Combined Cariology Flashcards

Acquired Pellicle

A thin film that forms on the surface of a tooth, primarily composed of proteins and glycoproteins from saliva. It serves as a protective layer and plays a crucial role in the initial stages of plaque formation.

Food Debris

Particles of food that remain on teeth and gums after eating and is present only transiently after meals

Dental Plaque (Biofilm)

soft, nonmineralized, bacterial deposit which forms on teeth that are not adequately cleaned

Dental Calculus

plaque which has hardened due to the mineralization of plaque matrix and microorganisms, making it difficult to remove without professional cleaning.

Dental caries

The name of the disease

a common dental disease characterized by the demineralization of tooth structure due to acids produced by bacteria from fermentable carbohydrates.

Dental caries lesion

the observable effect of dental caries disease activity

Active lesion

a dental caries lesion that is currently progressing and causing damage to the tooth structure.

Arrested lesion

a dental caries lesion that has stopped progressing and is not causing further damage to the tooth structure

usually leave a white-spot scar after treatment

Risk factors for dental caries

1. Dental plaque

2. Dietary sucrose

3. Fluoride insufficiency

4. Saliva insufficiency

Presence of cariogenic bacteria in the mouth can be attributed to

social environment, physical environment, genetic endowment, health care system

Official definition of dental caries

a non-communicable, bacterial-associated, and lifestyle- associated disease

What are the requirements for dental caries progression

1. cariogenic bacteria

2. bacterial plaque/biofilm

3. stagnation areas (ie. not brushing)

4. fermentable substrate (ie. sugar)

5. susceptible tooth surface

6. time

Why is sugar so important to causing dental caries

cariogenic bacteria on its own cannot cause damage

when cariogenic bacteria metabolizes sugar in the mouth, it ferments the sugar into acid that destroys tooth structure

What is the first sign of dental caries

presence of a white spot lesion on tooth surface

Role of saliva

1. assists in arresting lesions and remineralizing tooth - natural repair mechanism

2. saliva is alkaline and saturated with Ca and PO4 to aid in remineralization

Role of Fluoride

1. 1.0ppm and higher can reduce risk of caries by 40-60% compared to areas with less than 0.5ppm of fluoride

2. fluoride can become mineralized with apatite to make fluorapatite which makes tooth more resistance to future acid attacks

   • daily use of fluoride will place a fluoride veneer over the tooth surface

Common sites of plaque formation

• along gingival margins

• between teeth

• within grooves on occlusal surfaces

• sites where the gingiva has receded

• the margins of previous restoration sites

Requirements for prevention of caries

Reduction in:

• exposure to sucrose

• thickness of plaque biofilm

Sufficient exposure to:

• fluoride

• saliva

Bacteria that ferment sucrose into acid

• S. mutans

• Lactobaccilus species

• S. mitis

• S. gordoni

• S. sobrinus

• Actinomyces species

• S. oralis

• S. anginosus

Many Lazy Mice Get Sweet Apples Or Apricots

Process of dental caries formation

High carb diet → microorganisms in plaque → presence of glucan and fructan → break down sugars via dextranase and fructanase → acid production via eden meyerhoff pathway (bacteria glycolysis pathway) → low pH → acid diffusion into dentine → dental caries

Clinical progression of dental caries

1. White spot lesion

2. Loss of enamel

3. Hole developing resulting in soft, mushy dentine

4. Large hole with bacteria in pulp → inflammation and abscess

5. Tooth breaks down

6. Complete loss of tooth structure - requires extraction

The plaque factor

Natural cycles of mineralization and demineralization occurs in the mouth leading to no net loss of tooth structure

Once refined sucrose became widely available post 17th century, dental caries rose significantly

Model of dental caries

Risk of caries depends on what goes into the mouth and how individuals manage their plaque control.

What individuals do depends mainly on their social circumstances and peer group pressure

Plaque index scores

Score 0:

• Clean surface - no visible plaque

Score 1:

• no visible plaque - but plaque can be removed with perio probe

Score 2:

• visible plaque - will appear 24 hours after toothbrushing

Score 3:

• thick, visible plaque - present for days/week

How to complete a plaque index scoring

Record plaque index on teeth: 16, 26, 46, 36, 11, 41 on buccal and lingual surfaces

Total score out of 36 and convert to %

Bacteria present in White spot lesions, Cavitated lesions, Mushy dentine

In white spot lesion

• more S. mutans than someone with healthy enamel

  • but non-mutans species are still more prevalent

In cavitated lesions:

• S. mutans make up 30% of total flora

In mushy dentine:

• Lactobacilli, prevotellae, bifidobacterium most prevalent

  • more anaerobic and acid-tolerant bacteria in deep caries

When does oral pH rise

• increase saliva flow

• chewing sugar free gum

• cheese consumption

When does oral pH decrease

• at night when salivary flow decreases

• when sugar is consumed

• when eating sweet foods between meals

Functions of saliva

• Surface Coating of Mucosa and Teeth (pellicle)

• Lubrication and Humidification via Visco-elastic Properties

• Immune Surveillance (secretory IgA)

• Antimicrobial Proteins Against Bacteria, Fungi and Viruses

• Aggregation of Particle Material and Micro-Organisms for

• Oral Clearance

• Digestive Enzymes for Starch Hydrolysis

• Vehicle for Sensory Stimulus for Pleasurable and Noxious

• Taste Sensation

• Cohesive Food Bolus Formation to Facilitate Swallowing

• Phonation Improvement

• Modulation of Demineralization and Remineralization of

• Tooth Structure

Vipeholm Study conclusions

• sugar in solution during mealtime does NOT increase risk of caries

• sugar in sticky form at/or between mealtime DOES increase caries risk

• removing sugar completely does NOT fully eliminate risk of caries

Sticky candy snakes = Vipeholm

Hopewood House study

Children were eating whole meal bread while also not brushing teeth → low incidence of caries

• therefore, caries are highly attributed to refined sugar intake

House of Children = Hopewood House

Turku sugar study

1. Caries incidence between fructose and sucrose is inconclusive

2. xylitol is non-cariogenic and anti-cariogenic

   • less plaque develops

   • less S. mutans develop

Plaque reduction at the individual level

• brushing twice per day reduces plaque formation

• fluoride toothpaste reduces caries by 24%

Plaque reduction at the community level

• link between plaque and diet

• lowering sugar consumption

• plaque removal techniques

Disclosing agent (Tri-plaque gel)

Pink: thin deposit of plaque - recently cleaned with immature biofilm

Blue/purple: older - not cleaned in 48+ hours - complex biofilm - cause of gingivitis

Light blue: acid production - biofilm with pH ~4.5 - high risk of caries

Qualities of a good toothbrush

1. Handle:

   • appropriate for age and dexterity

2. Head size

   • appropriate for user’s mouth (small head preferred)

3. Compact, medium-soft bristles, nylon filaments

4. Bristle pattern

   • flat-trim, different heights of bristles

Two techniques of using a toothbrush

1. Modified bass technique

2. Toothpick method

Importance of using proper toothbrushing technique

• effective at cleaning cervical 1/3rd, under gingival margins, and interproximal areas

• suitable for any age and dexterity

• ensures periodontal maintenance

• cleans sulcus

Types of interdental cleaning tools

1. Dental floss

2. Interdental brushes

3. Single tuft brushes

4. superflosses

5. Water pick

Advice to patients for plaque control

1. Frequency of brushing

   • twice per day with fluoride toothpaste

2. Fluoride concentration

   • 0-18 months: no fluoride

   • 18 months - 6 years: 400 to 500 ppm

   • 6+ years: 1000-1100 ppm (1mg/g)

3. Rinsing behaviour

   • do not rinse with large volume of water

   • spit, don’t rinse

4. When to brush

   • brush after breakfast

   • last thing at night

What are the different fluoride compounds in toothpaste that are clinically effective

• sodium fluoride

• sodium monofluorophosphate

• stannous fluoride

Chlorhexidine

Usually in 0.2% or 0.12% solution or 1% gel/chewing gum

• antiseptic in the chemical group bisbiguanides

• batericidal and fungicidal

• works against gm+, gm-, and yeast

Who is chlorohexidine mainly advised for

1. physically/mentally handicapped patients (can’t brush teeth)

2. patients with acute periodontal inflammation

3. patients with greatly reduced salivary flow

4. bad breath

5. high caries risk patients

Brushing with fluoride reduces caries risk by what percent

50%

Fortnightly fluoride rinse reduces caries by what percent

25%

Arginine toothpaste

• arginine is metabolized by oral bacteria into ammonia which neutralizes plaque acid

• arginine increases oral resting pH

• results show that arginine+fluoride is more effective than fluoride alone

Stannous fluoride

(aka Tn(II) Fluoride)

• prevents gingivitis, dental infections, cavities, relief of dental hypersensitivity

• most effective at stopping and reversing dental lesions

Concentrations of stannous fluoride for pediatric and adult use

8% for children

10% for adults

Side effects of stannous fluoride

Permanent staining (yellow, brown, black)

Stannous fluoride with dentrifices stains LESS

Stannous fluoride in gel/solution form stain MORE

Stain can be removed by hygenist/dentist

Vitamin A and D AND caries

Vit A and D can disrupt salivary flow leading to increased caries risk

Phytates AND caries

• present in whole grains, seeds, legumes, nuts

• decrease absorption of Fe, Zn, Mg, Ca → bone demineralization

Non-nutritive sugar substitutes

• saccharin

• Acesulfame-K

• aspartame

• thaumatin

Nutritive sugar alternatives

• sorbitol

• mannitol

• xylitol

• malitol

Maximum sugar consumption per day

60g/day

Food that present low potential risk of caries

• Bread (sandwiches, toast,crumpets, pita bread)

• Pasta, rice,starchy staplefoods

• Cheese

• Fibrous foods (e.g. raw vegetables)

• Low sugar breakfast cereals (e.g. shredded wheat)

• Fresh fruit (whole and not juices)

• Peanuts (not for children under 5 years)

• Sugar-free chewing gum

• Sugar-free confectionery

• Water

• Milk

• Sugar free drinks

• Rea and coffee (unsweetened)

How much fluoride is in Australian water (in mg/L)

0.6 - 1.1 mg/L

What are the 3 fluoride compounds present in drinking water

1. hydrofluorosilicic acid

2. sodium fluorosilicate

3. sodium fluoride

Caries reduction from fluoridated water in permanent and primary teeth

60% reduction in permanent teeth

50% reduction in primary teeth

Mechanism of action of fluoride

1. Reducing demineralization

2. Promotes remineralization

3. Provide antimicrobial action

4. Inhibit bacteria sugar metabolism

Factors to consider fluoride supplementation

• caries risk (high, medium, low)

• cariogenicity of diet

• patient age and compliance

• systemic and topical use of fluoride

• community water fluoride levels

• existing medical conditions

Fluoride concentration of typical toothpaste

1000-1100 ppm

Fluoride concentration of high-fluoridated toothpaste

1500-5000 ppm

Fluoride rinses

• reduces caries by 20-50%

• weekly rinse = 0.2% NaF (900-910 ppm F)

• daily rinse = 0.05% NaF (220-227 ppm F)

Indications:

• undergoing orthodontic treatment

• hyposalivation after radiation treatment

  • doesn’t directly treat this

• unable to perform toothbrushing

• high risk of dental caries

*Do not give to children under 6

Fluoride gels

• more effective in permanent teeth than primary

• 9000-12,300 ppm

• Ex:

  • APF gel: 12300 ppm F (1.23%) - consists of NaF, hydrofluoric acid, orthophosphoric acid

  • Neutral NaF gel: 2% - used for eorsion, exposed dentine, carious dentine, hypomineralization, following restorations

  • Stannous fluoride gel: 0.4% - used for remineralization of white spot lesion, hypomineralization, root caries

Fluoride varnish

22,600 ppm F (22.6%)

Can contain fluoride, casein phosphopeptides, amorphous calcium phosphate

Indications:

• caries-prone adults that do not want to use fluoride rinse

• children over 6 with caries risks

• localized application at carious lesions

Contraindications:

• ulcers of gingiva and stomach

• allergies

• children who receive adequate fluoride

• home use

Casein phosphopeptide - amorphous calcium phosphate (CPP-ACP)

• releases F, Ca, P ions for local remineralization

• 900 ppm F

• for people over 6 years

• apply after brushing and flossing

• do not rinse out

• do not use if have milk allergy

Fluoride toxicity

• Toxic dose: 32-60 mg/kg F of body weight

Signs and symptoms:

• nausea, epigastric distress, vomiting

• excessive salivation, tear production, mucous discharge

• headache

• diarrhea

• weakness

Lethal Dose symptoms:

• convulsions

• hypotension

• hypocalcaemia

• hyperkalemia

• resoiratory acidosis

• unconciousness

Emergency treatment for fluoride poisoning

1. estimate amount of fluoride ingested

2. remove fluoride from body fluid - give milk OR administer orally 5% calcium gluconate / calcium lactate / milk of magnesia

3. support vital signs and call ambulance

The earliest clinical sign of dental caries

white spot lesion

Mechanism of white spot lesion

• dissolution of enamel crystal matrix due to caries allows fluid and air to fill space create a white appearance - hence white spot lesion

Perikymata

place where horizontal bands of enamel secreted by ameloblasts meet

Fluorosis

hypomineralized regions along the lines of perikymata

Reaction of dentine to caries infiltration past the enamel

Dentine becomes sclerotic at the DEJ to prevent bacteria from progressing towards the pulp

• if caries progresses, dentine becomes demineralized

Reactive dentine

As caries progresses closer to pulp, odontoblasts will secrete dentine into the pulp to create greater barrier between dentine and pulp

Affected vs Infected dentine

Affected dentine = dentine that has been impacted by caries acid but the bacteria has not penetrated through the DEJ

Infected dentine = bacteria that have broken through the enamel and have now infected the dentine

Natural history definition

refers to the study of disease as it naturally occurs

It includes:

1. the sequence of stages in the course of disease from onset until its natural end point which may include complete resolution, partial resolution, or death and;

2. the rate of occurrence of this sequence

Primary prevention

intervention to prevent disease occurrence

Secondary prevention

early intervention after disease onset to prevent undesirable outcomes

(most health dollars are spent on secondary preventive interventions)

Tertiary prevention

reconstruction type interventions following the occurrence of an undesirable outcome to prevent more serious consequences

Quarternary prevention

treatment to alleviate suffering when tertiary prevention has failed

Signs vs. Symptoms

Signs = what you can see (Ex, white spot lesion)

Symptoms = what the patient feels (Ex, toothache)

Characterization of carious lesions

1. affecting outer ½ of enamel

2. affecting inner ½ of enamel

3. affecting just into the dentine

4. affecting outer 1/3 of dentine

5. affecting inner 2/3rds of dentine

Bitewig radiographs

• show enamel in white and more organic material darker

• demineralized enamel appear as darker spots on enamel

Radiolucency

the evidence of loss of tooth mineral

Fissure, proximal, smooth surface lesion severity

Fissure lesions are vulnerable to cavity development

Proximal lesions progress very slowly and highly susceptible to arrest

Smooth surface lesions are rare and highly susceptible to arrest

Caries Management 1

• conservative approach to caries management

• not necessary to restore tooth unless cavitated

• focus on arresting and remineralizing lesion

Caries management 2

• high risk patients need 3 month recall to monitor plaque and arrested lesion progression

• apply F-varnish to non-cavitated lesions for remineralization

• focus on arresting non-cavitated lesions rather than restoring

Caries management 3

• focused on adjusting health behaviour

• patient must voluntarily take charge of their oral health

Dentist facilitation of oral health

Involves:

• the importance of good oral health

• that home care is absolutely fundamental to oral health

maintenance

• that maintenance of oral health also goes with a

commitment to life-long attendance for regular dental

care

• that frequency of attendance for dental care is tailored

to patient risk

• that reduction in caries risk is achievable but it is voluntary

• that the benefits of a commitment to pursue oral health

will accrue with immediate effect

• coaching in oral hygiene performance

• delivery of a program of caries risk reduction

strategies tailored to patient risk

• Patients needs to know that tooth decay can be

stopped, reversed, and prevented

Diagnosis of caries

1. History

2. Examination

3. Special diagnosis tests

4. Differential diagnosis

5. Provisional diagnosis

6. Diagnosis

Types of special diagnosis tests

• Clinical exams (Ex, ICDAS)

• Radiographic evidence

• Electrical conductance exam (for dentine caries detection)

• Laser and blue light fluorescence exam (measure preventative measures on enamel de- and remineralization)

• Fiber-optic methods (detect proximal cavitation)

Laser and blue light fluorescence examination

Ex, DIAGNOdent (KaVo)

• used for diagnosis of initial occlusal carious lesions

Ex, DIAGNOdent pen

• used for additional detection of proximal lesions or monitoring changes over time at different tooth sites

Ex, KaVo DIAGNOcam

• can determine extent of dental caries without using x-ray

• good for children and pregnant women

Qray

• powerful extension to naked eye

• reveals hard to see incipient caries, plaque, tarter, tooth/implant fractures, denture crack

Challenges in diagnosing caries

1. finding the caries in a single tooth

2. diagnosing the extent of the caries

3. diagnosing the activity of the caries - is it old or new

4. diagnosing primary caries, secondary caries, or caries adjacent to a retoration

Classifying caries

1. tooth surface site and size of caries

2. tooth surface integrity

3. caries prgression rate

4. initial attacks on sound teeth (primary) or subsequent attacks on restored sites (secondary)

What is the aim of the caries management system

1. To prevent new caries lesions from appearing

2. To prevent existing caries lesions from advancing further

3. To preserve tooth structure with non-operative care at more initial caries stages and

4. conservative operative care at more extensive caries stages While managing risk factors and recalling patients at appropriate intervals, with periodic monitoring and reviewing.

5. Would help to derive an appropriate, personalized, preventively based, risk-adjusted, tooth preserving management plan in order to enable improved long-term caries outcomes.

10 steps of caries management system

1. Diet assessment

2. Plaque assessment

3. Clinical and bitewig radiographic survey

4. Diagnosis and caries risk assessment

5. Preparation and treatment plan

6. Case presentation where patient is informed on:

   • Dental caries:

     • arrest

     • reversal/repair

     • prevention

     • number and status of current lesions

     • role of dentist

     • role of home care

     • current caries risk

   • result of diet and reccomendations

7. Oral hygiene coaching

8. Topical fluoride aplication

9. Monitoring plaque control and treatment in subsequent visits

10. Recall program tailored to caries risk status

Dentists Prefer Clear Diagnoses, Preaching Care Over Treating More Repetitively

What information needs to be collected on a diet history of a patient

Quantity of:

• snack between meals

• soft drinks between meals

• sugar in tea/coffee

• sports drinks

• acidic foods

What is ICDAS

International caries detection and assessment system

Clinical scoring system (code 0-6) for detection and classification of caries

What does ICDAS codes apply to

• smooth surface caries

• pit and fissure caries

• secondary caries

• root surface caries