PREVETION OF

DENTAL CARIES
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 INTRODUCTION
Dental caries is defined as a progressive irreversible
microbial disease affecting the hard parts of tooth
exposed to the oral environment, resulting in
demineralization of the inorganic constituents and
dissolution of the organic constituent, thereby leading to
a cavity formation.
• The word caries derived from Latin meaning ‘rot’ or
decay
• Similar to the Greek word ‘ker’ meaning death
• The relationship between diet and dental caries
Bacterial enzymes + fermentable carbohydrates = acid,
Acid + enamel = dental caries
 CURRENT TRENDS IN CARIES
INCIDENCE
• In developed countries, caries prevalence
declined in last decade, causes are
multifactorial. Eg: communal water
fluoridation.
• In developing countries increase in caries
prevalence, cause is increased use of
refined carbohydrates.
 CARIES SUSCEPTIBILITY JAW
QUADRANTS
• Bilateral distribution between the right and
left quadrant of both maxillary and
mandibular arches.
• Maxillary teeth more susceptible than
mandibular arch
 relate to gravity and saliva, with its
buffering action, would tends to drain from
upper teeth and collect around lower teeth.
 CARIES SUSCEPTIBILITY OF
INDIVIDUAL TEETH
• Upper and lower first molar  95%
• Upper and lower second molar  75%
• Upper second bicuspid  45%
• Upper first bicuspid  35%
• Lower second bicuspid  35%
• Upper central and lateral incisor  30%
• Upper cuspids and lower first bicuspid  10%
• Lower central and lateral incisor  3%
• Lower cuspids  3%
• Teeth farthest back in the mouth are more frequently carious.
• Caries susceptibility of individual tooth surface
occlusal > mesial > buccal > lingual
 ECONOMIC IMPLICATION OF
DENTAL CARIES
Factors changing the economic implication of
treatment of dental caries :-
• Economic status of population
• Increasing educational status
• Growing number of dental graduates
• Insurance programs
• Commercial pressure
• Governmental influences
 CLASSIFICATION OF DENTAL
CARIES
A) Black’s classification
CLASS I – cavities on the occlusal surface of premolars
and molars, on the occlusal two-third of the facial and
lingual surface of molars, on lingual surface of maxillary
incisors.
CLASS II – cavities on the proximal surface of posterior
teeth
CLASS III - cavities on the proximal surface of anterior
teeth that do not include the incisal angle
CLASS IV – cavities on the proximal surface of anterior
teeth that include the incisal angle
CLASS V – cavities on the gingival third of the facial or
lingual surface of all teeth
CLASS VI - cavities on the incisal edge of anterior teeth or
occlusal cusp height of posterior teeth
B[1] According to location on individual
teeth
- Pit and fissure caries
- Smooth surface caries
B[2] According to the rapidity of the process
- Acute dental caries
- Chronic dental caries
B[3]
- Primary caries (virgin)
- Secondary caries (recurrent)
PIT AND FISSURE CARIES
- Pits and fissures with high steep walls &
narrow base  retention of food, debris,
micro organisms  fermentation  acid
production
- Caries appear brown/ black, feel soft
- Enamel bordering  opaque bluish
white
- Large carious lesion with a tiny point of
opening
SMOOTH SURFACE CARIES
- Preceded by formation of microbial/ dental
plaque
- Begins just below contact point and appear in
early stages as faint white opacity of enamel
(chalky spot)  slightly roughened 
surrounding enamel bluish white as caries
penetrate enamel
- Cervical carious lesion crescent shaped
cavity (extend from areas opposite to the
gingival crest occlusally to convexity of tooth
surface)
ACUTE DENTAL CARIES
- Rapid clinical course & early pulp involvement
- Process rapid  little time for deposition of
sec. dentin. Dentin stained a light yellow
- Rampant caries, affecting deciduous dentition
 nursing bottle caries
- Commonly 4 maxillary incisors followed by
first molar and then cuspids
- Absence of caries in mandibular incisors
distinguished from ordinary rampant caries
• CHRONIC DENTAL CARIES
- Progress slowly and leads to involve pulp
much later
- Sufficient time for both sclerosis deposition of
sec. dentin
- Carious dentin stained deep brown.
- cavity shallow with min. softening of dentin
- Pain and undermining of enamel not a
common feature
RECURRENT CARIES
- Occurs in immediate vicinity of restoration
- Poor adaptation of filling material
ARRESTED CARIES
- Static or stationary caries
- Exclusively in caries of occlusal surface
- Large open cavity and lack of food
retention
- Superficially retained and decalcified
dentin gradually burnished until it takes a
brown stain, polished appearance and is
hard  EBURNATION OF DENTIN
- Caries on proximal surface of teeth 
adjacent approx. tooth extracted
 THEORIES OF CARIES
FORMATION
• Legend of the worm theory
• Endogenous theories
 Humoral theory
 Vital theory
• Exogenous theory
 Chemical (acid) theory
 Parasitic (septic) theory
 Miller’s chemicoparasitic theory – Acidogenic theory
 Proteolysis theory
 Proteolysis chelation theory
 Sucrose – chelation theory
• Other theories
 Auto immune theory
 Sulfatase theory
 ETIOLOGIC FACTORS IN
DENTAL CARIES

• Dental caries is a multifactorial

disease in which there is an interplay
of 3 principle factors.
I. The host ( teeth, saliva etc.)
II. Micro flora
III. Substrate (diet)
• In addition the fourth factor, time
must be considered.
 I. HOST FACTORS
Tooth
• Composition
• Morphologic characteristics
• Position
Composition of tooth
Enamel:-
- Inorganic : 96%
- Organic + water : 4%
Dentin:-
- Organic matter +water :35%
- Inorganic :65%
Cementum:-
- Inorganic : 45-50%
- Organic +water : 50- 55%
Morphological characteristics of the tooth
• Feature predisposed to the development of
dental caries is presence of deep narrow
occlusal fissure/ buccal and lingual pits

Tooth position
• Which are malaligned, out of position, rotated
or otherwise not normally situated, may be
difficult to clean and tend to favor the
accumulation of food and debris which
subsequently lead to dental caries
Saliva
• Composition
• PH
• Quantity
• Viscosity
• Antibacterial factors
Composition of saliva
Inorganic:-
Positive ions:- Ca, Mg, K,
Negative ions:- CO2, Cl, F, PO4,
thiocynate
Organic:-
Carbohydrates : glucose
Lipids : cholesterol, lecithin
Nitrogen : non- protein ammonia,
nitrites & amino acids
protein  globulin, mucin, total
protein
Miscellaneous : peroxides
Enzymes : carbohydrases, proteases,
oxidases
PH of saliva
• Determined by bicarbonate concentration
• PH increases with flow rate, normal PH 7.8
• Sialin is an argenine peptide described PH
rise factor, present in saliva
Quantity of saliva
• Normal quantity 700-800 ml per day
• In case of salivary gland aplasia and
xerostomia in which salivary flow may entirely
lacking, resulting in rampant dental caries
Viscosity of saliva
• Thick, mucinous saliva increases the dental
caries
Antibacterial properties of saliva
Lactoperoxidase
• They participate in killing of microorganisms
by catalyzing the H2O2 mediated oxidation of
a variety of substances in the microbes
• Utilizing thiocynate ions in saliva peroxidation
generate highly reactive chemical compound
that bond and inactivate general intracellular
microbial enzyme system, as well as
microbial surface compound.
Lysozyme
• Small, highly positive enzyme that catalyze
the degradation of negatively charged
peptidoglycan matrix of microbial cell wall
Lactoferin
• Fe binding basic protein found in saliva with mol. wt.
near 80,000.
• Tends to bind & link the amount of the free Fe which
is essential for microbial growth
IgA
• Immunoglobulin in saliva
• Inhibit adherence and prevent colonization of
microbial on tooth and mucosal surfaces
Other salivary components with protective function
Proline rich protein
• Mucus and glycoprotein
• Because of their high proline content, there are rigid
collagen like molecules designed to form a pseudo
membranous layer in the hard and soft oral surfaces
as well as on the oral flora.
Aromatic rich protein
• Statherin
• It causes remineralization
Other host factors
Age
• Dental caries decreases as age
increases
• Root caries are common in elders
• Gingival recession  cemental
exposure (improper brushing)
Socioeconomic status
• High  low chance
• Low  more chance
 II. MICROFLORA
• Strep. mutans  early carious lesions of enamel
• Lactobacilli  dentinal caries
• Actinomyces  root caries
Role of microorganisms in dental caries
• Prerequisite for dental caries initiation
• A single type of microbe is capable of
inducing dental caries
• Ability to produce acid  prerequisite
for caries induction
• Streptococcus strains are capable of
inducing caries
• Organisms vary greatly in their ability to
induce caries
Role of dental plaque
• soft, non mineralized, bacterial deposit which
forms on a teeth that are not adequately
cleaned
• Complex metabolically interconned highly
organized bacteria/ ecosystem
• Important component of dental plaque is
acquired pellicle  just prior or
concomitantly with bacterial colonization and
may facilitate plaque formation
• Microbial in dental plaque
 streptococci
 actinomycetes
 veillonella
• Strep. mutans  chief etiological agent of
dental caries
 III. DIET
• Increase in carbohydrate increase carious activity
• Risk of caries is greater if the sugar is consumed in a
form that will be retained on the surface of the teeth
• Risk of sugar increasing caries activity if it is consumed
between meals
• Increasing caries activity varies widely between
individuals
• Upon withdrawal of the sugar rich foods the increased
caries activity rapidly disappears
• Carious lesion may continue to appear desperate to
avoidance of refined sugar and maximum restriction on
natural sugars dietary carbohydrates
• High concentration sugar in solution and its prolonged
retention on the tooth surface leads to increased caries
activity
• Clearance time of the sugar correlates closely with caries
activity
 THE CARIES PROCESS
• Caries of enamel
 smooth surface caries
 pit and fissure caries
• Caries of dentin
• Caries of cementum
 SMOOTH SURFACE CARIES
• Earliest manifestation is the appearance of an
area of decalcification, beneath dental plaque
with a smooth chalky white area
• Loss of interprismatic substance with increase in
prominence and roughening of ends of enamel
rods
• Accentuation of incremental striae of retzius
• As this process advances and involves deeper
layer of enamel it forms a cone shaped lesion
with apex towards DEJ and base towards
surface of teeth
 PIT AND FISSURE CARIES
• Because pit and fissure provides more depth 
increased food stagnation with bacterial decomposition
• Here caries follow direction of enamel rods and forms a
cone shaped lesion with apex at outer surface and base
towards DEJ
Different zones present in lesion are
Zone 1: translucent zone 
Advancing front of enamel lesion, not always present
Zone 2: dark zone 
Referred as positive zone formed as a result of
demineralization
Zone 3: body of lesion 
Area of greatest mineralization
Zone 4: surface zone 
Appears relatively unaffected
 CARIES OF DENTIN
• Initial penetration of dentin by caries may result in
dentinal sclerosis
• This is a reaction of vital dentinal tubules and a vital pulp,
in which results in calcification of dentinal tubules, that
tend to seal them off against further penetration by
microorganisms
• The different zones which are present in carious dentin
are (beginning pulpally at advancing edge of lesion)
Zone 1 : zone of fatty degeneration of Tome’s fibres
Zone 2 : zone of degeneration
Zone 3 : zone of decalcification
Zone 4 : zone of bacterial invasion of decalcified but intact
dentin
Zone 5 : zone of decomposed dentin
 ROOT CARIES
• Defined as soft progressive lesion that is
found anywhere on root surface that has
lost connective tissue attachment and
exposed to oral environment
• Microorganisms involved in root caries are
filamentous
• Microorganisms invade cementum, along
sharpey’s fibres
INDICES USED TO ASSESSMENT
OF DENTAL CARIES
1. DMFT index
2. DMFS index
3. DEF index
4. Stone’s index
5. Caries severity index

Diagnosis of caries
1. Identification of subsurface demineralization
(inspection/ palpation, radiographs)
2. Bacterial testing (caries activity testing)
3. Assessment of environment conditions like salivary
PH, flow and buffering
METHODS OF CARIES CONTROL
• There are various levels for prevention of
dental caries
these include
1. Primary prevention
2. Secondary prevention
3. Tertiary prevention
levels of Primary prevention Secondary Tertiary prevention
prevention prevention
Preventive Health promotion Specific Early diagnosis Disability Rehabilitation
services protection and prompt limitation
treatment
Services Diet planning, Appropriate use Self examination Utilization of
provided demand for of fluoride, and referral, dental
by the preventive ingestion of utilization of services Utilization of
individual services, periodic fluoridated water, dental services dental services
visit to dental use of fluoridated
office dentifrices
Services Dental health Comm. or school Periodic provision of provision of
provided education water screening and dental dental services
by programs, fluoridation, referral, provision services
community promotion of lobby school fluoride of dental
efforts mouth rinse services
program, school
fluoride tablet
program, school
sealant program
Services Patient education, Topical Complete exam, Complex Removable and
provided plaque control application of prompt treatment restorative fixed
by the program, diet fluoride, of incipient dentistry prosthodontic
dental counseling, recall, supplements/ lesions, minor tooth
profession reinforcement, rinse preventive resin movement,
caries activity preparation, pit restoration, pulp implants
tests and fissure capping
sealants
 METHODS TO CONTROL CARIES
1. Chemical measures
2. Nutritional measures
3. Mechanical measures
 1. CHEMICAL MEASURES
A vast number of chemical substances have been
proposed for the purpose of controlling dental caries
Ideal properties:
• It should be safe for intraoral use
• Must be able to penetrate dense microbial plaque
• Agent used for topical application should not be
systematically toxic if swallowed accidentally
• Should not produce local tissue irritation
• Should be rapidly bactericidal as contact time is less
• Should possess degree of specificity
• Should be destroyed or inactivated by GIT
• Should have an acceptable taste
• Medically important antibiotics should not be used
Chemical measures include:
I. Substances which alter tooth surface or tooth structure
II. Substances which interfere with carbohydrate degradation
through enzymatic alteration
III. Substances which interfere with bacterial growth and metabolism
 I. SUBSTANCES WHICH ALTER
TOOTH SURFACE/ TOOTH
STRUCTURE
• Chemicals falling into this categories
include
a. Fluorides
b. Iodides
c. Bisbiguanides
d. Silver nitrates
e. Zinc chloride and potassium ferrocyanates
Fluoride
• Most widely used and promising chemical in
this category
• Fluorides have been administrated
principally in two ways
a. Systemic application
eg:- School water fluoridation, community water
fluoridation, milk fluoridation, self fluoridation
b. Topical application
eg:- Sodium fluoride, aciduated phosphate
fluoride, stannous fluoride
• A fluoride concentration of 1 ppm in drinking
water is associated with a marked decrease
in dental caries
• Other methods of using fluorides are
 As dietary supplementation of fluoride
 Fluoride dentifrices
 Fluoride in mouth washes/ rinses
 Fluoride incorporated in chewing gums and dental floss
• Rinses for caries reduction
Rinse Concentratio PH Application
n
Aqueous 0.2% 7 Once a wk/
NaF once
every 2
wk
Aqueous 0.5% 7 Once daily
NaF
Aqueous 0.02%` 4 Once daily
APF
 The effect of fluoride influencing its
anticaries actions are:-
• Interference in enzymatic process of
bacteria
• Direct bactericidal action
• Reduction of plaque formation
• Enhancement of enamel remineralization
• Stimulation of formation of large appetite
crystal
• Lowers the solubility of enamel
Iodine
• Used as a antibactericidal mouth
rinses
• Kills microorganisms immediately
• Disadvantages : metallic taste, stain
metallic or composite restorations
Bisbiguanides
• The two most common commercially
available bisbiguanides are:
a) Chlorohexidine
b) Alexidine
• These are potential anticaries agents
• They are bactericidal
• Have both hydrophobic and
hydrophilic constituents and possess a
net +ve charge – adsorbs –vely
charged membrane surface and
damage to the membrane by breaking
permeability barrier
• Disadvantages
1. Stains teeth and dorsum of tongue
2. Evidence of bacterial resistance
3. Bitter taste
4. Mucosal irritation and desquamation
5. Allergic reaction

Silver nitrate, zinc chloride and

potassium ferrocyante
- seal off the enamel caries invasion
pathway by getting impregnated to the
enamel
 II. SUBSTANCES WHICH INTERFERE
WITH CARBOHYDRATE DEGRADATION
THROUGH ENZYMATIC ALTERATIONS
• Includes:-
1. Vitamin K
2. Sarcoside
 Vitamin K
- Vit. K was found to prevent acid formation in
incubated mixtures of glucose and saliva
 Sarcoside
- Sodium-N-lauryl sarcosinate & sodium
dehydroacetate were promising enzyme
inhibitors or antienzymes. They have the ability
to reduce the solubility of powdered enamel
 III. SUBSTANCES WHICH INTERFERE
WITH BACTERIAL GROWTH AND
METABOLISM
Includes:-
• Urea and ammonium compounds
• Chlorophyll
• Nitrofurans
• Antibiotics
• Caries vaccines
Urea and ammonium compounds
• Potential anticariogenic agents.
• Urea  degradation by urease  ammonium
 neutralize acids
• They are cationic antiseptic and surface
active agents
• More active against GPB.
• Mechanism of action:- +vely charged
molecules reacts with –vely charged cell
membrane phophates and thereby disrupts
the cell wall structure microorganisms.
Eg:- benzathonium chloride, benzalleonium
chloride, cetylpyredinium chloride
Chlorophyll
• Water soluble form of chlorophyll is capable
of preventing or reducing the PH fall in
carbohydrate
• Saliva mixture invitro chlorophyll is
bactriostatic
Nitrofurans
• These compounds have been found to exert
bactriostatic and bactriocidal action
• Act on both aerobic and anaerobic
microorganisms
• Eg:- furacin 0.2% cream
Antibiotics
• Penicillin:- as an anticariogenic compound, act on cell
wall synthesis
disadvantage: resistance
• Erythromycin:- act on bacterial protein synthesis
Disadvantage: diarrhoea and resistance
• Kanamycin:- act on bacterial protein synthesis. It
reduced S. Mutans and S. Sanguis population in
plaque
Disadvantage: nephrotoxicity and ototoxicity
• Others:- spiramycin, tetrcycline, tyrothricin,
vancomycin
Caries vaccine
• Caries vaccine dates back to a period, when
lactobacilli were thought to be of paramount of
importance. Oral administration of S. Mutan vaccine
leads to accelerated clearance S. mutans from
mouth.
 NUTRITIONAL MEASURES
The chief nutritional
measures advocated for
the control of dental
caries is restriction of
refined carbohydrate
intake.

Other measures include

- Avoiding sugar that
retains of teeth surface
- Avoiding sugar in
between meals
- Eating of phosphated
diets
Phosphated diet
Phosphates are anticariogenic sodiummeta phosphate appear to be
most effective. Phosphate exhibit their cariogenic action via
local factors like:-
1. Reduction of enamel solubility
2. Buffering effect in neutralizing salivary plaque
3. Rendering fats, carbohydrates and proteins which are less
cariogenic
4. Interference with enzymatic process on enamel surface to
increase host resistance
5. Decrease in bacterial adhesion
6. Interference with enzymatic process on enamel surface to
increase host resistance
7. Interference with synthesis of extra cellular polysaccharide
formation
8. Maintenance or increase of plaque calcium and phosphorous
level.
• Other inhibitors like pyridoxine, fat, tannic acid, xanthines,
constituents of cocoa butter are believed to have caries
protective factors. Nutritional or dietary means of caries control
is impossible to achieve on basis of mass prevention program
 MECHANICAL MEASURES
• This refers to procedures specifically
designed for and aimed at removal of
plaque from tooth surface methods for
cleaning tooth mechanically are:
1. Prophylaxis by dentist
2. Tooth brushing
3. Mouth rinsing
4. Use of dental floss or tooth picks
5. Incorporation of detergents foods in
diet
6. Pit and fissure sealants
Dental prophylaxis
• Careful polishing of roughened
smooth surface and correction of
faulty restoration decreases the
formation of bacterial plaque and
there by reducing the development
of new carious lesion
Tooth brushing
Types of tooth brushing
- Manual
- Powered
- Sonic and ultrasonic
- Ionic
ADA specification for a tooth brush
- 1- 1.25 inches length
- 5/16 – 3/8 inches in width
- 2 – 4 rows of bristles
- 5-12 tufts per row
Mouth rinsing
• Use of mouth wash for the benefit of its action in loosening
food debris from teeth has been suggested to be of value
as caries control measures.
Dental floss
• Dental flossing is effective in removing plaque and dislodge
the irritating matter that is real source of disease.
• Used in type I gingival embrasures
It is available in:
- Multifilament – twisted / non twisted
- Bounded / unbounded
- Thick / thin
- Waxed / non waxed
Oral irrigators
- Use of flushing devices
- Irrigation devices composed of a built in pump and a
reservoir
- It can also be used to deliver antimicrobial agents
Detergent foods
• Fibrous food in diet prevent lodging of food in pit and
fissure and acts as detergent
Chewing gum
• Chewing gum tend to prevent caries by mechanical
cleaning action
Pit and fissure sealants
• A sealant is a dental resin that is firmly bounded to
enamel surface and isolates pit and fissure from
caries producing conditions in oral environment
• Types:
1st generation – ultraviolet light activated
2nd generation – chemical activated
3rd generation – visible light activated
4th generation – fluoride containing
• Examples of pit and fissure sealants
alphadent
helioseal F
helioseal
Seal – rite
baritone L3
concise white sealant
concise light cure white seal
 CONCLUSION
Dental caries is an irreversible process.
It is a disease of modern man and its
manifestation persist throughout life. There
are various methods of control and
prevention of disease. It is always better to
prevent disease. Once occurred it has to
be controlled as it has dangerous sequale.
THANK YOU