1. Preventive Dentistry I & II Dental caries Dr.Caroline Mohamed1

2. Objectives Define: Dental caries The dental caries process The role of diet in dental caries Classification of dental caries Epidemiology Incidence and prevalence and how can be measured Caries risk Dr.Caroline Mohamed2

3. 1. Dental caries definition Dental caries is a multifactorial microbial disease of the calcified tissues of the teeth, characterized by demineralization of the inorganic portion and destruction of the organic substance of the tooth, which often leads to cavitations. Dr.Caroline Mohamed3

4. Two groups of bacteria are responsible for initiating caries: Streptococcus mutans and Lactobacillus. If left untreated, the disease can lead to pain, tooth loss, infection, and, in severe cases, death. Today, caries remains one of the most common diseases throughout the world. Cariology is the study of dental caries. Dr.Caroline Mohamed4

5. The presentation of caries is highly variable; however, the risk factors and stages of development are similar. Initially, it may appear as a small chalky area that may eventually develop into a large cavitation. Sometimes caries may be directly visible, however other methods of detection such as radiographs are used for less visible areas of teeth and to judge the extent of destruction. Dr.Caroline Mohamed5

6. Tooth decay is caused by specific types of acid- producing bacteria that cause damage in the presence of fermentable carbohydrates such as sucrose, fructose, and glucose. The mineral content of teeth is sensitive to increases in acidity from the production of lactic acid. Specifically, a tooth (which is primarily mineral in content) is in a constant state of back-and-forth demineralization and remineralization between the tooth and surrounding saliva. When the pH at the surface of the tooth drops below 5.5, demineralization proceeds faster than remineralization (meaning that there is a net loss of mineral structure on the tooth's surface). This results in the ensuing decay. Dr.Caroline Mohamed6

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8. Socio-Economical Situation Knowledge Host 8 SALIVA pH Flow rate Composition Buffering capacity Bicarbonate levels SALIVA Educational level SUBSTRATE Carbohydrates Frequency of eating Oral clearance Physical nature of food Detergency of food FLORA Fluoride in plaque Lactobacilli Oral Hygiene Streptococci Virulence factors Transmissibility HOST Age Fluoride Genetics Morphology Nutrition Behavior Dr.Caroline Mohamed

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10. Demineralization - Remineralization Source: Collins F.M. The Role of Fluoride in Caries Control. http://www.ineedce.com/coursereview.aspx. March 17, 2009.

11. The role of diet in dental caries Dr.Caroline Mohamed11

12. Substrate Readily fermentable Sucrose- arch criminal Cariogenicity determined by 1. Frequency of ingestion 2. Physical form 3. Chemical composition-detergency 4. Texture of food 5. Presence of other constituents Dr.Caroline Mohamed12

13. Dr.Caroline Mohamed Cariogenicity determined by Frequency of ingestion 13

14. Frequency of ingestion D Caroline Mohamed14

15. Tooth enamel dissolves at 5.5 ph D Caroline Mohamed15

16. Dr.Caroline Mohamed Chemical composition-detergency Cow’s milk (cheese) contains calcium, phosphorus, and casein Wholegrain foods require more chewing Peanuts, hard cheeses, and chewing gum Black tea extract ( fluoride) 16

17. CARIES PROCESS Dr.Caroline Mohamed17 De- Remineralizatio n Enamel lesion Dentin lesion Pulpal lesion White spot TIME CARIESCARIES NO CAVITY DIAGNOSIS RESTORATION CAVITY

18. Depending on the extent of tooth destruction, various treatments can be used to restore teeth to proper form, function, and aesthetics, but there is no known method to regenerate large amounts of tooth structure, though stem cell related research suggests one possibility. Instead, dental health organizations advocate preventive and prophylactic measures, such as regular oral hygiene and dietary modifications, to avoid dental caries. Dr.Caroline Mohamed18

19. Epidemiology Definition of Epidemiology The word epidemiology comes from the Greek words:  epi, meaning on or upon  demos, meaning people, and  logos, meaning the study of  "the study of what is upon the people", 19Dr.Caroline Mohamed

20. Incidence and prevalence and how can be measured Prevalence Number or proportion of persons in a population affected by a condition at a given point of time Can be expressed as, count, proportion or percentage. Incidence Number of new cases of condition over a given point of time. Change in prevalence or severity. The period of time depend on time needed to disease to be observed expressed as a rate (case per the population per time) Determine the progress of condition Dr.Caroline Mohamed20

21. Different Age Groups Key risk groups from ages  Age-Three peaks 4-8yrs 11-18yrs 55-65yrs 1 to 2 years ( baby bottle caries) 5 to 7 years ( primary caries) 11 to14 years Key risk age group in young adults  and adults ( secondary caries/ root caries)  Sex- both sexes early eruption in females 21Dr.Caroline Mohamed

22. Adults continue to experience primary dental caries, but they also experience a significant amount of secondary caries around existing restorations. Children today, in developed countries, have comparatively few, if any restorations and experience mostly primary caries of the noncavitated type. Between 40 and 76% of dental carie in adults are arrested, a condition uncommoly observed in children. Dr.Caroline Mohamed22

23. Variation within dentition: Dr.Caroline Mohamed23 Early plaque formation occurs faster. 1. In lower jaw, compared to upper jaw. 2. In molars areas. 3. On buccal tooth surfaces, compared to oral sites. 4. In interdental regions compared to strict buccal or oral surface.

24. Tooth composition Dr.Caroline Mohamed24 Mineralization- Hypomineralization/ Dentinogenese imperfecta Trace elements Fluoride/ dental fluorose

25. Dr.Caroline Mohamed25 Dentinogenese imperfecta Dental Fluorose

26. Individual Teeth Dr.Caroline Mohamed26 First primary molars and first permanent molars are high risk.

27. Different tooth surfaces: Dr.Caroline Mohamed27 Are high risk: Interproximal surfaces of primary molars. Occlusal surfaces of first permanent molars.

28. Tooth morphology Dr.Caroline Mohamed28 Pits & fissures Irregularities in arch form Crowding Overlapping

29. Dr.Caroline Mohamed29

30. Tooth morphology Dr.Caroline Mohamed30

31. Behavior Age 31Dr.Caroline Mohamed

32. Regularity of snaks, more than 3 times a day, snacking between meals, this increases the acid challenge to the teeth for a high level Nocturnal bottle usage- additive On pacifier during sleep Breast feeding (Kawaba et al., 1997) 32Dr.Caroline Mohamed

33. Drinking sweet beverage Brushing by mother (Kawaba et al., 1997) 33Dr.Caroline Mohamed

34. Dental Caries classification 1.based on anatomical site 2.based on progression 3.based on virginity of lesion 4.based on extend of caries 5.based on tissue involvement 6.based on chronology 7. based on whether caries is completely removed or not. 8.based on surfaces to be restored 9. WHO system 9.Black’s classification 10.Caries risk Assessement 34Dr.Caroline Mohamed

35. Classification: 1) Based on anatomic site: Crown caries Root caries Pit & Fissure Caries Smooth surface Caries

36. Dr.Caroline Mohamed36 Pits and fissures are anatomic landmarks on a tooth where the enamel folds inward. Fissures are formed during the development of grooves but the enamel in the area is not fully fused. As a result, a deep linear depression forms in the enamel's surface structure, which forms a location for dental caries to develop and flourish. Fissures are mostly located on the occlusal surfaces of posterior teeth and palatal surfaces of maxillary anterior teeth.

38. Dr.Caroline Mohamed38 Pits are small, pinpoint depressions that are most commonly found at the ends or cross-sections of grooves. In particular, buccal pits are found on the facial surfaces of molars. For all types of pits and fissures, the deep infolding of enamel makes oral hygiene along the surfaces difficult, allowing dental caries to develop more commonly in these areas.

39. Dr.Caroline Mohamed39 The occlusal surfaces of teeth represent 12.5% of all tooth surfaces but are the location of over 50% of all dental caries. Among children, pit and fissure caries represent from 80 to 90% of all dental caries. Pit and fissure caries can sometimes be difficult to detect. As the decay progresses, caries in enamel nearest the surface of the tooth spreads gradually deeper. Once the caries reaches the dentin at the dentino-enamel junction (DEJ), the decay quickly spreads laterally.

40. Dr.Caroline Mohamed40 Within the dentin, the decay follows a triangle pattern that points to the tooth's pulp. This pattern of decay is typically described as two triangles (one triangle in enamel, and another in dentin) with their bases conjoined to each other at the DEJ. This base-to-base pattern is typical of pit and fissure caries, unlike smooth-surface caries (where base and apex of the two triangles join).

41. Dr.Caroline Mohamed41

42. Dr.Caroline Mohamed42 Clinical Manifestation: Entry site may appear much smaller than actual lesion, making clinical diagnosis difficult. In cross section, the gross appearance of pit and fissure lesion is inverted V with a narrow entrance and a progressively wider area of involvement closer to the DEJ. a) Initially, caries of pit & fissures appears brown or black in color & with fine explorer, it will feel soft & a catch is felt ( don´t do it ). b) The enamel which borders the pit & fissures appears opaque bluish white.

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45. Shape, morphological variation and depth of pit and fissures contributes to their high susceptibility to caries. The appearance of s.mutans in pits and fissures is usually followed by caries 6 to 24 months later. Sealing of pits and fissures just after tooth eruption may be the most important event in their resistance to caries. 45Dr.Caroline Mohamed

46. Smooth surface caries Smooth surface caries occurs on the gingival third of the buccal, lingual & proximal surfaces. On proximal surface, caries begins below the contact area & in early stage this appear as a faint white opacity of enamel without loss of continuity of surface. As caries progresses, it appears bluish white in later stage. Caries in cervical area are in the form of crescent shaped cavities. It appear as a slightly roughened, chalky area which gradually becomes deeper

47. Types of smooth surface caries 1. Proximal caries, also called interproximal caries, form on the smooth surfaces between adjacent teeth. 2. Root caries form on the root surfaces of teeth. 3. The third type of smooth-surface caries occur on any other smooth tooth surface. Less favorable site for plaque attachment, usually attaches on the smooth surface that are near the gingiva or are under proximal contact. 47Dr.Caroline Mohamed

48. Proximal caries are the most difficult type to detect. Frequently, this type of caries cannot be detected visually or manually with a dental explorer. Proximal caries form cervically (toward the roots of a tooth) just under the contact between two teeth. As a result, radiographs (bitewings) are needed for early discovery of proximal caries. Dr.Caroline Mohamed48

49. Dr.Caroline Mohamed49 In very young patients the gingival papilla completely fills the interproximal space under a proximal contact and is termed as col. Also crevicular spaces in them are less favorable habitats for s.mutans. Consequently proximal caries is less lightly to develop where this favorable soft tissue architecture exists.

50. Proximal surfaces Caries The proximal surfaces are particularly susceptible to caries due to extra shelter provided to resident plaque owing to the proximal contact area immediately occlusal to plaque. Lesion have a broad area of origin and a conical, or pointed extension towards DEJ. V shape with apex directed towards DEJ. After caries penetrate the DEJ softening of dentin spread rapidly and pulpally 50Dr.Caroline Mohamed

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54. Root surface caries The proximal root surface, particularly near the cervical line, often is unaffected by the action of hygiene procedures, such as flossing, because it may have concave anatomic surface contours (fluting) and occasional roughness at the termination of the enamel. These conditions, when coupled with exposure to the oral environment (as a result of gingival recession), favor the formation of mature, caries-producing plaque and proximal root-surface caries. 54Dr.Caroline Mohamed

55. Root-surface caries is more common in older patients. Caries originating on the root is alarming because: 1. It has a comparatively rapid progression 2. it is often asymptomatic 3. it is closer to the pulp 4. it is more difficult to restore Dr.Caroline Mohamed55

56. Characteristics of root caries: Root caries lesions have less well-defined margins, tend to be U-shaped in cross sections, and progress more rapidly because of the lack of protection from and enamel covering. 56Dr.Caroline Mohamed

57. When the gingiva is healthy, root caries is unlikely to develop because the root surfaces are not as accessible to bacterial plaque. The root surface is more vulnerable to the demineralization process than enamel because cementum begins to demineralize at 6.7 pH, which is higher than enamel's critical pH. Regardless, it is easier to arrest the progression of root caries than enamel caries because roots have a greater reuptake of fluoride than enamel. Dr.Caroline Mohamed57

58. Root caries are most likely to be found on facial surfaces, then interproximal surfaces, then lingual surfaces. Mandibular molars are the most common location to find root caries, followed by mandibular premolars, maxillary anteriors, maxillary posteriors, and mandibular anteriors. Dr.Caroline Mohamed58

59. Progressive caries Arrested caries Rapidly progressive - AcuteSlowly progressive- Chronic Nursing caries Radiation caries 2) BASED ON THE PROGRESSION OF THE LESION:

60. Acute caries Acute caries is a rapid process involving a large number of teeth. These lesions are lighter colored than the other types, being light brown or grey, and their caseous consistency makes the excavation difficult. Pulp exposures and sensitive teeth are often observed in patients with acute caries. It has been suggested that saliva does not easily penetrate the small opening to the carious lesion, so there are little opportunity for buffering or neutralizaton 60Dr.Caroline Mohamed

61. Nursing caries Nursing caries can also be called as: 1. Nursing bottle caries 2. Nursing bottle syndrome 3. Milk bottle syndrome 4. Baby bottle tooth decay 5. Early childhood caries   The new name given for early childhood caries is “maternally derived streptococcus mutans disease (MDSMD)” Dr.Caroline Mohamed61

62. NURSING CARIES This is the type of acute carious lesion, which occurs among those children who take milk or fruit juices by nursing bottle, for a considerably longer duration of time, preferably during sleep. As the child takes larger amount of easily fermentable sugars along with the milk, the sugar facilitates the cariogenic bacteria to produce caries at a rapid pace by fermenting those sugars. Nursing bottle caries commonly occurs in the upper anterior teeth (as these are constantly coming in contact with the sweetened milk); while the lower teeth are not usually affected as they remain under the cover of the tongue.

63. Radiation caries Radiotherapy is frequently associated with xerostomia due to decreased salivary secretion This and other cause of decreased salivation may lead to a rampant form of caries, indicating the significance of saliva in preventing caries. Dr.Caroline Mohamed63

64. Radiation caries Dr.Caroline Mohamed64

65. Three types of defects due to irradiation 1. Lesion usually encircling the neck of teeth amputation of crowns may occur 2. Begins as brown to black discolouration of tooth.occlusal surface and incisal edges wear away 3. Spot depression which spreads from any surface

66. Chronic caries These lesions are usually of long-standing involvement, affect a fewer number of teeth, and are smaller than acute caries. Pain is not a common feature because of protection afforded to the pulp by secondary dentin The decalcified dentin is dark brown and leathery. Pulp prognosis is hopeful in that the deepest of lesions usually requires only prophylactic capping and protective bases. The lesions range in depth and include those that have just penetrated the enamel. 66Dr.Caroline Mohamed

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68. Arrested caries Caries which becomes stationary or static and does not show any tendency for further progression Both deciduous and permanent affected. With the shift in the oral conditions, even advanced lesions may become arrested. Arrested caries involving dentin shows a marked brown pigmentation and induration of the lesion (the so called ‘eburnation of dentin’). Sclerosis of dentinal tubules and secondary dentin formation commonly occur. 68Dr.Caroline Mohamed

69. Arrested caries Exclusively seen in caries of occlusal surface with large open cavity in which there is lack of food retention. Also on the proximal surfaces of tooth in cases in which the adjacent approximating tooth has been extracted 69Dr.Caroline Mohamed

70. 3) BASED ON THE VIRGINITY OF THE LESION: Primary Caries Secondary or Recurrent caries Recurrent caries is that occurring immediately next to a restoration. It may be the result of poor adaptation of a restoration, which allows for a marginal leakage, or it may be due to inadequate extension of the restoration. In addition, caries may remain if there has not been complete excavation of the original lesion, which later may appear as a residual or recurrent caries.

71. Primary caries A primary caries is one in which the lesion constitutes the initial attack on the tooth surface. The designation of primary is based on the initial location of the lesion on the surface rather than the extent of damage. 71Dr.Caroline Mohamed

72. Secondary caries (Recurrent) This type of caries is observed around the edges and under restorations. The common locations of secondary caries are the rough or overhanging margin and fracture place in all locations of the mouth. It may be result of poor adaptation of a restoration, which allows for a marginal leakage, or it may be due to inadequate extension of the restoration. In addition caries may remain if there has not been complete excavation of the original lesion, which later may appear as a residual or recurrent caries. 72Dr.Caroline Mohamed

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76. 4.Based on the extend of the lesion- severity INCIPIENT CARIES OCCULT CARIES CAVITATION 76Dr.Caroline Mohamed

77. Incipient caries The early caries lesion best seen on the smooth surfaces of the teeth, is visible as a ‘White Spot’ Histologically, the lesion has an apparently intact surface layer overlying subsurface demineralization. Significantly many such lesions can under go remineralization & thus the lesion is not an indication for restorative treatment Remineralised with fluoride application D/d: developmental defects of enamel Dr.Caroline Mohamed77

78. White Spot Lesion: It is a subsurface lesion External (outer) surface Internal loss of minerals

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80. Occult caries Occult or hidden caries is used to describe such lesion, which is not clinically diagnosed but detected only on radiographs. It is believed that bitewing & OPG radiographs along with other noninvasive adjuncts like fibrooptic transillumination (FOTI), LASER luminescence, electrical resistance method(ERM) are used for diagnosing these occlusal lesions. Prevalence-0.8%-50% in age range of 14 -20 yrs Dr.Caroline Mohamed80

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82. Cavitation… Dr.Caroline Mohamed82

83. Cavitation Once it reaches the dentinoenamel junction, the caries process has the potential to spread to the pulp along the dentinal tubules and also spread in lateral direction. Thus some amount of sensitivity may be associated with this type of lesion. This may be generally accompanied by cavitation 83Dr.Caroline Mohamed

84. 5. Based on tissue involvement 1. Initial caries- demineralization 2. Superficial caries- enamel 3. Moderate caries- dentin caries 4. Deep caries – dentin close to the pulp 5. Deep complicated caries – pulp involvement 84Dr.Caroline Mohamed

85. Dental caries can be divided into 4 or 5 stages 1. Initial caries: Demineralization without structural defect. This stage can be reversed by fluoridation and enhanced mouth hygiene 2. Superficial caries (Caries superficialis):Enamel caries, wedge-shaped structural defect. Caries has affected the enamel layer, but has not yet penetrated the dentin. Includes larger lesions with adequate tooth structure to support the restoration 85Dr.Caroline Mohamed

86. 3. Moderate caries (Caries media): Dentin caries. Extensive structural defect. Caries has penetrated up to the dentin and spreads two-dimensionally beneath the enamel defect where the dentin offers little resistance. 4. Deep caries (Caries profunda): Deep structural defect. Caries has penetrated up to the dentin layers of the tooth close to the pulp. 5. Deep complicated caries (Caries profunda complicata) :Caries has led to the opening of the pulp cavity (pulpa aperta or open pulp). 86Dr.Caroline Mohamed

87. 6. Based on chronology EARLY CHILDHOOD CARIES ADOLESCENT CARIES ADULT CARIES 87Dr.Caroline Mohamed

88. Early childhood caries Early childhood caries would include, two variants: Nursing caries and rampant caries. The difference primarily exist in involvement of the teeth (mandibular incisors) in the carious process in rampant caries as opposed to nursing caries. 88Dr.Caroline Mohamed

89. Teenage caries (adolescent caries ) This type of caries is a variant of rampant caries where the teeth generally considered immune to decay are involved. The caries is also described to be of a rapidly burrowing type, with a small enamel opening. The presence of a large pulp chamber adds to the woes, causing early pulp involvement. 89Dr.Caroline Mohamed

90. Adult caries With the recession of the gingiva and sometimes decreased salivary function due to atrophy, at the age of 55-60 years, the third peak of caries is observed. Root caries and cervical caries are more commonly found in this group. Sometime they are also associated with a partial denture clasp. 90Dr.Caroline Mohamed

91. 7.Based on whether caries is completly removed or not during treatment RESIDUAL CARIES Residual caries is that which is not removed during a restorative procedure, either by accident, neglect or intention. Sometimes a small amount of acutely carious dentin close to the pulp is covered with a specific capping material to stimulate dentin deposition, isolating caries from pulp. The carious dentin can be removed at a later time.

92. 8.Based on surfaces to be restored Most widespread clinical utilization O for occlusal surfaces M for mesial surfaces D for distal surfaces F for facial surfaces B for buccal surfaces L for lingual surface Various combinations are also possible, such as MOD –for mesio-occluso-distal surfaces.

93. 9.World health organization (WHO) system In this classification the shape and depth of the caries lesion scored on a four point scale D1. clinically detectable enamel lesions with intact (non cavitated) surfaces D2. Clinically detectable cavities limited to enamel D3. Clinically detectable cavities in dentin D4. Lesions extending into the pulp

94. Diagnostic criteria for DC according to WHO, 1997 Caries is recorded as present when a lesion in a pit or a fissure is present with following criteria: 1. Obvious cavity 2. Undermined enamel 3. Softened floor 4. Temporary filling Crown –sound: no evidence treated/untreated caries…

95. Crown with following defects (absence of other positive criteria) coded as sound: 1- white chalky spot. 2- discolored rough spots. 3- stained pits & fissures in enamel, no visual signs of undermined enamel. 4- dark, shiny hard pitted areas of enamel. 5- lesions that, on the basis of their distribution or history, or visual/tactile examination, appear to be due to abrasion.

96. Measurement of dental caries DMF-T & - S indices D = Decayed M= Missed F = Filled DMF-T=how many Teeth havening caries DMF-S= how many Surface having caries

97. DMF- T & - S = Permanent teeth dmf- t & -s = Deciduous teeth df & def = mixed dentition e = extracted before normal shedding time

98. WHO oral health surveys manual means of DMF-T index very low = 0.0 - 1.0 low = 1.2 - 2.6 medium = 2.7 - 4.4 high = 4.4 - 6.5 very high = 6.5

99. D Index of treatment need = DMF F Care index of restorative provision = DMF M Index of treatment failure = or prosthetic need DMF ----------------------------------------------------------

100. Limitations of DMFT Values are not related to the number of teeth at risk. Invalid when teeth are lost for reasons other than dental caries. Can overestimate caries experience in teeth with preventive restoration.

101. Little use in estimating treatment needs Can not account sealed teeth  Sound  DMFSS It is not used to measure root caries

102. dmf index When written in lowercase letters, is applied to the primary dentition. The dmft index expresses the number of affected teeth in primary dentition, with scores ranging from 0 to 20 for children. The dmfs index expresses the number of affected surfaces in primary dentition (five per posterior tooth and four per anterior tooth), with a score range of 0 to 88 surfaces. Use: children < ages exfoliation m: missed dt caries if < 6 years Applied to primary molar teeth

103. Def index It is applied to the primary dentition during mixed dentition period, (e) means primary teeth indicated for extraction due to caries. d: decayed e: indicated for extraction f: filled Allows 2 grades of caries m: missed not recorded difficulty of distinguishing between extracted/ naturally exfoliated 1ry tooth

104. df index Because of the difficulty in distinguishing between teeth extracted due to caries and those that have naturally exfoliated, missing teeth may be ignored. m : ignored def- df : - numerically same - understate true extent carious attack - Reliable

105. The problem in caries diagnosis are not with the advance lesions but primarily with the early lesion, secondary caries and root caries Epidemiologist Clinician

106. 10. Assessement tools Stepwise progression toward diagnosis & treatment planning depends on thorough assessment of the following  Patient History  Clinical examination  Nutritional analysis  Salivary analysis  Radiographic assessment 106Dr.Caroline Mohamed

107. Conventional techniques of measuring and recording decay Dr.Caroline Mohamed107 Visual exam Mirror and explorer Dental radiographs Dyes Transillumination Dmfs/dmft

108. VISUAL-TACTILE METHODS Visual methods:  Detection of white spot, discoloration / frank cavitations.  Unable to detect subsurface caries.  Magnification loupes- Head worn prism loupes (X 4.5) or surgical microscopes (X 16) may be used.  Use of temporary elective tooth separation. 108Dr.Caroline Mohamed

109. Tactile methods:  Explorers,Dental floss. Use of explorer is not advocated because;  Sharp tips physically damage small lesions with intact surfaces.  Probing can cause fracture & cavitation of incipient lesion. It may spread the organism in the mouth.  Mechanical binding may be due to non-carious reasonsShape of fissure Sharpness of explorer Force of application Path of explorer placement Explores should be used to clean debris from teeth. 109Dr.Caroline Mohamed

110. X-rays + non –destructive + can detect subsurface caries - limited safety - unable to detect incipient demineralization - low resolution Dr.Caroline Mohamed110

111. Bitewings/ Periapical Dr.Caroline Mohamed111 Radiographic imaging of pit and fissures is of minimal diagnostic value because of the large ammount of sorrounding enamel. It is detrimental if used for non-invasive remineralization methods.

112. Direct fiberoptic transillumination 112Dr.Caroline Mohamed Enhanced visual technique that uses the principle of illuminating teeth to detect the presence of caries.. (Pretty, Maupomé, 2004)

113. Dental Caries Index DMF-T Decayed, Missed, Filled Teeth D = Decayed / not treated yet M = Missed / extracted because decayed F = Filled / restored after decay T = Permanent teeth dmf-t = Primary teeth S = Surface DMF-S / dmf-s ( Mesial/ Distal/ Vestibular / Occlusal) 113Dr.Caroline Mohamed

114. DMF-T CHART Dr.Caroline Mohamed114

115. 10. G. V. BLACK CLASSIFICATION:

116. Dr.Caroline Mohamed116 CLASS 1: pit and fissure cavities that occur in the occlusal surfaces of bicuspids and molars, the occlusal two thirds of the buccal and lingual surfaces of the molars, and the lingual surfaces of incisors. Cavities beginning in structural defects that occasionally occur on the occlusal or incisal two third of all teeth.

117. Dr.Caroline Mohamed117 CLASS 2: cavities in the proximal surfaces of bicuspids and molars

118. Dr.Caroline Mohamed118 CLASS 3: Cavities in the proximal surfaces of incisors and cuspids, not involving the incisal angle

119. Dr.Caroline Mohamed119 CLASS 4: Cavities in the proximal surfaces of incisors and cuspids involving the incisal angle

120. CLASS 5: Cavities in the gingival third, not pit and fissures cavities, of the labial, buccal and lingual surfaces of all teeth

121. Dr.Caroline Mohamed121 CLASS 6: Cavities on both mesial and distal proximal surfaces of bicuspid and molars that when restored will share a common isthmus; or cavities on the incisal edges of anterior or cusp tip of posterior teeth.

122. Dr.Caroline Mohamed122

123. HIGH RISK LOW RISK Social History Socially deprived High caries in siblings Low knowledge of caries Middle class Low caries in sibling High dental aspirations Medical History Medically compromised Xerostomia Long-term cariogenic medicine No such problem Dietary habits Sugar intake: frequent Infrequent 123Dr.Caroline Mohamed

124. HIGH RISK LOW RISK Use of fluoride Non-fluoridated area No fluoride supplements Fluoridated area Fluoride supplements used Plaque control Poor oral hygiene maintenance Good oral hygiene maintenance Saliva Low flow rate& buffering capacity  S.mutans & lactobacillus counts Normal flow rate& buffering capacity  S.mutans & lactobacillus counts 124Dr.Caroline Mohamed

125. HIGH RISK LOW RISK Clinical evidence New lesions Premature extractions Anterior caries restorations Multiple/repeated restorations No fissure sealants Multi-band orthodontics No new lesions No extraction for caries Sound anterior teeth No/few restorations Fissure sealed No appliances 125Dr.Caroline Mohamed

126. Thank you Dr.Caroline Mohamed126

127. Activity What is a fluoride bomb or fluoride syndrome? Dr.Caroline Mohamed127