Pediatric ‫زينب مجعة‬.

‫د‬
year

Dentistry

Lec. 10
DENTAL CARIES Assistant Professor
DEFINITION, Zainab Juma Jafar
CLASSIFICATION AND
ETIOLOGY
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Pediatric Dentistry/ 4 year/ lec.23
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DENTAL CARIES DEFINITION, CLASSIFICATION AND ETIOLOGY

DEFINITION:
The term dental caries is used to describe the signs and symptoms of a
localized demineralization of the mineral portion of these tissues followed by
the disintegration of their organic material, caused by metabolic events
taking place in the biofilm (dental plaque) caused by the action of
microorganisms on fermentable carbohydrates covering the affected area.
The destruction can affect enamel, dentin and cementum. The disease can
result in bacterial invasion and death of the pulp and the spread of infection
into the periapical tissues, causing pain. In its early stages, however, the
disease can be arrested since it is possible for remineralization to occur.
•Sequence of caries in primary dentition:
–First to be attacked are the mandibular molars followed by maxillary
molars, then the maxillary anterior teeth.
Only rarely are mandibular anterior teeth affected or the lingual/buccal
surfaces of the primary teeth generally, except in cases of rampant caries.
–First primary molars in both the mandibular and maxillary arches are less
susceptible to caries than the second primary molars, though the first
primary molars erupt earlier than the second. Difference is thought to be
due to differences in morphology of occlusal surfaces as the pits and
fissures in second primary molars are deeper, and less completely
coalesced.

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–Proximal caries progress more rapidly than occlusal caries and cause
higher percentage of pulp exposure. Therefore, regular bitewing radiographs
are essential for children once there are no spaces between the teeth or
after proximal contact is established.
•Sequence of caries in permanent dentition:
Once the first permanent molars erupt, one should expect frequent
occurrence of caries in the occlusal pits and fissures.
The maxillary and mandibular permanent incisors are not highly susceptible
to caries attack except in children with rampant caries (RC).
The mandibular second permanent molars are more susceptible to caries
than the maxillary second permanent molars.

THE CARIES DIAGNOSIS

1. Visual examination: The clinical visual examination consisting of five
stages form the basis of caries diagnosis.
 Systematic: Always start at the same place in the mouth – there is
logic in making this the most distal surface in the upper right quadrant
and working clockwise to the lower right, as these ties in with the FDI
tooth notation. For every tooth, work round its surfaces in a systematic
manner.
 Clean: Dental plaque is not translucent, so to diagnose even quite
advanced lesions it must be removed. Polish the patient‟s teeth prior to
attempting to diagnose caries.
 Illumination: The dentist requires a light source to make diagnosis
possible. In addition to good illumination provided by a suitably

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positioned operating light, the use of a light source will facilitate

transillumination.
 Dry: The detection of caries in its early stages relies on the differences in
the porosity and therefore refractive index of caries versus sound dental
hard tissue. When we dry the teeth we will have the ability to detect
disease at its earliest visible stage (the white spot lesion).
Drying the teeth helps with caries activity assessment:
A white spot enamel lesion has a matt enamel (acid-etched
appearance) surface; this frequently indicates an active lesion.
A lesion with a glossy surface is often arrested.

 Put the sharp probe away: For many years a visual-tactile

examination rather than a purely visual examination was the mainstay of
caries diagnosis. This should no longer be the case for a number of reasons:

The use of a probe does not improve the accuracy of caries diagnosis.
Probing of a demineralized site (which has the potential to remineralize)
will further destroy the enamel structure creating an iatrogenic cavity
and preventing any possibility of remineralization.
There is the possibility of inoculating other sites with cariogenic
bacteria.
However, a blunt probe, such as a periodontal probe, can be used to remove
plaque from fissures using a dredging motion. As it can be problematic
determining if a brown spot lesion is cavitated or not, the side of a blunt
probe may also be used to confirm if a surface has broken down.

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2. Radiographs: The views that are of value for caries diagnosis are:
 Bitewing: is the 1st choice of caries diagnosis, provide information on
both occlusal dentine caries and proximal enamel and dentine caries.
 Orthopantomogram (OPG): can detect the presence of an occlusal
dentine carious lesion with a high degree of accuracy. Proximal surface
lesions can also be seen on OPG but with much lower accuracy than
with bitewings.
 Bimolar view: Bimolars are not as useful a view as bitewings
because there is often overlap of structures. However, they are of use
in the pre-cooperative child who will not cope with bitewings or an
OPG.
 Periapical view: are as accurate as bitewings for caries diagnosis,
but obviously less information is available on any one film. The key
role of the periapical view is in the diagnosis of periodontal disease,
periapical disease and the diagnosis and monitoring of dental
traumatic injuries.
3. Adjuncts Aids to Caries Diagnosis
 Magnification: During restorative treatment, dentists are increasingly
using magnification to assist with the preparation of teeth. Magnification
can also help with the detection and diagnosis of caries.
 Fibre-Optic Transillumination (FOTI): FOTI helps with the detection
of proximal enamel and dentinal lesions, and occlusal dentinal caries.
Clinically, FOTI can be used in a number ways – for example, the dentist
can use it routinely at every examination helping to decide if radiographs
are indicated. It can also be used to provide further information when,

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despite a thorough clinical visual examination and radiographs, the clinician

still remains unsure. One particular use of FOTI is to help differentiate
between staining and caries on the occlusal surface.
 Temporary Tooth Separation (TTS): The placement of an orthodontic
separator for about three to four days to move the teeth apart allows direct
visual access to a surface for diagnosis. The tooth returns to its original
position following removal of the separator within hours. This approach has
two significant advantages over bitewing radiography:
 The avoidance of exposure to ionizing radiation.
 The ability to detect whether the surface is cavitated.
The drawbacks of TTS: the patient may experience some discomfort while
the separator is in place, and this discomfort is likely to be greater if all
contacts are separated.
 Laser Fluorescence: The currently available commercial device
(Diagnodent, KaVo Germany) measures the fluorescence of the porphyrins
made by bacteria in the caries. This device is designed for the diagnosis of
occlusal caries but it can be used on accessible smooth surfaces. It is not
designed to be a screening tool, where it is likely to generate a number of
false positive diagnoses, but to aid the dentist with equivocal lesions. In
use, the dentist applies the probe tip to the tooth surface under investigation
and a digital reading indicates the status of the surface through sound to
deep dentine caries.
 Electric Caries Meter (ECM): Enamel is a very poor conductor of
electricity. However, following carious attack the enamel becomes more
porous and the ions present in the pores in the lesion will conduct electricity

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with much less resistance than sound enamel. This is the principle behind
the working of the ECM (ECM Lode Netherlands). Like the laser fluorescence
devices, the ECM is principally of use on occlusal surfaces. ECM is
technique-sensitive. Of particular relevance to pediatric dentistry is that the
ECM is not reliable on immature teeth.
All of the above methods have both advantages and disadvantages, but
they should be considered a toolkit from which the dentist selects to improve
the accuracy of caries detection and diagnosis.

All of the above methods have both advantages and disadvantages, but
they should be considered a toolkit from which the dentist selects to
improve the accuracy of caries detection and diagnosis.

THE CARIES CLASSIFICATION

Carious lesions can be classified according to their anatomical site.
There is nothing chemically special about these sites.
1. Lesions may commonly be found in pits and fissures or on smooth
surfaces. Smooth surface lesions may start on enamel (enamel caries) or on
the exposed root cementum and dentin (root caries).
2. Primary caries is used to differentiate lesions on natural, intact tooth
surfaces from those that develop adjacent to a filling, which are commonly
referred to as recurrent or secondary caries. As such, the etiology of both is
similar
3. Residual caries, as the term implies, is demineralized tissue that has
been left behind before a filling is placed.

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An important classification is whether a lesion is cavitated or non-

cavitated, as it impinges directly on the management of the lesion.
Caries lesions may also be classified according to their activity. This is
a very important concept and one that impinges directly on management,
although it will be evident from the text that the clinical distinction between
active and inactive (arrested) lesions is sometimes difficult. Clinically, if in
doubt the dentist should always react as though he or she is dealing with
an active lesion.
A lesion considered to be progressing (the lesion would have developed
further at a subsequent examination if not interfered with) would be
described as an active carious lesion. In contrast to this is a lesion that may
have formed years previously and then stopped further progression. Such
lesions are referred to as arrested carious lesions or inactive carious lesions.
The first sign of a carious lesion on enamel that can be detected with the
naked eye is often called a white-spot lesion. This appearance has also
been described as an early, initial or incipient lesion, but not all white-spot
lesions are incipient! These terms are meant to say something about the
stage of lesion development.
Rampant caries is the name given to multiple active carious lesions
occurring in the same patient. This frequently involves surfaces of teeth that
do not usually experience dental caries. These patients with rampant caries
can be classified according to the assumed causality, e.g. bottle or nursing
caries, early childhood caries, radiation caries or drug-induced caries.

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Hidden caries is a term used to describe lesions in dentin that are

missed on a visual examination but are large enough and demineralized
enough to be detected radiographically. It should be noted that whether a
lesion is actually hidden from vision depends on how carefully the area has
been cleaned and dried and whether an appropriate clinical examination
has been performed.

THE CARIES ETIOLOGY

•Dental caries is a multifactorial disease
–The primary factors are:
 The tooth
 The microorganisms
 Fermentable Carbohydrates
 Time
–The secondary factors are:
A. Local factors:
 Anatomy of the teeth in early eruption
 Crowding or irregular teeth (makes cleaning difficult)
 Presence of dental appliances, e.g. partial denture , space maintainer,
orthodontic appliances
B. Systemic factors: such as
1. Childhood Fever and Caries Susceptibility: Common childhood
illnesses such as:(chickenpox, measles, middle ear infections, fevers caused

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by respiratory or urinary tract infections, and other fevers that cause skin
rashes because enamel and skin share a common ectodermal origin) all can
affect the coincidental dental hard-tissue formation. This can result in
hypomineralization and discoloration, due to:
 Altered tooth morphology
 enamel porosity
 Difficulties in maintaining good oral hygiene due to sensitivity.
An example of this is molar incisor hypomineralization (MIH), in which the
permanent incisors and first permanent molars are affected (and possibly
also the tips of the canines). The affected teeth appear to be prone to post-
eruptive enamel loss.
2. Inherited defects: Children with congenital enamel defects such as
amelogenesis imperfecta or disease of the other dental hard tissues (e.g.
dentinogenesis imperfecta) may be more susceptible to caries, but these
conditions are rare.
3. “Family” caries: Families do tend to pass on their dietary habits
through generations. Therefore, granny losing her teeth early could be an
indication of a “sweet tooth” being a family phenomenon. Furthermore;
Streptococcus mutans, the main pathogen responsible for caries, is
transmissible and there is very good evidence to show that it is passed from
mother to baby.
4. Medicines: in particular, elixirs, CAN cause caries BUT only if they
contain sugar. Some medicines are sucrose-free, but may contain other
sugars such as glucose syrup. “Sugars-free” means no sugar at all.

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Dentists and their teams should advise parents and medical and pharmacy
colleagues to add the letters „SF‟ for sugars-free to written prescriptions –
this is particularly important in cases in which repeated prescriptions are
required.

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