
CARIOLOGY

Enamel
CARIOLOGY

Ca+
+
Acid
Minerals
PO4--FF-
Enamel
Ca+
Ca+
Minerals
PO4---
Acid
Ca+
+
CARIOLOGY
PO4--OPERATIVE DENTISTRY, COLLEGE OF

Ca++
F
Acid
Minerals
Minerals
PO4--Minerals
F
FMinerals
Ca++
Enamel
Ca++
PO4--PO4---
Minerals
-
Acid
Ca++
CARIOLOGY
PO4--OPERATIVE DENTISTRY, COLLEGE OF

CLASSIFICATION
OF
DENTAL CARIES
CARIOLOGY

CLASSIFICATION OF DENTAL CARIES

Dental caries could be classified according
to:
a)
b)
c)
d)
e)
f)
g)
CARIOLOGY
The
The
The
The
The
The
The
anatomical site.
attack.
invasion.
extent.
onset.
visibility and degree of destruction.
severity of carious challenge.
CLASSIFICATION
A)
THE ANATOMICAL SITE

1.
Pits &
Fissure
surface
Stagnation area
carbohydrates.
2.
Smooth
surface
Which may start on enamel or on the

exposed root cementum or dentin.
CARIOLOGY
that
accumulate

CLASSIFICATION
A)
THE ANATOMICAL SITE
Capillary Attraction Theory

CARIOLOGY


to:
a)
b)
c)
d)
e)
f)
g)
CARIOLOGY
The
The
The
The
The
The
The
anatomical site.
attack.
invasion.
extent.
onset.
CLASSIFICATION
B) THE ATTACK
1.
Primary
Caries
Which is the first attack of caries in

previously
sound
healthy
tooth
surface.
2.
Recurren
t Caries
Which is the secondary caries attack

to a tooth surface previously restored
developed at the margins of the
restoration.
CARIOLOGY

CLASSIFICATION
B) THE ATTACK
Recurrent Caries
Caries Invitation
CARIOLOGY
Caries extension


to:
a)
b)
c)
d)
e)
f)
g)
CARIOLOGY
The
The
The
The
The
The
The
anatomical site.
attack.
invasion.
extent.
onset.
CLASSIFICATION
C) THE INVASION
1.
Backwar
d Caries
When the spread of caries along the

DEJ exceeds the caries in the
contiguous enamel, caries extends
into this enamel from the DEJ and
termed backward caries.
2.
Forward
Caries
Forward caries is whenever the caries

cone in enamel is larger or at least
the same size as that of dentin.
CARIOLOGY


to:
a)
b)
c)
d)
e)
f)
g)
CARIOLOGY
The
The
The
The
The
The
The
anatomical site.
attack.
invasion.
extent.
onset.
CLASSIFICATION
D) THE EXTENT
1.
Incipient
Caries
2.
Cavitate
d Caries
CARIOLOGY
The first evidence of caries activity in the

enamel, that is not extended to the
dentino-enamel junction, and the enamel
surface is fairly hard and still intact.
The lesion can be remineralized if
immediate corrective measures alter the
oral
environment,
including
plaque
removal and control. This lesion, then,
may be stated as reversible.
In cavitated caries the lesion has
advanced into dentin, the enamel surface
is
broken
(not
intact),
and
remineralization is not possible.
Treatment by cavity preparation and
restoration is indicated.
May be stated as irreversible.

to:
a)
b)
c)
d)
e)
f)
g)
CARIOLOGY
The
The
The
The
The
The
The
anatomical site.
attack.
invasion.
extent.
onset.
CLASSIFICATION
E) THE ONSET
1.
Acute
Caries
2.
Chronic
Caries
CARIOLOGY
Painful, lightly
consistency.
discolored
and
soft
in
Histologically,
the
acid
penetration
proceeds bacterial invasion, i.e. the last
layer is affected by acids but not infected
by microorganisms.
Painless, due to increased chance for
formation of reparative dentin, dark or
brownish
discoloration
and
hard
in
consistency.
Bacterial invasion proceeds or coincides
with acid penetration; i.e. the last layer is
both affected by acid decalcification and
infected by microorganisms.
CLASSIFICATION
E) THE ONSET
Special Clinical Forms of Acute Caries

a) Rampant Caries
It is the name given to a sudden rapid destruction
of many teeth, frequently involving surfaces of
teeth that are usually caries free.
It may be seen in permanent teeth of teenagers and
is usually due to taking frequent cariogenic snacks
and sweet drinks between meals.
CARIOLOGY

CLASSIFICATION
E) THE ONSET

a) Rampant Caries
(Cont.)
It is also seen in mouths where there is a sudden

marked reduction in salivary flow (xerostomia).
Radiation in the region of salivary gland, used in the
treatment of malignant tumors, is the most common
cause of an acute xerostomia.
CARIOLOGY

CLASSIFICATION
E) THE ONSET

a) Rampant Caries
CARIOLOGY
(Cont.)

CLASSIFICATION
E) THE ONSET

b) Nursing Caries
It is a particular form of rampant caries in the
primary dentition of infants and young children.
It is found in an infant or toddler who falls asleep
sucking a bottle (called a nursing bottle) which has
filled with sweetened fluids (including milk).
The frequency of sugar intake combined with a low
salivary flow at night are important in the
development of this form of rampant caries.
CARIOLOGY

CLASSIFICATION
E) THE ONSET

b) Nursing Caries
(Cont.)
The clinical pattern is characteristic, with the four

maxillary deciduous incisors most severely affected.
CARIOLOGY

CLASSIFICATION
E) THE ONSET
Special Clinical Forms of Chronic

Caries
a) Arrested Caries
This term describes a carious lesion, which does not
progress.
It is seen when the oral environment has changed
from
conditions
predisposing
to
caries,
to
conditions that tend to arrest the lesion.
CARIOLOGY

CLASSIFICATION
E) THE ONSET
Special Clinical Forms of Chronic

Caries
a) Arrested Caries
CARIOLOGY
(Cont.)


to:
a)
b)
c)
d)
e)
f)
g)
CARIOLOGY
The
The
The
The
The
The
The
anatomical site.
attack.
invasion.
extent.
onset.
CLASSIFICATION
F) THE VISIBILITY &

DEGREE OF DESTRUCTION
1) Shallow
Cavity:
2) Moderate
Cavity:
3) Deep Cavity:
CARIOLOGY
Showing a slight destruction in enamel

due to short period of time.
Showing destruction of enamel up to

DEJ.
Showing destruction of enamel and

dentin approaching the pulp tissues
due to long period of time.

to:
a)
b)
c)
d)
e)
f)
g)
CARIOLOGY
The
The
The
The
The
The
The
anatomical site.
attack.
invasion.
extent.
onset.
CLASSIFICATION
G) THE SEVERITY OF
CARIOUS CHALLENGE
1) Mild
Challenge:
In which only the most vulnerable teeth and

surfaces are attacked, such as cervical
margin of the teeth or pits and fissures of
molar teeth.
2) Moderate
Challenge:
In which carious lesions involving also the

approximal surfaces of teeth.
3) Severe
Challenge:
In which the anterior teeth which normally

remain caries free, also becomes carious.
CARIOLOGY

PREVENTION
OF
DENTAL CARIES
CARIOLOGY

PREVENTION OF DENTAL CARIES
Prevention or control of dental

caries could be achieved by one or
both of the following:
a) FLUORIDE SUPPLEMENTATION.
b) CONTROL OF DENTAL PLAQUE.
CARIOLOGY

A) FLUORIDE
SUPPLEMENTATION
CARIOLOGY

A) FLUORIDE SUPPLEMENTATION
AGENDA
I. CRYSTALLINE
STRUCTURE
OF
ENAMEL.
II. DEPOSITION OF FLUORIDE IN
ENAMEL.
III. CARIOSTATIC
MECHANISM
OF
FLUORIDE.
IV. FLUOROSIS.
CARIOLOGY

V. FLUORIDE
APPLICATION.
I.
CRYSTALLINE STRUCTURE OF ENAMEL
Enamel mineral is crystalline and has a lattice

structure characteristic of hydroxyapatite, the
smallest repeating unit of which can be
expressed by the formula Ca10 (PO4) (OH)2.
However, it is not a pure hydroxyapatite since it

also has a non-apatite phase (amorphous calcium
phosphate or carbonate).
CARIOLOGY

I.
Cross section
of rods in mature
human enamel
Hexagon-shaped
enamel
crystallites
CARIOLOGY

I.
Additional ions or molecules are adsorbed on to

the large surface area of the apatite crystals.
This can happen in several different ways:

1. The crystal lattice has the capacity to substitute
other ionic species of appropriate size and
charge.
Thus within the lattice, calcium can be
exchanged for radium, strontium, lead, and
hydrogen
ions
while
phosphate
can
be
exchanged for carbonate, and hydroxyl for
fluoride.
CARIOLOGY

I.
2. Sodium, magnesium, and carbonate can be

substituted or adsorbed at the crystal surface.
3. There may be defects present in the internal
lattice.
4. It is also possible for part of the lattice to be
lost without the whole crystal disintegrating.
Similarly, remineralization can occur.
CARIOLOGY

AGENDA
I. CRYSTALLINE
STRUCTURE
OF
ENAMEL.
ENAMEL.
III. CARIOSTATIC
MECHANISM
OF
FLUORIDE.
IV. FLUOROSIS.
CARIOLOGY

V. FLUORIDE
APPLICATION.
II.
DEPOSITION OF FLUORIDE IN ENAMEL

There is a great deal of scope to affect the fluoride
concentration of enamel since it can be deposited in
three stages of enamel development:

1) Low concentrations, reflecting the low levels of
fluoride in tissue fluids, are incorporated in the

apatite crystals during their formation.
2) After calcification is complete, but before
eruption, more fluoride is taken up by the
surface enamel which is in contact with the
tissue fluids.
3) Finally, after eruption and throughout life, the
enamel continues to take up fluoride from its
external environment.
CARIOLOGY
II.
DEPOSITION OF FLUORIDE IN ENAMEL
Any increase in porosity facilitates the diffusion and

uptake of fluoride by enamel.
The fluoride content of intact surface enamel is much

higher than the interior enamel but tends to be
extremely variable.
It varies between primary and permanent teeth,

between different individuals living in the same area,
between different teeth in the same individual, and
even between different surfaces of the same tooth.
In carious enamel, white-spot or brown-spot 1esions,

fluoride levels are raised whereas in areas worn by
attrition the levels are low.
CARIOLOGY
AGENDA
I. CRYSTALLINE
STRUCTURE
OF
ENAMEL.
ENAMEL.
III. CARIOSTATIC
MECHANISM
OF
FLUORIDE.
IV. FLUOROSIS.
CARIOLOGY

V. FLUORIDE
APPLICATION.
III. CARIOSTATIC
MECHANISM OF FLUORIDE
1. The presence of fluoride ions greatly enhances

the precipitation of fluoroapatite from calcium
and phosphate ions present in saliva making
enamel more acid resistant.
2. Fluoride inhibits enolase enzyme essential for
completion of the process of glycolysis.
3. Fluoride ion inhibits glycosyl transferase,
that prevents the polymerization of glucose to
form
extracellular
polysaccharides
with
subsequent reduction of bacterial adhesion to
tooth structure.
CARIOLOGY

III. CARIOSTATIC
MECHANISM OF FLUORIDE
4. Fluoride ions used in topical fluoride application

are directly toxic to some microorganisms
including S. mutans, suppression of growth of S.
mutans
following
single
topical
fluoride
application may last several weeks.
5. Fluorides alter the surface energy of enamel
rendering it less susceptible for adhesion of
bacteria.
6. Fluoride accelerates the
in saliva.
CARIOLOGY
7. Fluoride
clearance of glucose
OPERATIVE DENTISTRY, COLLEGE

OF
minimizes
the
transportation
of
AGENDA
I. CRYSTALLINE
STRUCTURE
OF
ENAMEL.
ENAMEL.
III. CARIOSTATIC
MECHANISM
OF
FLUORIDE.
IV. FLUOROSIS.
CARIOLOGY

V. FLUORIDE
APPLICATION.
IV. FLUOROSIS
Signs:
The first sign of excessive intake of fluoride

during the period of tooth formation is the
eruption of teeth with fluorosed or mottled
enamel.
Its appearance varies from fine white lines in the

enamel to chalky, opaque enamel, which turns
brown, or black after eruption.
The enamel may even break apart soon after

tooth eruption.
CARIOLOGY

IV. FLUOROSIS
Mild Fluorosis
CARIOLOGY
Moderate Fluorosis
Severe Fluorosis

IV. FLUOROSIS
Mechanism:
The exact mechanism is not fully understood, but

fluoride is thought to affect ameloblast function
during both the secretory and the maturation
phases, leading to defective mineralization.
Fluorosis can be caused by a single high fluoride

dose, lower but multiple doses, and by low-level
continuous exposure.
Consequently, it can be produced by ingestion of

fluoride from the drinking water and toothpaste
as well as by use of dietary fluoride supplements.
CARIOLOGY

IV. FLUOROSIS
Mechanism
(Cont.):
Although permanent teeth go on developing from

birth to adolescence, it is the anterior teeth that
are of most concern from an aesthetic viewpoint.
Thus, the most critical time is from birth to 8

years but the risk is greatest during the first two
years of life.
CARIOLOGY

AGENDA
I. CRYSTALLINE
STRUCTURE
OF
ENAMEL.
ENAMEL.
III. CARIOSTATIC
MECHANISM
OF
FLUORIDE.
IV. FLUOROSIS.
CARIOLOGY

V. FLUORIDE
APPLICATION.
V.
FLUORIDE APPLICATION
Fluoride Application
I. Systemic
1. Drinking water
2. Fluoride tablets
II. Topical
a) Frequent Use
Low Concentration
3. Fluoridated salt
1. Tooth paste
4. Fluoridated Milk
5. Pre-natal
fluoride
2. Mouth rinses
b) Periodic Use
High Concentration
1. Sodium fluoride
varnish
2. APF gel
3. Stannous fluoride gel
4. Prophylaxis paste
CARIOLOGY

AGENDA
I. CRYSTALLINE
STRUCTURE
OF
ENAMEL.
ENAMEL.
III. CARIOSTATIC
MECHANISM
OF
FLUORIDE.
IV. FLUOROSIS.
CARIOLOGY

V. FLUORIDE
APPLICATION.
VI. FLUORIDE TOXICITY
Anyone recommending the use of fluoridecontaining dental preparations should be aware

of the fluoride content and the potential hazards.
The exact mechanism by which fluoride produces

its toxic effect is not known.
Symptoms of sub-lethal poisoning:

1. Salivation, nausea and vomiting.
2. The symptoms usually appear within an hour of
ingestion.
CARIOLOGY

Management:
A small quantity of fluoride (less than 5 mg/kg

body weight) is neutralized by drinking a large
volume of milk.
If more than 5 mg/kg have been ingested or if

there is any doubt about the exact quantity
consumed, the child should be taken to hospital
and given gastric lavage.
CARIOLOGY

Although no cases of acute toxicity due to ingestion

of toothpaste have ever been reported, a 5-year-old
could be severely poisoned by consuming about
two-thirds of a 100-ml tube of 1500-ppm fluoride
paste; a 1-year-old would need to consume only half
this amount.
Fluoride toothpaste should therefore be kept out of
the reach of young children.
CARIOLOGY

Prevention or control of dental

caries could be achieved by one or
both of the following:
a) FLUORIDE SUPPLEMENTATION.
b) CONTROL OF DENTAL PLAQUE.
CARIOLOGY

B) CONTROL OF DENTAL
PLAQUE
CARIOLOGY

B) CONTROL OF DENTAL PLAQUE
AGENDA
I. REVIEWING
PLAQUE
HYPOTHESIS.
II. METHODS
OF
PLAQUE
CONTROL.
CARIOLOGY

I.
REVIEWING PLAQUE HYPOTHESIS
a) Non-specific plaque hypothesis:
It suggests that all plaque is potentially

cariogenic.
This would imply that daily mechanical plaque
removal is important in the management of the
carious process.
CARIOLOGY

I.
b) Specific plaque hypothesis:

It proposes that plaque is not always cariogenic
and that only certain plaques, colonized by
specific microorganisms, are responsible for
dental decay.
This would imply that targeting of specific
organisms, such as mutans streptococci, might
control the carious process.
This approach is the rationale behind considering
the use of topical antimicrobials such as
chlorhexidine, in the management of dental
CARIOLOGY
caries.
I.
c) Ecological plaque hypothesis:
It combines the two previous approaches.

The argument behind the ecological plaque
hypothesis can be summarized as follows:
1. Cariogenic bacteria are found naturally in

dental plaque.
2. At neutral pH these organisms are a small
proportion of the total plaque community.
3. With a conventional diet, the processes of deand remineralization are in equilibrium and the
carious process does not progress.
4. If the frequency of carbohydrate intake
increases, plaque spends more time at an acid
CARIOLOGYpH.
I.
c) Ecological plaque hypothesis
(Cont.):
5. This low pH favors the proliferation of mutans

streptococci and lactobacilli and tips the
balance towards demineralization.
6. Now greater numbers of mutans streptococci
and lactobacilli in plaque produce acid at faster
rates, enhancing demineralization.
. This
hypothesis explains the lack of total

specificity in the microbial etiology of dental
caries.
. It explains the pattern of bacterial succession and
shows why both the approach of total plaque
removal and chemical targeting of specific
CARIOLOGY
OPERATIVE
microorganisms may have a role
to DENTISTRY,
play inCOLLEGE
the OF
AGENDA
I. REVIEWING
PLAQUE
HYPOTHESIS.
II. METHODS
OF
PLAQUE
CONTROL.
CARIOLOGY

II.
METHODS OF PLAQUE CONTROL

Methods of Plaque Control
a) Mechanical
b) Chemical
1. Seeing Plaque.
1. Chlorhexidine.
2. Tooth Brushes.
2. Enzymes.
3. Inter-dental
Cleaning.
3. Surface active
agents.
4. Dentifrices.
4. Antibiotics.
5. Antibacterial agents.
CARIOLOGY

II.

a) Mechanical
1. Seeing Plaque
In order to learn how to remove plaque effectively it is

helpful for the patient to see where it is present.
Since plaque is translucent and has a color similar to
teeth, it must be stained in order to be seen clearly.
Liquids, tables, and capsules containing erythrosin or
vegetable dyes are used to stain plaque and are called
disclosing agents.
The disclosing agent should be applied after tooth
brushing so that areas where oral hygiene is
inadequate can be seen easily.
CARIOLOGY

II.

a) Mechanical
2. Tooth Brushes
Tooth brushes vary widely in shape and size of the

head, the material, texture, and arrangement of
filaments as well as in the size and shape of the
handles.
However, at present nearly all tooth brushes available
are multi-tufted with nylon filaments.
It is particularly important that brushes are replaced
regularly, at least every three months or sooner if the
bristles become permanently bent.
However, for the physically handicapped, where manual
dexterity is limited, an electric tooth brush is very
helpful.
CARIOLOGY

II.

a) Mechanical
3. Inter-Dental Cleaning
Approximal surfaces and areas where teeth are

maligned cannot be reached with an ordinary tooth
brush.
Consequently, additional aids such as dental floss or
tape, woodsticks, single-tufted brushes, or interdental brushes may be required for these areas.
Choice will depend on the shape of the inter-dental
area and the dexterity of the individual.
CARIOLOGY

II.

a) Mechanical
4. Dentifrices
In the past dentifrices were used in conjunctions with a

tooth brush solely for cosmetic and social reasons.
However, in the last 30 years fluorides, antibiotics,
ammonium compounds, enzyme inhibiting dental
caries, were added.
Of all these agents only fluoride has stood up to clinical
testing for safety and efficacy in caries prevention.
It is also becoming increasingly common for
manufacturers to add other therapeutic or preventive
agents to reduce gingivitis and calculus formation.
A few toothpaste also contain desensitizing agents.
CARIOLOGY

II.

b) Chemical
1. Chlorhexidine
Mechanism of action:
Chlorhexidine is an antiseptic belonging to the

chemical group of compounds called bisbiguanides,
which are bactericidal and fungicidal.
It has a broad spectrum of activity against grampositive and gram-negative organisms as well as yeast.
The chlorhexidine molecule is cationic, which means it
is positively charged and because of its positive
charge, it is attracted to bacterial cell walls, which are
negatively charged.
The bacterial cell wall is then irreversibly damaged
with subsequent precipitation of its cytoplasmic
components, resulting in cell death.
CARIOLOGY

II.
Side - Effects:
b) Chemical
1. Chlorhexidine
1) Staining:
The most conspicuous side effect is the
development of yellow/brown stain on the teeth
and tongue and on the margins of anterior
restorations.
Staining around these restorations can be
prevented if they are coated with Vaseline before
rinsing.
The stain is caused by the interaction of
chlorhexidine with certain constituents of the
diet.
This limits the long-term use of chlorhexidine.
CARIOLOGY
II.

b) Chemical
1. Chlorhexidine
2) Taste:
Chlorhexidine has a bitter taste and there is a
general dulling of taste sensation for a few
minutes to several hours after rinsing.
The bitter taste has been masked quite
successfully by flavoring agents.
3) Parotid gland swelling:

A few cases of unilateral or bilateral swelling of
the parotid glands have been reported.
However, they were all reversible when rinsing
was discontinued.
CARIOLOGY

II.

b) Chemical
1. Chlorhexidine
4) Desquamation of oral mucosa:
Few cases of painful desquamatous lesions have
been reported.
5) Long-term effects:
There is a slight change in the balance of oral
flora in favor of the organisms that are less
sensitive to it, but this returns to normal after
three months.
CARIOLOGY

II.
Indications:
b) Chemical
1. Chlorhexidine
1. Individuals who have been assessed to be at high

risk to active caries.
This assessment should be made on the basis of
history, clinical and radiographic examination,
dietary history, salivary secretion rate, and buffer
capacity.
2. Patients with greatly reduced salivary flow, who
are consequently very much at risk to caries,
benefit from the prophylactic use of chlorhexidine
in conjunction with fluoride.
CARIOLOGY

II.

b) Chemical
1. Chlorhexidine
Indications:
3. May also be used prophylactically to prevent the
transmission of cariogenic microorganisms from
parents to children and from primary teeth to
the permanent dentition.
CARIOLOGY

II.

b) Chemical
2. Enzymes
Hydrolytic, proteolytic, and glycolytic enzymes

have been tested in attempts to break down the
plaque matrix and so cause disruption and
dispersal of the plaque.
So far these attempts have proved ineffective or

impractical due to:
1. The complex nature of the inter-microbial
matrix of dental plaque.
2. The specificity and short duration of action of
some of these enzymes.
CARIOLOGY

II.

b) Chemical
3. Surface Active Agents
In vitro studies show that fluoride may be

capable of retarding the deposition of pellicle and
plaque although there is little evidence in vive to
support this.
Attempts have been made to form moisturerepellent coatings on the smooth surfaces of
tooth.
Preliminary
studies
substituted alcohols
CARIOLOGY
using
the
aminehave been encouraging.

II.

b) Chemical
4. Antibiotics
Antibiotics are important for the treatment of

more serious infections so that the potential
dangers associated with sensitization and the
development of resistant strains of organisms as
well as super-infection by fungal organisms
prohibit their use for routine plaque.
CARIOLOGY

II.

b) Chemical
5. Anti Bacterial Agents
a) Fluoride:
The effect of fluoride on plaque bacteria and

bacterial metabolism has been discussed.
The daily home use of fluoride at such a high
concentration cannot be generally recommended
because of safety considerations.
Although lower concentrations of fluoride can
affect bacterial metabolism the bactericidal effect
of the concentrations used in dentifrices and
mouthwashes remains to be confirmed.
CARIOLOGY

II.

b) Chemical
b) Triclosan:
Triclosan has a broad spectrum of anti-microbial

activity against yeast and gram-positive and
gram-negative bacteria.
Although it has been shown to reduce plaque
deposition and gingivitis to some extent, its value
as a cariostatic agent is not yet proven
adequately.
CARIOLOGY

II.

b) Chemical
c) Metal ions:
Zinc, thin, and copper have shown some antiplaque activity.

Adverse reactions related to clinical use are an
unpleasant metal taste with a feeling of dryness
and some staining.
CARIOLOGY

CARIOLOGY
THANK
YOU


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COLLEGE OF DENTISTRY

DEPARTMENT OF RESTORATIVE DENTAL SCIENCE

The Staff Members of Operative

OPERATIVE DENTISTRY, COLLEGE OF

Designed by Al-Wasifi, Y.A.

Intended Learning Outcomes (ILOs)

Designed by Al-Wasifi, Y.A.

OPERATIVE DENTISTRY, COLLEGE OF

Designed by Al-Wasifi, Y.A.

DEFINITIONS & INTRODUCTION

Dental caries is a disease of

OPERATIVE DENTISTRY, COLLEGE OF

Designed by Al-Wasifi, Y.A.

DEFINITIONS & INTRODUCTION

OPERATIVE DENTISTRY, COLLEGE OF

Designed by Al-Wasifi, Y.A.

DEFINITION & INTRODUCTION

OPERATIVE DENTISTRY, COLLEGE OF

Designed by Al-Wasifi, Y.A.

DEFINITION & INTRODUCTION

2. Multifactorial: that involves the shift of the

OPERATIVE DENTISTRY, COLLEGE OF

Designed by Al-Wasifi, Y.A.

DEFINITION & INTRODUCTION

Dental Caries is:

a state of demineralization &

4. Disease process: Involves microorganisms.

OPERATIVE DENTISTRY, COLLEGE OF

Designed by Al-Wasifi, Y.A.

OPERATIVE DENTISTRY, COLLEGE OF

Designed by Al-Wasifi, Y.A.

ETIOLOGY OF DENTAL CARIES

The complete divorcement of dental practice from

Designed by Al-Wasifi, Y.A.

ETIOLOGY OF DENTAL CARIES

OPERATIVE DENTISTRY, COLLEGE OF

Designed by Al-Wasifi, Y.A.

ETIOLOGY OF DENTAL CARIES

OPERATIVE DENTISTRY, COLLEGE OF

Designed by Al-Wasifi, Y.A.

ETIOLOGY OF DENTAL CARIES

OPERATIVE DENTISTRY, COLLEGE OF

Designed by Al-Wasifi, Y.A.

A complete explanation of how the dental caries

OPERATIVE DENTISTRY, COLLEGE OF

Designed by Al-Wasifi, Y.A.

Recently many theories were developed to explain

OPERATIVE DENTISTRY, COLLEGE OF

Designed by Al-Wasifi, Y.A.

Assigned and proposed by Miller and also known as

Cariogenic bacteria produce acid that decalcifies

The caries process continues by breakdown of the

OPERATIVE DENTISTRY, COLLEGE OF

Designed by Al-Wasifi, Y.A.

Recently many theories were developed to explain

OPERATIVE DENTISTRY, COLLEGE OF

Designed by Al-Wasifi, Y.A.

Assigned and proposed by Gottlieb, et al.

Proteolytic micro organisms of the oral cavity have

The formed acid could then demineralize the

OPERATIVE DENTISTRY, COLLEGE OF

Designed by Al-Wasifi, Y.A.

Recently many theories were developed to explain

OPERATIVE DENTISTRY, COLLEGE OF