2. Epidemiology Of Dental Caries

4. Dental Caries Dental caries is an ancient disease; paleontological evidence shows that it has troubled humans from the time that agriculture replaced hunting as the principal source of food. Dental caries is an ancient disease; paleontological evidence shows that it has troubled humans from the time that agriculture replaced hunting as the principal source of food.

5. Low Caries incidence existed in Ancient Man Examination of ancient skulls shows that:

6. Low caries incidence in the ancient man is due to diet which was : Comparatively low in carbohydrates. Comparatively low in carbohydrates. Natural (unrefined) diet. Natural (unrefined) diet. Coarse & not fully prepared or cooked. Coarse & not fully prepared or cooked.

7. Pattern Of Ancient Dental Caries The pattern of ancient caries as revealed by lesions in ancient skulls was mostly cervical or root caries and coronal caries was relatively uncommon. The pattern of ancient caries as revealed by lesions in ancient skulls was mostly cervical or root caries and coronal caries was relatively uncommon. Coronal caries seemed to start in the occlusal fissures but developed no further because the rate of attrition was faster than the rate of progression. Coronal caries seemed to start in the occlusal fissures but developed no further because the rate of attrition was faster than the rate of progression.

8. Pattern Of Ancient Dental Caries cont. The ancient pattern of dental caries was replaced in the 17 th century by a new pattern where a lesion begins in fissured surfaces and develops later on proximal surfaces. The ancient pattern of dental caries was replaced in the 17 th century by a new pattern where a 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. This pattern took place in the industrialized nations as a result of the increased use of sucrose as sugars became more available.

9. 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.”

10. Global Distribution The most obvious reason for this historical pattern is diet; the high level of consumption of refined carbohydrates in developed countries in contrast to diets low in fermentable carbohydrates in poorer societies where hunting and farming are the main source of food. The most obvious reason for this historical pattern is diet; the high level of consumption of refined carbohydrates in developed countries in contrast to diets low in fermentable carbohydrates in poorer societies where hunting and farming are the main source of food.

11. High level of consumption of refined carbohydrates in developed countries led to increase in cariogenic bacteria. High level of consumption of refined carbohydrates in developed countries led to increase in cariogenic bacteria. Diet low in fermentable carbohydrates in developing countries surviving on farming &hunting lower level of cariogenic bacteria. Diet low in fermentable carbohydrates in developing countries surviving on farming &hunting lower level of cariogenic bacteria. Explanation of this pattern is : diet

12. 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. 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. 2- Marked reduction among children & young adults in developed countries.

13. In both developed and developing countries, there are distinct variations in caries experience from one country to another and from region to another within In both developed and developing countries, there are distinct variations in caries experience from one country to another and from region to another within The same Country.

14. The decline of caries is attributed to: Use of fluoridated tooth paste. Use of fluoridated tooth paste. Fluoridation of water supplies. Fluoridation of water supplies. The use of fissure sealants. The use of fissure sealants. Implementation of preventive programs Implementation of preventive programs better access to health care better access to health care better living conditions. better living conditions. Change of sugar consumption, although the change is not substantial. Change of sugar consumption, although the change is not substantial.

15. Global Distribution cont. upward trend of caries in many developing countries is related to: upward trend of caries in many developing countries is related to: The absence of widespread caries preventive strategy. The absence of widespread caries preventive strategy. Increasing consumption of sugar containing products. Increasing consumption of sugar containing products.

16. 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. 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. Variation of caries within the mouth:

17. These sites are: 1. The fissures in the occlusal surfaces of molars. 2. The proximal areas. 3. The marginal area between the tooth and the gingiva.

18. I- Types of dental caries 1)Pit & fissure caries: It is the first to appear in the mouth. It is the first to appear in the mouth. Pits &fissure surfaces constitute the most susceptible surfaces in the mouth. Pits &fissure surfaces constitute the most susceptible surfaces in the mouth.

19. 2) Proximal caries: It is the next to appear in the mouth. It is the next to appear in the mouth. It is related to plaque accumulation in the non-self cleansing areas (beneath the contact points). It is related to plaque accumulation in the non-self cleansing areas (beneath the contact points).

20. 3) Cervical caries Is the third type of dental caries that occurs uniformly throughout life. Is the third type of dental caries that occurs uniformly throughout life. It is related to progressive changes in the free gingival margin, poor oral hygiene & decreased salivary flow (xerostomia) It is related to progressive changes in the free gingival margin, poor oral hygiene & decreased salivary flow (xerostomia),.,.

21. 4) Root caries: Occurs usually in old age (60 y<). Occurs usually in old age (60 y<). Root surfaces become exposed by gingival recession in advancing age. Root surfaces become exposed by gingival recession in advancing age. These exposed areas provide perfect areas for plaque accumulation. These exposed areas provide perfect areas for plaque accumulation.

22. II-Susceptibility of different teeth Dental caries in the human mouth is usually distributed in a bilateral symmetry.

23. Susceptibility Of Different Teeth According to the pioneering Hagerstown studies (1937), the rank order of susceptibility of teeth to caries was listed as follows: According to the pioneering Hagerstown studies (1937), the rank order of susceptibility of teeth to caries was listed as follows:

24. 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

26. Dental Caries It is the disease of calcified tissues. It is the disease of calcified tissues. It is a maltifactorial disease in which the following risk factors play role in its causation process: It is a maltifactorial disease in which the following risk factors play role in its causation process: 1. Agent: Microorganisms 2. Host: Personal and tooth risk factors. 3. Environment: Dietary, and oral hygiene related risk factors.

27. Host 1- Age. 2- Gender. 3- Race. 4- Genetic &familial. 5- Role of saliva. 6- Nutrition 7-Systemic diseases and drugs. Agent 1-Streptococcus mutans. 2- Lactobacilli. 3- Actinomyces. Environmental 1-Flouride. 2-diet. 3-Social factors.

28. Microbial agent Dental caries is a bacterial disease. Dental caries is a bacterial disease. Regardless of any other factor, caries does not occur in the absence of bacteria. Regardless of any other factor, caries does not occur in the absence of bacteria.

29. Agent Factors of Dental Caries Microorganisms Mainly Streptococcus mutans are responsible for initial development of dental caries with contribution of other species such as: Mainly Streptococcus mutans are responsible for initial development of dental caries with contribution of other species such as: Lactobacillus acidophilus Lactobacillus acidophilus Lactobacillus casei Lactobacillus casei Streptococcus salivarius Streptococcus salivarius Strpetococcus milleri Strpetococcus milleri Streptococcus sanguis Streptococcus sanguis Actinomycis (root caries) Actinomycis (root caries)

30. Strept. Mutans has the ability to: 1- Implantation on tooth surface by synthesis of adhesive extra- cellular polysaccharides (glucans) from sucrose which they use to stick and colonize on tooth surface. 1- Implantation on tooth surface by synthesis of adhesive extra- cellular polysaccharides (glucans) from sucrose which they use to stick and colonize on tooth surface.

31. 2- Store intra-cellular polysaccharides which act as a transient reserves of fermentable carbohydrates. 2- Store intra-cellular polysaccharides which act as a transient reserves of fermentable carbohydrates. 3- Fermentation of dietary carbohydrates as an energy source for its metabolic activity and produces lactic acid. 3- Fermentation of dietary carbohydrates as an energy source for its metabolic activity and produces lactic acid.

32. Streptococcus mutans

33. Lactobacilli could be considered as secondary contributors for the process. Lactobacilli could be considered as secondary contributors for the process. They generally constitute less than 1% of the plaque microbiota. They generally constitute less than 1% of the plaque microbiota.

34. Their number is often increased in caries active plaque because they grow well under acid condition. Their number is often increased in caries active plaque because they grow well under acid condition. Lactobacilli are more a consequence than a cause of caries initiation. Lactobacilli are more a consequence than a cause of caries initiation.

35. The host Risk Factors 1- Age. 1- Age. 2- Gender. 2- Gender. 3- Race. 3- Race. 4- Genetic & familial. 4- Genetic & familial. 5- Role of saliva. 5- Role of saliva. 6- Nutrition 6- Nutrition 7-Systemic diseases and drugs. 7-Systemic diseases and drugs.

36. Age Caries was considered a childhood disease because all susceptible tooth surfaces become carious during early child years and few carious lesions are affected during adulthood. Caries was considered a childhood disease because all susceptible tooth surfaces become carious during early child years and few carious lesions are affected during adulthood.

37. Age Age In communities with lower attack rate, young people reach adulthood with most surfaces caries free and caries attack spread out more throughout life. In communities with lower attack rate, young people reach adulthood with most surfaces caries free and caries attack spread out more throughout life.

38. Age Age Caries increases progressively by age, and the increase is more slowly during adult years Caries increases progressively by age, and the increase is more slowly during adult years This is due to: This is due to:  Most of the susceptible surfaces are likely to have been attacked by that time.  The build up fluoride in outer layers of enamel over time.

39. After age of 60 years, caries increases again because of root caries. After age of 60 years, caries increases again because of root caries.

40. Gender Gender It is observed that caries prevalence is higher in females than in males of the same age. It is observed that caries prevalence is higher in females than in males of the same age.

41. Females generally demonstrate higher DMF scores than males probably due to : The earlier tooth eruption in females; their teeth are at risk for a longer time. The earlier tooth eruption in females; their teeth are at risk for a longer time. Females visit the dentist more frequently (treatment factor). Females visit the dentist more frequently (treatment factor). The impact of these determinant, however has not been well quantified. The impact of these determinant, however has not been well quantified.

42. Race Early studies, observed that some races as those in Africa & India, had high degree of caries resistance than “ Europeans ”. Early studies, observed that some races as those in Africa & India, had high degree of caries resistance than “ Europeans ”. Recently, the concept of racial differences have been faded, and the evidence reveals that the global differences are the result of environment.. Recently, the concept of racial differences have been faded, and the evidence reveals that the global differences are the result of environment..

43. Race This was supported by the fact that these racial groups, once thought to be resistant to caries (Africans and Indians), quickly developed the disease when they moved to areas with different cultural and dietary patterns. This was supported by the fact that these racial groups, once thought to be resistant to caries (Africans and Indians), quickly developed the disease when they moved to areas with different cultural and dietary patterns. The variation in caries prevalence is the result of environmental rather than they are of racial attributes. The variation in caries prevalence is the result of environmental rather than they are of racial attributes.

44. Familial & genetic pattern Dental caries has long ago shown to b e grouped according to families. Dental caries has long ago shown to b e grouped according to families. Members of the same household were found to be alike in their caries pattern than between unrelated groups of individuals. Members of the same household were found to be alike in their caries pattern than between unrelated groups of individuals.

45. Such familial tendency may be due to: 1- Interfamilial bacterial transmission, especially from mother to baby. 1- Interfamilial bacterial transmission, especially from mother to baby. 2- similarity in dietary & oral hygiene habits. OR, 2- similarity in dietary & oral hygiene habits. OR, 3- Genetic factor: as inheritance of tooth structure (deep narrow pits & fissures) or special arch form (irregularities & crowding). 3- Genetic factor: as inheritance of tooth structure (deep narrow pits & fissures) or special arch form (irregularities & crowding).

46. Socioeconomic status It is a measure of the individual’ background; education, income, occupation, and attitudes and values. It is a measure of the individual’ background; education, income, occupation, and attitudes and values. It is inversely related to the status of many disease. It is inversely related to the status of many disease. It is a powerful determinant of caries status in any community. It is a powerful determinant of caries status in any community.

47. Socioeconomic status Earlier studies found that higher SES groups had higher DMF scores than those in the lower SES groups. Earlier studies found that higher SES groups had higher DMF scores than those in the lower SES groups. Details of DMF scores showed that lower SES groups had higher values for D and M, lower for F. Details of DMF scores showed that lower SES groups had higher values for D and M, lower for F. Whereas, the increased number of filled teeth (F) raised the DMF index among the high SES groups “ treatment factor ”. Whereas, the increased number of filled teeth (F) raised the DMF index among the high SES groups “ treatment factor ”.

48. The difference between social groups is due to increased number of filled teeth (F) that raised the whole DMF index among high SES groups “ treatment factor ”. The difference between social groups is due to increased number of filled teeth (F) that raised the whole DMF index among high SES groups “ treatment factor ”.

49. Socioeconomic Status (SES): With the reported caries decline, the DMF values of the higher SES groups became considerably below those in the lower SES group. With the reported caries decline, the DMF values of the higher SES groups became considerably below those in the lower SES group. The inverse relationship between caries status and SES have been reported from Britain and elsewhere in Europe. The inverse relationship between caries status and SES have been reported from Britain and elsewhere in Europe. The same was reported in Africa. The same was reported in Africa.

50. Nutrition Nutrition Nutrition refers to the absorption of nutrients and their utilization by the body cells for structural and functional efficiency. Nutrition refers to the absorption of nutrients and their utilization by the body cells for structural and functional efficiency. Nutrition can act only through the systemic route through influencing the host during tooth development. Nutrition can act only through the systemic route through influencing the host during tooth development.

51. Nutrition and Dental Caries There is some evidence that chronic malnourishment during development periods in a poor society may predispose to caries. There is some evidence that chronic malnourishment during development periods in a poor society may predispose to caries. No relation between nutritional adequacy and DMF scores could be find. No relation between nutritional adequacy and DMF scores could be find. Vitamin D deficiency may cause enamel hypoplasia. Vitamin D deficiency may cause enamel hypoplasia. Selenium: Is a cariogenic trace element when consumed during tooth developmental period. Selenium: Is a cariogenic trace element when consumed during tooth developmental period.

52. Prior to modern preventive methods : Caries prevalence was low in countries with low living standards, where generalized malnutrition was the norm. Caries prevalence was low in countries with low living standards, where generalized malnutrition was the norm. Current epidemiological evidence favors the conclusion that nutritional status does not directly influence the prevalence of dental caries (except for fluoride). Current epidemiological evidence favors the conclusion that nutritional status does not directly influence the prevalence of dental caries (except for fluoride).

53. Role of Saliva Diluting effect on fermented food residues. Diluting effect on fermented food residues. Buffering capacity to neutralize acid end products resulting from such fermentation. Buffering capacity to neutralize acid end products resulting from such fermentation. Provides ions for remineralization of early carious lesions. Provides ions for remineralization of early carious lesions. Provides antibacterial, antifungal and antiviral agents. Provides antibacterial, antifungal and antiviral agents.

54. Systemic diseases and drugs causing diminished salivation (xerostomia). Oral Symptoms Dry mouth (xerostomia) Dry mouth (xerostomia) Thirst Thirst Difficulty in swallowing (dysphagia) Difficulty in swallowing (dysphagia) Difficulty in speaking (dysphonia) Difficulty in speaking (dysphonia) Difficulty in eating dry food Difficulty in eating dry food Need do drink water frequently at meals Need do drink water frequently at meals Difficulty in wearing Difficulty in wearing dentures dentures Frequent pain of the throat, Frequent pain of the throat, simulating tonsillitis. simulating tonsillitis.

55. Systemic diseases and drugs causing diminished salivation (xerostomia).

56. Causes of xerostomia 1. Drugs/medications: Analgesics Analgesics Antiarthritic Antiarthritic Antispasmodic (gastrointestinal) Antispasmodic (gastrointestinal) Antidepressant Antidepressant Antidiarrheal Antidiarrheal Antihistaminic Antihistaminic Antihypertensive Antihypertensive

57. 2. Irradiation particularly of the head and neck area. 3. Systemic diseases :  Rheumatoid conditions  Psychogenic disorders (depression)  Anorexia nervosa, malnutrition  Menopause  Salivary gland stones  Aging (a contributory factor)  Decreased masticatory activity (liquid diet, soft food)

58. Environmental Risk Factors of Dental Caries Diet : Diet refers to the total intake of substances that provide nourishment and energy. Diet refers to the total intake of substances that provide nourishment and energy.

59. Diet

60. Balanced Diet It is one which contains all nutrients in such quantities and proportions so as to fulfill the need of calories. It is one which contains all nutrients in such quantities and proportions so as to fulfill the need of calories.

61. Diet Intake of refined carbohydrates especially sucrose (sugar) is considered a strong etiologic factor in the causation of dental caries. Intake of refined carbohydrates especially sucrose (sugar) is considered a strong etiologic factor in the causation of dental caries.

62. Diet and Dental Caries Cariostatic effect Carbohydrate: Sucrose is the most cariogenic carbohydrate. Carbohydrate: Sucrose is the most cariogenic carbohydrate. Protein: High protein diet is cariostatic. Protein: High protein diet is cariostatic. Fat: Fats are cariostatic. Fat: Fats are cariostatic. Phosphates: Phosphates are cariostatic. Phosphates: Phosphates are cariostatic. Fluorides: Increase the resistance of enamel to acid dissolution. Fluorides: Increase the resistance of enamel to acid dissolution. Vitamin B6 (Pyridoxine): prevent dental caries by altering the microbial flora. Vitamin B6 (Pyridoxine): prevent dental caries by altering the microbial flora.

63. Diet and Dental Caries Cariogenicity of the diet : Sugars and fermentable carbohydrates are a major etiological factor in the causation of caries. Cariogenicity of the diet : Sugars and fermentable carbohydrates are a major etiological factor in the causation of caries. Cleansing nature of the diet : Accumulation of fermentable carbohydrates could be removed by eating hard and fibrous foods (detersive food). Cleansing nature of the diet : Accumulation of fermentable carbohydrates could be removed by eating hard and fibrous foods (detersive food). Salivary stimulation effect of the diet : Food that induce salivary flow keeps the mouth free of fermentation. Salivary stimulation effect of the diet : Food that induce salivary flow keeps the mouth free of fermentation.

64. Sugar-Caries Relationship The role of sugar in dental caries is related to: The role of sugar in dental caries is related to: 1. Frequency of consumption of sugars; the risk increased if sugars are taken between meals. 2. The frequency of consumption is of major importance. 3. The nature of sugars; the risk is greatest if the sugar is in sticky form.

65. Environmental Risk Factors of Dental Caries Oral hygiene practices Oral hygiene practices Poor level of personal oral hygiene maintained by the individual is considered an important environmental risk factor for dental caries. Poor level of personal oral hygiene maintained by the individual is considered an important environmental risk factor for dental caries. Healthy oral hygiene practices include thorough daily removal of dental plaque and other debris by toothbrushing, flossing and mouth rinsing. Healthy oral hygiene practices include thorough daily removal of dental plaque and other debris by toothbrushing, flossing and mouth rinsing.

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