Discipline : Preventive Dentistry

Programme of lectures: 7 lectures + 7 lectures

Textbooks for self-study are:

- Norman O. Harris, Primary Preventive Dentistry,
6th Ed !"##$%& 7
th
ed!"##'%
- Hardy Limeback , (omprehensive Preventive
Dentistry, "#)"
Exam : after 7
th

semester - in January !"#. $xam consists : "
%ritten &uestion from the syllabus and test ' multi(le choice),
all in one day.
$tiolo*y and (atho*enesis of
dental caries.
+rof.d-r ,.-abaktchie.a- !"/

The three *eneral disease cate*ories of

focus in dentistry are :
-
dental decay,
-
(eriodontal disease,
-
oral cancer.

0entistry in the (ast has been

treatment oriented,but %e are
%itnessin* an interest (re.ention.

1t is ob.iously better to (re.ent

the disease in the first (lace,
than treat it once it has ha((ened.

The *oals of (re.enti.e dentistry are

to a.oid disease alto*ether.

2aintainin* a disease-free state

can result from primary prevention

3hen lifestyle chan*es are made early on,

the risk for de.elo(in* dental disease are minimi4ed.
Lifestyle chan*es

5 less carbohydrates

5 better oral hy*iene

5 im(ro.ed nutrition

5 better education

*econdary prevention 're.erse, arrest inci(ient caries) and

early intervention '210 67+re.enti.e ,esins8)
can be used to re.erse the initiation of disease.

9n outcome of *ood health can still be achie.ed,

%hen inci(ient enamel lesions are re.ersed before
ca.ities form.
210- minimal inter.ention dentistry

:ar too often thou*h, dentists s(end most

of their time treatin* dental disease
in an endless cycle of re(eat restorations,
%hich leads;; to tooth loss.
<
+he goal of (rimary (re.ention
is ne.er to ha.e had
any kind of dental disease.
:i*. =lobal (re.alence of caries from 3orld 3ar 11 to (resent.
The relati.e decline in caries, %as re(resented by 02:T 'decayed, missin*, filled
teeth)
9re also sho%n other factors that have contri,uted to the decline in caries
%orld%ide 'labeled a to -%
(omprehensive Preventive Dentistry. / Limeback
Dental decay !dental caries%: glo,al patterns

>he (re.alence of caries has chan*ed o.er the

decades.

1n e.ery de.elo(ed country, there has been

a steady decline in dental decay.

$x(erts belie.e, that it %as (rimarily

the introduction of fluoride thera(ies after the
"?@!s that had a hu*e im(act on dental decay rates.

To kno% ho% to (re.ent ,

need to kno% disease,
its etiolo*y and (atho*enesis
$tiolo*y and +atho*enesis of 0ental Aaries
1n dealin* %ith disease,
7(re.ention is better than a cure.8

Definition

0ental caries is a dietary

carbohydrate-modified
bacterial infectious disease
%ith sali.a as a critical
re*ulator.

1t is the most common

chronic infectious disease of
childhood
(ontemporary definition :

Tooth decay is locali4ed (ro*ressi.e disease,

%hose character consists in the destruction of tooth
structures mainly under the influence of metabolic (roducts
of the oral microfloraB

$ach le.el of decom(osition is clinically differentiated.

0idd

(aries process
ta1es place in the ,iofilm on the tooth
surface
(arious lesion is the result of carious process developing
,et2een the micro,ial ,iofilm and tooth structure
The metabolic acti.ity of the microor*anisms in
the biofilm is in.isible to the clinician,
but carious lesion that is a result of this acti.ity


is clinically a((arent
The classic Cenne
dia*ram of caries.
2ust ha.e a tooth, (la&ue bacteria,
fermentable carbohydrate, sali.a,
and enou*h time in order for a
carious lesion to de.elo( .
Aaries results %hen all of the factors
that contribute to caries o.erla(.
'red color, center%
De.eral factors influencin* each
com(onent, '
see

the dia*ram,) affect
the rate and se.erity of the caries.
Aaries :actors
dia*ram
This is a con.enient analo*y to understand and is an
offshoot of the classic Cenn dia*ram ' first introduced by -eyes '"?@).
The role of microor*anisms

Aaries is an infectious disease that is

actually transmissible,
usually %hen the mother infected %ith
S. mutans, infects her infant when the
childs first teeth a((ear in the oral
ca.ity '-ulkarni et al. 1989).

0ental caries does not occur in a sterile

mouth. 'no mouth can e.er be made sterile)

The conditions in the oral ca.ity are ideal for

the *ro%th of bacteria that metaboli4e su*ar to
acids.

The oral ca.ity is *enerally a %arm (lace, at

body tem(erature 'E7FA) encoura*in* the *ro%th
of bacteria.
Non-s(ecific +la&ue Hy(othesis

2icroor*anisms in dental caries first

obser.ed by .an Leeu%enhoek in "@GE

3.0. 2iller 5 Hni.ersity of Ierlin "G?! 5

considered all bacteria in mouth %ere
(otentially cario*enic 5 hence, non-specific plaque
theory

9cid (roduction by bacteria considered

res(onsible for breakdo%n of tooth
D(ecific +la&ue Hy(othesis

"?/ 5 Alarke isolated a stre(tococcus

s(ecies from a ca.ity in a child

The bacteria under%ent some chan*es

as the culture a*ed 5 Alarke named it
Streptococcus mutans for 7mutation8
2utans stre(tococci

"?@! 5 -eyes 7redisco.ered8 S. mutans

He demonstrated that:
5
s(ecific microor*anisms %ere res(onsible for caries
5
caries %as transmissible

Later, the res(onsible bacteria %ere found to

com(rise se.en distinct s(ecies 5 only mutans and
sobrinus are associated %ith caries in humans
Aharacteristics of 2D

$colo*ical niche: human oral ca.ity

71ntentionally desi*ned ; to be a cario*enic

or*anism8 'Aoykendall "?7@)

Aario*enic (ro(erties
5
ability to (roduce acid 'acido*enicity)
5
ability to %ithstand acid conditions 'aciduricity)
5
ability to adhere to teeth
Aharacteristics of 2D

2etabolism yields:
5
acids, (rimarily lactic, from a .ariety of su*ars
5
extracellular (oly*lucose, called *lucan, %hich
creates irre.ersible attachment 'from sucrose
metabolism only)

2D is res(onsible for initiation of caries

2D is a necessary, but not solely sufficient, factor for

dental caries

9c&uisition of 2D by 1nfants

2D coloni4e oral ca.ity after eru(tion of teeth 5

re&uire hard, non-des&uamatin* surfaceB

Dome belie.e in 7window of infectivity 7 that relie.s

on .ir*in tooth surfaces for initial coloni4ationB

Decond 7%indo% may o(en8 %hen (ermanent

dentition eru(ts
9c&uisition of 2D by 1nfants

2D is (oor com(etitor for coloni4ation 5 once

stable biofilm is in (lace, ability for 2D to
coloni4e is reduced

1nfants %ho ac&uire san*uis early ha.e less 2D

Iirth
mitis
"
san*uis
G
""
"?
@ EE mos.
mutans
Transmission of 2D

Certical transmission

Dource is usually mother

:idelity is J7!K

Transmission may occur at

birth, but 2D reside in lo%
numbers in reser.oirs such
as tonsils or dorsum of
ton*ue
Other 2icroor*anisms

3acto,acilli sp
5
found in lar*e numbers in some children
5
considered opportunistic, not initiators
5
numbers in ca.ity increase after 0$J
in.aded
5
lactobacilli are *ood indicators of total
carbohydrate intake
$tiolo*y - 0iet

Ho(e%ood House '9ustralia) "?/7 5 # determine

5
diets de.oid of su*ar and %hite flour- extremely lo%
dental caries (re.alence

Ci(eholm 'D%eden) "?/# 5 # determined

5
effects of fre&uency of su*ar consum(tion
5
effects of consistency 'retenti.eness) of su*ar
5
su*ar at meals .s. in bet%een meals
Lessons from Ci(eholm
'D%eden)

Sugar consumption at meals 5 sli*ht increase in cariesB

Sugar between meals 5 marked increase in cariesB

Sugar in sticky candies 5 *reatest caries acti.ityB

Aaries acti.ity differs amon* indi.iduals

Aaries acti.ity declines %ith %ithdra%al of su*ar-rich

foods
Not all su*ars are cario*enic.
+he role of dietary sugars
The more common dietary su*ars are (resented.
The cario*enic (otential of carbohydrates are (resented too.
The su*ars %ith the most
cario*enicity are sucrose
and glucose 'red%
Other carbohydrates 'maltose,
lactose, fructose, and starch% are
less cario*enic.
The sugar alcohols, such as
sor,itol and mannitol, are the
least cario*enic 'yello%)
4ylitol has e.en been sho%n to
be anticario*enic !green%

The disaccharide sucrose and the

monosaccharide *lucose ' a com(onent of sucrose),
are most cario*enic.

:re&uent in*estion, can cause se.ere dama*e

to the tooth.

There is no &uestion that carbohydrates are

the main etiolo*ical reason for the de.elo(ment of caries.

One of the strate*ies in (re.ention of caries is to limit

access to the more cario*enic su*ars and substitute them
%ith the anti-cario*entic ones.

Not only does their con.ersion to acid result in

enamel dissolution, but they also encoura*e the *ro%th
of more .irulent cario*enic bacteria.
Ducrose

=lucose L fructose
*lucan
fructan
metaboli4ed by (la&ue bacteria
L
extracellular (oly*lucose,
*lucan, 'from sucrose metabolism only)
creates irre.ersible attachment
=lucan

3ater soluble

$xtracellular 7*lue8

$nables adhesion to tooth

5
reduced susce(tibility to mechanical
disru(tion

1nhibits diffusion (ro(erties of (la&ue

5
reduces bufferin* ca(acity of sali.a
5
inhibits trans(ort of acid a%ay from tooth
,ole of Other Du*ars

:ructose and *lucose are as effecti.e as sucrose in

their ability to cause a (H dro(B

:ructose is nearly e&ual to sucrose in cario*enicityB

,a% starch causes only a small dro( in (la&ue (H

,ole of ,efined Dtarch

Doluble starch and refined

starch can be broken do%n by
sali.ary amylase into su*ars

These refined carbohydrates

cause a .ariable (H dro( that
may be as lar*e as that caused
by sucrose

The su(ra*in*i.al bacteria are

dominated %ith stre(tococci
and lactobacilli that can lo%er the
(la&ue (H and induce decalcifications

%hite s(ot lesions.
'") The enamel 'e) has (la&ue biofilm 'b) *ro%in* at the border of the inflamed
*in*i.al '*).
') Dame (la&ue at closer look. There is a M%hite s(otN lesion '%) de.elo(in* at
the mar*in of the *in*i.a, and bro%n calculus 'c) de.elo(in* in the sulcus
attached to the tooth.
'E) Alose-u( .ie% of (la&ue. Iiofilm bacteria, %hich
consists of se.eral s(ecies of ,acteria 'cocci, rods, motile s(irochetes),
organic material 'sali.ary (roteins) and organic matter secreted by the
bacteria 'yello%-stained)
:i*ure sho%s an illustration of dental (la&ue at
the *in*i.al mar*in.

The (la&ue that is res(onsible for caries is *enerally

located su(ra*in*i.ally and is acido*enic.

+eo(le %ho consume su*ars fre&uently in their diet increase the le.els of
stre(tococci and lactobacilli

The t%o bacteria s(ecies thou*ht to be res(onsible for caries.

These bacteria continue to thri.e as the (H dro(s.

1f the (la&ue is not remo.ed, e.entually, the enamel starts to decalcify

and an inci(ient M%hite s(otN lesion ensues.

:i*ure .The enamel %hite s(ot lesion at the mesial contact 4one of the
first maxillary ri*ht molar .
These %hite-s(ot lesions are sometimes filled by dentists
but can be reminerali4ed.

2arsh '"??/) %as able to sho%,

that feedin* of bacteria a meal of *lucose
can encoura*e the *ro%th of cario*enic bacteria
%hen the (H is allo%ed to dro( .
,e(eated *lucose rinses encoura*es D2 and LI *ro%th %hen (la&ue acid is not
controlled
:luoride at hi*h concentrations inhibits D2 , but not LI <<<
Oylitol had inhibitory (ro(erties for both cario*enic and (eriodontal bacteria.
+he deminerali5ationreminerali5ation
,alance in caries

The (la&ue thickness dominated by cario*enic bacteria, can

effecti.ely kee( the sali.a from reachin* the enamel surface.

1n addition, the more (la&ue there is, the more acid is (roduced.

These acids ha.e a lon*er time to (enetrate into the enamel under
thick biofilm - This allo%s the tooth to deminerali4e<<<<

1f the sali.a reaches the acids they are %ashed a%ay and neutrali4ed
by the sali.ary buffers - This allo%s the tooth to reminerali4e.

The cycle re(eats itself o.er and o.er

%ith e.ery s%eet snack and meal
containin* fermentable su*ars

Aaries occurs %hen the fre&uency of

su*ar ex(osure durin* the day is hi*h.
The re(eated cycle of Msu*ar attacks.N
The (H of dental (la&ue in
res(onse to *lucose has been
studied usin* the classic
Dte(han cur.e
+he diagram illustrates the pla6ue p/ response curves
that have ,een o,tained from patients 2ith different
ris1s for caries

9 hi*h-risk indi.idual, %hen

*i.en a *lucose rinse , %ill
ex(erience a dramatic dro( in
the (la&ue (H %ell belo% the
critical (H of #.#.

The reco.ery to neutral (H in

the hi*h risk indi.idual %ill be
slo%.

+he area under the p/.time curve

!78(%representing the time spend at p/
lo2er than the critical p/

The 9HA for a hi*h risk

indi.idual

%ill be .ery lar*e.

78( is a ,etter measure of total caries

ris1

The (erson %ith a hi*h risk for caries snacks

fre&uently durin* the day,
and the total 9HAs clearly are excessi.e
and %ill not allo% reminerali4ation to occur.

1f that daily trend continues, the (erson %ill

ex(erience dental decay.

:or a moderate risk

indi.idual 'yello%), the
initial (H dro( may only
be a little lo%er than the
critical (H, and the 9HA
%ill be much less.

:or a caries-resistant (erson

'*reen),the initial (H dro( of that
(ersonNs (la&ue may
not e.en reach the critical (H, and
the reco.ery %ill be .ery &uick.

The (erson %ith moderate caries risk mi*ht ha.e three

meals and one snack of moderate cario*enic (otential
on a daily basis,
and the 9HAs belo% the critical (H mi*ht result in a net
loss of mineral.

9t this sta*e, reminerali4ation

strate*ies mi*ht %ork.

>he (erson at lo% risk may not snack

at all and has three meals of lo%
cario*enicity s(read a(art durin* the
day.

This allo% reminerali4ation to occur.

,esearchers ha.e determined that:

it is not only the fre&uency of in*estion that is
im(ortant, but it is also
the type of fermenta,le car,ohydrate that is
ingested

-leinber* et al. 198!) determined
that increasin* *lucose concentrations
results in lo%er (H dro(s
".!K =lucose #!K =lucose
7.!
G.!
@.!
! ! /! @! G! "!!
".!K =lucose
$tiolo*y 5 Host :actors

Tooth factors
5
&uality of enamel
5
(resencePde(th of (its and fissures
5
hy(o(lasia
5
fluoride ex(osure

Dali.a
5
(H
5
flo% rate
5
bufferin* ca(acity
5
antimicrobial com(onents
Dali.a

71s to teeth %hat blood is to cells of the body8

Aom(osition
5
su(ersaturated %ith Aa, +
5
bicarbonate 5 (rinci(al buffer
5
(roteins, immunolo*icPantibacterial com(onents
5
fluoride
5
.iscosity de(ends on *land, ner.ous control of
secretion

(H normally around 7.!B .aries from Q#.#-G.!

+he main components of saliva and their function
(lassification
of component
9ngredient :unction
1nor*anic 3ater '??K)
1nor*anic, or*anic Aarbonate,
(hos(hate, (rotein
Iuffers acid
Or*anic 9mylase, li(ase,
(rotease,
(yro(hos(hatase,
lyso4yme
9ntibacterial
Or*anic
Or*anic
2ucins
1*9
Lubricant, calcium bindin*
9ntibacterial
+he role of saliva

Dali.a contains antibacterial (roteins,

electrolytes for reminerali4ation and
the essential nutrients for bacteria to *ro%.

The host (ro.ides the dietary carbohydrates

that are easily con.erted to ener*y and acids by
the bacteria that leads to dissolution of dental
hard tissues.

Iecause of its bufferin* ca(acity and ability to

neutrali4e acids,
a sim(le inter.ention such as stimulatin* the sali.a
%ith che%in* *um can arrest %hite s(ot lesions
and (re.ent ca.ities from formin* 'Dtookey !!G).
+he role of saliva
Dali.a

:lo% rate 1ncreased by:

5
*ustatory stimulants 'su*ar-free candy)
5
masticatory stimulants 's-f che%in* *um)

reduced by:
5
medications 'antihistamines, antiasthmatics, others)
5
disease 'de*enerati.e, meta(lastic)
5
dehydration
5
radiation
5
a*e
. +atho*enesis of dental caries
2echanism of de.elo(ment of dental
caries
2echanism of acid deminerali4ation
0e.elo(ment of caries in the
(resence of inhibitors
R

+re.enti.e inter.entions aim

to modify the ste(s in the re(eat
deminerali4ation and
reminerali4ation cycles.
". Neutrali4e the (la&ue acids:

This can be done by addin* base

or addin* buffers such as sodium
bicarbonate 'bakin* soda) to the
sali.a to boost its ability to neutrali4e
acids.
. 1m(ro.e hy*iene:

3ith bacterial le.els lo%, less acid is

(roduced.

+la&ue layers donNt ha.e a chance to *ro%

thickB

Dali.a can (enetrate better to the

enamel surface throu*h thin layers of (la&ue.
; 9ntroduce antimicro,ials:

*ince caries is a disease caused by

bacteria, sim(ly eliminatin* the
bacteria or controllin* their *ro%th
%ill reduce the caries incidence.

Ahlorhexidine, xylitol, o4one,

e.en ex(erimental antibodies, ha.e
been used to control bacterial *ro%th.
$ *timulate saliva:

*aliva contains numerous components -

that fi*ht tooth decay

buffers, reminerali4in* minerals,

antimicrobial en4ymes, antibodies.
< +opical fluorides:

:luoride added to the reminerali5ing

inci(ient lesion increases the enamel crystalsN
resistance to dissolution by (la&ue acids.
6 =eminerali5ing strategies:
=eminerali5ation can ,e
(romoted %ith the use of calcium-
(hos(hate com(lexes such
and 9A+-A++.
end