1. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Primary Preventive Dentistry Seventh Edition Primary Preventive Dentistry, Seventh Edition Norman O. Harris, Franklin García-Godoy, and Christine N. Nathe Chapter 3 Dental Caries to Carious Lesions

2. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Primary Preventive Dentistry, Seventh Edition Norman O. Harris, Franklin García-Godoy, and Christine N. Nathe Introduction Dental caries –One of the most common diseases in humans –Causes pain and disability –Can lead to infection, tooth loss, and edentulism

3. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Primary Preventive Dentistry, Seventh Edition Norman O. Harris, Franklin García-Godoy, and Christine N. Nathe Historical Perspective One of the oldest theories of caries and toothache was that of a tooth worm that lived in the center of the tooth Treatments included henbane seeds, magical formulas, and oaths Then caries were thought to be caused by erosion of the enamel and recommended that the caries be smoothed by a file

4. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Primary Preventive Dentistry, Seventh Edition Norman O. Harris, Franklin García-Godoy, and Christine N. Nathe Historical Perspective (Continued) Then in the 1800s caries were theorized to be caused by the presence and proliferations of organisms Then an American dentist teaching in Germany published a chemicoparisitic theory of caries Dr. G.V. Black, the founder of modern dentistry, then added that microbic plaque was the source of the acids, which is still believed today

5. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Primary Preventive Dentistry, Seventh Edition Norman O. Harris, Franklin García-Godoy, and Christine N. Nathe Multifactorial Disease Process 1.There must be a susceptible tooth and host 2.Cariogenic microorganisms must be present in a sufficient quantity 3.There must be frequent excessive consumption of refined carbohydrates 4.This process must occur over a sufficiently long period of time

6. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Primary Preventive Dentistry, Seventh Edition Norman O. Harris, Franklin García-Godoy, and Christine N. Nathe FIGURE 3–1 Dental caries: multifactorial disease process.

7. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Primary Preventive Dentistry, Seventh Edition Norman O. Harris, Franklin García-Godoy, and Christine N. Nathe FIGURE 3–2 Oral disease risk assessment worksheet. (Baylor School of Dentistry, Texas A&M Health Science Center, Dallas. Used with permission.)

8. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Primary Preventive Dentistry, Seventh Edition Norman O. Harris, Franklin García-Godoy, and Christine N. Nathe Dental Caries Description Carious legions occur in four general areas of the tooth: –Pit and fissure caries –Smooth surface caries –Root surface caries –Secondary/recurrent caries (on tooth surface adjacent to an existing restoration)

9. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Primary Preventive Dentistry, Seventh Edition Norman O. Harris, Franklin García-Godoy, and Christine N. Nathe Physical and Microscopic Features of Incipient Caries Three distinct stages of caries: –Incipient lesion  The initial stage of tooth decay that has not penetrated the outer surface of the tooth  The lesion looks like a white spot on the enamel –The progress of demineralization toward the dentinoenamel junction –Overt or frank lesion which is characterized by actual cavitation

10. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Primary Preventive Dentistry, Seventh Edition Norman O. Harris, Franklin García-Godoy, and Christine N. Nathe FIGURE 3–3 Development of a carious lesion. (Retrieved June 27, 2007, from http://www.gsbs.utmb.edu/microbook/ch099.htm. Used with permission.)

11. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Primary Preventive Dentistry, Seventh Edition Norman O. Harris, Franklin García-Godoy, and Christine N. Nathe FIGURE 3–4 Incipient caries in an occlusal fissure. The bilaterality of the lesion is evident in the microradiograph. (Courtesy of J. S. Wefel, University of Iowa College of Dentistry, Iowa City.)

12. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Primary Preventive Dentistry, Seventh Edition Norman O. Harris, Franklin García-Godoy, and Christine N. Nathe FIGURE 3–5 The bilaterality of caries development. Note coalescence of two lateral carious areas at base of fissure. (From Konig, K. G. (1963). Dental morphology in relation to carious resistance with special reference to fissures as susceptible areas. J Dent Res, 42:461–76.)

13. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Primary Preventive Dentistry, Seventh Edition Norman O. Harris, Franklin García-Godoy, and Christine N. Nathe Physical and Microscopic Features of Incipient Caries (Continued) Rampant decay occurs: –If the development of overt elsions is rapid or extensive (on more than one tooth) –After excessive and frequent intake of sucrose and/or presence of xerostomia

14. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Primary Preventive Dentistry, Seventh Edition Norman O. Harris, Franklin García-Godoy, and Christine N. Nathe Incipient Lesion Zones Surface zone Body of lesion Dark zone Translucent zone

15. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Primary Preventive Dentistry, Seventh Edition Norman O. Harris, Franklin García-Godoy, and Christine N. Nathe Pore Spaces of the Different Zones The translucent zone has a 1% pore space The dark zone has a 2%-4% pore space The surface zone has a pore space of approximately 1% A body of a lesion ranges from 5%- 25% pore space

16. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Primary Preventive Dentistry, Seventh Edition Norman O. Harris, Franklin García-Godoy, and Christine N. Nathe Direct Connection of the Bacterial Biofilm to the Body of a Lesion Demineralization Remineralization

17. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Primary Preventive Dentistry, Seventh Edition Norman O. Harris, Franklin García-Godoy, and Christine N. Nathe FIGURE 3–6 Diagram of a trichotomized lesion attributable to diffusion of acids in both directions under the enamel and directly into the body of the lesion in the dentin. T, translucent zone; B, body of the lesion; R, reactionary dentin; P, pulp. (From Silverstone L. M., & Hicks, M. J. (1985). The structure and ultrastructure of the carious lesion in human dentin. Gerodontics, 1:185–93.)

18. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Primary Preventive Dentistry, Seventh Edition Norman O. Harris, Franklin García-Godoy, and Christine N. Nathe Mutans Streptococci and Caries Mutans streptococci and caries –Considered to be the major pathogenic bacterial species involved in the caries process –Usually found in relatively large numbers in the placquethat forms immediately over developing smooth-surface lesions

19. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Primary Preventive Dentistry, Seventh Edition Norman O. Harris, Franklin García-Godoy, and Christine N. Nathe Lactobacilli and Caries Lactobacilli are cariogenic, acidogenic, and aciduric Are not required for caries development

20. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Primary Preventive Dentistry, Seventh Edition Norman O. Harris, Franklin García-Godoy, and Christine N. Nathe Adherence of Bacteria to Teeth Continous adherence of the bacteria to the solic tooth surface is necessary both before and after initial colonization The first bacteria must establish a foothold on the acquired pellicle on the tooth surface Then they must maintain their positions while other bacteria continue to colonize

21. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Primary Preventive Dentistry, Seventh Edition Norman O. Harris, Franklin García-Godoy, and Christine N. Nathe Ecology of Caries Development: Caries Transmission It has been suggested that an effective means of preventing caries in your children would be to reduce the number of MS in the parents’ and siblings’ mouths before a child’s birth

22. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Primary Preventive Dentistry, Seventh Edition Norman O. Harris, Franklin García-Godoy, and Christine N. Nathe Dental Caries Coronal dentin caries Root caries Secondary/recurrent caries

23. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Primary Preventive Dentistry, Seventh Edition Norman O. Harris, Franklin García-Godoy, and Christine N. Nathe FIGURE 3–7 Root caries. The darker staining of the coronal half of the root indicates considerable gingival recession, which is a prerequisite to lesion development.

24. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Primary Preventive Dentistry, Seventh Edition Norman O. Harris, Franklin García-Godoy, and Christine N. Nathe Measuring Plaque pH, and The Stephan Curve There is a continuous pH change in plaque every time food is consumed Stephan Curve is the term for the immediate drop in pH when sugar or sugary snacks are eaten, followed by a longer recovery period when other foods are eaten

25. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Primary Preventive Dentistry, Seventh Edition Norman O. Harris, Franklin García-Godoy, and Christine N. Nathe FIGURE 3–8 Stephan curves. These curves show the typical plaque pH response to an oral glucose rinse (indicated by the screened area). An immediate fall in the pH is followed by a gradual return to resting values after about 40 minutes. Each curve represents the mean of 12 subjects; the pH was measured by sampling method and therefore is an average value for the whole-mouth plaque pH. In individual sites away from the salivary buffers, the pH values may fall close to 4.0. The upper curve was obtained from reconstituted skim milk and the lower one from an apple-flavored drink, showing a large difference in the acidogenicity of these two drinks. (Courtesy of M. W. J. Dodds, University of Texas Dental School, San Antonio.)

26. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Primary Preventive Dentistry, Seventh Edition Norman O. Harris, Franklin García-Godoy, and Christine N. Nathe Relationship of Saturation to pH The concentration of calcium and phosphate ions in plaque fluid bathing the tooth at the plaque-tooth interface is extremely important because these are the same elements that compose the hydroxyapatite crystal found in the enamel

27. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Primary Preventive Dentistry, Seventh Edition Norman O. Harris, Franklin García-Godoy, and Christine N. Nathe Demineralization and Remineralization Principles Demineralization is caused by plaque acid, which dissolve the tooth minerals making up the basic calcium, phosphate, and hydroxyl crystals of the enamel, dentin, and cementum Remineralization requires the same ions, preferably with fluoride as a catalyst

28. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Primary Preventive Dentistry, Seventh Edition Norman O. Harris, Franklin García-Godoy, and Christine N. Nathe Relationship of HAP, FHA and CaF ₂ After an attack by plaque acid(s), CaF 2 disolves first, followed in a sequence by HAP and FHA

29. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Primary Preventive Dentistry, Seventh Edition Norman O. Harris, Franklin García-Godoy, and Christine N. Nathe Depth of Remineralization Topical procedures are successful in stimulating surface remineralization Some researchers believe that remineralization is a reasonable objective even for lesions reaching the dentin

30. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Primary Preventive Dentistry, Seventh Edition Norman O. Harris, Franklin García-Godoy, and Christine N. Nathe Summary Multifactorial process Dental caries description Plaque bacteria Demineralization Remineralization