Dental Caries Lecture #8 30/04/2009 Root Caries As we know from previous lectures caries can be divided into two

main parts according to the lesions location: 1. Crown caries 2. Root caries And in this lecture we are going to talk about root caries, because root caries has special circumstances regarding its etiology, factors, and the population who are more affected by root caries. Definition of Root Caries: Root caries is defined as A soft irregular shaped lesion either (1)Totally confined to the root surface or, (2) Involving the undermining of enamel at the cementoenamel junction but clinically indicating that the lesion initiated on the root surface. Both of those conditions should initiate root caries, so the initial medium should be on the roots, either it is confined to the root OR sometimes extended from the root to the crown, but it SHOULD start (the initial region) at the root if it is to be called root caries. Root caries can be initiated only if the root surface is exposed to the oral environment. Because usually in the normal situation the root is covered by the dental tissue, and thus it is not exposed to the oral environment and the bacteria and dental plaque cannot stick on the surface of the root, but in certain circumstances when there is recession of the periodontal tissues leads to the exposure of the root, then the exposed root is subjected to the oral environment and then itll become susceptible to root caries. Student asked: the bacteria that are on the root will be present even if the root is covered by the gingiva right?

Dr. Answered: yes, but for caries to develop there should be a pocket (space between the gingiva, periodontal ligament and root) So the bacteria Are always present but cannot initiate because it is covered by the PDL.

This is an example of root caries, initiated on the root then extended to the crown of the tooth. This patient has a lot of lesions and cavitations the lesions appear white in color.

New lesions appear as small, well-defined areas of a yellowish to light brown color. As caries progress, the surface of the lesion has a leathery consistency that can be easily peeled away. Any instrument can be used to easily take off the lesion; it is leathery and can e moved away easily. Advanced lesions appear darker brown to black and may be hard.

This is a special character for the root caries, sometimes re-mineralization can occur in the lesion, and so it becomes hard, sometimes it even may become darker in color which appears very dark black, this is called arrested lesion.

Initial lesions are more common on facial and proximal surfaces.

Rather than lingual or palatal surfaces, so the lesions appear usually on the facial surfaces of the teeth more than the lingual or palatal surface of the teeth.

In the mandible, molars appear to be most susceptible to root caries followed by premolars, canines and incisors, while in maxilla the order is reversed.

Dr. asked: Why? Answer: The orifices of the salivary glands So in the maxilla susceptibility is as follows from the most susceptible: Incisors > Canines > Premolars > Molars While in the mandible it is as follows: Molars > Premolars > Canines > Incisors Caries activity: By activity we mean the expansion of the lesion by appearance or location How can we differentiate between active and arrested root caries? Active - Close to gingiva and plaque covered - Soft or leathery Arrested - Distant from gingiva and not clean and shiny not covered by plaque - Hard healthy root surface even if it is lighter or darker in color than normal As long as it is away from the gingiva away from the plaque accumulation then it is arrested root caries. Histochemistry:

The caries process on root surface is very similar to that in coronal caries.

Root surface is more susceptible to chemical dissolution more than enamel surface. (this is one exception or one special characteristic of root caries)

Sometimes there may be demineralization of the root surface and the root surface can be removed by acid. The root can be removed by acid (erosion) in addition to demineralization. The drop in pH necessary for demineralization in cementum and dentin is 6.2 to 6.7. So dentine and cementum need a smaller drop in pH to become demineralized so this means root caries develops faster than coronal caries. Very important note: The root surface should be exposed either by gingival recession or PDL problem to cause the caries; the root is covered by cementum which is a very thin layer, usually people who have sorry I cant hear the name of the problem need to get their teeth cleaned, cementum sometimes is already removed exposing the dentine, that is why root caries doesnt always occur at the cementum but sometimes it can start on dentin itself. Given the proper environment, both the initiation and progression of root surface caries will occur more rapidly in dentin than on enamel surface. Microbiology:

Early studies pointed to Actinomyces viscous as a prime suspect. Recent studies emphasized the importance of Streptococcus mutans and Lactobacillus.

So as in all dental caries the processes of Streptococcus Mutans bacteria are suspected to start the lesion by various processes then when the lesion is deep enough Antinomyces Viscous gets involved.

It is likely that root caries is a continuous, destructive process involving a succession of bacterial population that varies depending on the condition of the substrate and the depth of the lesion.

Prevalence and Incidence: (it is well explained in the reference) It is very difficult to detect as root caries frequently occurs in old people, and its not that wide spread throughout the population, so very few studies were made about this type of caries. Population at risk of root caries is older adults. As usually in old age there will be more recession, more teeth will have been lost, and more PDL problems will be present that is why it is present more in older people. However, younger patients with periodontal problems are susceptible to root caries as well.

International surveys have estimated that the diseases affect 60% to 90% of adults.

It has been suggested that 1 in 9 root surfaces is at risk of becoming carious.

Studies on caries incidence reported that root caries/root restoration experience ranging from 19% to 69%. (A very wide range due to the differences in the studies and the studys population).

Risk Factors and Assessment: It is of critical importance to identify persons at risk early in the root caries process. Because if we can recognize those people, who are at high risk of developing root caries, and know the risk factors, then we can identify these factors and prevent them in the first place. Early detection permits preventive and chemotherapeutic intervention. Root caries is generally more prevalent among males than females.

Risk Factors:

Exposure of root surfaces: patients with attachment loss, gingival recession, and periodontal pocketing are at risk of initiation of the disease process. (No root exposure means no root caries) Inadequate oral hygiene. (This is applied to any carious lesion) Cariogenic diet. (Of course sucrose and carbohydrates diet will increase the chance of all caries) Diminished salivary flow (and this is very important we have a whole lecture talking about saliva) and/or buffering capacity (if the saliva decreases or the buffering activity of the saliva decreases; this means that acidic food will drop the pH, and it will take much more time to raise the pH again, which allows the bacteria to work and start lesions, you find this factor more prevalent in the elderly as the salivary glands usually go through hypertrophy, this obstructs the amount of saliva going to the mouth,(Flow stays the same) increasing the susceptibility to caries): as result of radiation therapy, immunosuppressive therapy, autoimmune diseases, HIV infection and a number of commonly prescribed medications.

Previous caries/restorations: Individuals who have coronal caries are 2 to 3.5 times more likely to develop root caries.

Lack of access and/or interest in dental services. Removable prosthesis: retention of food debris and gingival recession.

As people age they tend to lose teeth, and so they will be obliged to put on dentures, these dentures are known to get debris of food stuck on them, and so increase the susceptibility to dental caries. Advanced age: the effect of all these risk factors may be magnified with aging related to health problems and treatments. Eight or more missing teeth.

Gender: Root caries is generally more prevalent among males than females. Smoking, alcoholism and drug use. Possible ethnicity: (this has a big question mark on it as it might not be related to the ethnicity itself but rather to the socioeconomic status) Asian and blacks exhibit a higher incidence of root caries.

Diagnosis: (How to know that there is root caries)

The first step in diagnosis of root caries is early identification of contributory factors and oral hygiene factors. Dental prophylaxis should be done prior to examination to remove plaque and debris that might limit the visibility of root surface.

If the carious lesion is covered by dental plaque or debris the lesion cannot be detected. Prevention: (3 ways of prevention) Preventing or arresting root caries through: 1. Plaque removal. 2. Diet modification. (Low consumption of sugar, carbohydrates and cariogenic food) 3. Topical fluoride application. The Doctor got angry and simply didnt continue the lecture There were to slides left so here they are Topical Fluoride Fluoride is accepted as an appropriate chemotherapeutic agent in the management of root caries.

Prevention or arrest of root caries has been demonstrated using fluoridated water, fluoride gels, fluoride mouth rinses, fluoride dentifrices, fluoride varnishes, fluoride chewing gum and fluoride releasing devices.

Restorative Treatment Amalgam Vs tooth colored restorations (composite and glass inomer cement) Glass-inomer cement is the material of choice for most root caries lesions. The material offer adhesive bonding to tooth structure and long-term fluoride release.

THE END I would like to thank each and every member of creative, here we are at the end of the semester with all our written; lectures, reviews, questions, and even summaries. We proved that when we want something hard enough we can surely achieve it, and even better, be great at it. Thanks to every writer, editor, and even every supporter of this group, I really hope we all do great in the final exams, I wish you all the best of luck. I would finally like to give a really special dedication of gratefulness and appreciation to Mouhamad Hajsaleh creative would have been lost without your precious contributions. Done By: Mutaz Sari Jarallah Edited By: #7