GOOD MORNING

EPIDEMIOLOGY OF DENTAL CARIES

SUBMITTED BY, JITHIN.K

GUIDED BY, DR.MAHMOOD MOOTHEDATH

DR.AZEELA AHAMMED

INDEX Introduction – Dental caries Classification of dental caries The stages of tooth decay Caries in prehistoric man Caries incidence in modern society Assessment of dental caries prevalence in modern day population Factors affecting caries prevalence Race Age Gender Familial Current trends in caries incidence in the world Caries susceptibility of jaw quadrant Caries susceptibility of individual tooth surface

CONTINUES….. Epidemiological studies Tristan da cunha study During world war 2 Hereditary fructose intolerance (HFI) Epidemiological triad Economic implication of dental caries Management of dental caries Conclusion Reference

INTRODUCTIONDENTAL CARIES is an infectious, microbial disease that results in localized dissolution and destruction of the calcified tissues of the teeth. The word caries is derived from Latin meaning ‘ROT’ or DECAY. It is similar to Greek word ‘KER’ meaning death.DENTAL CARIES is defined as a progressive, irreversible, microbial disease affecting the hard parts of the tooth exposed to the oral environment, resulting in demineralization of the inorganic constituents and dissolution of the organic constituents, there by leading to a cavity formation.

DENTAL CARIES may be considered as a disease of modern civilization, since prehistoric man rarely suffered from this form of tooth destruction. Anthropologic studies revealed that the Dolichocephalic skulls of men from pre Neolithic periods (12,000 BC) did not exhibits dental caries. But the skulls of brachycephalic man of Neolithic periods (12,000 – 3000 BC) contained carious teeth. The cervical areas of teeth in older persons were frequently affected.

IN GENERAL…..

CLASSIFICATION

Based on the location of the caries Pit and fissure caries Seen in pit and fissure found on occlusal, buccal and lingual surface of posterior teeth as well as on the lingual surfaces of maxillary anteriors. Smooth surface caries Seen in smooth surface of tooth without pits, fissures and grooves. Root surface caries Occurs on the root surfaces of teeth.

Based on the spread of caries progression Acute or Rampant caries Rapidly invading caries, involving several teeth. It appears soft and light coloured.

Chronic caries Slowly progressive long standing caries. It appears hard in consistency and is dark coloured.

Arrested caries Sometimes the chronic caries lesion can become arrested due to a change in local environment. This appear dark brown in colour and hard in consistency.

Based on whether it is new or recurrent carious lesion

Initial or primary caries The 1st attack of caries on a tooth surface.

Recurrent or secondary caries Caries seen under or around the margins of an existing restoration. It occurs due to micro leakage and other favorable conditions.

Based on the extent of caries Incipient caries 1st evidence of caries activity in enamel. It consists of demineralized enamel which has not extended to DEJ. The enamel surface is still hard and still intact. Incipient caries can be demineralized.

Cavitated caries Caries spread beyond enamel in to dentin. The enamel surface is broken down and demineralization is not possible. Hence, it is referred as Irreversible caries.

Based on pathway of caries spread with in the tooth

Forward caries Whenever the caries cone in enamel is larger or same size as that of dentin. It is referred as Forward caries.

Backward caries Whenever the spread of caries along the DEJ exceeds the caries cone in enamel, the caries extend in to enamel from the junction. Since the spread of caries here is in backward direction , it is referred to as Backward caries.

Based on the number of tooth surface involved Simple caries Involves any 1 surface of tooth.

Compound caries Involves 2 surfaces of tooth.

Complex caries Involving 3 or more surfaces of tooth.

G.V.BLACK’S CLASSIFICATION Based on the treatment and restoration design

Class 1 caries Caries occuring in pits, fissures or defective grooves on the tooth surface. Usually has 3 locations : Occlusal surface of molars and premolars. Occlusal 2/3rd of facial and lingual surface of molars. The lingual surface of maxillary anteriors. Class 2 caries Caries found on proximal surfaces of molars and premolars.

CONTINUES…..

Class 3 caries Caries occuring in proximal surface of anterior teeth without involving incisal angle. Class 4 caries Caries found on proximal surface of anterior teeth with involvment of incisal angle. Class 5 caries Caries seen at the gingival 3rd of the facial and lingual surfaces of the anterior and posterior teeth. Class 6 caries Caries found on the incisal edge of anterior teeth and cusp tips of posterior teeth

Based on the age of patient Nursing bottle caries During early infancy, bottle fed babies develop rapidly spreading caries usually on maxillary incisors. Adolescent caries Acute caries is also frequently seen in the teenage population due to dietary habit.

Senile caries Caries occuring in the elderly population is mostly characterized by involvement of root surfaces. This happens because of gingival recession coupled with other factors like reduced salivation and poor oral hygiene.

Based on the tooth surfaces to be involved O : Occlusal surface M : Mesial surface D : Distal surface F : Facial surface B : Buccal surface L : Lingual surface Various combinations are also possible, such as MOD for mesio-occluso-distal surfaces.

CARIES IN PREHISTORIC MANDental caries may probably be considered a disease of modern civilization, since

prehistoric man rarely suffered from this tooth destruction. Data on the occurrence of dental caries in ancient population are available owing to the fact that teeth are relatively imperishable in dry burial site for many years, anthropologic studies revealed that the dolichocephalic skulls of men from pre Neolithic periods did not exhibits dental caries, but skulls from brachycephalic man of Neolithic period contained carious teeth. The carious lesions were found at or just below the contact areas and an increased frequency of caries at CEJ was noted.

CARIES INCIDENCE IN MODERN SOCIETY

By 17th century, there was a significant increase in the total caries experience and a smaller increase in the number of carious lesions involving the interproximal contact areas of teeth. Today, dental caries is virtually a universal disease. Extensive studies have been made to illustrate the influence of civilization on dental disease. However, it is noticed that isolated populations that have not acquired the dietary habits of modern industrialized man retain a relative freedom from dental caries. Eskimos living in north west territories of Canada, Alaska and Greenland who consume native food had a lower evidence of carious lesion compared to those living at traditional parts.Although there may be a certain degree of racial resistance to dental caries, the dietary factors appears to be more significant especially, since caries incidence is increased by contact with civilized foods.

ASSESSMENT OF DENTAL CARIES PREVALENCE IN MODERN DAY POPULATION

Dental caries is pervading in modern man living in highly industrialized society. The difference in caries rate noted in different part of the world are extreme from rates fewer than 1 decayed, missing and filled (DMF) tooth per person at all ages. Finding from the Interdepartmental Committee on Nutrition for National Defense (ICNND) and WHO studies indicates that caries prevalence follows definite regional patterns. Caries prevalence is generally lowest (.5-1.7DMF) in Asian and African countries and highest (12-18DMF) in American and other Western countries.

FACTORS AFFECTING CARIES PREVALENCE

RaceSome studies show remarkable difference in the caries experience

between various races. American blacks and whites living in the same geographic areas under similar conditions, offer excellent opportunity for comparison. Investigation indicates that blacks have the fewer carious lesion than whites.

AgeCarious lesions that results in cavitation are irreversible and therefore

cumulative with age. There is a strong correlation between age and DMF indices. Several studies have shown that by the age of six years, about 20% of children have experienced dental caries in their dentition and a DMFT of .5 can be experienced. By the age of 12 years 90% of children’s would have experienced and a DMFT of approximately5.5. the decayed, missing and filled surface (DMFS) accelerates at a greater rate than DMFT beyond the age of 8 years. So that by age 12, a DMFS of 7.5 can be taken as an average figure.

CONTINUES.… Gender

Studies indicates that total caries experience in permanent teeth is greater in females than in males of the same age. Caries experience in deciduous teeth is greater in males. Familial

The familial pattern of the caries experience seems to hold true. Sibling of individuals with high caries susceptibility are also generally caries active. Children’s of parents with low caries experience also tend to have low caries ; vice versa

CURRENT TRENDS IN CARIES INCIDENCE IN THE WORLD

Significant data have been presented since 1980 to substantiate numerous observations that there has been marked improvements in dental health as measured by prevalence of dental caries, especially in children and young adults, throughout the ‘civilized western world’. This trend Has become so definitively established that the first international conference on the declining prevalence of dental caries was held in Boston in june 1982 to evaluvate the evidence and impact on dental education dental research and dental practices.

Studies carried out under the National Caries Program in 1979-80 and reported by Burnelle and Carlos on 38000 school children, aged 5-17 years, and representative of approximately 48 million US school children, revealed a substantial decrease in the prevalence of dental caries.

CONTINUES…..Glass reported treads in caries prevalence in 1775 children 7-13

years of age, analyzed over a period of 20 years. He similarly reported that dental caries prevalence had decreased by about 50% and extraction due to caries decreased by 70%. In addition , secondary caries had decreased to near zero. These changes had occurred in the absence of both fluoridation and organized preventive programs.

The cause of this widespread decline in the prevalence of dental caries is a matter of speculation but almost certainly multifactorial. In some instance communal water fluoridation has been present in the areas studied, but in other instance, it was not. Organized preventive dentistry programs had been available in some cases but not in others.

However, time period is involved in most of these studies coincides with the introduction and increased utilization of fluoride dentifrices and dietary fluoride supplements, as well as an increased awareness of the importance of oral health.

CONTINUES…..Finally, dietary habits and eating patterns are difficult factors

to study and analyze. However, there has been an obvious movement towards improved physical health through food and exercise, although this has been directed more towards adults than children. Still, it could be conceivable that a reduction in carbohydrate consumption might be related to this reduction of caries prevalence.

CARIES SUSCEPTIBILITY OF JAW QUADRANTS

Dental caries experience was found to be higher in the maxillary arch. The reason for the difference between the arches in caries susceptibility is not well documented. It may relate to gravity and the fact that saliva, with it’s buffering action, would tend to drain from upper teeth and collect around the lower teeth.

CARIES SUSCEPTIBITY OF INDIVIDUAL TOOTH SURFACE

HYATT and LOTKA (1929) studied carious involvement of various tooth surfaces in 2943 patients under 25 years of age. The data indicates the occlusal surfaces are the most commonly affected, followed by mesial, buccal and lingual surfaces in descending order. Other studies indicate that the occlusal cavity is the most prevalent type of lesion in both permanent and deciduous dentition.

EPIDEMOLOGICAL STUDIES Tristan da cunha studies

Tristan da cunha is a remote rocky island in south atlantic region. Before 1930 and 1940 on wards study showed no evidence of dental caries in this region because of consumption of raw diet. But after volcanic eruption in 1964 people living in this area moved to other areas where they developed dental caries because of change in dietary habit. During world war 2

Due to sugar restriction in world war 2 (1939-1944) dental caries reduced among civilians. At the same time, dental caries experience among army personals was increased due to increase in sugar consumption as more quantity of ready made food items was supplied during war time.

CONTINUES..… Hereditary Fructose Intolerance(HFI)

HFI (1956) an autosomal recessive disorder of fructose metabolism. Patients having intolerance to fructose avoid fructose and fructose containing dietary factors because consumption of fructose causes malaise, vomiting, sweating, cramps, coma and finally death. Hence, dental caries experience among these patients is very low.

EPIDEMIOLOGICAL TRIADThe occurrence and manifestations of any disease, whether communicable or non communicable are determined by the interaction between the agent, the host and the environment, which together constitute the epidemiological triad. ENVIRONMEN

T

AGENT HOST

THE AGENTThe agent is defined as “an organism, a substance or a force, the presence or lack

of which may initiate a disease process or may cause it to continue.”They may be classified as Living or biological agentsEg: bacteria, virus, fungi Non-living or inanimate Nutrient agentsEg: protein, fat Chemical agents : they can be• External (eg: lead, arsenic)• Internal (eg: urea in renal failure, ketone bodies in diabetes) Physical agentsEg: atmospheric pressure, temperature

THE HOSTThe host is the man himself. The characteristics of a human being

that determine how he reacts to the agents in the environment are called “host factors”. The host factors are: Demographic characteristics: age, sex, ethnicity Biological characteristics: genetic background, physiologic and

biochemical characteristics, immune status, nutritional status. Socio-economic characteristics: social class, religion, education,

marital status. Life style: living habits, food habits. In terms of infectious disease epidemiology host is defined as “a person or an animal that affords subsistence and lodgement to an infectious agent under natural conditions.”

THE ENVIRONMENTEnvironment is the source or reservoir for the agents of

disease. It helps in the transmission of agents to the host, bringing about their contact and interaction. During such interaction the environment may be favourable to man and unfavourable to the agent and vice versa. Thus there is a constant attempt towards adjustment and readjustment between the man and the causative agent with in the same environment.The environment of man is of two types: Internal environment

The internal environment of man pertains to “each and every component part, every tissue, organ and organ system and their harmonious functioning with in the system.” internal environment is directly related to internal health. Fault in functioning of one or more component parts results in disharmony and disease.

External environmentIt is defined as “all that which is external to the individual

human host”.Macro-environment is another term used to denote external

environment. Macro environment is the term sometimes used to denote

someone’s personal environment comprised by the individual’s way of living and life style. Man is making a constant endeavor to maintain health by adjustment to all sorts of agents in the external environment. When the host(man) is well adjusted, he is in a state of comfort or health. Maladjustment of body creates an imbalance or disharmony which is responsible for discomfort and disease.

Generally, the environment can be studied under the three headings: Physical environment is the space around man containing gases, liquids and solids.

Biologic environmentMeans the universe of all living things that surrounds man. It

comprises both animals and plants. They may be reservoirs of disease germs, they may be transmitter of disease agents or they may be the causative agents of disease. Social environment

Comprises of all human beings around man and their activities and interactions. It includes social and economic factors.Social factors pertain to the society in which man lives. They provide stimuli that effect the physical, mental and social state of man to which he must adjust. Economic factors refers to the material assets and gains of the human society. They determine the economic status of man, which in turn affects his health. Thus low economic status means less diet, poor housing and less resources for medical aids.

ECONOMIC IMPLICATION OF DENTAL CARIES

Surveys have been done by the Bureau of economic and behavioural research of the ADA and by the office of Health research, statics and the technology of the U.S department of the health and human services to characterize certain economic aspects of dental care in U.S.

In 1976, ten billion dollars has spent in the U.S for dental care. This represents 6.2% of the total health expenditure.

There is a striking relationship between family income, education and percentage of persons visiting the dentist. It has been found that when the income was less then 5000 dollars per year, only 34% of persons visited the dentists. In a given year, where as with an income over 15000 dollars per year, 61.9% visited the dentist.

The economic status of the population and their increasing educational status, the growing number of dental graduates, insurance programme, commercial pressure and governmental influences are just some of the factors that are changing the economic implications of treatment of dental caries. But, the fact still remains that 45.5% of the people over 64 years of age have both of the population is not being treated for dental diseases.

MANAGEMENT OF DENTAL CARIES

Traditionally, caries has been managed by placing restorations. However, merely placing the restoration does not guarantee a sound future for the tooth. Rather, it is the beginning of a restorative cycle in which the restoration will be replaced several times.

Currently, based on increasing evidence from several studies, a different approach is recommended to manage dental caries. Preventive management of caries

The 1st step is to evaluate the causative and modifying factors for caries and arrive at the risk status of the patient.

Following this, preventive measures must be started to prevent new lesions from forming and to encourage remineralization of incipient caries.

CONTINUES….. Operative management of caries

For cavitated carious lesions appropriate restoration must be placed to restore the integrity of the tooth.

There are five basic reasons to place restorations when cavitations occurs due to caries:-1. To remove infected dentin2. To protect the pulp and avoid pain3. To remove the habitat for cariogenic bacteria4. To facilitate plaque control5. To restore esthetics and integrity of the tooth

In deep carious lesions direct or indirect pulp capping procedures are recommended to preserve vitality of pulp.

CONCLUSIONSince dental caries is a highly prevalent disease, control of

dental caries is a concern of all the people. The ideal control measure for dental caries must have immediate, high and lasting effectiveness and reach all of the people at a cost of money and facilitates well with in the economic capabilities of the community.

For the developing country like India, the focus should be on assessing the caries risk and identifying those individuals at high risk to develop caries. Preventive measures can then be targeted at this group thereby not only reducing the economic burden of the restorative care but also eliminating pain and improving the overall quality of life.

REFERENCE Essential of preventive and community

dentistry – Soben peter(3rd and 4th edition)

Text book of oral pathology – Shafer’s Clinical operative dentistry –

Ramyaraghu Dental caries the disease and it’s clinical management – Ole fejerskov and Edwina kidd (2nd edition)