COURSE : BACHELOR OF DENTAL SURGERY

NAME: SHAMITA SIVARAJOO

ID NUMBER : D21100770

ROLL NUMBER : 61

BATCH : 17

SUBJECT : ORAL PATHOLOGY

TITLE : ETIOPATHOGENESIS AND HISTOPATHOLOGY OF DENTAL CARIES

DATE OF SUBMISSION : 15TH FEBRUARY 2024

TOTAL WORD COUNT : 2120 WORDS ( EXCLUDING REFERENCES)

TABLE OF CONTENT

Content Pages

Introduction 3

Ethiopathogenesis of dental caries 4-10

Histopathology of dental caries 11-17

Conclusion 17

References 18

Plagiarism checker 19
Introduction

Dental caries is an 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 ( Shafer). Miller's chemico-parasitic
theory suggests caries is caused by oral cavity microorganisms producing acids. Dental decay is
a chemico-parasitic process involving two stages: decalcification of enamel and dentin and
dissolution of softened residue. Primary decalcification occurs from starch and sugar
fermentation in teeth's retention centers.

Figure 1 : Multifactorial disease involves 4 major factors

Dental caries is a complex disease that is affected by host factors, plaque, substrate, and time. It
has varying effects on teeth depending on the surface and the subject. Dental susceptibility is
influenced by morphology, tooth location, and composition of the teeth.
Ethiopathogenesis Of Dental Caries

Morphological characteristics of teeth

Deep, narrow occlusal fissures or buccal or lingual pits collect food, pathogens, and debris and
are the primary cause of dental caries. These fissures can form rapidly in these locations due
to attrition progresses, the inclined planes flatten, minimising food trapping in the fissures.
Certain tooth surfaces are more prone to decay, particularly mandibular first molars. The lingual
surface of maxillary lateral incisors is more vulnerable to caries than the labial surface due to a
frequent pit. The most vulnerable permanent teeth are the mandibular first molars, followed by
the maxillary first molars and the mandibular and maxillary second molars. The mandibular
incisors and canines have the lowest risk of developing lesions.

Figure 2 : Tooth depressions are always anatomical points for dental caries.
Position of the teeth

The location of teeth has a substantial impact on dental caries. Teeth that are misaligned, out of
place, rotated, or otherwise abnormally positioned can be difficult to clean and gather food and
debris, potentially leading to cavities in a tooth that would not form under typical alignment
settings.

Figure 3 : Crowded tooth with food debris not removed interdentally

Saliva composition

Saliva content varies across individuals and may not always match blood composition . Saliva
provides calcium and phosphate, which are required to maintain an inorganic phase of enamel.
The inorganic phase of enamel is composed of crystalline hydroxyapatite, which dissociates
when pH decreases, resulting in a free active concentration of ions. Saliva's solubility
equilibrium occurs when a chemical substance in its solid form is chemically balanced with a
solution of that component. Saliva contains calcium and phosphate, which create a natural
defence mechanism against tooth disintegration. The most recognised and significant is
Amylase, an oral enzyme that degrades starch.

Figure 4 : Components of the saliva

pH of the saliva

The critical pH is the value at which saliva is no longer saturated with calcium and phosphate,
allowing inorganic tooth material to dissolve. It fluctuates depending on the calcium and
phosphate concentrations, which are normally about 5.5. As the number of hydrogen ions in
plaque increases, more phosphate ions exit the solid apatite phase. The pH level during rest
periods can indicate a patient's caries status and the buffering capacity of saliva. Patients with a
resting salivary pH of around 7.0-7.8 had less caries activity than those with a pH of 5.5, who
have a higher caries incidence. The presence of dental caries affects carbohydrate elimination,
resulting in extended interaction with dental plaque and a steady reduction in salivary pH value.
This causes acid production, increased bacterial adhesion, and decreased salivary clearance
activity. Low pH increases the incidence of caries caused by oral bacteria.

Quantity of saliva

The normal and usual quantity of saliva secreted in the oral mucosa by humans are
approximately 700- 800 ml per day . In the cases such as salivary gland dysplasia and xerostomia
in which the salivary flow may be decreased in the volume, it leads to rampant dental caries .
Diabetes can cause reduced salivary flow, affecting oral health, particularly tooth integrity.
Dental caries, dry mouth, and gingival inflammation were shown to be more common in young
patients with type I diabetes than in healthy people. This is due to poor dental hygiene, reduced
salivary flow rate, and changed saliva composition.

Viscosity of the saliva

Salivary viscosity affects its cleansing action, leading to higher dental caries rates. Increased
salivary viscosity results in a reduction in water content and thickening of saliva, causing
decreased cleaning and clearance. This viscosity negatively impacts oral health by affecting
bacterial clearance from the oral cavity, causing the coaggregation of oral Streptococci with
Actinomyces. This reduced clearance increases the risk of infectious diseases, including dental
caries.

Antibacterial properties of saliva

Lactoperoxidase

Lactoperoxidase (LPO) in saliva is an important component of the nonspecific immune response

that contributes to maintaining dental health. This enzyme oxidises salivary thiocyanate ions
(SCN-) in the presence of hydrogen peroxide (H₂O₂) to produce antibacterial compounds.

Lysozyme

Small , highly positive enzyme that catalyzes the degradation of negatively charged
peptidoglycan matrix of microbial cell wall.

Lactoferin

Iron binding basic protein found in saliva with mol. wt. near 80,000. It tends to bind & link the
amount of the free iron which is essential for microbial growth

IgA

It’s a type of immunoglobulin in saliva. Inhibit adherence and prevent colonization of microbes
on tooth surface and mucosal surfaces.
Microflora

There are several types of bacteria in the oral cavity which is frequently associated with dental
caries such as Streptococcus mutans, Lactobacillus and Actinomycetes. These organisms exhibit
selectivity for the tooth surface they target. A wide variety of organisms can initiate pit and
fissure caries, with S. mutans being particularly significant. Root caries differ from other smooth
surface lesions as the initial lesion involves the cementum or dentin. Bacteriological sampling of
plaque covering root surfaces has predominantly yielded Actinomyces viscosus. Nocardia and S.
sanguis strains may also cause root caries. In deep dentinal caries, Lactobacillus is the
predominant organism.

Figure 5 : Localization of carious microflora significance to humans

Role of dental plaque

Plaque is a soft, nonmineralized bacterial coating that accumulates on teeth and dental prostheses
that are not cleaned frequently. It appears as a thin, tenacious layer and can form within 24-48
hours. Plaque is resistant to physiologic and oral cleaning processes, however it may be
eliminated using a toothbrush. Acquired pellicle, a glycoprotein generated from saliva, occurs
before or during bacterial colonisation and may aid in plaque development. Although not
dependent on bacteria, it may act as a nutrition for plaque germs. Enamel caries typically
originate beneath tooth plaque. Plaques may not always indicate the development of carious
lesions.

Diet

Role of carbohydrates

High-frequency exposure to fermentable carbohydrates, such as sucrose, may be the most critical
element in the formation of cariogenic biofilm and, eventually, caries lesions. Frequent
consumption of fermentable carbohydrates triggers a sequence of changes in the local dental
environment, promoting the growth of highly acidogenic bacteria and finally leading to caries.
Sticky, solid carbohydrates, soft-retentive foods, monosaccharides, and disaccharides are more
likely to cause caries. In contrast, when fermentable carbohydrates are substantially limited or
absent, biofilm formation usually does not result in caries.

Role of acids

The presence of acids in the oral cavity is less significant than acid localization on the tooth
surface, implying a mechanism for retaining acids at a specific location for extended periods of
time. The slower dispersion of larger starch molecules and the low concentration of maltose
produced from starch cause acid creation to be slower.
Histopathology Of Dental Caries

Figure 6 : Histopathology of dental caries

The principal approach for examining enamel caries is by grinding portions of teeth, which are
generally 60-100mm thick. Microradiography has a distinct benefit since the photo density of the
picture is proportional to the amount of mineral. This enables the quantitative determination of
demineralization degree. The histology of dental caries is classified as enamel, dentin, and root
caries.
 Figure 7: Types of cavity formation

Caries of the enamel

Smooth surface caries

Cariogenic biofilm often forms exclusively on smooth surfaces near the gingiva or under
proximal interactions. The proximal surfaces are especially vulnerable to caries because of the
increased protection afforded to resident cariogenic biofilm by the proximal contact region
(Figure 8). Lesions that form on smooth enamel surfaces have a large region of origin and a
conical, or pointed, extension towards the DE. The lesion's invasion path runs almost parallel to
the long axis of the region's enamel rods. A cross-section of the enamel portion of a smooth-
surface lesion reveals a V-shape, with a large region of origin and the tip pointing towards the
DEJ and is usually a white opaque lesion, sometimes brown spot lesion. After caries reaches the
DEJ, dentin softening spreads fast laterally and pulpally (Figure 9).
 Figure 8 : Longitudinal sections showing initiation and progression of caries on
interproximal surfaces.

Figure 9 : Extracted tooth showing extensive caries lesion just gingival to the proximal
contact area.
Pit and fissure enamel caries

Bacteria quickly colonise the pits and fissures of newly formed teeth, with the kind and nature of
the organisms in the oral cavity dictating the colonisation outcome. Lesion arising from fissure
walls, not base. Shaped as a conical lesion with the base towards the EDJ . Unlike smooth
surface , this caries progresses through the enamel rods. Lateral spread at the EDJ which causes
more tubules to be involved as base is wider therefore a larger dentinal lesion is formed.

Figure 10 : Histological zones of enamel caries

Zone 1: Translucent zone, and it lies at the advancing front of the lesion, slightly more porous
than sound enamel

Zone 2: Dark zone, and this zone is usually present and referred to as positive zone which is
formed due to demineralization.

Zone 3: Body of the lesion is found between the surface and the dark zone while it is the area of
greatest demineralization

Zone 4: Surface zone, relatively unaffected area and greater resistance probably due to greater
degree of mineralization and greater Fluoride concentration.
Caries of the dentin

Begins with the natural spread of the process along the DEJ and rapid involvement of the
dentinal tubules. The dentinal tubules act as tracts leading to the pulp .

Early Dentinal Changes

Early dentinal alterations occur when caries penetrate the dentin, progressing to dentinal
sclerosis. In the early stages, when only a few tubules are involved, microorganisms such as
Pioneer Bacteria may be discovered invading them. As the tubules are filled with bacteria, the
walls decalcify first, allowing them to expand. Each tubule appears to be packed with pure types
of bacteria, e.g., one tubule with coccal forms and the other with bacilli.

Advanced dentinal caries

Advanced Dentinal Changes occur when the walls decalcify, the dentinal tubules confluence, and
microscopic "liquefaction foci" are generated by the localised coalescing and dissolution of
dentinal tubules, as Miller reported. These are ovoid zones of damage that run parallel to the
tubule course, fill with necrotic material, and grow in size as they expand. The surrounding
tubules are deformed and bent as a result of the growth. Dentin is destroyed in several focal
regions by decalcification and proteolysis, resulting in a necrotic mass of dentin with a leathery
consistency.
 Figure 11 : Progression of caries in dentin

Zone 1; Zone of Fatty Degeneration of Tome’s Fibers,(next to pulp) which is due to degeneration
of the odontoblastic process. This occurs before sclerotic dentin is formed and makes the tubules
impermeable.

Zone 2; Zone of dentinal sclerosis, where deposition of Calcium salts in the tubules.

Zone 3; Zone of decalcification of dentin

Zone 4; Zone of bacterial invasion

Zone 5; Zone of decomposed dentin due to acids and enzymes.

Root caries

HAZEN defines root caries as a soft, gradual lesion on the root surface caused by loss of
connective tissue connection and exposure to the environment. Caries cannot grow on the root
surface without exposure to the oral environment. Plaque and microorganisms, particularly
Actinomyces, play a crucial role in the development and progression of lesions. Microorganisms
can enter the cementum through Sharpey's fibres or between bundles of fibres. Cementum forms
in concentric layers, therefore it spreads laterally. Decalcification of the cementum leads to
matrix breakdown, similar to dentin, resulting in tissue weakening and eventual disintegration.
Microorganisms invade dentinal tubules, resulting in pulp involvement.

Figure 12: receding of the gums resulting in root caries formation

Conclusion

The prognosis of dental caries is determined by the patient's overall health, oral hygiene, and
severity of the problem. Early symptoms can be corrected with preventative measures and
modest dental interventions, however middle stages necessitate filling and rebuilding if the tooth
loses particular structure. Carious lesions have traditionally been diagnosed visually, with
clinical inspection and radiological evaluation serving as the primary methods. Tactile
information derived from the use of a dental explorer or "probe" is also used in diagnostic
procedures.
References :

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