HISTOPATHOLOGY OF

DENTAL CARIES

Caries of enamel
Smooth surface caries
Pit and fissure caries
Caries of dentin
Early dentinal changes
Advanced dentinal changes
Secondary dentin involvement
Root Caries

Caries of enamel
Smooth surface caries
Pit and fissure caries

Smooth surface caries

clinical appearances
histopathology
zones

The carious process begins only following

the deposition of a layer of dental plaque,
which is composed of (salivary pellicle +
food debris microorganisms).

Clinical Appearance

An area of decalcification, which

resembles a chalky white surface
beneath the dental plaque.

Histopathology
This chalky white are is mainly due to Loss of
inter prismatic or inter rod substance of
enamel resulting increased prominence of
the enamel rods or due to roughening of the
ends of the enamel rods hence here the
enamel rods are more susceptible acid
attack.

As the caries progresses the other

histopathological changes occurring are
Appearance of transverse dark lines /bands
at right angles to the enamel rods. These
lines are due to changes occurring in the
enamel prisms.

The incremental line of retzius

undergoes accentuation. This darkening
appearance of the ILR in the carious
lesion is an optical phenomenon, which
occurs due to the loss of minerals due to
the carious process as a result of which
the organic structures appear more
prominent.

 As the carious lesion advances to involve

the deeper layers of enamel the lesion said
to obtain a typical or distinctive triangular or
cone shape whose base is towards the
enamel and apex towards the dentin.
Eventually there is a loss of continuity of
the enamel surface and the surface feels
rough to the tip of an explorer.

 This is due to disintegration of the enamel

prisms following the dissolution of the
interprismatic substance followed by
accumulation of debris and
microorganisms.
Before the complete disintegration of
enamel several zones can be appreciated
starting from the advancing end of the
lesion (apex).

Zone 1-Translucent zone

Zone 2-Dark zone
Zone 3-Body of the lesion
Zone 4-Surface zone

Zone 1- Translucent zone

This zone is present at the advancing end of
the enamel lesion. It is not always present.
This zone is best visualized by polarized
light and this zone has been shown to be
slightly more porous than sound enamel

Zone 2-Dark zone

Lies adjacent to the translucent zone
It is usually present hence termed as the
positive zone
this zone is due to demineralization of
enamel

Zone 3- Body of the lesion

Lies in between the dark zone and the
surface layer wiz relatively unaffected.
It is the area of greatest demineralization
It has a pore volume of 5% at the periphery
and 25% at the centre of the lesion.

Zone 4- Surface zone

Superficial most zone.
Most unaffected zone due to the great
resistance of the surface zone to
decalcification because of
(1) the greater degree of mineralization of
the surface zone and
(2) increased conc. of fluoride in the surface
enamel.

Certain researchers suggest than enamel

lamellae that are present in smooth surface

act as pathway for caries invasion hence
allowing caries occurrence to be more
likely. But other researchers report no
direct relation between the occurrence of
enamel lamellae and smooth surface caries.

Pit and fissure caries

Shallow pit and fissures
Deep pit and fissures

The caries process in pits and fissures is

almost the same as in smooth surfaces.
Here too the caries process begins beneath
and bacterial plaque.
Pits and fissures can be either
Shallow pit and fissures
Deep pit and fissures

Shallow pit and fissures

Increases of shallow pits +fissures a

relatively thick layer of enamel is
present at the base of pit, hence no
dentinal involvement occurs.

Deep pit and fissures

Here due to the increase depth of pit +fissure

food stagnation occurs followed by bacterial
decomposition. The amount of enamel at the
base of pit is relatively thin hence early
dentinal Involvement occurs.

 In case of pit and fissures enamel rods are said

to flare laterally at the bottom of the pit. Caries is
said to follow the path of enamel rods hence a
characteristic triangular lesion is formed whose
base is towards dentin and apex is towards the
outer surface.
A greater number of dentinal tubules are
involved in pit and fissure caries than in smooth
surface caries.

Caries of dentin
Early dentinal changes
Advanced dentinal changes
Secondary dentin involvement

Early dentinal changes

Once the enamel caries reach is the DEJ then natural spread
of the carious process occurs along the DEJ with the
rapid involvement of a great number of dentinal tubules.
Each dentinal tubules act as a tract along which
microorganism travel to the pulp.
In cases of caries spreading via an enamel lamellae
clinically only a small lesion may be present but in the
underlying dentin large cavity may be present.

 The initial penetration of caries in the

dentinal tubules results in two reactions.
First reaction in the Tomes dentinal fibers in
the further end of the dentinal tubule undergo
fatty degeneration hence fat globules are
deposited in the dentinal tubules. The
significance of this fatty degeneration is not
clearly understood but is has been suggested
that this fat contributes to the impermeability
of the dentinal tubules, also to the sclerosis of
dentinal arch.

As a result of the caries penetrating into

dentin there is a reaction of the vital
dentinal tubules and vital pulp. The
dentinal tubules and pulp lay down a
calcific barrier thus protecting the dentinal
tubules from further invasion by
microorganisms. The calcific barrier is
termed as dentinal sclerosis or transparent
dentin-as this zone appears transparent in
polarized light and dark in reflected light.

 In cases of slowly progressing chronic

caries a thick transparent dentin zone is
present but in case of rapidly advancing
caries only a thin zone of transparent
dentin is present.

 The rate at which the caries process progresses

depends on age. In older individuals increased
amounts of secondary dentine sclerotic dentin is
present hence caries process is slower but in
younger individuals the caries spreads much
faster even before the carious process becomes
evident clinically, a few bacteria are seen to be
present in the dentinal tubules. These are termed
as the pioneer bacteria. These pioneer bacteria are
said to be present in the dentinal tubules prior to
the occurrence of decalcification.

Close examination of the dentin behind the

zone of dentinal sclerosis reveals a zone of
decalcification of dentin. This decalcified
zone occurs prior to bacteria invasion.
The initial decalcification involves the walls of
the dentinal tubules allowing them to
distend slightly.
These dentinal tubules become packed with
masses of microorganisms

Close examination reveals adjacent tubules with

different strains of microorganisms say one
tubule with coccal organisms, adjacent with
bacilli type.
In the early stages of dentinal caries acidogenic
organisms are responsible for the decalcification
of dentinal tubules as these organisms depend
on the carbohydrate substrate present at the
surface

 As the carious lesion progress deeper, and the

carbohydrate source moves further away, the
organisms found in the dentinal tubules are
proteolytic in nature i.e. they depend on the
proteins of the dentinal tubules.
Hence the organisms responsible for the initiation
of the caries (acidogenic) are replaced by other
organisms (proteolytic) as the lesion progresses.
However certain microorganisms do exist that
have acidogenic as well as proteolytic activity.

Advanced dentinal changes

Further decalcification of the individual
dentinal tubules result in their confluencing
and increasing in diameter.
The dentinal tubules undergo further
packing with microorganisms.
Tiny liquefaction foci form due to
breakdown of dentinal tubules. These foci
are ovoid areas of destruction parallel to the
course of the dentinal tubules.

 As areas of liquefaction foci undergo expansion

the adjacent dentinal tubules undergo distortion
and their course is bent around liquefaction foci.
In areas of globular dentine the decalcification
process is said to be faster.
In last stages destruction of dentin occurs
through a process of decalcification and
proteolytic breakdown. There are numerous focal
areas of destruction present and dentin becomes
leathery in consistency.

 The caries extends at right angles along

branching of dentinal tubules thus resulting
in clefts. These clefts account for the
manner in which carious dentin can be
excavated peeled away in thin layers using
hand instruments.
As the caries lesion progresses various
zones of caries in dentin can be appreciated
which assumes a triangular shape with base
towards DEJ and apex towards the pulp.

various zones of caries in dentin

Zone of decomposed dentin.

Zone bacterial invasion

Zone of deminerlized dentin

Zone of dentinal sclerosis characterized by

calcium salts deposited in dentinal
tubules.

Zone of decalcification

A - Zone of decomposed dentin.

B -Zone bacterial invasion
C -Zone of deminerlized dentin
D -Zone of dentinal sclerosis
characterized by calcium salts
deposited in dentinal tubules.
E-Zone of decalcification

Secondary dentin involvement

The carious process is the same as in primary dentin but
here the process is much slower as the
Dentinal tubules are fewer in number
More irregular in course
Hence delaying the penetration of invading microorganisms
but sooner or later the involvement of the pulp results.
Sometimes the caries process may spread laterally between
primary and secondary dentin producing separation of
the two layers.

Root caries

Root caries can be defined as a soft

progressive lesion that is found any
where on the surface of the root that has
lost the connective tissue attachment
thus exposing the root surface to the oral
cavity.

 Also referred to as the caries of the

cementum. This is mainly said to occur in
older individuals. As age advances the
gingiva undergoes recession hence
exposing the cementum covering the root.
Leads increasing root caries.

 Enamel may get secondarily involved during

progression of the lesion.
The microorganisms in root caries is said to
be filamentous type. The microorganisms
are said to invade the cementum along the
Sharpeys fibers or in between bundles of
Sharpeys fibers similar to the spread of
caries through dentinal tubules.

 After decalcification of cementum

destruction of the remaining cementum
occurs. As the process continues
microorganisms invade into the
underlying dentinal tubules with
subsequent matrix destruction and
pulpal involvement.

references
Gordon Nikiforuk - understanding dental
caries,part1,etiology and mechanisms
garger,1985.
Fejerskov -fluorides in dentistry2nd ed,Munksgard
Norman o Harris-primary preventive
dentistry-3rd ed.