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TYPES OF TOOTH LOSS
Loss of tooth substance in different
ways:
Non microbial tooth Microbial tooth loss
loss (dental caries)
(attrition, abrasion,
erosion & abfraction)
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What about
What is
caries in What are
Dental
infants? & the causes?
Caries? How acid
What is root
surface production
caries? occurs?
Topic =
Can caries What
Dental Caries problems
be arrested?
are caused
by
sucrose?
What are the How enamel is
What are
dentinal destructed by
the types
responses to caries?
of dental
caries? caries?
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What is
Dental Def. of Dental Caries
Caries?
Dental caries is a progressive largely
irreversible bacterial damage of hard
tooth structure exposed to the oral
environment.
Characterized by demineralization of
the inorganic portion and destruction
of the organic substance of the tooth
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What are
Etiology of Dental
the
Caries
causes?
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Susceptible Tooth
1-
Position
Upper teeth are more susceptible to
caries than lower
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Susceptible Tooth
1- Position
Is g
Why??
Posterior teeth are more
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susceptible than anterior teeth
Susceptible Tooth
1- Position
??
The stagnation area in an occlusal pit
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Susceptible Tooth
1- Position
Teeth related to clasps and orthodontic
appliance are more susceptible to caries
What else regarding
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Susceptible Tooth
2- Morphology
Pits and fissures,
Areas below the proximal contact point,
Sites below buccal and lingual
convexities are stagnation or retention
sites and are most susceptible to caries.
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Shape, morphological variation and depth of pits and
fissures contributes to their high susceptibility to
caries
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Susceptible Tooth
2- Morphology
Proximal contact point
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Occlusal Dental
Caries
Interproximal
Dental Caries
Cervical Dental
Caries
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Susceptible Tooth
3- Structure
Caries in the primary dentition
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Susceptible Tooth
3- Structure
Enamel hypoplasia and enamel hypocalcification may
affect
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Susceptible Tooth
3- Structure
Mechanism of action of fluoride:
a) Increasing enamel resistance to
demineralization.
b) Enhancement of remineralization.
c) Inhibits bacterial enzymes and thus stops
bacterial activities.
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Mechanism of action of fluoride
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Susceptible Tooth
4- Genetic Factors
A person may inherit a more favorable
tooth morphology as having fewer
fissures, thus showing low caries
susceptible .
Of more importance is the consideration of
environmental factors :i.e. food habits and
dental care.
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The essential role of bacteria
Miller's work in 1890 revealed that caries-
like lesions were produced by incubating
teeth in saliva when carbohydrates were
added.
He was the first to suggest that the caries
process could result from the
fermentation of carbohydrates by the
bacteria present in the saliva.
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Orland Experiment
In 1954, Orland and co-workers provided
experimental evidence which proved
conclusively the essential role played by the
bacteria in the development of dental caries.
They found that germ-free rats (free from
bacteria) did not develop caries when fed a
sterile cariogenic diet.
Caries only developed in the animals when
bacteria were introduced, i.e. become infected.
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Orland Experiment
These experiments involved the introduction of
single known strains of bacteria into the oral
cavities of germ-free rats (the production of
gnotobiote rats ="known life").The gnotobiotic
studies showed that mutants streptococci and
some strains of lactobacilli and actinomyces
were of particular relevance to caries in animals
and might be also cariogenic in man.
The transmissible and infectious nature of
caries in animal was also demonstrated.
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The characteristics features of cariogenic
bacteria
1. Acidogenic.
2. Aciduric.
3. Extracellular polysaccharide (dextran and
).
levan
4. Amylopectin.
5. Attachment mechanisms.
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The principal species in the mutans
streptococci group are S. mutans and S.
sobrinus.
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Characteristics of Mutans
Streptococci
1. Acidogenic.
2. Aciduric.
3. 7 species (surface antigensindigenous
species ), members of the viridance group.
4. The name mutans.
5. Transmissible.
6. Both smooth surface and pit and fissure caries
(Dextrans, are more important ).
7. Amylopectin.
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Lactobacilli
1. Acidogenic (facultative anaerobic)& Aciduric.
2. large numbers in saliva.
3. The lactobacilli count was once used as an
index of caries activity.
4. Produce pit and fissure caries in gnotobiote
animals but fail to produce smooth surface
caries (Dextran), secondary invaders.
5. Isolated from carious dentin and are pioneer
organisms (caries progression ).
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Other cariogenic bacteria
Actinomyces:
(Proteolytic-Gram +ve bacilli and filaments)
Actinomyces viscosus and Actinomyces naeslandi
proteolytic enzymes.
Clostridia:
(Proteolytic bacteria)
proteolytic enzymes (depth of dentin caries).
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Dental Plaque
Def.
A tenaciously adherent soft deposits
(mainly of bacterial origin) that
accumulates on the teeth.
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Composition of Dental Plaque
1. Plaque is a complex microbial community, with
greater than 10 billion bacteria per milligram.
2. extracellular matrix, which is formed from
bacterial products and saliva.
3. Inorganic (calcium and phosphorus).
4. Supragingival or subgingival.
5. Plaque Matrix (Production – Retention –
Prevention).
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Mechanism of formation of
dental plaque:
1- Acquired Enamel Pellicle
Enamel
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2- Initial Community
A- Colonization phase (8 hours):
(pioneers bacteria) are S. sanguis, S.
oralis and S. mitis.
(adhesions) which bind to complementary
molecules (receptors) in the pellicle
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(b) Growth phase (8-48 hours):
Monolayer of organisms covering the pellicle.
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3) Intermediate community:
This begins with the ingress and proliferation
of secondary invaders (S.mutans).
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3) Intermediate community
Streptococcus mutans have 2 effects:
1 - positive interaction & negative
interaction.
2- Synthesis of extracellular
polysaccharides, dextran and levan.
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3) Intermediate community:
1. Deepest layers anaerobic micro-organisms;
2. Midlayers, facultative anaerobic organisms
3. Superficial
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4) Mature community
Note filamentous
organisms:
arranged parallel to
one another and at
right angels to the
tooth surface
Climax community (the
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"corn cobs"
central
filament
covered with
a dense
layer of
coccal
forms.
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Acid production in the dental
plaque:
(Stephan's Experiment - Curves)
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pH Meter
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Stephan’s Curves
Single Person
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Stephan’s Curves
(Two Persons with Different
Resting pH)
A
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Consequences of frequent snacking
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Biochemical reactions in the dental
plaque
1. Acid production in dental plaque (Stephan's
experiment).
2. Formation of extracellular polysaccharides
specially (Dextran and levan).
3. Formation of intracellular polysaccharides
(amylopectin).
4. Demineralization phase.
5. Remineralization phase.
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Biochemical reactions in the dental
plaque
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Factors affecting cariogenicity of
carbohydrates
1. Types of carbohydrates.
2. Total amount of carbohydrate intake.
3. Frequency of carbohydrate intake.
4. Consistency and texture of
carbohydrate.
5. Refinement of carbohydrate.
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Tooth
Demineralization
and
Remineralization
of enamel
Plaque
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Demineralization phase
Pathogenesis of dental decay
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Ca10(PO4)6(OH)2
CaHPO4 + Ca2+ H
+ H2O
Ca (H2PO4)2 +
Ca2+
Ca2+ +
2H3PO4-
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(phosphoric acid)
Types of Dental Caries in the Hard Tooth Structure
Enamel Caries Dentin Caries Cementum Caries
(Root caries)
Smooth surface caries Pit and fissure caries
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Types of Dental Caries
(According to Rapidity of Lesion)
Acute (Rampant): dental caries that involve
several teeth, appear suddenly, and often
progress rapidly.
Chronic: dental caries progressing slowly over
time in several teeth
Recurrent: caries that arise around an existing
restoration due to an alteration in the integrity of
the restoration.
Baby Bottle Tooth Decay: wide spread carious
destruction of deciduous maxillary incisors with
absence of caries in mandibular incisors.
Arrested Caries (in enamel – appear as brown-
stained area at or below the contact point after
extraction of the adjacent tooth). ( in dentin:
eburnation of dentin).
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Enamel Caries
caries lesion rarely
occurs at an
enamel/saliva
interface.
Dental plaque is
the usual
intermediary to the
caries process.
Supraginigival plaque
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Enamel Caries
Early enamel caries is a
subsurface lesion
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Macroscopic Appearance
of Smooth Surface Caries
Early enamel
caries in
a proximal
white
tooth surface
spot
lesion
Why?
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The established early lesion (white spot lesion) in
smooth surface enamel caries is cone shaped with the
base of the cone on the enamel surface and the apex
pointing towards the ADJ
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The established early lesion (white
spot lesion) is a subsurface cone-
shaped lesion
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Conclusion & Significance
of Early Enamel Caries
Initial caries: Demineralization without
structural defect.
This stage can be reversed by
fluoridation and enhanced mouth hygiene.
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Cone shaped with the base of the cone on the
enamel surface and the apex pointing towards the
ADJ
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Proximal smooth surface caries appear in the bite-
wing radiographs as a wedge or cone shaped
radiolucent area in enamel
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The zones of Initial Enamel Caries Seen in
Ground Section Examined by Transmitted
Light Microscope:
1. Translucent zone
2. Dark zone
3. Body of the lesion
4. Surface zone
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In concave surface
(pit and fissures)
base towards DEJ.
In convex surfaces
(smooth surface)
base away from DEJ.
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The early enamel lesion consists of four zones of
alternating levels of mineralisation
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The early enamel lesion (Cone Shaped Lesion)
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The zones of Initial Enamel Caries Seen in
Ground Section Examined by Polarized Light
Microscope:
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The zones of Initial Enamel Caries Seen in
Ground Section Examined by Polarized Light
Microscope:
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Early Enamel Caries
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White Spot" Lesion (SEM)
small pits representing accentuation of prism outline as the earliest
stage of enamel decay.
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Demineralized Enamel (SEM)
This represents initial surface breakdown of
enamel and is the next stage after the white
spot lesion
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TRANSLUCENT ZONE
Zone of Intial demineralization
More porous than the normal enamel.
contains 1% by volume space
These pores are larger than the normal
enamel.
Chemical analysis show that there is a fall in
the magnesium and carbonate content as
compared to the normal enamel
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Dark zone
This zone contains 2-4% by volume pores
Some pores are large and some are smaller
than the translucent zone suggesting that
some remineralization has occurred.
In rapidly advancing lesion the dark zone
narrow.
In this zone previously liberated salts are
redeposited
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Body of the Lesion
This zone has pore volume of 5-25%
It contains appetite crystals larger than the
normal enamel.
The is more of an effort for the
remineralization but by the further attack
there is further dissolution of the mineral
Thus this is the zone of maximum
demineralization.
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Surface zone
This is about 40 micrometer thick
This part is relatively normal because in this
area there is maximum remineraization from
the inorganic components of both the plaque
and saliva.
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Early Dentinal
Changes
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Direction of Cones in Pit
& Fissure Caries AND
Smooth Surface Caries
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DENTINAL CARIES
This differs from the enamel caries as it is a
living tissue it responds in a unique way.
So there is also a defense mechanism that is
activated in the dentine caries by pulp-predentin
complex.
Caries spreads much faster in this zone
because it is much porous and has dentinal
tubules.
Bacteria produce large amount of proteolytic
enzymes causing destruction of dentin.
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Early Dentinal Changes
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Early Dentinal Changes
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Early Dentinal Changes
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Early Enamel & Dentine Caries
(Two Successive Cones)
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Advanced Dentinal Changes
(Cavitation of Enamel)
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The events of the dentinal
caries are as follows:
1- Defense reaction of the pulpodentinal
complex:
A. Seclerosis
B. Reactionary dentine formation
C. Sealing of the dead tracts
2- Carious destruction:
A. Demineralization
B. proteolysis
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Bacterial Invasion of Dentinal Tubules
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Bacterial Invasion of Dentinal Tubules
The first wave consists of acidogenic organisms
(pioneers) mainly lactobacilli produce acids which
diffuse ahead into the demineralized zone.
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Bacterial Invasion of Dentinal Tubules
Distention
of dentinal
tubules
“beading”
The second wave, mixed acidogenic and proteolytic
organisms then attack the demineralized dentin and
causing the digestion of protein matrix.
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Adjacent beads coalescing with each other forming larger
distended segments of dentinal tubules filled with micro-
organisms, this is referred to as liquefaction foci.
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Transverse Clefts in Dentine
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Transverse Clefts are due to lateral spread of acids
and bacteria along incremental lines or along lateral
branches of dentinal tubules.
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Nursing Bottle Caries
Baby bottle tooth decay
Def. & Incidence:
Baby bottle tooth decay is a dental problem that
frequently develops in infants that are put to bed
with a bottle containing a sweet liquid.
Baby bottle tooth decay is also called nursing-
bottle caries and bottle-mouth syndrome.
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Nursing Bottle Caries
Baby bottle tooth decay
Etiology:
Bottles containing such liquids as milk, formula,
fruit juices, sweetened drink mixes, and sugar
water continuously bathe an infant's mouth with
sugar during naps or at night.
The bacteria in the mouth use this sugar to
produce acid that destroys the child's teeth.
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Nursing Bottle Caries
Baby bottle tooth decay
Pathogenesis:
Bacteria and substrate need to be present
for a prolonged time to allow
demineralization and caries progression.
The bottle at nap time or bedtime is most
dangerous.
Fluids may pool around the teeth for
hours.
The teeth primarily affected by that are
the maxillary incisors.
Lower teeth are in general less affected
since they are covered by the tongue.
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Nursing Bottle Caries
Baby bottle tooth decay
Clinical Features:
The first signs of damage are
chalky white spots or lines
across the teeth. As decay
progresses, the damage to the
child's teeth becomes obvious.
Nursing pattern decay has also
been reported with prolonged
and unrestricted nighttime
breast-feeding.
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Nursing Bottle Caries
Baby bottle tooth decay
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ROOT CARIES
This starts when the root is exposed to the oral
environment as a result of the periodontal disease
this is followed by the bacterial colonization.
There is subsurface demineralization of the
cementum and the chain of events is similar in the
dentine as it is in the crown portion.
Micro-organisms invade the cementum either
along the Sharpey’s fibers or between the bundles
of fibers.
Spread laterally, since cementum is formed in
concentric layers.
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ROOT CARIES
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Caries originating on the root is alarming
because
1. It has a comparatively rapid progression
2. It is often asymptomatic
3. It is closer to the pulp
4 it is more difficult to restore
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Arrested
Caries
Arrested Caries Arrested Caries
of Enamel of Dentine
On lingual Hardness of
Hard Discolored
and labial the
Proximal Spot
aspects
Smooth-surface Remineralization dentine surface
After cavitation
lesion from saliva and a yellow to
of
prior to cavity or dark brown
Enamel
formation topical
& Destruction colour.
application
of edges
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Arrested Caries of Enamel
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Arrested Caries of Dentine
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Arrested Caries of
Dentine
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Sequelae of Dental Caries
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