DENTAL CARRIES

KHUBAIB ALI
DENTAL CARRIES

• Dental caries is one of the most common infectious diseases.

• Dental caries is seven times more common than hay fever and five times more common
than asthma (2000).
• Approximately 20% to 25% of U.S children have 80% of the dental caries
• Lack of access to care
• Cost of care
• Lack of knowledge of preventive dental carries
PATHOPHYSIOLOGY

• Dental caries is an oral infectious disease

• Organic acid metabolites produced by the metabolism of oral microorganisms lead to
gradual demineralization of tooth enamel, followed by rapid proteolytic destruction of the
tooth structure.
• Caries can occur on any tooth surface
 ETIOLOGY OF DENTAL CARRIES
Factors
1. A susceptible host or tooth surface
2. Microorganisms such as Streptococcus or Lactobacillus in the dental plaque or oral cavity
3. Fermentable carbohydrates in the diet which serve as the substrate for bacteria
4. Time (duration) in the mouth for bacteria to metabolize the fermentable carbohydrates,
produce acids, and cause a drop in salivary pH to less than 5.5 (Once the pH falls below
5.5, oral bacteria can initiate the demineralization process. Plaque pH can fall in as little as
5 minutes and take up to 2 hours to return to neutral levels if no oral hygiene measures are
introduced).
ANATOMY OF TOOTH FORMATION OF DENTAL CARIES
 NUTRITIONAL FACTORS IN TOOTH DEVELOPMENT

• Primary tooth development begins at 2 to 3 months gestation.

• Mineralization begins at about 4 months gestation and continues through the
preteen years.
• Inadequate maternal nutrition will consequently impact tooth development.
• Teeth are formed by the mineralization of a protein matrix.
• In dentin, protein is present as collagen, which depends on vitamin C for normal
synthesis.
• Vitamin D is essential to the process by which calcium and phosphorus are
deposited in crystals of hydroxyapatite, a naturally occurring form of calcium and
phosphorus that is the mineral component of dental enamel and dentin.
 NUTRITIONAL FACTORS IN TOOTH
DEVELOPMENT
• Fluoride added to the hydroxyapatite provides unique caries-resistant properties to
teeth in both pre-natal and post-natal developmental periods.
• Diet and nutrition are important in all phases of tooth development, eruption, and
maintenance.
• Diet and nutrient intake continue to affect tooth development and mineralization, enamel
development and strength, and eruption patterns of the remaining teeth.
• The local effects of diet, particularly fermentable carbohydrates and eating
frequency, affect the production of organic acids by oral bacteria and the rate of decay.
• Throughout the life span, diet and nutrition continue to affect tooth, bone, and oral
mucosal integrity; resistance to infection; and tooth longevity
 EFFECTS OF NUTRIENTS ON TOOTH DEVELOPMENT
NUTRIENTS EFFECT OF TISSUES
Protein/calorie • Delayed tooth eruption
malnutririon • Decreased tooth size
• Decreased enamel solubility
• Salivary gland dysfunction
Vitamin A deficiency • Decreased epithelial tissue development
• Tooth morphogenesis dysfunction
• Increased enamel hypoplasia (incomplete development)
• Hypomineralization (hypoplastic defects)
• Compromised tooth integnty (decreased mineral
concentration)
• Delayed eruption patterns
Ascorbic acid deficiency • Dental pulpal alterations
• Odontoblastic degeneration
• Aberrant dentin
 EFFECTS OF NUTRIENTS ON TOOTH DEVELOPMENT
NUTRIENTS EFFECT OF TISSUES
Fluoride presence • Increased stability of enamel crystal (enamel formation)
• Inhibition of demineralization
• Stimulation of remineralization
• Mottled enamel(excess)
• Inhibition of bacterial growth
Iodine deficiency • Delayed tooth eruption
• Malocclusions

lron deficiency • Slow growth

• Salivary gland dysfunction
SUSCEPTIBLE TOOTH
• The development of dental caries requires the presence of a tooth that is vulnerable to
attack.
• The composition of enamel and dentin, the location of teeth, the quality and
quantity of saliva, and the presence and extent of pits and fissures in the tooth
crown are some of the factors that govern susceptibility.
• The composition of the saliva also is important. Alkaline saliva may have a protective
effect, whereas acidic saliva increases susceptibility to decay
• Lifestyle, genetics, and oral hygiene also can affect caries risk.
• A lifestyle with A diet regimen consisting of small frequent meals rather than two or three
meals per day may expose the teeth more frequently to fermentable carbohydrates,
increasing the risk of caries.
• Genetic variations of the type and quantity of bacteria present in the oral cavity.
MICROORGANISMS

• Bacteria are an essential part of the decay process.

• Several Microorganisms are capable of fermenting dietary carbohydrates.
• Streptococcus mutants is the most prevalent, followed by Lactobacillus casein and
Streptococcus sanguis.
• All three contribute to the process because they metabolize carbohydrates
• In the mouth, producing acid as a by-product, which is sufficient to cause decay
SUBSTRATE FOR DENTAL CARRIES
• Fermentable carbohydrates are those carbohydrates susceptible to the actions of
salivary amylase, are the ideal substrate for bacterial metabolism.
• The acids produced by their metabolism cause a drop in salivary pH to less than 5.5,
creating the environment for decay.
• In light of the dietary guidelines for americans and the my pyramid food guidance system,
both of which support a diet high in carbohydrates, it is important to be aware of the
cariogenicity of foods that can affect the potential for bacterial action on fermentable
carbohydrates.
• Individuals should be aware of the form of food consumed and the frequency of intake in
order to integrate positive diet and oral hygiene habits to help improve oral health
status.
SUBSTRATE FOR DENTAL CARRIES
• Fermentable carbohydrates are found in (l) grains, (2) fruits, (3) dairy Products (4) added sugars in the category
of fats and Sweets.

• Some vegetables may contain fermentable Carbohydrates. Examples of grains and starches that are
cariogenic by nature of their fermentable carbohydrate composition, which can cause a decrease in salivary pH
to less than 5.5, include crackers, chips, pretzels, hot and cold cereals and breads.

• All fruits (fresh, dried, canned) and fruit juices may be cariogenic.

• Fruits with high water content such as melons have a lower cariogenicity than others such as bananas and
dried fruits.

• Fruit drinks, sodas, ice teas, and other sugar-sweetened beverages, desserts, cookies;, candies and cake
products may be cariogenic.

• Dairy products sweetened with fructose, sucrose or other sugars can also be cariogenic because of the added
sugars.

• Dairy products are rich in calcium, and their alkaline nature may have a positive influence reducing the
cariogenic potential of the food.
 CARCINOGENICITY OF INDIVIDUAL FOODS
• Cariogenic foods are those that contain fermentable carbohydrates, which, when in contact with
microorganisms in the mouth, can cause a drop in salivary pH to 5.5 or less and stimulate the caries
process.
• Cariostatic foods, or foods that do not contribute to decay, are not metabolized by microorganisms in
plaque and do not cause a drop in salivary pH to 5.5 or less within 30 minutes.
• Examples of cariostatic foods are protein foods such as eggs, fish, meat and poultry, most vegetables, fats, and
sugar less gums

• Anticariogenic foods are those that prevent plaque from recognizing an acidogenic food when it is eaten
first.
• The five-carbon sugar alcohol, xylitol, is considered anticariogenic.

• It is not broken down by salivary amylase and is not subject to bacterial degradation.
• Its mechanisms of action include antimicrobial activity against S. mutans and the impact of gum chewing
on salivary stimulation.
 CARCINOGENICITY OF INDIVIDUAL FOODS

• Sophisticated testing methods have enabled an evaluation of the carcinogenicity

of specific foods
• Amount of acid produced is not proportional to sugar amount in food
• Amount of tooth demineralization not necessarily parallel to acid produced from food
• Formation of different types of fermentation products or the presence of substances
in the food may reduce or enhance the caries-producing action of a sugar
• Carcinogenicity also is influenced by the volume and quality of saliva a person
produces, the sequence, consistency and nutrient composition of the foods
eaten, plaque build up, and the generic predisposition of the host to decay.
 CARCINOGENICITY OF INDIVIDUAL FOODS
• Salivary stimulation leads to increased buffering activity of the saliva and
subsequent increased clearance of fermentable carbohydrates from tooth
surfaces.
• Sugar free chewing gum may help to reduce decay potential because of its ability to
increase saliva flow and is recommended after meals and snacks to reduce the caries
risk.
• Remineralization (mineral resrorpation to the hydroxyapatite in the dental enamel)
capabilities are Subsequently enhanced.
FACTORS EFFECTING CARCINOGENICITY OF
FOODS
1. FORMS AND CONSISTENCY
• Significant Impact on its cariogenic potential and pH-reducing or Buffering capacity.
• Food form determines the duration of Exposure or retention time of a food in the
mouth, which, In turn, affects how long the decrease in pH or the acid producing activity
will last.
• Liquids are rapidly cleared from the mouth and have low adherence (or retentiveness)
Capabilities.
• Solid foods such as crackers, chips, pretzels, dry cereals and cookies can stick
between the teeth and have high adherence capability.
• Consumption of hard Candies, lollipops, and sugared breath mints result in
prolonged sugar exposure in the mouth.
FACTORS EFFECTING CARCINOGENICITY OF
FOODS
• Consistency also affects adherence.
• Chewy foods such as gum drops and marshmallows although high in sugar content,
stimulate saliva production and have a lower adherence potential than solid, sticky foods
such as pretzels, bagels, or bananas.
• High-fiber foods with few or no fermentable carbohydrates, such as popcorn and raw
vegetables, are cariostatic.
FACTORS EFFECTING CARCINOGENICITY OF
FOODS
2. Exposure
• The duration of exposure may be best explained with starchy foods, which are
fermentable carbohydrates subject to the action of salivary amylase.
• The longer starches are retained in the mouth, the greater their carcinogenicity.
• When food particles become lodged between the teeth, salivary amylase makes
additional substrate available as it hydrolyzes starch to simple sugars.
• Processing techniques make some starches rapidly fermentable, either by partial
hydrolysis or by reducing particle size, thus increasing availability for enzyme action.
• Although sugar-containing candies cause a rapid increase in the amount of sugars
available in the oral cavity to be hydrolyzed by bacteria, their effect is short lived.
 FACTORS EFFECTING CARCINOGENICITY OF
FOODS
3. Nutrient Composition
• Nutrient composition contributes to the ability of a substrate to produce acid and to the duration of acid
exposure.
• Dairy products, by virtue of their calcium and phosphorus buffering potential, are considered to have
low cariogenic potential.
• Studies have shown that cheese and milk, when consumed with cariogenic foods, help to buffer the
acid pH produced by cariogenic foods. Because of the anti-cariogenic properties of cheese, eating
cheese with a fermentable carbohydrate, such as dessert at the end of a meal, may decrease the
carcinogenicity of the meal.
• Nuts, which do not contain a significant amount of fermentable carbohydrates and are high in fat and
dietary fiber, are cariostatic.
• Protein foods such as seafood, fish, meats, eggs and poultry, along with other fats such as oils,
margarine, butter and seeds, are also cariostatic.
• Overall good dietary habits in children are associated with reduced caries experience.
FACTORS EFFECTING CARCINOGENICITY OF
FOODS
4. Sequence and Frequency of Eating
• Eating sequence and combination of foods also affect the caries potential of the
substrate.
• Bananas which are cariogenic because of their fermentable carbohydrate content and
adherence capability, have less potential to contribute to decay when eaten with cereal
and milk than when eaten alone as a snack.
• Milk, as a liquid, reduces the adherence capability of the fruit. Crackers eaten with
cheese are less carcinogenic then when eaten alone.
• The buffering capacity of cheese and milk makes them desirable foods to eat at the
end of a meal or in combination with other fermentable carbohydrates.
THE DECAY PROCESS
The carious process begins with the production of acids as a by-product of bacterial
metabolism taking place in the dental plaque. Decalcification of the surface enamel
continue until the buffering action of the saliva is able to raise the pH above the critical
level.
Plaque formation
• Plaque is a sticky, colorless mass of microorganisms and polysaccharides that forms
around the tooth and adheres to teeth and gums.
• It helps acid-forming bacteria and keeps the organic products of their metabolism in
close contact with the enamel surface.
• As a cavity develops, the plaque shields the tooth, to some extent, from the bufferinq and
remineralization action of the saliva.
• In time the plaque combines with calcium and hardens to form calculus.
THE DECAY PROCESS
Acid production
• Several beverage categories such as soft drinks (diet and Regular), sports beverages,
citrus juices and vitamin C supplements have high acid content and therefore who
consumed large amounts of juice showed a trend toward greater incidence of dental caries
versus those who consumed milk or water.
• Foods and beverages may also contribute to dental erosion, a loss of minerals from tooth
surfaces by a chemical process in the presence of acid.
• For example, diet soft drinks, which may not contain sugar also are acidic by nature and therefore
cause a drop in pH.

• Chewable vitamin C supplements provide an acidic substance that directly contacts tooth
surfaces and causes a drop in pH of the oral cavity making teeth susceptible to decay.
THE DECAY PROCESS
Saliva function
• Salivary flow clears food from around the teeth by means of the bicarbonate-carbonic acid
and phosphate buffer system, it also provides buffering action to neutralize bacterial acid
metabolism.
• Chewing promote saliva production and may account for the reduced carcinogenicity of
fermentable carbohydrates consumed with a meal.
• Saliva is supersaturated with calcium and phosphorus once buffering action has restored
pH above the critical point, remineralization can occur.
• If fluoride is present in the saliva, the minerals are deposited in the form of fluoroapatite,
which is resistant to erosion.
Caries Patterns
• Caries patterns describe the location and surfaces of the teeth affected.
FLUORIDE
• Fluoride is a primary anticaries agent.
• Used systemically and locally, it is a safe, effective public health measure to reduce the
incidence and prevalence of dental caries
• The impact of fluoride on caries prevention continues with water fluoridation,
fluoridated toothpastes, oral rinses, as well as beverages made with fluoridated
water.
• Fluoridation is "the adjustment of fluoride in the water supply to an optimal concentration
of 0.7 to 1.2 ppm.
• Optimal water fluoridation concentrations (0.7 to 1.2 ppm) can provide protection against
caries development without causing tooth staining
FLOUROSIS
• Fluorosis, or mottling of the tooth, can occur secondary to excessive fluoride intake
from diet and supplements
• Excessive topical fluoride or ingestion of fluoridated tooth pastes, rinses or dentifrices
during the early years of tooth development.
• Excessive dietary intake of fluoride can occur as a result of long-term use of infant
formulas in powder form that are reconstituted with fluoridated water.
• Mild fluorosis starts with white patchy spots.
• Fluorosis Progresses to dark brown stains on the teeth as it becomes Severe.
• Mottling occurs in severe fluorosis, which results in pitting in the enamel surface of the
tooth, weakening it and making it susceptible to decay.
PREVENTIVE ACTION
• Caries prevention programs focus on a balanced diet, modification of the sources and quantities of
fermentable carbohydrates, and the integration of oral hygiene practices into individual life style.
• Meals and snacks should be followed with brushing, rinsing the mouth vigorously with water, or
chewing sugarless gum for 15 to 20 minutes.
• Avoid sipping carbonated beverages over extended periods, frequent snacking and harbouring
candy, sugared breath mints or hard candies in the mouth for extended periods.
• Over-the-counter chewable or liquid medications and vitamin preparations also may contain sugar.
• Chewable vitamin C is one example of a sugar containing acid product that may contribute to tooth
decay.
• Careful label reading is important to avoid or minimize the use of such products.
• Fermentable carbohydrates such as candy, crackers, cookies, pastries, pretzels, snack crackers,
chips, and even fruits should be eaten with meal.
• Balance diet plan for low carcinogenic risk