Clinical Features of Dental

Caries
 Unique Aspects of Dental Caries
• Teeth are tools that have evolved to ensure survival of species
• Teeth function for chewing – fashioned by nature to
withstand trituration forces: covered by hard enamel and
protected by suspensory mechanism of PL
• Drawback: enamel is avital and acellular - incapable of any
natural defense mechanism, cannot heal itself thru cellular
repair
• But metabolically inert –undergo physico-chemical exchange
reactions such as remineralization
It is a paradox that enamel, a tissue so benign in its
ability to mobilize biological defense mechanisms
against noxious agents, should be positioned in the
relatively hostile environment of the oral cavity
 Unique Aspects of Dental Caries
•dental caries is ubiquitous worldwide
•sugar-driven
•biofilm-dependent - “dental plaque” is in fact a
“dental biofilm”
•multifactor disease
•and in many aspects a dynamic process.
 Unique Aspects of Dental Caries
•most carious dental lesions are restricted to specific
anatomical sites
•as caries disproportionally affect certain groups of
individuals, the same is true for certain groups of teeth
•caries affect molars more than incisors
•mandibular molars were much more susceptible to
carious attack than mandibular canines and incisors
•The morphology of a tooth and its eruption
time may carry a certain importance
for the development of dental caries
•Due to favorable conditions for plaque
accumulation (biofilm formation),
erupting teeth are more likely to
develop dental caries
 Dental Morphology
•human dental anatomy presents many instances of
biologic variation
•Klein and Palmer (1938 & 1941) were the first
investigators to clearly describe relationships
between dental caries and the various
morphological tooth types
 Dental Morphology
•individual tooth surfaces have vastly different
susceptibilities to caries
•more prevalent in occlusal surfaces as compared to free
and smooth surfaces
•pit and fissure (occlusal) surfaces the most susceptible
•most frequent on occlusal of first and second
permanent molars
•smooth (labial and lingual) surfaces the least susceptible
Hannigan A, O'Mullane DM, Barry D, Schäfer F, Roberts AJ. A caries susceptibility
classification of tooth surfaces by survival time. Caries Res. 2000
 Dental Morphology
Pit & fissure
•shape, morphological variation and depth contributes
to high susceptibility
•enamel in extreme depth – very thin or occasionally
absent exposing dentin
•early caries may appear brown or black and feel slightly
soft and “catch” a fine explorer point
 Dental Morphology
Pit & fissure
•in cross section gross
appearance is inverted V
with a narrow entrance
and a progressively wider
area if involvement closer
to the DEJ
Morphological types of pits &
fissures (Nango, 1960)
•V (34%) – wide at top
gradually narrowing towards
bottom self-cleansing and
somewhat caries resistant
•U type –(14%) almost the
same width from top to
bottom; caries susceptible
Morphological types of pits &
fissures (Nango, 1960)
•IK type (26%) – extremely
narrow slit with a larger space
at bottom; also very
susceptible to caries
•Inverted Y type (7%)
•I type (19%)- extremely
narrow slit
 Dental Morphology
Smooth surface
•less favorable site for plaque attachment
•plaque usually attaches near gingiva or under proximal
contact
• in young individuals interproximal space is filled with
gingival papilla
•crevicular spaces are less favorable habitats for s.
mutans
 Dental Morphology

Smooth surface
•lesions have a broader
area of origin and a
conical or pointed
extension towards DEJ
– V shape with apex
towards DEJ
Root surface caries Dental Morphology
•are more common in older
individuals
•Alarming because:
1.has a comparatively rapid
progression
2.often asymptomatic
3.is closer to the pulp
4.more difficult to restore
 Dental Morphology
Root surface
•proximal root surface near cervical line often
unaffected by action of hygiene procedures
•may have concave anatomic surface contours
(fluting)
•and occasional roughness at the termination of
enamel
•these coupled with exposure to oral environment
due to gingival recession favor formation of caries
 Dental Morphology
Root surface
•at CEJ, readily allows plaque formation in the
absence of good oral hygiene
•At CEJ cementum is extremely thin offering little
resistance to caries attack
•root caries have less well-defined margins
•tend to be U-shaped in cross section
•progresses more rapidly: lack of protection from
enamel
 Dental Morphology
Root surface
•at CEJ, readily allows plaque formation in the
absence of good oral hygiene
•At CEJ cementum is extremely thin offering little
resistance to caries attack
•root caries have less well-defined margins
•tend to be U-shaped in cross section
•progresses more rapidly: lack of protection from
enamel
 Histopathology of Caries
Enamel
•caries on enamel progresses through the ff stages:
A. early submicroscopic lesion
B. phase of non-bacterial enamel crystal
destruction
C. cavity formation
D. bacterial invasion of enamel
*C & D occur almost simultaneously
Early Lesion – Smooth surface

•EM shows loss of

interrod enamel,
accentuation of stria of
Retzius and perikymata
•As caries progresses,
lesion show distinctive
conical shape
Early Lesion – Smooth surface

•Under light microscope

conical lesion shows 4
different zones:
1. Translucent zone
2. Dark zone
3. Body of lesion
4. Surface zone
 1. Translucent zone Zones of Decay
•unrecognizable clinically
and radiographically
•occurs due to formation
of submicroscopic pores
at enamel rod boundaries
•slightly more porous than
sound enamel
•pore volume 1% vs 0.1%
of sound enamel
 2. Dark zone Zones of Decay
•superficial to
translucent zone
•called positive zone as it
is always present
•pore volume is 2-4%
•increased porosity is
due to greater degree of
demineralization
 3. Body of Lesion Zones of Decay
•forms bulk of lesion
•between relatively
unaffected surface zone
and dark zone
•area of greatest
demineralization
•pore volume of 5% near
periphery, 25% in the
center
 4. Surface zone Zones of Decay
•remains intact during
early stages of caries
attack
•become more heavily
mineralized
•pore volume of only 1%
•Eventually
demineralized when
caries penetrates dentin
 Histopathology of Caries
Dentin (Early changes)
•initial (non-infected) lesion in dentin forms beneath
enamel before any cavity has formed
•once bacteria penetrate enamel, they spread laterally
along DEJ and attack dentin over a wide area
•even though acids formed from fermentation of
carbohydrate substrate diffuse into dentin, they
leave the organic matrix intact
 Histopathology of Caries
Dentin (Early changes)
•the dentinal tubules serve as pathway for the
spread of bacteria in infected dentin
•bacteria now liberate proteolytic enzymes and
bring about destruction of organic matrix of
dentin which is already softened by
demineralization
 Histopathology of Caries
Dentin (Early changes)
1. Fatty degeneration of the Tome’s fiber – with
deposition of lipid globules within these fibers
2. Dentinal sclerosis – minimal in rapidly
advancing acute caries and maximum in slow,
chronic caries; considered a protective measure
 Histopathology of Caries
Dentin (Advanced changes)
• Continued decalcification of dentinal tubules
leading to confluence – structure of organic
matrix may still be maintained for some time
• Confluence of tubules occurs due to packing of
the tubules with the invading bacteria
 Histopathology of Caries
Dentin (Advanced changes)
•Coalescence and breakdown of adjacent dentinal
tubules leads to formation of “Miller’s
liquefaction foci”
•An ovoid area of destruction of tubules parallel to
the course of tubules and packed with necrotic
debris derived from destruction of tubules
 Histopathology of Caries
Dentin (Advanced changes)
•Continued dentinal destruction by decalcification
followed by proteolysis occurs at many focal areas which
ultimately coalesce to form a necrotic leathery mass of
dentin
•In this mass, clefts occur at right angles to tubules and
parallel to the course of lateral branches of tubules or
along the collagen fibers of organic matrix
•Due to these clefts, carious dentin can be peeled away
in thin layers by hand instruments
•Zone 1 – Zone of fatty Zones of Dentinal Caries
degeneration of Tomes’
fibers
•Zone 2 – Zone of dentinal
sclerosis
•Zone 3 – Zone of
decalcification
•Zone 4 – Zone of bacterial
invasion
•Zone 5 – Zone of
decomposed dentin
Cones of Decay – follows enamel rods and dentinal
tubules
 VII. Bite Wing Radiograph Classification
(Grondahl, modified from Moller & Poulsen)
 VII. Bite Wing Radiograph Classification
(Grondahl, modified from Moller & Poulsen)
 I. Based on Location
Pits and fissure Smooth surface Root surface caries
caries caries (senile caries)
 I. Based on Location
Pits and fissure Smooth surface Root surface caries
caries caries (senile caries)