I.

Definition of Caries
Caries is a disease wherein bacterial processes damage hard tooth
structure (enamel, dentin and cementum).These tissues progressively
break down, producing dental cavities (holes in the teeth). Two kinds of
bacteria which are responsible for initiating caries are Streptococcus
mutans and Lactobacilli. Cavity or decay of a tooth is a localized disease
begins at the surface of the tooth and may progress through the dentine
into the pulp cavity. It is believed that the action of microorganisms in the
mouth on ingested sugars and carbohydrates produces acids that eat
away the enamel. The protein structure of the dentine is then destroyed
by enzymatic action and bacterial invasion. Diet, general health,
structural defects of the teeth, and heredity affect one’s chances of
developing caries.
Dental caries is a pandemic disease affecting individuals of almost
all age groups. It is a multifactorial, irreversible microbial disease of the
calcified tissues of the teeth, characterized by demineralization of the
inorganic portion and destruction of the organic substance of the tooth,
which often leads to cavitations. It involves complex and dynamic
processes with multitude of factors that influence and initiate the
progression of disease. Although effective methods are known for
prevention and management of dental caries, it is a major health problem
affecting mankind, in that its manifestations persist throughout life
despite treatment. In this presentation, we will be discussing
etiopathogensis, mode of presentation, diagnostic tests and different
modes of treatment in dental caries.

II. Causes of Caries

Caries is a disease which to happen need 4 factors. When these
factors are exist, it will create the caries. The factors that create the
caries are the fragile tooth surface, bacteria in plaque, carbohydrate and
sugar, and time.
Tooth surface which fragile is a perfect place for caries to develop.
This condition can happen firstly because the dentin and cementum are
more susceptible to caries than enamel due to their lower mineral
content. Caries is a disease in which enamel doesn’t fully form or forms in

1
 insufficient amounts and can fall off a tooth. It can happen because 96%
of enamel is composed of minerals (hydroxyapatite) and will become
soluble when exposed to acidic environments and demineralized at a Ph
of 5,5.
The second factor is bacteria in plaque. Plaque is a sticky, clear film
which forms everyday on teeth. Plaque is made up mainly of microscopic
germs which are in the mouth at all times. Plaque sticks to the teeth.
Plaque is found mostly between the teeth and near or under the gum line.
Plaque germs feed on many of the food we eat. Carbohydrate and sugar
are their favorite. When these germs stay on the teeth, they grow in
number and form into clumps. Plaque produces acid as they feed. This
acid is the major cause of caries. The bacteria which the most dangerous
to create caries are Streptococcus mutans and Lactobacilli
The third factor is carbohydrate and sugar. Carbohydrate when
there are large quantities and is often consumed, especially the kind that
stick or cling to the teeth, it will cause caries. These carbohydrates
provide the substrate for the production of acid for the bacteria and
extracellular polysaccharide synthesis. Carbohydrates in fruits do not
cause dental caries, because there were not many. Although
carbohydrates can cause caries, however, we need not fear to consume
them, provided we are diligent to clean and care for our teeth properly
and correctly
The fourth factor is time. Time contributes to the development of
caries, which after a person consumes sugar or carbohydrate, if not be
cleaned, it will attract bacteria, than it will lower the pH. pH can be normal
because it is neutralized by saliva and to return it to normal pH, it takes
30-60 minutes. Therefore, frequent consumption of sugar and repeatedly
will keep plaque pH below normal and can cause enamel
demineralization. Demineralization will occur after 2 hours. Therefore it is
recommended to brush your teeth after eating and before bedtime, as an
effort to prevent early caries. When all of these factors meet, it will create
a disease called caries.

III. Process of Caries

2
 The process of caries starts when we eat food that contains
carbohydrate (especially sucrose) or sugar. When we eat this kind of food,
in our mouth, there will be a metabolism process through glycolic process
by bacteria called Streptococcus mutans or Lactobacilli. From this
metabolism process, plaque will be produce, which is invisible from our
naked eye. Plaque that formed in our teeth needs food for energy. It gets
the energy from food debris that left in our teeth after we eat and can be
seen by naked eye. The interaction between plaque and food debris will
create an acid, called lactic acid. In the early stage, it will form as a very
little strain with white color in teeth surface that we called white spot.
When we do not do anything with this white spot (like going to the dentist
so they will cure it), this strong acid will create a hole, due to it’s
strengthens that can ruin calcium in our teeth. This is how caries happen.

IV. Symptoms and Signs of Dental Caries

A person experiencing caries may not be aware of the disease. The
earliest sign of a new carious lesion is the appearance of a chalky white
spot on the surface of the tooth, indicating an area of demineralization of
enamel. As the lesion continues to demineralize, it can turn brown but will
eventually turn into a cavitation ("cavity"). Before the cavity forms, the
process is reversible, but once a cavity forms, the lost tooth structure
cannot be regenerated. A lesion which appears brown and shiny suggests
dental caries was once present but the demineralization process has
stopped, leaving a stain. A brown spot which is dull in appearance is
probably a sign of active caries. As the enamel and dentin are destroyed,
the cavity becomes more noticeable. The affected areas of the tooth
change color and become soft to the touch. Once the decay passes
through enamel, the dentinal tubules, which have passages to the nerve
of the tooth, become exposed and cause the tooth to hurt. The pain may
worsen with exposure to heat, cold, or sweet foods and drinks. Dental
caries can also cause bad breath and foul tastes. In highly progressed
cases, infection can spread from the tooth to the surrounding soft tissues.
Signs :

1. Brown or Black Discoloration :

3
 • The earliest sign of a new carious lesion is the appearance of a chalky white
spot on the surface of the tooth, indicating an area of demineralization of
enamel.

• A lesion which appears brown and shiny suggests dental caries was once
present but the demineralization process has stopped, leaving a stain.

• A brown spot which is dull in appearance is probably a sign of active caries.

2. Cavity :

• As the lesion continues to demineralize, it can turn brown but will eventually
turn into a cavity.

• When a cavity forms, the lost tooth structure cannot be regenerated.

3. Pulpitis  feeling pain :

• A dental caries that penetrate through the enamel and dentin to reach the
pulp can causes pulpitis.

• Pulpitis can increases sensitivity to stimuli and pain, especially from hot, cold,
and sweet foods or drinks.

V. Classification of Caries
Caries can be classified as five kinds based on location, etiology,
progrecity, hard tissue that been affected and time.

V.1 Location
V.1.1Smooth Surfaces
There are three types of smooth surface caries. Proximal caries,
also called interproximal caries, formed on the smooth surfaces between
adjacent teeth. Root caries is formed on the root surfaces of teeth. The

4
 third type of smooth surface caries occurs on any other smooth tooth
surface, this type is easily to be detected and is associated with high
levels of plaque. Proximal caries is the most difficult type to be detected
and cannot be detected visually or manually with a dental explorer.
Based on Black's classification system, caries on buccal or lingual of
molars, and also pits and fissures on the occlusal surfaces are classified as class
I. Proximal caries on posterior teeth (premolars and molars) is designated as
class II. Proximal caries on anterior teeth (incisors and canines) are indicated as
class III if the incisal edge (chewing surface) is not included and class IV if the
incisal edge is included. Class V includes caries near gingiva on 1/3 cervical of the
facial and lingual surfaces of a tooth. Cusp tips on posterior teeth and incisal
edges of anterior teeth are classified as class VI.
Root caries is usually occurred when the root surfaces have been exposed
due to gingiva recession. When the gingival is healthy, root caries is unlikely to
develop because the root surfaces are not as accessible to bacterial plaque. The
root surface is more vulnerable to the demineralization process than enamel
because cementum begins to demineralize at 6.7 pH, which is higher than
enamel's critical pH. Root caries are most likely to be found on facial surfaces
and on molar teeth. It is easier to arrest the progression of root caries than
enamel caries because roots have a greater reuptake of fluoride than enamel.

V.1.2 Pit and Fissure

Pits and fissure caries are anatomic landmarks on a tooth where the
enamel folds inward. Fissures are formed during the development of
grooves but the enamel in the area is not fully fused. As a result, a deep
linear depression forms a location for dental caries to develop flourish.
Fissures are mostly located on the occlusal (chewing) surfaces of posterior
(rear) teeth. Pits are small, pinpoint depressions that are most commonly
found at the ends of cross-sections of grooves. In particular, buccal pits
are found on the facial surfaces of molars. For all types of pits and
fissures, the deep unfolding of enamel makes oral hygiene along these
surfaces difficult, allowing dental caries to develop more commonly in
these areas.

5
V.2 Etiology
V.2.1 Baby-bottle Caries
"Baby bottle caries", "early childhood caries", or "baby bottle tooth decay"
is a pattern of decay found in young children with their deciduous (baby)
teeth. ECC is a specific form of severe decay found in the teeth of infants
and toddlers who fall asleep with bottles of milk, juice or any sweetened
liquid in their mouths. ECC is also known as baby-bottle tooth decay,
nursing-bottle caries and milk-bottle syndrome. It is the only severe
dental disease common in children under 3 years of age. The teeth most
likely affected are the maxillary anterior teeth, but all teeth can be
affected.

V.2.2 Rampant Caries

“Rampant caries", is signified advanced or severe decay on multiple
surfaces of many teeth. Rampant caries can be seen in individuals with
xerostomia (dry mouth due to the lack of saliva), poor oral hygiene,
stimulant use (due to drug-induced dry mouth), and or large sugar intake.
If rampant caries is a result of previous radiation to the head and neck, it
may be described as radiation-induced caries. Problems can also be
caused by the self destruction of roots and whole tooth resorption when
new teeth erupt or later from unknown causes. Rampant caries is
suddenly appearing, widespread, and rapidly progressing type of caries.

V.3 Progrecity
V.3.1Accute
This stage shows a progress of caries which quickly developed and usually
getting worse quickly. The example for this kind of caries is rampant
caries.

V.3.2Chronic
This condition shown a caries stage which has taken an extended time to
develop where thousands of meals and snacks, many causing some acid
demineralization that is not remineralised and eventually results in
cavities.

6
V.3.3Arrested
Arrested caries in dentine is clinically defined by hardness of the
dentine surface and a yellow to dark brown color. Arrested carious lesions
are found most commonly on lingual and labial aspects of teeth and less
commonly inter-proximally. In caries which has become arrested, the
dentinal tubules in the area between the soft and hard dentine have been
shown to be obstructed by large crystals. This process appears to occur in
a number of stages.
First Stage: The acids produced by advancing bacteria dissolve the
mineral in the surrounding inter-tubular dentine. The tubule fluid becomes
saturated with calcium magnesium
and phosphate ions. The lesion progresses unless the level of metabolic
activity of the bacterial is reduced. If less acid is produced then the
second stage can occur.
Second Stage: The saturated solution precipitates, producing large
crystals of tri-calcium-phosphate. These crystals are comparatively
soluble but nevertheless block the tubule.
Third stage: The odontoblast process, protected by the large crystals
blocking the tubule, secretes collagen into the dentin tubule. Small plate-
like crystals of hydroxyapatite accumulate, which are less soluble than tri-
calcium phosphate and therefore block the tubule more effectively. At the
same time crystal growth occurs in the inter-tubular dentine.

V.4 Hard-Tissue Affected

V.4.1Enamel Caries
Enamel is almost entirely mineral by weight (96%) but only 87%
mineral by volume. Thus 13 % of the space in enamel is water and soluble
and insoluble proteins (Le Geros, 1991). The organic and water
component of enamel allow diffusion of ions from plaque and saliva into
and out of enamel. The early enamel lesion consists of four zones of
alternating levels of mineralization. It illustrates the dynamic nature of
the caries process. The surface zone blocks the passage of calcium ions
into the body of the lesion and may have to be removed to allow the
lesion to become arrested (After Kidd & Joyston-Bechal, 1987).

7
 The outer surface zone is well mineralized by replacement ions from
plaque and saliva. But the body of the lesion is poorly mineralized. Deeper
to the body of the lesion, a darker zone represents some
demineralization, while the deepest zone, is yet again demineralised (Kidd
and Joyston-Bechal, 1987).
This of course is more destructive than deproteinising the surface,
but there is evidence that tooth wear may be a significant process in
arresting enamel lesions.

V.4.2Dentin Caries
Caries of enamel is clearly a dynamic process. The pulp and its
dentine is a fully vital tissue capable of defending itself. The essential
relationship between pulp and dentine promotes the term pulp-dentine as
a structural and functional biological unit.
The caries process in dentine involves the demineralization of the
mineral component and the organic component of collagen fibers. The
outer layer is heavily infected by bacteria which are mainly located in the
tubule spaces. The collagen fibers are denatured and the organic matrix is
not being remineralized. The inner layer is scarcely infected, but affected
by plaque acid. It still contains high concentrations of mineral salts and
can be remineralized.
Dentine caries comprises two main layers. In the outer layer, the
dentine is heavily infected with bacteria. Both organic matrix and mineral
have been lost and the dentine is beyond repair. In the deeper layer, the
dentine has been affected by plaque acids and demineralized. The
damage in this layer is reversible if bacterial metabolism can be halted.

V.4.3Cementum Caries
"Cementum caries" may be used to describe the decay on roots of teeth,
very rarely does caries affect the cementum alone. Roots have a very thin
layer of cementum over a large layer of dentin, and thus most caries
affecting cementum also affects dentin.

V.5 Time

8
 Based on time, we can divine caries into two types, primary caries and
secondary caries. Primary caries is caries that happen in location that has
no history of caries before. Secondary caries is caries that happen in
location with caries-history before. It happens on location near the filling.

VI. Prevention of Caries

VI.1 Oral Hygiene
Personal hygiene care consists of proper brushing and flossing daily.
Brushing and flossing are needed to remove and prevent the formation of
plaque, which consists mostly of bacteria. As the amount of bacterial
plaque increases, the tooth is more vulnerable to dental caries when
carbohydrates in the food are left on teeth after every meal or snack. A
toothbrush can be used to remove plaque on accessible surfaces, but not
between teeth or inside pits and fissures on chewing surfaces. When used
correctly, dental floss removes plaque from areas which could otherwise
develop proximal caries. Other adjunct hygiene aids include interdental
brushes, water picks, and mouthwashes. However, oral hygiene is
probably more effective at preventing gum disease than tooth decay,
because the brush and fluoride toothpaste have no access inside pits and
fissures, where chewing forces food to be trapped. Professional hygiene
care consists of regular dental examinations and cleanings. Sometimes,
complete plaque removal is difficult, and a dentist or dental hygienist may
be needed.

VI.2 Low Carbohydrate Diet

For dental health, frequency of sugar intake is more important than the
amount of sugar consumed. In the presence of sugar and other
carbohydrates, bacteria in the mouth produce acids which can
demineralize enamel, dentin, and cementum. The more frequently teeth
are exposed to this environment, the more likely dental caries are to
occur. Therefore, minimizing snacking is recommended, since snacking
creates a continual supply of nutrition for acid-creating bacteria in the
mouth. Also, chewy and sticky foods (such as dried fruit or candy) tend to
adhere to teeth longer, and consequently are best eaten as part of a
meal. We recommeded for brushing the teeth after meals. For children,

9
 the American Dental Association and the European Academy of Pediatric
Dentistry recommend limiting the frequency of consumption of drinks with
sugar, and not giving baby bottles to infants during sleep. Mothers are
also recommended to avoid sharing utensils and cups with their infants to
prevent transferring bacteria from the mother's mouth. Milk and cheese
also have potentially harmful to teeth. Chewing gum is containing xylitol
(a sugar alcohol) is widely used to protect teeth in some countries.
Xylitol's effect on reducing plaque is probably due to bacteria's inability to
utilize it like other sugars. Chewing 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 pH in the
mouth to the point where enamel may become demineralized.

VI.3 Using Flouride

Fluoride ions increase the resistance of the hydroxyapatite in enamel
and dentine to dissolution by plaque acids. The source of fluoride ions, to
carry out this protective role, has mostly been via toothpastes.
Fluoride has the benefit and the weakness when we use it. The benefit
of using fluoride are increasing the resistance of hidroxyapatite in enamel
and dentin, releasing the restorative material such as glass ionomers
,reachable, it means that fluoride is able to be found effortlessly such a in
toothpaste form, in water -fluoridation, and supplement tablet formed,
preventing and controlling the dental caries, reducing demineralization in
enamel and dentin, helping enamel and dentin to remineralize .In other
hands, there are the weakness of using fluoride. If we consume too much
or swallow it, it can cause cancer in our body, changing the structure and
strength of our bones, neuro toxic and lower IQ, birth defects and
perinatal deaths, proven ineffective. Actually we can find fluoride as a
ingredient in toothpaste mostly or we can find in water fluoridation and
supplement tablet.

6.4 Dental Sealant

The term "dental sealant" or "tooth sealant" refers to a plastic resin
that a dentist bonds into the grooves of the chewing surface of a tooth as a
means of helping to prevent the formation of tooth decay. Tooth decay is caused
by the bacteria found in dental plaque (the white film that forms on a person's

10
 teeth). Most tooth decay in children and teens occurs on these surfaces.
Sealants protect the chewing surfaces from tooth decay by keeping germs and
food particles out of these grooves. Dental sealants are an important tool in
preventing dental caries by providing a protective barrier on the teeth,
particularly when used during a child's formative years.

VII. Curative

VII.1 Filling
The fillings and inlays will be needed to repair the small and larger
cavities. Once the tooth-decay is removed, the missing tooth structure
requires a dental restoration. Composite or white fillings are used when
esthetics is a concern. We advise silver amalgam and gold restorations for
posterior teeth where chewing forces are huge.
The materials which are usually used to fill the decay, there are:
1. Amalgam inlay
2. Gold inlay
3. Ceramic
4. Metal filling

VII.2 Root-canal treatment

Root Canal Therapy, also called "Endodontic Therapy", is
recommended. To understand endodontic treatment, it helps to know
something about the anatomy of the tooth. Endodontic treatment is
necessary when the pulp, the soft tissue inside the root canal, becomes
inflamed or infected. The inflammation or infection can have a variety of
causes: deep decay, repeated dental procedures on the tooth, or a crack
or chip in the tooth. Some signs to look for the treatment; include pain,
prolonged sensitivity to heat or cold, tenderness to touch and chewing.
The steps of the treatment will be removing inflamed or infected pulp,
cleans and shapes the inside canal, a channel inside the root, then fills
and seals the space. Afterwards, you will return to your dentist, who will
place a crown or other restoration on the tooth to protect and restore it to
full function. After restoration, the tooth continues to function like any
other tooth.

11
7.3 Extraction
A dental extraction or tooth removal is the removal of a tooth from the
mouth. An extraction or tooth removal can also serve as treatment for
dental caries. If a tooth has been broken or damaged by decay, dentist
will try to fix it with a filling, crown or other treatment. Sometimes, there's
too much damage for the tooth to be repaired. This is the most common
reason for extracting a tooth. The removal of the decayed tooth is
performed if the tooth is too far destroyed. Extractions including Wisdom
Tooth are sometimes considered if the tooth will probably cause further
dental problems. Tooth removal may also be preferred by patients unable
or unwilling to go through the expense or difficulties in dental restoration.
Tooth-removal maybe causes an infection. Infection can set in after an
extraction, although you probably won't get an infection if you have a
healthy immune system.

12