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Dental Caries

Ouyang Yong
Associate professor
Department of Endodontics and Operative Dentistry

Sun Yat-sen University


Photos of dental caries

Photos of dental caries

Photos of dental caries

'Caries' is Latin for 'rot' or 'rotten'. Dental caries means rotten teeth. Caries is the noun which names the disease Carious is the adjective, not 'a caries, 'a carious area' or 'an area of caries'.

Dental caries can be defined as

Chronic progressive deconstructive disease of hard dental tissues Bacterial infected diseases caused by specific bacteria a reversible multifactorial process of tooth demineralization and remineralization.

Dental caries
Dental caries, a bacterial infection, may be define as a posteruptive pathological process of external origin, involving the softening of the hard dental tissue and proceeding to cavity formation. This is distinct from the dissolution of the hard dental tissues of an unerupted tooth which is not dental caries but tooth resorption.

The carious process

a pathological process of localized destruction of calcified tooth tissues by acids produced by organisms. Etiologically caries is considered a multi-factorial disease, which involves interplay between the host (saliva and teeth) micro organisms (streptococcus mutans), and the substrate (dietary carbohydrate sucrose), with the production of Lactic acid. Dental plaque (Bio-film) serves as the medium for caries development.

Basic pathological changes

demineralization of inorganic tissues of tooth Disintegration of the organic tissues of tooth involves enamel, dentin, cementum

Epidemiology of dental caries

Measuring caries activity

Prevalence rate is the proportion of a population affected by a disease of a condition at one point time. Incidence is a mesurement of the rate at which a disease progresses the increase or decrease in the number of new cases occurring in a population within the same time period

DMF index
D the mean number of decayed teeth with untreated carious lesions M the mean number of teeth which have been extracted and are therefore missing F the mean number of filled teeth DMF(T) to denote decayed,missing, and filled teeth DMF(S) to denote decayed,missing, and filled surfaces in permanent teeth dmf(t) dmf(s) similar indices for the primary dentition

Frequency distribution of dental caries according to various tooth location

permanent dentition

Deciduous dentition

distribution of dental caries according to tooth surface

Occlusal > interproximal >buccal

Caries is world wide in its distribution

1. 2. 3. 4. 5. The prevalence of dental caries increases with the development of economy High DMF before 1970 in the industrialized country To decrease after 1970 in the industrialized country More prevalence in industrialized than in the third word country Caries experience tends to increase in the developing country and decline in many western countries. Caries experience is higher in urban than in rural communities in developing countries.

Prevalence of dental caries (1995) special for 12-18Y age groupsis increased significantly 20-40% In recent 10 years, prevalence of dental caries in primary dentition is increased significantly than the permanent

Why has caries prevalence decreased in modern population?

The is possibly attributable to 1. The fluoridation of drinking water, use of fluoride toothpastes and improved oral health 2. A changing pattern of sugar consumption 3. A decrease in virulence( ) of the organsims

Aetiology of dental caries

The organic deposits on the enamel surface

(primary enamel cuticle) reduced enamel epithelium) acquired pellicle food debris, material alba dental plaque calculus, tartar

four factors is essential for the initiation of dental caries, namely:

1. Micro-organism mutans streptococci Lactobacilli Actinomyces

2. Substrate Refined carbohydrates( ) such provide a suitable substrate on as sucrose which the cariogenic micro-organisms act to produce the acids that lead to dissolution of the hard dental tissues Caries experience is influenced by the quantity, quality and especially frequency of consumption of the refined carbohydrate

3. Susceptible teeth The ingestion of fluorides during tooth mineralization leads to the formation of fluorapatite in enamel. Its presence in enamel makes the tooth less susceptible to dental caries because it is less soluble in acid than the hydroxyapatite( ) which is normally present in the hard dental tissues

4. Time All the factors should be present for sufficiently long time for the caries process to be initiated.

Dental plaque

Classification of Dental plaque

supragingival plaque -----dental caries subgingival plaque -----periodontal diseases

STRUCTURE OF DENTAL PLAQUE Plaque on smooth surface Plaque-dental surface Middle layer---- condensed microbial layer body of plaque The surface layer of plaque Plaque in pit and fissure

Composition of Dental plaque

bacteria which form 50-70% of dental plaque
a small number of epithelial cells Leukocytes Macrophages

glycoproteins which, together with extracellular polysaccharides, form the plaque matrix mucopolysaccharides ( ) such as glucans and fructans( )

Inorganic components
calcium phosphorus fluorides .


The attachment, growth, removal and reattachment of bacteria to the tooth surface is a continuous and dynamic process.

Several distinct processes can be recognized

Absorption of salivary proteins and glycoproteins, together with some bacterial molecules, to the tooth surface to form a conditioning film (the acquired pellicle). non-specific interaction of microbial cell surfaces with the acquired pellicle via van der Walls attractive forces.

Irreversible adhesion can occur if specific inter-molecular interactions take place between adhesions on the cell surface and receptors in the acquired pellicle.

Secondary or late-colonizers attach to primary colonizers (coaggregation ), also by specific inter-molecular interactions.


1. Formation of acquired pellicle and primary aggregation 2. Bacteria growth and development 3. The mature of dental plaque

Pellicle formation
Microorganisms do not attach thermselves directly to the mineralized tooth surface and the teeth are always covered by an a cellular proteinaceous film, the pellicle Forms on the naked tooth surface within minutes to hours

Major constituents of Pellicle

Salivary glycoproterns Carbohydrates Lipid a lesser extent components from the gingival crevicular fluid( )

Function of Pellicle
1. Because of its selective nature restrict transportation of irons in and out of the dental hard tissue. It may play an important modifying role in caries 2. Provide further protection against demineralization of the enamel 3. Modify the number of potential adsorption sites for different bacterial species 4. As the substrate for the microorganisms

microbial colonization
Initial microbial colonization streptococcus mutans( Actinomyces spp( ) a minor proportion gram-negative bacteria(G-) )
accounting for 56% of the total initial microflora

Microbial succession
The initial establishment of a streptococcal flora appears to be a necessary antecedent for the subsequent proliferation of other organisms The most striking changed is shift from streptococcus-dominated plaque to plaque dominated by Actinomyces.


animal studies micro-organisms are involved in the aetiology of dental caries

cariogenic microorganisms Streptococcus mutans lactobacillus Actinomyces

Cariogenic properties ( )
1. they are able to produce acid rapidly from fermentable carbohydrates (acidogenic). 2. They thrive under acid conditions (aciduric) 3. able to adhere to the tooth surface because of their ability to synthesize sticky extracelluar polysaccharides from dietary sugars

Micro-organism and caries

Advanced lesions often have a high proportion of lactobacilli dentinal lesions have a diverse micro flora with many Gram positive Gram negative bacteria. Root surface caries was originally associated with Actinomyces spp. but recent studies suggest a similar aetiology to enamel caries Rampant caries can occur in xerostomic patients and in infants fed with high levels of sugar in pacifiers (nursing bottle caries). The plaque contains high levels of mutans streptococci and lactobacilli.

Hypotheses and theory relating to Aetiology of dental caries

1. Chemico-parasitic theory ( )
This postulates that oral bacteria act on sugar to produce acid which demineralizes the inorganic component of enamel, resulting in the development of a carious lesion.


Proteolytic theory(

It is thought that the organic component of enamel is first broken down by proteolytic enzymes, opening up path-ways for bacteria to attack the enamel by other processes such as by acid or by chelation.


Chelation theory(

This postulates that enamel is demineralized by chelating agents at neutral pH. Protein breakdown products as well as lactic acid are some chelating agents known to exist in nature.


Auto-immunity theory

In this theory, it is suggested that 'forbidden clones' of lymphocytes attack target cells (odontoblasts) rendering the tooth vulnerable to caries attack.

5. Four foctors theories


Host & tooth



The four circle diagrammatically represent the parameters involved in the carious process. All four factors must be acting concurrently (overlapping of the circles) for caries to occur.


The role of dietary carbohydrate

Nutrition -----systemic dietary effects Diet -----local dietary effects

epidemiological studies
 Caries prevalence is low in populations adhering to a primitive way of living and a diet of local products with little sugar  A drastic increase in caries is invariably seen when these population improvetheir standard of living and adopt a modern civilizeddiet with high sugar content  A strong correlation between caries development and sugar consumption

 Sucrose( )------called the arch-criminal in dental caries  Monosaccharides ,disaccharides and of the polysaccharide starch can be fermented to acid by the plaque bacteria xylitol ( ) -----sugar  Sorbitol substitutes used in sugar-free chewing-gums  Dietary habits and caries prevalence

Host & tooth (susceptible teeth)

It was a clinical experience that not all individuals with poor oral hygiene and frequent sugar consumption develop caries In the laboratory, extracted teeth exposed to the same acidic buffer challenge certainly do not develop artificatial carieslike lesions to the same degree within a short period of time

Host & tooth

Tooth morphology: susceptible sites Environment of the tooth: Saliva fluoride

Tooth morphology bacterial plaque is an essential precursor of caries , sites on the tooth surface which favour palque retention and stagnation are particularly prone to decay Saliva under normal conditions, the tooth is continually bathed in saliva. It is capable of remineralizing the early carious lesion because it is supersaturated with Ca and P. when salivary buffering capacity has been lost, a low Ph environment is encouraged and persists longer Fluoride particular interest was the discovery of the association between fluoride concentration in water supplies and prevalence of dental caries in children

1. It is evident that the mere existence of the three factors operating together does not result in instantaneous mineral loss 2. therefore a fourth circle is often added to stress the time dimension taken for dental caries to develop

Other factors
Age Sex Geography Race Economics status Nutrition Health status

Thank you for your attention!