INTRODUCTION:
Dental Caries affect both primary and permanent teeth. (Mathur & JK, 2018) When we eat food rich in carbohydrates, the bacteria make acid (Mathur & JK, 2018) that have the capacity to damage the enamel and dentin of our teeth (Mathur & JK, 2018). So that causes the formation of dental caries. (Mathur & JK, 2018) Bad oral hygiene can also result in the initiation of dental caries, and prevention is more affordable than treating it. (Mathur & JK, 2018) So good oral hygiene and dietary alteration should be suggested. (Mathur & JK, 2018). When there is a reduction in salivary flow, dental caries develops. (Xiaoli, Jiang, Koh, & Hsu, 2016) Saliva moisturizes and lubricates the oral tissues. (Xiaoli, Jiang, Koh, & Hsu, 2016) It also has antimicrobial and buffering action, which neutralizes acids in the mouth. (Xiaoli, Jiang, Koh, & Hsu, 2016)
Caries can be categorized as occlusal caries, proximal caries, buccal/lingual caries and cemental caries. Cemental caries are more commonly found in the older if there is a recession of gingiva that has occurred. (Sikri, 2019) Early discernment of caries is crucial as it can be stopped with non-invasive methods (Gomez, 2015). There are several ways to detect dental caries. (Gomez, 2015) It can either be distinguished by signs and symptoms like pain while eating, or it can also be characterized if it is discolored and damaged. (Sikri, 2019) Cavitated caries lesion located on both occlusal and smooth surfaces of the teeth can be detected with the visual-tactile method. (Gomez, 2015) But for deep cavitated lesions and proximal lesions, we need X-rays (Gomez, 2015). The carious surface on X-ray appears as radiolucent. (Gomez, 2015).
There are many types of microorganisms involved with dental caries, (Mosaddad, Tahmasebi, & Yazdanian, 2019) some of them are facultative anaerobes and some obligative anaerobes species like Actinomyces, Lactobacillus, Eubacterium (Mosaddad, Tahmasebi, & Yazdanian, 2019) It can also be caused by some other species of microorganisms like Fusobacterium, Enterococcus, Streptococci, Prevotela (Mosaddad, Tahmasebi, & Yazdanian, 2019). There is also a relationship between dental caries and periodontitis. (Robert, Roufegarinejad, & Chandad, 2019) People with three or more teeth with caries are more probably to develop periodontitis. (Robert, Roufegarinejad, & Chandad, 2019)
Role of Microorganisms:
Figure 1: Role of Microorganisms in Dental Caries. Source (slideshare/drjaffarraza/02dental-caries)
The oral cavity contains both acid-producing and acid-tolerant bacteria. (Kaidonis & Townsend, 2016)The most common microorganism responsible for dental caries is Streptococcus mutant and Lactobacillus Species. (Kaidonis & Townsend, 2016) Streptococcus mutans has been proven for the initiation of caries ( Figure 1) This microorganism forms insoluble, sticky extracellular polysaccharides like glucans and dextrans (Mosaddad, Tahmasebi, & Yazdanian, 2019). These polysaccharides help in further colonization and increase the contact of the acids with the tooth structure leading to further demineralization, which ultimately leads to cavitation. (Mosaddad, Tahmasebi, & Yazdanian, 2019)
Prevalence: Dental caries increases with age due to denture use and poor hygiene. (DAMLE, 2018) Caries experience is high in all age groups, but in old age, there are high chances because of the medications they are on, and these medications cause xerostomia (Gavriilidou & Belibasakis, 2019). Also, the incidence is high in developing countries because they don’t have access to dental health care. (DAMLE, 2018)
Caries in Children: Early childhood caries (ECC) is one of the most common oral diseases in children. (Seow, 2018) . There are four stages of ECC, Initial stage, circular stage, destructive stage, and radix relicta stage (Zafar). It causes severe pain and psychological disturbances in children (Mathur & JK, 2018). It most often affects anterior maxillary teeth but can also affect mandibular anterior teeth. (Seow, 2018) It is vital to get treatment early to cease decay (Mathur & JK, 2018). There are many factors responsible for this type of caries in children, such as poor and prolonged feeding habits, poor oral hygiene. (Seow, 2018). In infants, the leading cause of tooth decay is the addition of sugars in milk or fruit juices (Seow, 2018). One of the simple methods to prevent is by not placing your kid to bed with a bottle filled with milk, juice, and by adopting a healthy balanced diet. (Seow, 2018)
Classification of Dental Caries: Depending on the location, Dental Caries can be: Primary caries or Secondary caries. (Sikri, 2019). Primary caries can be located in the pits and fissures, on smooth surfaces and root surfaces. There are four types of primary caries, such as Pit and fissure caries, Smooth surface caries, root caries, Residual caries. (Sikri, 2019). Secondary caries referred to as recurrent caries and begin around or beneath the restoration. Secondary caries can be, Incipient caries, Advanced/Cavitated caries, Acute caries, Chronic caries. (Sikri, 2019)
Caries Etiology: There are many causes, but the first important reason is diet: Whenever carbohydrates are consumed, oral microorganisms rapidly start their fermentation, producing acid. (Mathur & JK, 2018) (DAMLE, 2018) This leads to a drop in the pH of the saliva. (Mathur & JK, 2018) The organic acids attack the tooth structure (DAMLE, 2018). It causes demineralization. (DAMLE, 2018). The other important factor is the microorganism which is responsible for the initiation of dental caries is Streptococcus mutans (Mosaddad, Tahmasebi, & Yazdanian, 2019)
Figure 2: Occlusal caries as seen in molar and premolar( Source: Textbook of operative dentistry by Nisha Garg, 3rd Edition)
In Figure 2, it has been shown that deep pit and fissures on molar and premolar favor food impaction and thereby dental caries.
Risk and modification factors for caries:
Figure 3: In Figure 4, we can see that there are many factors involved in tooth decay. So, according to this carious process can be viewed as a complex, multifactorial interaction between the tooth, oral microorganisms, and fermentable carbohydrates, with factors like saliva playing critical roles in this dynamic interplay. (Source: Pocket Dentistry, Chapter:2)
Pathogenesis of Dental Caries:
Figure 4: Source: American Academy of Pediatric Dentistry and Procter & Gamble
As shown in Figure 4, caries can occur if bacteria produce acids by metabolizing fermentable carbohydrates, causing demineralization.
Three main factors: Tooth (host) Substrate ( fermentable carbohydrate) and Microorganisms (bacteria). (Conrads, 2018) Attempts are being made to control each of these (Conrads, 2018). Modifying the tooth surface by use of fluoride and controlling the microbial factors by various plaque control methods, have been met with some degree of success. (Pajor, Pajchel, & Kolmas, 2019)
Sign and symptoms of Dental Caries: Symptoms can vary from patient to patient, and also, it depends on stages of caries (SWC, LiCF, JSP, Wong, & VWK, 2019). If it is the initial stage, it could be asymptomatic. (SWC, LiCF, JSP, Wong, & VWK, 2019) In later stages, it can be mild to severely painful. (SWC, LiCF, JSP, Wong, & VWK, 2019) Toothache is the main symptom of a tooth cavity, and in some cases, you experience tooth sensitivity regularly or pain while biting (SWC, LiCF, JSP, Wong, & VWK, 2019). In advanced stages of tooth decay, one may notice pus around the affected tooth. (SWC, LiCF, JSP, Wong, & VWK, 2019)
Diagnosis of Dental Caries: Although current research and new technologies have enabled early detection of caries, no current diagnostic method fulfills all the criteria for optimal caries diagnosis. (DAMLE, 2018) Diagnosis of caries, if done at an early stage, can prove to be extremely valuable in preventing its progression and ensuring a healthy dentition, which would last a lifetime emphasizing the need to develop more accurate and reliable methods of diagnosing dental caries. (DAMLE, 2018) The use of a mirror and a sharp probe is the most common method of diagnosing tooth decay, but it is not as reliable as dental radiographs. (Gomez, 2015) (Akarslan, 2018)
Figure 5: Source: White and Pharoah Radiology 6th Edition
- As shown inFigure 5, Severe Occlusal caries appears as a large radiolucent lesion in the mandibular first molar
The radiographic examination has great value in the detection and determination of those carious lesions, which are not resolved by clinical examination. (Akarslan, 2018) it is among the most important techniques for the detection of caries. It is highly accurate for proximal lesions and dentine caries lesions. (Gomez, 2015) Bitewing radiographs are used for the diagnosis of proximal decay and occlusal dental lesions. (Gomez, 2015) (Akarslan, 2018)The use of radiographs must be interpreted with caution as it presents a two-dimensional picture of a three-dimensional object. (Gomez, 2015)
Treatment/Management: Treatment depends on whether the carious lesion is cavitated or non cavitated. (Carvalho, Dige, & Machiulskiene, 2016)(Akarslan, 2018) If a lesion is non-cavitated, it is also referred to as initial caries or reversible caries (Carvalho, Dige, & Machiulskiene, 2016). At this stage, the lesion is in a reversible state, and it can be remineralized if good oral hygiene is followed. (Akarslan, 2018)
In cavitated lesions or advanced stage, caries has progressed to the dentin-enamel junction and is no longer reversible (Carvalho, Dige, & Machiulskiene, 2016). At this stage, the lesion cannot be remineralized and requires cavity preparation and restoration for treatment (Carvalho, Dige, & Machiulskiene, 2016). (Akarslan, 2018)
Restorative material: After removing the decayed material from the tooth with bur and handpiece. (Carvalho, Dige, & Machiulskiene, 2016) Dentists fill it with restorative material like composite or dental amalgam. (Chesterman, Jiwett, Gallacher, & Nixon, 2017) Composite- resin is usually preferred than dental amalgam because of the esthetic reason (Akarslan, 2018), But in the case of posterior teeth, dental amalgam, or composite can be used. (Akarslan, 2018)
Root Canal: As caries progress and reach close to the pulp and causes infection of the pulp, root canal treatment is started to remove the infected pulp and fill the area with an appropriate restorative material. (Sui & Dahl, 2019)
Crowns: Full metal crowns or porcelain fused metal dental crowns are used when there is dental caries destroys a large area of the tooth. (Sequeira; Byron; Fedorowicz; Carter; Nasser; Alrowaili, 2015) A crown is necessary when the tooth is broken down, and merely fillings cannot restore the tooth to its normal structure and function. (Akarslan, 2018)
Extraction: In some cases, the tooth cannot be repaired or after the failure of the root canal (Almasri, 2019) or if it is severely damaged, so in those cases, we need to extract the tooth to stop the infection from spreading to the bones. (Almasri, 2019)
Preventive measures: The goals of dentistry should be to promote and preserve oral health and restore it only when it is impaired. (Pitts, DT, & PD, 2017) Educating the public and patients on good oral health behavior and thus empowering them to be responsible for their health is the ultimate goal of prevention. (Pitts, DT, & PD, 2017)
Oral Hygiene: Patients should be educated by dentists and staff about optimal oral hygiene practices like proper brushing and flossing daily to remove the formation of plaque. (Pitts, DT, & PD, 2017)
Salivary stimulation: A person with a complete absence of saliva production runs a very high risk of dental caries, and in the case of xerostomia, commercially available substitutes like methylcellulose, mucin, etc. can be used. (Morales, Ortega, & Rojas, 2017)
Topical Fluoride Application for Caries Prevention: The most commonly used form of topical fluoride is fluoride dentifrices. (Talwar, Borzabadi, Lynch, Borsboom, & Ruben, 2019) Fluoride inhibits demineralization and promotes remineralization by causing fluorapatite formation. (Talwar, Borzabadi, Lynch, Borsboom, & Ruben, 2019) So the presence of fluoride in the aqueous phase in the oral fluids is very important. (Talwar, Borzabadi, Lynch, Borsboom, & Ruben, 2019) They act by inhibiting demineralization and promoting remineralization at the tooth to oral fluids interface (Talwar, Borzabadi, Lynch, Borsboom, & Ruben, 2019)
Pit and Fissure Sealants: Food and plaque gain access deep into the groove where a toothbrush cannot reach, and a cavity develops easily (Wright, 2018). The pit and fissure sealant essentially prevent dental caries. (Wright, 2018)
Dietary Modification: Frequent snacking between meals should be avoided. (Marshall, 2019) Natural sugars like lactose and fructose in milk and fruits have as much potential to cause dental caries as processed sugars (Marshall, 2019). So we should avoid it as much as possible. (Marshall, 2019) Sugar should not be added to bottle feeds, and not should sugary drinks be given. (Marshall, 2019). A healthy diet rich in vitamin D and green vegetables should be promoted. (Holick, 2017)
Regular recall visits: Patients should be encouraged to visit their dentists for professional cleaning and another dental appointment. (DAMLE, 2018)
Discussion: It is important to understand the etiological factors related to dental caries to prevent the disease before it starts or at least to prevent its progression and complications (Garg, 2015). Extensive damage from caries can affect an individual functionally and esthetically (DAMLE, 2018). Changing dietary habits to improve health is not easy (DAMLE, 2018). The health professional has to encourage them to change in the right direction. (DAMLE, 2018) This involves much more than merely giving advice. Dental professionals should educate patients about maintaining good oral hygiene through regular brushing, flossing, and regular checkup at the dental office (Inglehart, 2019). Dental personals should educate and motivate patients to reduce the intake of sugar. (Bowen & William, 2015) They should educate patients to brush after every meal with a fluoridated toothpaste to control dental caries. (Bowen & William, 2015) They should increase public awareness about the overall importance of maintaining good health by changing lifestyles and the importance of a healthy diet like a diet rich in vitamin D and green vegetables (Inglehart, 2019). Health professionals should provide expertise at national and community levels so that health promotion is based on the best scientific evidence. (Inglehart, 2019)
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