PRESENTED BY

OMANAKUTTAN KR

INTRODUCTION
DEFINITION
PATTERN AND TRENDS
GLOBAL AND INDIAN SCENARIO
FACTORS INVOLVED
RECENT CONCEPTS
- DIAGNOSIS
- PREVENTION
- MANAGEMENT


EPIDEMIOLOGY

The study of the distribution and the determinants
of health related states and events in specified population and
the application of this study to control health problems
( John Last 1988.)

EPIDEMIOLOGIST
A person who defines the frequency and severity of
health problems in relation to such factors like age, sex, geography,
nutrition, diet etc
2 terms are of utmost importance in epidemiology



INCIDENCE and
Point
PREVELANCE
Period

DURATION OF DISEASE AND INCIDENCE /PREVALANCE

RELATION
KEYS TRIAD
1960
MODIFIED KEYS TRIAD
(NEWBURNS) 1983


Dental Caries is an oral disease of pandemic proportion and to
measure its extend and severity accurately is impossible


The closest we can assess these parameters are by epidemiological
studies that target a population which can then be generalized.









LOW CARIES INCIDENCE EXISTED IN
ANCIENT MAN
LOW CARIES INCIDENCE IN THE
ANCIENT MAN IS DUE TO DIET
WHICH WAS :
Comparatively low in
carbohydrates.
Natural (unrefined) diet.


The pattern of ancient caries was mostly cervical or root caries

in the 17
th
century a new pattern emerged
lesion begins in fissured surfaces and develops later on proximal
surfaces.


This pattern took place in the industrialized nations as a result of the
increased use of sucrose as sugars became more available.
CURRENT GLOBAL
DISTRIBUTION
During most of the 20
th
century, dental caries
pattern was :
I. High prevalence in developed
countries & higher
socioeconomic group.
II. Low prevalence in developing
countries with less economic
development.
Caries was referred to as
a disease of civilization.
High level of consumption of refined carbohydrates in developed

countries

Diet low in fermentable carbohydrates in developing countries

surviving on farming lower level of cariogenic bacteria.
Explanation of this pattern is :
BY THE LATE 20
TH
CENTURY,
CARIES PATTERN WAS
CHANGING IN TWO WAYS:
1- Sharp rising in caries prevalence and severity in most
developing countries especially urban areas.

2- Marked reduction among children & young adults in
developed countries.


M0LLER et al.1999


The decline of caries is attributed to:

Use of fluoridated tooth paste. (Brathall et al.1996)

Fluoridation of water supplies.

The use of fissure sealants.

Implementation of preventive programs

better access to dental care

better living conditions.


Upward trend of caries in many developing countries is related to:

The absence of widespread caries preventive strategy.

Increasing consumption of sugar containing products.

Moeller et al 1999
Dental caries is still a major health problem in most industrialized countries, affecting
60-90% of school children

Substantial decrease in caries prevalence in the last decades in western countries
In developing and underdeveloped countries, prevalence of caries seems to be
increasing

REASONS FOR THIS CHANGE.
Increase in dental man power along with an upswing in dental health education,
more demand for dental care have resulted in decrease in dental caries experience.
Caries experience is high in all age groups

percentage of subjects with caries increased as age advanced.

The percentage of subjects with caries range from about
52% in primary dentition
85% in permanent teeth in older adults(65-74 years).

Root caries prevalence was 4.5% among the 35-44 years individuals
and 5.5% among the 65-74 years individuals.
Prevalence of root caries was higher in rural areas than in urban areas.
B S Shivakumar et.al 2002

1) Saliva
Composition
pH
Quantity
Viscosity
Antibacterial factors.
2) Race and ethnic groups
3) Age
4) Gender
5) Hereditary
6) Emotional disturbances.

PREDISPOSING FACTORS:-

1.Presence of deep, narrow, occlusal fissures or buccal and lingual pits.
2. Alteration of tooth structure by disturbance in formation or in
calcification
Teeth which are malaligned, rotated or out of position

The fact that teeth are in constant contact with and bathed in saliva would
suggest that this factor could profoundly influence the state of oral health
of a person.
One of the most important function of saliva is its role in removal of micro
flora & food debris from the mouth


The distribution pattern of dental caries closely follows that of
plaque. Thus, the sites in the mouth which are most prone to
caries are those where plaque accumulates.

DISTRIBUTION PATTERN OF CARIES
Determined mainly by the Bicarbonate concentration
Salivary pH increases with flow rate
Salivary buffers increase pH of saliva in the oral cavity.

Decrease pH favors
caries
Certain races has high degree of resistance to caries.
These beliefs have faded as evidence suggests that these
differences are more due to environmental factors than inherent
racial attributes
Russel et al.1986
Caries
incidence
Age in years
1 6 17 22 50
higher caries experience in girls than boys

Root caries is more prevalent in males

Increased susceptibility may be due to:
1. Early eruption of teeth in females

2. Increased fondness towards sweets among girls
3. Due to hormonal changes

Kaste et al 1986

GOOD OR BAD TEETH RUN IN THE FAMILY
Family studies have shown that offsprings have the same score as
parents
Mansbridge (1987) found a greater resemblance in dmf score
between identical twins or fraternal twins than unrelated pair of
children

Periods of stress have been associated with high caries incidence


Schizophrenics have reduced caries activity which may be attributed to
increased salivation and higher pH of saliva

It is difficult to correlate caries pattern with socioeconomic status due to its
complexity


low SES groups have more number of decayed & missing teeth but less
number of filled teeth and vice versa in high SES group
Mutans Streptococcus initiation of
smooth surface caries

Lactobacillus - Initiation of pit and
fissure caries, progression of
smooth surface caries


Actinomyces - Root caries




1. The fissures in the
occlusal surfaces of
molars.

2. The proximal areas.

3. The marginal area
between the tooth and
the gingiva.
According to the pioneering Hagerstown
studies (1937), the rank order of
susceptibility of teeth to caries is listed
as follows:
Mandibular 1
st
& 2
nd
molars
Max. 1st & 2nd molars
Mand. 2
nd
,max. 1
st
& 2
nd
premolars
max. central & lateral incisors.
Max. canines & mand.
1
st
premolars
Mand. Central& lateral
Incisors & canines.
1
2
3
4
5
Hagerstown studies
(1937)
Upper and Lower first molars - 95%
Upper and Lower second molars 75%
Upper second bicuspids -45%
Upper first bicuspids 35%
Lower second bicuspids -35%
Upper central and lateral incisors
30%
Upper cuspids and lower
first bicuspids 10%
Lower central and
lateral incisors 3%
Lower
cuspids 3%
RUTHERFORD 1978
OCCLUSAL
MESIAL
BUCCAL
LINGUAL

Scientific advances in cariology have led to the understanding that
dental caries is a chronic, dietomicrobial , site-specific disease
caused by a shift from protective factors favoring tooth
remineralization to destructive factors leading to
demineralization.
JADA 2009;140(9 suppl):25S-
34S.

From antient times there has been multiple theories involving the
initiation of dental caries


THEORIES

Legend of Worm Humoral Theory
Chemical Theory Vital Theory
Parasitic Theory
Acidogenic Theory
Proteolytic Theory
Proteolytic Chelation Theory
WHAT IS DIAGNOSIS?

Defined as utilization of scientific knowledge for identifying a disease
process and to differentiate it from other disease process.
CARIES DIAGNOSIS
44
IMPORTANCE OF DIAGNOSIS
To identify etiological factors
Determine nature of the disease involved
To determine treatment planning
To access prognosis
45
46
INTERNATIONAL and CARIES DETECTION ASSESSMENT
SYSTEM (ICDAS)

Created in 2002 based on visual examination aided by a WHO
PROBE
2 digit system (x-y)
Scoring system of 0,1,2,3,4,5,6 with respective criterias

NYVADS SYSTEM

For activity assessment of non cavitated and cavitated lesions

Scores of 0,1,2,3,4,5,6,7,8,9 assigned

CLASSIFIES A LESION AS ACTIVE OR INACTIVE

ADVANCES IN X RAYS:

Xeroradiography

Digital radiography

Computer aided radiography

Digital subtraction radiography

Tuned aperture computed tomography

52
XERO RADIOGRAPHY
Technique simulates that of photo-copying

Image recorded on aluminium plate with a layer of
selenium particles

Xerographic films to record the images produced by
X-rays

These are a given a uniform electrostatic charge

X-rays-passes through film-causes the discharge of
particles producing a latent image-converted in a
processing unit.
53
Advantages-

-edge enhancement
-less radiation
-economical

Disadvantages -

electrical charge may cause discomfort to patients
exposure time varies with thickness of film
process of development cannot be delayed
more than 15min
54
DIGITAL IMAGING
Principle: works on a CCD which is electronically
connected to computer

CCD-is a semi-conductor made of metal oxide silicon
coated with x-ray sensitive photons
55
Advantage
no dark room processing
greater exposure latitude
reduced radiation dose
capability of teletransmission
image manipulation
ability to enlarge specific area

Disadvantage
high cost of the system
life expectancy is not fixed
56
Digital radiography

Direct:
Indirect
57
DIGITAL IMAGING
Variety of multiple well established digital
sensors are available

1. Charge couple device based sensors (CCD)
2. Complimentary metal oxide
semiconductors (CMOS)
3. Photo stimulable phosphor plates (PSP)
58
Charge-Coupled device:CCD
Egs: Durr Vista Ray
Trophy RVG, Sens-A-
Ray, Visualix/Vixa
59
DIGORA SYSTEM
60
According to Kantor et al ( J. Dent. Aug
2005) who compared the conventional
radiography with digital radiography and
found no statistically significant difference
in diagnosis of proximal caries
61
COMPUTER AIDED
RADIORAPHY
Assessment and
recording of lesion
size
Trophy 97 system
DIGITAL SUBSTRACTION RADIOGRAPHY
Principle:Optimally, all unchanged anatomical
background structures will cancel, and
unchanged areas will be displayed in a neutral
grey shade in the subtraction image.

Areas with mineral loss appear in darker
shades of grey, and areas of gain appear
lighter than the background.


63

64
TUNED APERTURE COMPUTED
TOMOGRAPHY
It constructs radiographic slices, cross
sections, through teeth-viewed for
radiolucencies

Images brought to a 3D image- known
as pseudohologram

Used in early caries and recurrent caries
detection
65
ADDITIONAL DIAGNOSTIC
METHODS:
66
Based on light:

DIFOTI- DIGITAL FIBRE OPTIC
TRANSILLUMINATION

Quantitative laser light fluorescence

Diagnodent

67
FLUORESCENCE
A phenomenon by which the
wavelength of the emitted light is
changed into a larger wavelength
as it travels back.
68
Omnii InspektorPro QLF
QUANTITATIVE LASER/LIGHT
FLUORESCENCE
Bejelkhagen & Sundstrom
(1981)
Mechanism
Argon laser-488 nm
Xenon arc lamp 370 nm
Argon laser:
Tooth appears
yellow-green

Demineralized areas-
dark

ADVANTAGES:
Incipient lesions 25
m
Monitor changes in
lesion
Red fluorescence-
plaque, leaky margins

70
LIMITATIONS:
On accessible smooth surfaces only
Cant discriminate between enamel & dentin
lesions
Cant differentiate between decay , hypoplasia


71
Diagnodent
72
73

Readings (Tam & McComb, J Can Dent
Assoc, 2001)
5-25: initial lesions
25-35:early dentinal caries
35: advanced dentinal caries
74
75
FIBRE OPTIC
TRANSILLUMINATION
Principle: decayed matter scatter light
more strongly

76
ELECTRICAL CONDUCTANCE
MEASUREMENTS (ECM)
77
Indications:
Pit and fissure
caries
Failure of fissure
sealants

False +ve results:
Immature teeth
Cracks in enamel


78
Demineralization-Remineralization cycle
Demineralization -Remineralization cycle
(Mount & Hume 2005)

CARIES MANAGEMENT BY RISK ASSESSMENT (CAMBRA)

CARIOGRAM


TOOTH MOUSSE (CCP-ACP)




Built on the understanding that dental caries is a dynamic disease

Determines and deals with multiple factors that cause the expression of
the disease and helps take corrective actions

An evidence based approach for prevention of dental caries

A visual representation of the multifactorial nature of the disease

Risk of demineralization can be assessed by weighing all the disease
indicators and risk factors against protective factors
CARIES RISK ASSESSMENT
A graphical illustration of the caries risk profile of an individual.

Includes factors directly and indirectly involved in biochemical
events on the tooth surface

ILLUSTRATES AN OVERALL RISK SCENARIO
CARIES EXPERIENCE
RELATED DISEASE
DIET- CONTENTS AND FREQUENCY
PLAQUE LEVEL
MUTANS STREPTOCOCCI
FLUORIDE EXPOSURE
SALIVA SECRETION
SALIVARY BUFFER TEST
CPP-
ACP
BIOACTIVE PEPTIDE

HAS SPECIFIC PHOSPHORYLATED ELEMENTS CAPABLE OF
CALCIUM BINDING

STABILIZES CALCIUM PHOSPHATE AS AMORPHOUS CALCIUM
PHOSPHATE

CPP + ACP



SUPERSATURATION
CALCIUM SODIUM PHOSPHOSILICATE (BIOACTIVE
GLASS) NOVAMIN

AIR ABRASION

POLYMER CUTTING INSTRUMENTS
CALCIUM SODIUM
PHOSPHOSILICATE (BIOACTIVE
GLASS) NOVAMIN
A ceramic material used for remineralization

Combines with water to release calcium, phosphorous , sodium , and silicon
ions and results in hydrocarbonate crystal formation (HCA)

ions
DENTINAL TUBULE OCCLUSION USING NOVAMIN
PSEUDO MECHANICAL, NON- ROTARY METHOD OF CUTTING AND TISSUE
REMOVAL

PRINCIPLE ACTION IS OF END CUTTING TYPE

DESSICATED ABRASIVE PARTICLES ASSIST CUTTING




DIFFERENTIATE BETWEEN DECAYED AND HEALTHY DENTINE

REMOVES CARIOUS DENTINE NOT SOUND DENTINE

DESIGN IS BASED ON THE DIFFERENTIAL HARDNESS OF TOOTH TISSUE

DOESNT EXPOSE VITAL ODONTOBLASTS AND HENCE LIMITED PATIENT
DISCOMFORT

SINGLE USE DISPOSABLE BURS