Index

S.No. Topic

1. Development of Pulp

2. Definition

3. Functions

4. Layers of Pulp
5. References
 Etiology and Etiological theories of
Dental Caries

Definition of Dental Caries

Dental Caries is an infectious microbiological disease of the teeth
that results in localised dissolution and destruction of calcified tissues.

Etiological factors in Dental Caries

Dental Caries is a multifactorial disease, in which there is an
interplay of 3 principle factors :-
• Host factor
• Microflora
• Substrate
• In addition, a IV factor i.e. Time is also considered
• The 4 factor contributing to the caries process, individually &
collectively & explained below :-

A) Host Factor -
i) Tooth
a) Morphology & position in the arch.
b) Chemical Nature
ii) Saliva
a) Composition, pH & antibacterial activity
b) Quantity & viscosity of flow

B) Microflora -
i) According to Oral Habitats
 ii) Role of Dental Plaque
C) Substrate and Diet -
i) Physical Nature of the Diet
ii) Chemical Nature of the Diet
- Carbohydrate content of the diet
- Vitamin content of the diet
D) Time

A) Host Factor -
i) Tooth
a) Morphology & position in the arch
Tooth morphology is recognized as as important factor for
initiation of caries. Deep pits and fissures in any tooth make them
susceptible to caries because of food impaction and bacterial stagnation.
That is why the occlusal surface are more prone to caries. The most
susceptible teeth are the mandibular first molars amongst the permanent
teeth, closely followed by maxillary first molars, then mandibular and
maxillary second molars and so on.
Irregularities in the arch form, crowding and overlapping of the
teeth also favour the development of caries. Partially impacted third
molars are more prone to caries and so are the bucally or lingually placed
teeth.
b) Chemical Nature
Presence of inorganic constituents, such as dicalcium phosphate
dihydrate, and fluoroapatite etc. makes the enamel resistant to some
extent. It has been observed and proved scientifically, that surface
enamel is more caries resistant than the subsurface enamel. The surface
enamel has more minerals and more organic matter and relatively less
water. In addition certain elements such as, fluoride, chloride, zinc, lead
etc. accumulate more on the surface enamel than the subsurface enamel.
With the passage of time, teeth become more resistant to caries
because of decrease in permeability and increase in nitrogen and fluoride
content. The increase in nitrogen and fluoride content. The increase in
concentration of fluoride at the subsurface is because of ingestion of
fluoride with age.

ii) Saliva
a) Composition, pH and antibacterial activity
The composition of saliva varies considerably. The concentration
of inorganic calcium and phosphorous shows considerable variation
within resting and stimulated saliva. Caries prone individuals have low
calcium and phosphorous levels.
The caries immune persons exhibit a greater ammonia content in
saliva, probably because the higher ammonia content in saliva retards the
plaque formation and neutralizes acid formation to a certain extent.

The pH of saliva shows great variation. The pH at which any

particular saliva ceases to be saturated with calcium and phosphorous is
referred to as the 'critical pH'. Under normal conditions the critical pH is
5.5. Below this value, the inorganic material of the tooth may dissolve.
The normal pH of resting saliva is 6-7. A buffer is a solution that tends to
maintain a constant pH. A fall in buffer capacity of saliva leads to
increase in caries incidence.
The antibacterial properties of saliva have a definite relation with
caries incidence. Lysozyme - an antibacterial agent present in saliva -
can inhibit airborne and water-borne micro-organisms in the oral cavity to
some extent, but its role in caries inhibition is doubtful.
 It may be effective against the carioigenic micro-organisms
maintaining the ecological balance of oral flora. Salivary peroxide has
been involved in antibacterial system in saliva.

b) Quantity & Viscosity of flow -

The quantity and viscosity of saliva has definite influence on caries
incidence. Human beings suffering from decreased flow of saliva or lack
of salivary secretions (xerostomia) usually experience increased rate of
dental caries. This is evidenced in various diseases such as Sjogren's
syndrome, sarcoidosis, diabetes etc.
The caries susceptibility has been observed to increase in numerous
patients following radiation therapy of the mouth regardless of whether
the teeth are present inside or outside the field of radiation, because ofthe
decreased flow of saliva.
Certain drugs influence salivary flow, and in turn result in rampant
caries. Drugs, which may lead to xerostomia, either partial or total,
include antidepressants, anti-histamines etc. Prolonged use of these drugs
may cause dry mouth and extensive caries.
Physiological xerostomia occurs in all human beings during sleep.
Since there is less or no saliva to buffer and wash away fermentation
products of plaque during sleep.

B) Microflora
i) According to Oral Habbits -
As early as Koch's postulates, it was observed that for caries to
occur, bacteria played a definite role. The following factors further prove
the role of bacteria in caries :
a) Caries will not occur in complete absence of micro-organisms
(germ-free animals do not develop caries).
b) Caries can occur in animals even if kept on single type of bacterial
growth.
c) All oral organisms are not cariogenic, but histologically majority
can be isolated from carious enamel and dentine.
 Habitat Predominent Species
• Mucosa S. Mitis
S. Sanguis, S. Salivarius
• Tongue S. Mutans
S. Sanguis
S. Salivarius
• Teeth (non carious) S. Sanguis
• Gingival Cervice Fusobacterium
Spirochaete
Actinomyces
Vellionella
• Enamel Caries S. Mutans
• Dental Caries S. Mutans
Lactobacillus
• Root Caries Actino Myces

ii) Role of Dental Plaque -

• Plaque is the soft, non-mineralized, bacterial deposit with forms on
teeth that are not adequately clearned - Loe
• G.V. Black - Regarded plaque as important in the caries process &
in 1899, described it thus, "the gelatinous plaque of the caries fungus is a
thin, transparent film that usually escapes observation and which is
revealed only by careful research.
• An important component of Dental Plaque is "Acquired Pellicle"
which forms just prior to or concomitantly with bacterial colonization and
may facilate plaque formation. However, the presence of plaque does not
necessarily mean that a carious lesion will develop at that point.
• The microbiology of dental plaque includes three germs of
microorganisms namely -
 1) Streptococci
2) Actinomyces
3) Veillonellae

• Of all these, S. Mutans is considered to be the chief etiologic agent

is dental caries. It is now generally and universally agreed that the
Aceumucation of dental plaque, even on a clean tooth surface can result
in dental caries in an individual susceptible to the disease and consuming
a diet conductive to the disease.

C) Diet
i) Physical Nature of the Diet
It has been suggested as an factor, responsible for the difference of
caries experience between primitive man & modern man.
The diet of primitive man consisted of a great deal of roughage,
which cleanses the teeth of adherent debris during mastication.
In the modern diet soft refined foods tend to cling because of the
general lack of roughage.
So, the mechanical cleansing by detergent food may have same
value in caries control.

ii) Chemical Nature of the Diet

a) Carbohydrate Content of Diet
It has been almost universally accepted as one of the most
important factor in the dental caries process & are of the few factors
which may be voluntarily altered as a preventive dentistry pressure.
b) Vitamin content of the Diet
The vitamin ingredient of diet has also been considered to have
significant effect on dental caries incidence. Vitamins A, C and K rarely
have any effect on caries production. Vitamin B deficiency may exert a
caries protective influence on teeth since several B vitamins are essential
in growth of oral acidogenic flora.
Vitamin D is necessary for the normal development of teeth.
Malformation especially hypoplasia and an increase caries incidence has
been reported in vitamin D deficiency cases.

D) Time
• Prior to the ingestion of carbohydration the pH in the oral cavity is
slightly acidic or alkaline.
After ingestion of carbohydrates the plaque pH rapidly drops by 2
or these.
The length of time that is acidic environment (low pH) is sustained
to damage the enamel is extremely important 2 occurance of dental
caries.
Hence there is higher chances of occurance of dental caries. In
those persons who repeated ingest carbs at short intervals.
 Etiological Theories of Dental Caries

A) Exogenous Theories
i) Acidogenic Theory / Miller's Chemico Parasitic Theory
This theory is known as "Miller's chemicoparasitic theory" as it
was first postulated by W D Miller in the year 1889 and it proposes that
acids formed due to the fermentation of dietary carbohydrates by oral
bacteria leads to progressive decalcification of the tooth structures with
subsequent disintegration of the organic matrix.
Therefore acidogenic theory states that the process of dental caries
involves two stages :
• Initial Stage - Production of organic acids occur as a result of
fermentation of carbohydrates by the plaque bacteria.
• Later Stage - The acids cause decalcification of enamel followed
by dentin and thereby cause total destruction of these two along with
dissolution of their softened residues.
The final results is the loss of integrity ofthe tooth structures at a
particular point on the surface with formation of a cavity.
According to Miller, there are four important factors which can
influence the process of tooth destruction in the process of dental caries
and these factors are as follows :
i) Dietary carbohydrates
ii) Microorganisms
iii) Acids; and
iv) Dental plaque
Limitation of the Acidogenic Theory
Although the acidogenic theory of dental caries has got an wide
acceptance, it has the folowing limitations -
• It cannot explain subsurface demineralization
• It fails to justify the rampant caries
• It cannot explain the caries in impacted tooth

ii) Proteolytic Theory -

• The proteolytic theory of dental caries was first proposed by
Gottelib in 1944 and this theory states that the proteolytic enzymes
liberated by cariogenic bacteria cause destruction of the organic matrix of
enamel. As a result of which the inorganic crystals ofthe enamel become
detached from one another and finally the whole structure collapse,
leading to a cavity formation.
• The concept of the proteolytic theory was further extended by
Pincus in 1949 and he proposed that the 'sulfatase enzyme' liberated by
gram-negative bacilli, hydrolyze the sulfated mucosubstances of enamel
matrix and therefore liberate sulfuric acid, glutamic acid and aspartic
acid, etc. which dissolve the mineral portion of the enamel as well.
• The scope of the proteolytic mechanism in initiating the enamel
caries is very limited because the organic (protein) content of enamel
matrix as such, is very scanty. However, this mechanism can be a more
appropriate one in cases of dentinal and cemental caries.

Limitation of Proteolytic Theory

• The carious lesion cannot be reproduced in vitro by the proteolytic
mechanism.
• Proteolytic bacteria are very uncommon in the oral cavity.
• This theory cannot explain the role of sucrose, pH and fluoride,
etc. in dental caries.

Proteolytic Chelation Theory

The proteolytic chelation theory explains the process of dental
caries in the following way, "during caries, first of all proteolytic
breakdown of the organic portion of the enamel matrix takes places.
Following this a chelating agent is formed by the combination of the
proteolytic breakdown products, acquired pellicle and food debris, etc.
and the whole process is helped by the bacterial enzymes.
The chelating agent, which is formed, is always negatively charged
(mostly due to its protein content) and it releases the positively charged
calcium ions (Ca++) from the enamel or dentin-this process is called
"chelation", and it eventually results in tooth decay. So, the chelation can
be defined as a process that involves the complexing of a metallic ion to a
complex substance by a coordinate covalent bond, which results in a
highly stable, poorly dissociated and weakly ionized compound called
"chelate".
The proteolytic chelation theory explains that the destruction of the
organic matrix ofthe enamel as well as its mineral parts both ocur
simultaneously and interdependently.

Sucrose Chelation Theory

Sucrose chelation theory proposes that if there is a very high
concentration of sucrose in the mouth of a caries active individual, there
can be formation of complex substances like calcium saccharates and
calcium complexing intermediaries, etc., by the action of phosphorylating
enzymes. These complexes cause release of the calcium and phosphorus
ions from the enamel and thereby resulting in tooth decay.
 This theory is unlikely to be a significant because once the sucrose
is in the oral cavity, it readily gets metabolized to form acids, and there is
hardly any scope for formation of calcium saccharates, etc. moreover, for
the formation of calcium saccharate, a very high level of pH is required,
the range which is never achieved in the oral cavity.

Autoimmune Theory
The autoimmune theory of dental caries suggests that few
odontoblast cells at some specific sites, within the pulp of few specific
teeth are damaged by the autoimmune mechanisms. For this reason, the
defense capacity and integrity of the overlying enamel or dentin in those
specific areas are compromised, and they can be the potential sites for
caries development in future.
 References

1. Sturdenant's
2. Vimal K. Sikri
3. Soben Peter