Cariology

Definition:
• Dental Caries
• Dental caries is a biofilm-mediated,
diet modulated, multifactorial, non-
communicable, dynamic disease
resulting in net mineral loss of dental
hard tissues. It is determined by
biological, behavioral, psychosocial,
and environmental factors. As a
consequence of this process, a caries
lesion develops.
Etiology of dental caries
• Caries is a chronic, multifactorial
disease, which causes destruction and
demineralization of hard tissues of
teeth by acid production occurring
from bacterial fermentation of food.
DENTAL CARIES AS DISEASE
• Dental caries develops because certain
bacteria in the oral cavity ferment
carbohydrates (sugars) into organic
acids, which in the case of lactic acid
may result in dissolution of dental hard
tissue.
• Cariogenesis- production of dental
caries
 Dental plaque and biofilm
• Biofilms are usually associated with the • This accumulation of microbes on the tooth
etiopathogenesis of periodontal diseases. In surface is called plaque, which can be
order to survive in a niche, the ability of defined as “a structure entity in which the
microbes to adhere to tooth surface and microbes are embedded in a highly
multiply in protected environments like tooth organized intercellular matrix,” These
cervices and periodontal pockets is very microbes are involved in different metabolic,
important. physical, and molecular interactions. This
consortium provides advantages to the
participating microbes for resistance to
antimicrobial agents, increased
pathogenicity, growth, and host defenses .
• The primary colonizers of tooth • This occurs by means of
from the biofilm by auto- accumulation of different
aggregation and co-aggregation signaling compounds that
resulting in different morphological facilitate the intercellular
structures. The microenvironment communication. This gives
moves from aerobic to facultative biofilm their unique
anaerobic. The bacteria multiply characteristics
and in matured biofilm occur.
Quorum sensing is another
important characteristic seen in
biofilm-associated bacteria, which
actually involves the regulation of
specific gene expression.
Caries Activity
• Caries activity is a concept that
reflects the mineral balance, in
terms of net mineral loss, net
mineral gain, or stasis over time.
Caries active implies caries
initiation/progression; caries
inactive implies caries
arrest/regression.
Caries Diagnosis
• Caries diagnosis is the clinical
judgement integrating available
information, including the detection
and assessment of caries signs
(lesions), to determine presence of the
disease. The main purpose of clinical
caries diagnosis is to achieve the best
health outcome for the patient by
selecting the best management option
for each lesion type, to inform the
patient, and to monitor the clinical
course of the disease.
Caries Prevention
• Caries prevention traditionally meant
inhibition of caries initiation, otherwise
called primary prevention. Primary,
together with secondary and tertiary
prevention, comprising non-operative
and operative treatments, are now
summarized under Caries
care/management/control.
Caries Care/Management/Control
• Caries care/management/control are
actions taken to interfere with mineral
loss at all stages of the caries disease ,
including non-operative and operative
interventions/treatments. Because of
the continuous de/remineralization
processes, caries control needs to be
continued throughout the life course.
The terms caries
care/management/control may be more
appropriate than the term Caries
prevention.
Definitions of Terms Related to the
Dental Caries Lesion
Caries Lesion
• Caries lesion is the clinical sign of
caries. Caries lesions can be
categorized according to their
anatomical location on the tooth
(coronal or root/cementum surface),
their severity (e.g., non-cavitated,
cavitated), depth of penetration into the
tissue (e.g., enamel, dentin, pulp), and
their activity status (active, inactive).
Initial Caries Lesion
• Initial caries lesion is a frequently used
term for non-cavitated caries lesion.
Although the term implies an early-
stage lesion, the lesion could have been
present in the mouth for a lifetime. The
term refers to the stage of severity and
does not inform about lesion activity.
White-Spot Lesion = “White Spot”
• The first clinical signs of caries.
• It appears white, because a greater proportion of the
incoming light is being backscattered as compared
with the surrounding sound enamel.
• When located at the vestibular or oral aspect of the
tooth just above the gingival margin, they are spread
out in a line
• When located interproximally, typically appear as
oblong shapes below or around the contact point
• When located occlusally, white spot caries lesions
develop locally in particular in the fossa areas and
grooves
Active vs Inactive White Spot
Lesion
• A. Active white spot- lesion shows a
matt, dull surface.
• B. Inactive lesion- presents a shiny
surface
o mainly due to incorporation of minerals
(remineralization), and abrasion and polishing related
to plaque removal
Secondary Caries/Recurrent Caries
• Secondary caries/recurrent caries is a
caries lesion developed adjacent to a
restoration.
Residual Caries
• Residual caries is a demineralized
carious tissue left in place before a
restoration is placed.
“Hidden” Caries
• “Hidden” caries is a caries lesion in
dentine missed on visual inspection but
detected radiographically or with other
detection devices. In the context of
present diagnostic knowledge, it is a
historic and confusing term.
Rampant Caries
• Rampant caries is a historic term used
to describe multiple caries lesions in
the same patient, often used in
association with early childhood caries
or radiation caries.
ROOT CARIES
• Development of root caries relies on the
exposure of root areas, mostly due to gingival
recession, and the accumulation of plaque.
• The cementum layer may cover the outer
surface of the exposed root. This layer can be
removed with time by toothbrushing or dental
therapeutic removal of tartar,polishing, or
periodontal treatment (scaling and root
planing).
• It has been observed that bacteria are already
able to penetrate the cementum layer in an
early state of root caries development, while
bacteria penetrate into the underlying dentin at
a later state of lesion development.
ICDAS 1
ENAMEL CARIES
*Lesion progression of white spot lesions within
enamel roughly follows the rod/prism direction
Caries Progression
• Approximal surface or smooth surface resembles a
cone with its base at the enamel surface and its tip
toward the enamel–dentin junction.

• Occlusal fissure lesion is with the tip at the

surface and the base toward the EDJ due to the
directions of the prisms in the fissure area.
DENTIN CARIES
• As soon as the EDJ is reached, the caries may spread
along the EDJ to a certain extent and from there into the
dentin
• The spread of the caries process within dentin
follows the direction of the dentinal tubules.

• Enamel is a cell-free tissue which does not show any

cellular response in the case of caries attack; enamel
reaction is based on chemical dissolution and
precipitation phenomena.

• Dentin is different, because it has to be considered as

vital tissue, since it contains living cellular processes
from the odontoblasts lining the pulpo-dentinal wall
• The dentin–pulp unit is an organ in itself, consisting
also of blood and lymphatic vessels, connective tissue,
nerve tissue, stem cells, etc. This allows the dentin–pulp
unit to react to stimuli, albeit physiological masticatory
forces, traumatic injury (thermal, mechanical or
chemical), or caries.
Early Signs of Dentin Reaction
• first sign of dentin reaction is tubular sclerosis.

1. Tertiary Dentin
• the odontoblasts start building a layer of reactive dentin,
also referred to as reparative or tertiary dentin.

• Under highly cariogenic conditions—

that is the expression of reactive dentin is accelerated
and its structure may be poorly organized (dysplastic)
with lack of dentinal tubules, and is called osteodentin
or fibrodentin.

• Mature tertiary dentin consists of type I

collagen, as normal dentin does, while its predentin
also comprises type III collagen.

• In the earlier state of dentin affected by the caries

process, a layer of normal, unaffected dentin
remains below the reactive dentin.
2. Sclerotic Dentin (Subtransparent Zone)
✔ Demineralization
✔ Damage to odontoblastic process
✔ No bacteria
✔ Dentin is still capable of remineralization
• Sclerotic dentin shows occluded tubules
with a thick peritubular layer, and a calcified tubular
lumen that contains predominantly highly organized
apatite crystals and, to a lesser degree, crystals of the
Whitlockite type.
3.Dead Tracts
• Due to tubular occlusion within the sclerotic
zone and retraction of the odontoblastic
cellular processes, the dentinal tubules in
the dead-tract zone appear empty and cut
off from the living odontoblast; that is why
it is commonly termed“dead tract.”
4. Demineralized Zone (Transparent Dentin)

• Demineralized zone can be found, usually when carious

enamel demineralization reaches the DEJ. It is caused by
the penetration of organic acids of bacterial origin into
the dentin
• As long as the enamel has not collapsed, it is unlikely
that bacteria penetrate the underlying dentin. This
means that the cariogenic acids, enzymes, and toxins
of bacterial origin are synthesized in the dental
plaque covering the enamel surface and,
consequently, travel deep into the dentin by diffusion
as long as the enamel surface has not broken down.

• Still at this point, the zone of demineralization

precedes the bacterial invasion.This is of some clinical
relevance, because it means that demineralized dentin
does not necessarily contain bacteria and may be left
during excavation.
i = demineralized enamel with initial cracks
ii = black/dark brown discoloration of demineralized
dentine
iii = light brown discoloration of demineralized
dentine (the dark discoloured zones reflect areas of
arrested caries)
iv = hypermineralized dentine (zone of sclerosis)
v = tertiary dentine (reactionary dentine))