Cariology

PART 2

Presented by-
Dr. Neha Sultana
Post graduate student
Department of conservative dentistry and endodontics
Contents
• Introduction and definiton
• Epidemiology
• Related theories
• Etiological agents
• Plaque development
• Pathophysiology of caries
• Clinical characteristics
• Classification
• Histopathology
• Diagnosis
• Caries risk assessment
• Caries activity tests
• Treatment modalities
• Recent advances
• Concept of remineralisation
• Minimally invasive dentistry
• Caries vaccine
• Caries prevention
Demineralization- remineralization cycle
Classification
• According to site of the lesion
(1) pit and fissure caries

(2) smooth surface caries

• (3) root caries
• Based on the rate of caries progression
(1) acute dental caries

(2) chronic dental caries.

• (1) primary

• (2) secondary (recurrent) caries.

• Based on chronology,
• Infant caries (nursing bottle caries)

• adolescent caries.
• Active

• Arrested or inactive
G V Black’s classification
• Class I
• Class II
• Class III
• Class IV
• Class V
• Class VI (Simon)
Site and size concept . (BY MOUNT AND
HUME, 1997)
Caries lesion occur only on 3 sites on the crown/root of a
tooth :
• SITE 1. pits, fissures and enamel defects on occlusal
surfaces of posterior teeth or other smooth surfaces;

• SITE 2. proximal enamel in relation to areas in contact

with adjacent teeth ;

• SITE 3. the cervical one-third of the crown or, following

gingival recession ,the exposed root.
• 5 separate sizes:
• Size 0: initial stage of demineralization.

• Size 1: minimal surface cavitations with involvement of dentin

just beyond treatment by remineralization alone.

• Size 2 : moderate involvement of dentin

• Size 3: the lesion is enlarged beyond moderate.

• Size 4: extensive caries or bulk loss of tooth structure has

already occurred.
Clinical characteristics
• Color

• Texture

• Shape
 Changes in enamel
Accumulation of plaque

1week
No changes macroscopically but changes at ultra
structural level and histologically
14 days

Enamel changes- whitish opaque on air drying. Subsurface

lesion stars to form

3-4 weeks

Clinical changes can readily be seen without air drying

After 4 weeks
Active enamel lesion with a characteristic chalky surface due to
demineralization, causes a loss of translucency and this makes the
enamel appear opaque
This experiment was demonstrated by Thylstrup and Fejerskov in 1981 and Holmen et al in
1985
• Mineral loss occurs predominantly underneath the enamel
surface.

• Protective role of salivary proline rich proteins and other

salivary inhibitors such as statherin during enamel
demineralization has been suggested (Hay et al).

• These inhibitors
– prevent spontaneous and selective precipitation of calcium phosphate
or crystal growth of these salts directly onto the enamel surfaces
– they also tend to inhibit demineralization.

• Specific and inherent properties of the outer surface in terms

of ultrastructural and chemical composition may play a role in
the relative protection of the surface layer (Weatherell et al).
Approximal white spot lesion
• Shape- determined by the accumulation of microbial deposits
between the contact facet and the gingival margin
• Kidney shaped appearance
• Thin extensions of the opaque area in buccal and lingual
directions
SEM features of normal enamel

Perikymata and Tomes’ processes pits Ends of rounded crystals separated by

intercrystalline spaces
SEM features of white spot lesion
• Contact facet has a smooth appearance without the
perikymata pattern

• Along the periphery of the facet, irregular fissures and other

small defects

• Innumerable irregular holes- are deepened and more

irregular pits of Tomes’ processes
Dissolution of rod (R ) and inter rod areas
(IR)
Characteristic of active lesion at subclinical
stage.
After 4 wks, loss of larger parts of
perikymata overlappings
• Final enamel exhibits widened inter crystalline spaces, and
minor fractures of the perikymata edge

• In extensive lesions, they involve 2,3 or more perikymata

whereby microcavities are formed.

• At the bottom of such microcavities, the classical honeycomb

pattern is seen.
Inactive enamel lesion with a mirocavity.
At the bottom of the cavity, openings of striae of Retzius are seen.
Rod pattern is clearly visible in exposed parts of enamel.
Histology of white spot lesion
• Four zones

(1) Surface zone-

• Pore volume exceeding 1%

• Wedge shaped defect with the base at enamel surface
• 20-50 microns in width
• Zone of negative birefringence
(2) body of the lesion
• pore volume exceeds 5%
• about 25% in the centre of the intact lesion.

(3) Dark zone

occurs in 90-95% of lesions
pore volume 2-4 %
terminology ??
positive birefringence under polarized microscope
(4) Translucent zone

apparently structureless translucent zone

50-100 microns in width

volume of slightly greater than 1%

reason for the translucent appearance??

 HISTOLOGY OF ENAMEL CARIES

1. Surface zone
2. Body of the lesion
3. Dark zone
4. Translucent zone

Ground section examined in polarized light after imbibition in water

Pore volume
distribution of the four
zones
Progression of enamel lesion

1. Reactive dentin, 2. sclerotic dentin, 3. zone of deminerlization, 4. zone of

bacterial invasion, 5. peripheral rod direction.
1. Reactive dentin, 2. sclerotic dentin, 3. zone of deminerlization, 4. zone of
bacterial invasion, 5. peripheral rod direction.
Histologic sections exhibiting progression of occlusal caries
Arrest of the carious lesion
• The first step is removal of the acid producing origin of the
disease, the cariogenic plaque.

• Secondly, clinical changes associated with wear and polishing

of the partly dissolved external microsurface of the active
lesion.

• remineralization does not play any causal role in arrest.

• Concerning redeposition of mineral through the surface layer
into the internal surface in vivo, available data suggest that
the surface layer in itself forms a diffusion barrier against
subsurface uptake of mineral (Larsen and Fejerskov, 1989).

• Arrested lesions with an intact surface layer remain as scars in

the tissue.
Occlusal caries
• Occlusal surfaces of posterior teeth- most vulnerable sites
• Presence of narrow and inaccessible pits and fissures
• Two factors are important (Carvalho et al) -
– stage of eruption or functional usage of teeth
– tooth specific anatomy
 In deep pits and fissures, accumulation of bacterial deposits
occurs and demineralization starts.

enamel demineralization always follow the rods, lesion initiated in a fossa

gradually assumes the shape of a cone with its base towards DEJ.

With progressive enamel destruction, a proper cavity is formed which is

shaped as a truncated cone

openings of occlusal cavities are always smaller than the base

The ‘closed’ nature of the process obviously favors

undisturbed growth of bacteria and hence accelerated
destruction of the tissue.
Ground sections
showing
progression of
caries
Caries progression in dentin
• Enamel and dentin caries are two different entities as they
are different structurally as well as embryologically.

• As enamel is considered to be a microporous solid, stimuli

from the oral cavity pass through the tissue to the pulpo-
dentinal organ, even in intact enamel.

• With increasing porosity due to enamel demineralization it is

to be expected that the underlying pulpo-dentinal organ
reacts.
• Most common defence reaction is formation of tubular
sclerosis or transparent dentin. (Massler 1967, Johnson et al
1969, Levine 1974, Stanley et al 1983)

• Age changes and attrition causes tubular sclerosis, a reason

why caries progression is slow in older adults.

• Caries accelerates tubular sclerosis, minimal in rapidly

advancing caries and most prominent in slow chronic caries.
• Appears transparent when a ground section is viewed under
transmitted light.

• Under reflected light, it appears dark.

DZ- outer dentin

TZ- sclerotic dentin in transmitted light
Early dentinal caries
• Fatty degeneration of Tomes fibers

– Terminology- questioned

– deposition of fat globules in the Tomes processes

– Special stains- Sudan red

– Significance
• Fat contributes to impermeability
• Predisposing factor for dentinal sclerosis
• Sclerotic dentin-
– it is a defense mechanism of the pulpo-dentinal complex.
– seals off the dentinal tubules from further penetration of microbes.

• Decalcification of dentinal tubules-

– above the zone of dentinal sclerosis.
– appears to occur slightly in advance of the bacterial invasion.
– Pioneer bacteria-microorganisms may be found penetrating the
tubules before any clinical evidence of caries.
• Zone of microbial invasion-

– microorganisms penetrating farther into dentin, more

separated from the carbohydrate substrate.

– high protein content of dentin favor proteolytic organisms

– acidogenic forms are more prominent in early caries.

 Advanced dentinal changes
LIQUEFACTION FOCI- Focus- ovoid area of destruction, parallel to
formed by focal coalescence the course of the tubules,filled with
and breakdown of a few necrotic debris which tends to increase in
dentinal tubules size by expansion

compression and distortion of adjacent dentinal tubules

Acidogenic organisms- initial decalcification

Proteolytic organisms- matrix dectruction

Multiple areas of destruction

Necrotic mass of dentin (leathery consistency)

Formation of transverse clefts and peeling away of carious dentin

Root caries
• Occurs supragingivally, most often at or close to (i.e. within
2mm) the CEJ (Banting, 1976; Banting et al, 1985; Lynch and
Beighton, 1994).
• Location associated with age and gingival recession.

• Root caries occurs predominently on the proximal (mesial and

distal) surfaces, followed by the facial surface (Banting et al,
1985; Schaeken et al, 1991, Fure, 1997; Banting et al, 2001).
Clinical appearance
• Ranges from small, slightly softened, and discolored areas to
extensive, yellow-brown soft or hard areas, which may
eventually encircle the entire root surface.
• Classified as-
Active lesion-
– is a well defined, softened area
– yellowish or light brown discoloration
– likely to be covered by plaque.
– leathery consistency on probing with moderate pressure.
Arrested lesion –
– appears shiny
– smooth and hard on probing with moderate pressure
– color may vary from yellowish to brownish or black
– margins appear smooth
– No visible microbial deposits cover such lesion.
Histopathology of root caries
Early lesion appears as a
radiolucent zone in the
root cementum and the
surface may appear softened.

Ground section showing root caries

C- cementum , SZ- sclerosis
• At more advanced stages of destruction, the demineralization
spreads into the underlying dentin, often extending several
hundred microns below the surface.

• Root caries lesions can be converted from active into inactive

stages by non-operative treatment (Nyvad & Fejerskov, 1987).
• Regular plaque removal from the surface of active root caries
lesion is not likely to eliminate the microorganisms that have
penetrated deep into the dentin.

Change in the environmental

condition may result in
mineral deposition within
the microbial
mass (calculus formation- CA).

Note the subsurface lesion cervical to

the calculus formation
Diagnosis of caries
• Accurate diagnosis of the presence, extent and activity of a
disease process -fundamental requirement in health care.

• 5 reasons why is it important (Knottnerus and van Weel,

2001).
– Detecting and excluding disease
– Assessing prognosis
– Contributing to the decision making process with regard to further
diagnostic and therapeutic management
– Informing the patient
– Monitoring the clinical course of the disease
Diagnostic techniques
• Visual and tactile examination
• Radiographic examination
• Newer techniques
– light scattering
– Optical coherence tomography
– Dyes
– Electrical conductance measurements
– Xeroradiography
– Computerized tomography
– Subtraction radiography
– Quantitative laser and light induced fluorescence (QLF)
– FOTI
– DIFOTI
Visual-tactile examination
• 3 prerequisites are there:
• Well illuminated field and clean, dry teeth
• Sensible use of the probe- serves 2 functions

– to remove the biofilm (using the side of the probe)

– to ‘feel’ the surface texture of a lesion

• Knowledge of the caries predilection sites
• preschool age-distal surface of the first primary molar
followed by the mesial surface of the second primary molar
• Teenagers- distal surfaces of the second premolars and the
mesial surfaces of the second molars are most prone to lesion
development

• elderly age group, with gingival recession root caries may

become a problem
• In vitro visual examination has limited sensitivity i.e. below
30%

• With experience and specific training, sensitivity greater than

60% (60% accurate detection of true disease) and specificity
greater than 80% (80% accurate determination of absence of
disease) are possible for diagnosis of borderline dentin caries
lesions, those in the zone of diagnostic doubt
(Downer MC. Validation of methods used in dental caries
diagnosis. Int Dent J 1989; 39(4):241-6.)
Additional aids in visual method
• Fibre-optic transillumination

– visible light is transmitted through the tooth from an

intense light source

– principle -increased mineral loss in an enamel lesion leads

to a twofold increase in scattering coefficient.
• Sensitivity -50-85% (Vaarkamp et al, 2001)

• Higher values for dentin

lesions than for enamel
lesions and
specificity is reported
to be high, over 95%.
• Tooth separation-
– to identify the approximal lesions
– with the help of orthodontic elastic separator
– Tooth separation is an important tool as compared to
tactile-visual examination alone and bitewing radiography
(Pitts and Rimmer 1992, Hintze et al 1998).
• Magnification-

– no scientific evidence that magnification per se improves

caries detection in clinical settings but some contemporary
books advocate the use of magnification for caries
diagnosis.
• Visual tactile criteria -
– Recording of cavities only (WHO 1997)

– Recording of cavitated and non-cavitated lesions (Pitts and Fyffe, 1998)

– Lesion depth assessment (Ekstrand et al, 1995, 1997)

– Lesion activity assessment (Nyvad et al, 1998)

– Root surface caries (fejerskov et al, 1991)

– UniViSS system comprising of (1) severity assessment (the severity also

determines the detection level, if a caries lesion is present); (2)
discoloration assessment; and (3) activity assessment.
Radiographic methods
• Findings on bite-wing radiographs are useful indicators of
dentinal decay on occlusal surfaces, and the prevalence of
occlusal caries may be underestimated without such imaging
(Ketley CE, Holt RD)
(Br Dent J 1993; 174(10):364-70).

• In vitro experiments have shown that, once an occlusal lesion

is clearly visible on radiographs, demineralization has
extended to or beyond the middle third of the dentin (Ricketts
DN, Kidd EA, Smith BN, Wilson RF)
(Clinical and radio- graphic diagnosis of occlusal caries: a
study in vitro. J Oral Rehabil 1995; 22(1):15-20).
• In vitro bite-wing radiography alone resulted in a sensitivity of
58%, higher than that of visual inspection

• specificity of 87% (i.e., 13% false positives), lower than that of

visual inspection
(Ferreira Zandoná AG, Analoui M, Schemehorn BR, Eckert GJ,
Stookey GK Caries Res 1998; 32(1):31-40).
• Limitations-
– underestimate lesion size
(Kidd EA, Ricketts DN, Pitts NB. Occlusal caries diagnosis: a
changing challenge for clinicians and epidemiologists. J
Dent 1993; 21(6):323-31).

– false positives can occur

– superimposition of buccal and lingual enamel, caries of the

occlusal enamel are not generally visible and early dentinal
involvement is difficult to ascertain
• False positives due to-

– Mach band effect

– Cervical burnout

– restorative material like porcelain, silicates etc may mimic

dental caries
Newer techniques
• TRANSILLUMINATION-
– for early caries detection without the need for ionizing
radiation but visible light
– can also be used to inspect the integrity of
tooth/restorations for fracture and wear
• Technique –
– tooth decay scatters and absorbs more light than does
surrounding healthy tissue and thus appears darker .

The DIFOTI
(Electro-Optical
Sciences Inc.) uses
white light, a CCD
camera, and
computer-controlled
image acquisition
and analysis to detect
caries.
• Limitations-

– does not measure the lesion depth.

– learning curve is involved in discerning the differences

among deep fissures, stains and actual dentinal lesions.

– Over diagnosis can occur

– White spots can be mistaken for cavitations

• DYES-

– Introduced by Fusuyama in 1972 using basic fuschin red

stain

– potential carcinogenicity of basic fuchsin ,replaced by

another dye, acid red 52

– Commercial products
• Based on acid red 52- Caries Detector, Kuraray
• red and blue disodium disclosing solution -Cari-D-Tect
• ENAMEL DYES –

– Procion dyes: irreversibly stains enamel by reacting with nitrogen and

hydroxyl groups.

– Calcein dyes: makes a complex with calcium and remains bound to

lesion

– Fluorescent dye: like Zyglo ZL-22 are made visible by U-V light.

– Brilliant Blue: enhances the diagnostic quality of FOTI.

– Modified Dye Penetration method

the iodine (potassium iodide) method is used for measuring the
enamel porosity of incipient carious lesions (Bakhos,1977)
• Principle

irreversible breakdown of collagen cross-linking

loosens the collagen fibers.

Staining occurs

POINT TO REMEMBER- dyes do not stain bacteria but instead

stain the organic matrix of poorly mineralized dentin
• Technique
– 1% acid red 52 solution for 10 seconds.

– rinse with water for 10 seconds

– If the stained tooth structure is soft and appears carious, it should be

removed.
• Dyes for dentinal caries-

– to differentiate two zones in dentin, the outer

demineralized and inner one that remains unstained.

– Basic fuchsin in propylene glycol had been used. Due to its

carcinogenic potential it has now been replaced by Acid
Red and Methylene Blue eg. Cari-D-Tect
• ELECTRICAL CONDUCTANCE MEASUREMENTS

– Magitot in 1878

– Principle –

• sound surfaces should possess limited or no conductivity

• carious or demineralized enamel should have a measurable

conductivity that will increase with progressing demineralization

• Demineralization results in increased porosity, saliva fills these

pores and forms conductive pathways for electric current.
• Instruments developed for ECM:
• 1)      The Vanguard electronic caries monitor.
• 2)      The Caries meter

The electronic caries

monitor (Lode
Diagnostics) measures a
tooth’s electrical
resistance during
controlled air drying to
determine its mineral
content.
Vangaurd • Reading is converted to
an ordinary scale 0 to 9
electronic
caries
monitor

• Reading is converted to
4 coloured lights
Caries • Green – No caries
• Yellow – Enamel caries
meter • Orange – Dentine caries
• Red – Pulpal caries
• Electric resistance value of any given area of a tooth
depends on
– local porosity
– amount of liquid present
– Temperature
– mobility of the liquid
– ion concentration of the liquid

To avoid the influence of surface liquid (saliva), the ECM

technique involves drying the tooth surface using a
standardized airflow procedure
• QUANTITATIVE LIGHT INDUCED FLOURESCENCE
(Benedict)
Principle-
• interaction of the wavelength illuminating the object and
the molecule in this object

• energy is absorbed and electronic transition to a higher

level state

• From here the electrons may fall back to the ground state
and release the gained energy in terms of longer
wavelength and color, which is related to the energy
given off and fluorescent light can be emitted
• Booiji and Bosch suggested that

– chromophore dityrosine is responsible for blue

fluorescence

– yellow by cross-linked structural proteins

– red attributed to protoporphyrins( bacterial metabolites).

• DIAGNOdent (KaVo)

– laser fluorescence device

• operates at a wavelength of 655nm at which clean healthy
tooth structure exhibits little or no flourescence
• very low scale readings on the display
• carious tooth structure will exhibit flourescence
proportionate to the degree
• elevated scale readings on the display of DIAGNOdent,
enabling the practioner to access the carious lesion.
• Sheehy et al and Lussi et al proved it to be a valuable
clinical adjunct in caries detection.

• Data from Indiana- Iowa study reveals specificity of

DIAGNOdent to be 98.9%.
Disadvantages
• the question of what the method really measures has yet to
be resolved.

• more research is needed to clarify the origin of the increased

fluorescence

• poor correlation between LF readings and the mineral content

.
• DIAGNOdent device was not able to distinguish clearly
between deep dentinal caries and more superficial dentinal
caries (Journal of the Canadian Dental Association ,
September 2001, Vol. 67, No. 8).
• XERORADIOGRAPHY
– simulates the photocopying machine
– image is recorded on an aluminum plate coated with a
layer of selenium particles

x-rays are passed on to the film

selective discharge of the particles

this forms the latent image

converted to a positive image by a process

called development
• TOMOGRAPHY

– radiographic technique that essentially “slices” the teeth into

thin sections

– computers then reassemble the sections to generate a three-

dimensional image

– all angled views will be simultaneously captured in one exposure.

• DIGITAL SUBTRACTION RADIOGRAPHY

– uses a computer to assess, in two or more radiographs

– the two digital images to be compared are brought into

the computer software

– stored in a numeric format in the computer memory and

can be compared mathematically

– the background images that have not changed—crowns,

fillings, etc.—are subtracted
• DIGITAL TECHNIQUES

DIRECT INDIRECT

•receptor sends the •receptor is inserted

data directly to a into a reader or
computer via wires or scanning device that
wireless transmission sends the data to the
computer

•create images using

Phosphor Storage
Plates (PSP)
• PHOSPHOR STORAGE PLATES
– Primarily made of a remnant phosphor layer that
"remembers" the image, hence the name of "storage
plates”

– to read out the image, phosphor plates need to be put into

a phosphor plate reader

– it illuminate the plate by a tiny laser beam and emits light

which is collected by a digital imaging device.

– An image is said to be digital when it is composed of

separate (distinct) elements. Each element is called a
"picture element" or pixel.
• RVG

– x-ray beam crosses the object and reaches the sensor.

– sensor catches the information immediately

– turns it into electrical signal that is sent to the computer.

• Advantages

• Eliminates image distortions due to film bending.

• high resolution of the image (over 20 line pairs per mm)

• Unparalleled diagnostic capabilities dueto :the ultimate

imaging filter, sharpness filter, pre-programmed modes and
high light tool
TO BE CONTINUED…