🦷 MADT ⧫ MJLS - Cariology - Midterms
The Epidemiology of Dental Caries
Epidemiology
- Is the study of health and disease in populations, and how these
states are influenced by heredity, biology, physical environment,
social environment and human behavior.
- Role is to identify the risk factors for disease.
Risk factor
- An environmental, behavioral, or biologic factor confirmed by
temporal sequence, usually in longitudinal studies, which if
present directly increases the probability of a disease occurring,
and if absent or removed reduces the prob- ability. Risk factors
are part of the causal chain, or expose the host to the causal
chain. Once disease occurs removal of the risk factor may not
result in a cure
Measuring dental caries
- "Properties of an ideal index"
a. Validity
- The index must measure what it is intended
to measure, so it should correspond with
clinical stages of the disease under study at
each point.
b. Reliability
- The index should be able to measure
consistently at different times and under a
variety of conditions. The term reliability is
virtually synonymous with reproducibility,
repeatability and consistency, meaning the
ability of the same or different examiners to
interpret and use the index in the same way.
c. Clarity, simplicity and objectivity
- The criteria should be clear and
unambiguous with mutually exclusive
categories. Ideally, it should be readily
memorized by an examiner after some
practice.
d. Quantifiability
- The index must be amenable to statistical
analysis, so that the status of a group can be
expressed by a distribution, mean, median or
other statistical measures.
e. Sensitivity
- The index should be able to detect
reasonably small shifts, in either direction, in
the condition.
f. Acceptability
- The use of the index should not be painful or
demeaning to the subject.
The DMF index
D - was for decayed teeth
M - for teeth missing due to caries
F - for teeth that had been previously filled
➔ Criteria used to diagnose caries in a survey usually are not the
Diagnosis Through the Full Range of Caries
- the D1-D3 scale
0
- Surface sound
- No evidence of treated or untreated clinical caries
- (slight staining allowed in an otherwise sound fissure)
D1
- Initial caries
- No clinically detectable loss of substance. For pits and fissures,
there may be significant staining, discoloration or rough spots in the
enamel that do not catch the explorer, but loss of substance cannot
be positively diagnosed. For smooth surfaces, these may be white,
opaque areas with loss of luster.
D2
- Enamel caries
- Demonstrable loss of tooth substance in pits or fissures, or on
smooth surfaces but no softened floor or wall or undermined
enamel. The texture of the material within the cavity may be chalky
or crumbly, but there is no evidence that cavitation has penetrated
the dentin.
D3
- Caries of dentin
- Detectably softened floor, undermined enamel or a softened wall,
or the tooth has a temporary filling. On approximal surfaces, the
explorer point must enter a lesion with certainty.
D4
- Pulpal involvement
- Deep cavity with probable pulpal involvement. Pulp should not be
probed.
- (Usually included with D3 in data analysis)
Diagnosis at the dentinal lesion stage only ; the dichotomous
scale
● Pits and fissures on the occlusal, vestibular and lingual
surfaces are carious when the explorer "catches" after
insertion with moderate to firm pressure and when the
"catch" is accompanied by one or more of the following
signs of decay
1. softness at the base of the area
2. Opacity adjacent to the area provides
evidence of undermining
3. Demineralization
4. Softened enamel adjacent to the area that
maybe scrape away away by the explorer
● These areas should be diagnosed as sound when there
is apparent evidence of demineralization, but no
evidence of softness.
Reasons why the DMF index is of limited value in measuring
the treatment needs of a population
same as those used by practitioners in forming a patient's
treatment plan. For example, a practitioner has to judge whether a
minor lesion will develop into a major lesion over time, and
whether a lesion in a primary tooth can safely remain untreated
🦷 MADT ⧫ MJLS - Cariology - Midterms
for the life of the tooth. A Survey scores a tooth by how it appears
at the present time
➔ Patients' own perceived needs, level of interest in their dental
conditions and ability or willingness to pay, all influence the level
of treatment carried out. These factors are not part of survey data.
➔ Treatment philosophies change with expanding knowledge and
technological developments; a treatment that is standard today
may not be so tomorrow.
1) Age and gender
- Caries used to be considered just a childhood disease,
a perception from those days of high caries severity
when most susceptible surfaces were usually affected
by adolescence. With younger people now reaching
adulthood with many surfaces free of caries, the carious
attack is spread out more throughout life. Adults of all
ages can, and do, develop new coronal and caries has
to be viewed as a lifetime disease.
2) Root caries
- One important offshoot of the age-caries relationship is
root caries, defined as caries that begin on cemental
root surfaces exposed to the oral environment and
hence when bacterial plaque can accumulate around
these exposed roots.
3) Race and ethnicity
- Most surveys before the 1970s found that whites had
higher DMF scores than AfricanAmericans, although
the latter usually had more decayed teeth. One of the
early national surveys 1960-1962 showed that whites
had higher DMF scores than did African-American
adults of the same age group, a difference that
remained even when the groups were standardized for
income and education.
4) Familial and genetic patterns
- With the explosion of research discoveries of genetic
influences in many diseases, dental caries are being
looked at in a different light. It is plausible that host
attributes that could affect an individual's caries
experience, such as salivary flow and composition,
tooth morphology and arch width, are genetically
determined, and the genetics of the cariogenic bacteria
themselves may have an effect.
5) Diet and dental caries
- Dietary quality is a major determinant of caries levels in
a community, and is a major factor in the social
environment. The relation between the intake of refined
carbohydrates, especially sugars, and the prevalence
and severity of caries is so strong that sugars are
clearly a major etiological factor in the causation of
caries.
6) Caries and soft drinks
- Sugar in liquid form is cariogenic; it served well to
demonstrate demineralization in landmark experimental
caries studies. Soft drinks have also been implicated as
part of the cause of the global epidemic of obesity in
children (Mann, 2003), for it is now common to find soft
drinks and juices replacing formula and milk in children
up to 2 years of age.
Summary
- The epidemiology of caries has traditionally been expressed in
terms of bad diet, poor oral hygiene, cariogenic bacteria in
plaque, 'acid attacks' and demineralization, salivary flow and
exposure to fluoride.
Etiological Theories
● ACIDOGENIC THEORY
- According to this theory dental decay is a
chemo parasitic process
- It is a two stage process where there is
decalcification of the enamel which also
results in the destruction of the dentin. In the
second stage there is dissolution of the
softened residue of the enamel and dentin
- In the first stage destruction is done by the
acid attack where the dissolution of the
residue is carried by the proteolytic action of
the bacteria.
- This whole process is supported by the
presence of carbohydrates, microorganisms
and dental plaque.
● PROTEOLYTIC THEORY
- The evidence given by the acidogenic theory
was considerable but it was not conclusive,
and an alternative explanation was given in
the form of proteolytic theory. There has been
evidence that the organic portion of the tooth
plays an important role in the development of
dental caries. There are some enamel
structures which are made of the organic
material such as enamel lamellae and
enamel rods. These structures prove to be
the pathways for the advancing
microorganisms.
- It has been established that enamel contains
0.56 % of organic matter of which 0.18% is
keratin and 0.17 % is a soluble protein
- Microorganisms produce proteolytic enzymes
which destroy the organic matrix of enamel
loosening the apatite crystals...so they are
eventually lost and tissue collapses.
- However, even though proteolysis may not
play any role in initiation of caries, their role in
progression of more advanced carious
lesions cannot be ruled out.
● PROTEOLYSIS- CHELATION THEORY
- Some of the minor flaws of the acidogenic
and the proteolytic theory were addressed in
the proteolysis
- CHELATION - It is a process in which there is
complexion of the metal ions to form complex
substance through coordinate covalent bond
which results in:
1. Poorly dissociated or weakly
ionized compound.
2. Chelation is independent of the PH
of the medium.
3. The bacterial attack on the surface
of the enamel results in the
breakdown of the protein chiefly
keratin and results in the formation
of soluble chelates with calcium
🦷 MADT ⧫ MJLS - Cariology - Midterms
which decalcify enamel even at
neutral PH.
4. Mucopolysaccharides may also act
as secondary chelators.
5. However, although chelation may
not be actually responsible for
initiating caries, it may still have
some role to play in advanced
carious lesions where the pH levels
return to neutral.
Diagnostic Criteria for Dental Caries
- 3 key terms relevant to diagnostic criteria and their use
1. Lesion detection - which implies an objective method of
determining whether or not disease is present
2. Lesion assessment - which aims to characterize or
monitor a lesion, once it has been detected
3. Caries diagnosis - which should imply a human
professional summation of all available data
Caries Diagnostic Thresholds and Specific Epidemiological
Considerations
- Epidemiology studies the distribution and determinants of
health-related states or events in specific populations and applies
this study to control health problems
Importance of correct terminology when recording no visual dentin
caries
- It must be remembered that in epidemiological surveys, the
combination of the limitations imposed by the diagnostic criteria
chosen, the challenging environment of field conditions and the
lack of diagnostic aids available to the clinician will inevitably
mean that epidemiological results systematically underscore
caries prevalence, extent and severity
- It is unfortunate and misleading, for politicians and decision
makers, to continue to use the term “caries free”.
The Oral Microflora and Biofilms on Teeth
- Dental caries is the result of the metabolic activities of bacteria in
microbial communities on teeth termed dental biofilms.
What is Microflora?
- Are community of bacteria that exist on or inside the
body, and possess a unique ecological relationship with
the host. This relationship encompasses a wide variety
of microorganisms and the interactions between
microbes.
The resident microflora
- Acquisition of this resident microflora occurs from birth and is a
natural process, during which all environmentally exposed
surfaces of the body become colonized.
Acquisition of the resident oral microflora
- The mouth of the newborn baby is usually sterile. Acquisition
depends on the successive transmission of microbes to the site of
potential colonization.
Saliva
- The main route of transmission
- Molecular typing studies have shown that the
acquisition of oral streptococci and Gram-negative
species in children is predominantly from their mother
(vertical transmission).
Benefits of the resident microflora
- Contributes directly and indirectly to the normal
development of the host, and functions as part of the
innate host defenses by acting as a barrier to
permanent colonization by transient organisms, some
of which are potentially pathogenic.
Site distribution of oral bacteria
- Mouth is highly selective for the microorganisms that
are able to colonize and become established, more
than 700 different types have now been detected in the
mouth.
Ecological factors affecting the growth and metabolism of
oral Bacteria
- Saliva plays other roles in regulating the growth and
metabolic activity of the oral microflora. Saliva helps to
maintain the pH in the oral cavity at values around
6.75-7.25 and the temperature around 35-36 Degree
Celsius, which is optimal for the growth of many
organisms.
- Saliva is a sufficient source of nutrients to sustain the
growth of a natural and diverse oral microflora in the
absence of other nutrients.
- Saliva delivers a spectrum of innate and specific
immune host defense of factors which are essential to
the maintenance of healthy mouth
Development of dental biofilms
- Several arbitrary stages, as revealed by experimental
studies in situ (Nyvad, 1993)
1. Pellicle formation
2. Attachment of single bacterial cells (0-24 h)
3. Growth of attached bacteria leading to the
formation of distinct microcolonies (4-24h)
4. Microbial succession (and coadhesion)
leading to increased species diversity
concomitant with continued growth of
microcolonies (1-7 days)
5. Climax community/mature biofilm (1 week or
older)
- The pellicle plays an important modifying role in caries
and erosion because of its permeable selective nature
restricting transport of ions in and out of the dental hard
tissues.
- For many years it was believed that mutans
streptococci constructed a significant part of the initial
microflora because of their ability to elaborate sticky
extracellular polysaccharides from sucrose in vitro
Structure of dental biofilms
- Biofilms’ is used to describe communities of
microorganisms attached to a surface
- Organisms are spatially organized into a three
dimensional structure enclosed in a matrix of
extracellular material derived from both the cells and
the environment.
🦷 MADT ⧫ MJLS - Cariology - Midterms

Pattern of initial colonization

- For hours after a tooth surface has been exposed to the oral
environment following professional tooth cleaning surprisingly few
bacteria are found. The enamel is covered by a granular deposit
reflecting the pellicle, which is unevenly distributed over the
surface (Figs 10.9, 10.10). The pellicle is primarily located
corresponding to depressions in the enamel (pits and perikymatal
grooves), but it does not completely mask the anatomical
characteristics of the enamel surface.

Properties of enamel biofilms

- Novel imaging and molecular techniques have confirmed that
dental biofilms display properties that are consistent with those of
biofilms present in other natural habitats

Caries microbiology
- Miller introduced the ‘chemico-parasitic’ theory of caries by
suggesting that in order for caries to develop, two factors always
have to be in operation; the action of acids and the action of
germs’
- Historically, for a microorganism to be considered responsible as
an etiological agent for a disease, it would need to satisfy Koch’s
postulates. Thus:
1. The microorganism should be found in all cases of the
disease, which distribution corresponding to the
observed lesions
2. The microorganism should be grown on artificial media
for several subcultures
3. A pure subculture should produce the disease in a
susceptible animal

Enamel caries
- Fissures are the most caries prone sites of the dentition and the
strongest correlations between the plaque levels of mutans
streptococci and caries have been found at these sites