Caries Prevention

DRG RATIH WIDYASARI, SP.KG

DRG RINA PUTRI NOER FADILAH,M.KM

BLOK 18 - KESEHATAN GIGI MASYARAKAT < 1 >

 Textbooks for self-study are:
- Norman O. Harris, Primary Preventive Dentistry,
6th Ed. (2004); 7th ed.(2009)
- Hardy Limeback , Comprehensive Preventive
Dentistry, 2012

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The three general disease categories of focus in dentistry are :

Dental Decay Periodontal disease Oral cancer

f in t @ f in t @ f in t @

It is obviously better to prevent the disease in the first place,

than treat it once it has happened

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 Caries prevention
Maintaining a disease-free state can result from primary prevention.

When lifestyle changes are made early on, the risk for developing dental disease are minimized.

LIFESTYLE CHANGES

01 02 03 04
Less carbohydrate Better oral hygiene Improved nutrition Better education

To know how to prevent , need to know disease, :

its etiology and pathogenesis

BLOK 18 - KESEHATAN GIGI MASYARAKAT < 4 >

 Name Surname Name Surname Name Surname

Sed ut perspiciatis unde omnis
iste natus error sit voluptatem
doloremque laudantium, totam
rem aperiam, eaque ipsa quae
ab illo inventore veritatis et
quasi dicta sunt explicabo.
Sed ut perspiciatis unde omnis
iste natus error sit voluptatem
doloremque laudantium, totam
rem aperiam, eaque ipsa quae
ab illo inventore veritatis et
quasi dicta sunt explicabo.
Sed ut perspiciatis unde omnis
iste natus error sit voluptatem
doloremque laudantium, totam
rem aperiam, eaque ipsa quae
ab illo inventore veritatis et
quasi dicta sunt explicabo.

f in t @ f in t @ f in t @

NEMO ENIM IPSAM VOLUPTATEM QUIA VOLUPTAS < 5 >

 Dental caries
01 Etiology
< >
Pathogenesis

In dealing with disease,

prevention is better than a cure.
 Proses karies terjadi akibat
adanya biofilm pada
permukaan gigi.
Lesi karies adalah hasil
Dental caries proses karies yang
berkembang antara mikroba
biofilm dan struktur gigi
< >
Aktivitas metabolisme mikroorganisme dalam biofilm
tidak terlihat oleh klinisi,

Tapi lesi karies yang merupakan hasil aktivitas ini secara

klinis terlihat.
SED UT
Etiology of
PERSPICIATIS UNDE
dental caries
OMNIS ISTE NATUS
ERROR SIT
 Concepts of caries etiology

Microorganism

Tooth Substrate

Time

dental caries < >

Current concepts of Dental Caries
The development of dental caries is a dynamic process of
demineralization of the dental hard tissues by the
products of bacterial metabolism, alternating with
periods of remineralization

Dental caries is an infectious, communicable disease resulting in destruction of

tooth structure by acid-forming bacteria found in dental plaque, in the presence
of sugar
 Dental decay
Cyclic process of decay Demineralization/Remineralization
Cyclic Process of Decay

Bacteria plus food

Demineralization
makes the saliva
very acidic within
5 minutes

Remineralization
Saliva is normal
30 minutes
after eating

Tooth susceptibility
Bacterial plaque
Etiology of Carbohydrates
Oral sugar clearance
f in dental
t @ caries f in t @ Time f in t @
Saliva flow & pH

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 Diagram
The classic Venne
diagram of caries.

< >

Caries Factors
Sed adanya
ut perspiciatis unde omnis iste natus error sit voluptatem accusantium
Harus gigi, bakteri plak, fermentasi karbohidart, saliva, dan
doloremque laudantium, totam rem aperiam, eaque ipsa quae ab illo inventore
waktu yanget cukup
veritatis untuk proses
quasi architecto beatae terjadinya karies
vitae dicta sunt explicabo. Nemo enim ipsam
Terjadinya
voluptatemkaries,harus
quia voluptasmelibatkan semua
sit aspernatur aut oditfaktor2
aut fugit,tersebut. (red color
sed quia consequuntur
at the
magnicenter)
dolores eos qui ratione voluptatem sequi nesciunt.
Beberapa faktor yang mempengaruhi masing-masing komponen, (see
the diagram) mempengaruhi tingkat keparahan karies.
This is a convenient analogy to understand and is an
offshoot of the classic Venn diagram ( first introduced by Keyes (1962).

NEMO ENIM IPSAM VOLUPTATEM QUIA VOLUPTAS < 12 >

 Mutans streptococci

02 The role
Microorganisms


1960 Keyes rediscovered S. mutans

He demonstrated that:

< > specific microorganisms were responsible

for caries

caries was transmissible

Later, the responsible bacteria were found to

comprise seven distinct species only mutans
and sobrinus are associated with caries in
humans
 Characteristics of MS
Characteristics of MS qEcological niche: human oral cavity
q Intentionally designed to be a cariogenic
organism (Coykendall 1976)

01
qCariogenic properties

ability to produce acid (acidogenicity)

Characteristics of MS
ability to withstand acid conditions (aciduricity)
ability to adhere to teeth
qMetabolism yields:
acids, primarily lactic, from a variety of sugars

02
extracellular polyglucose, called glucan, which creates
irreversible attachment (from sucrose metabolism
only)
qMS is responsible for initiation of caries
qMS is a necessary, but not solely
sufficient, factor for dental caries
qMS colonize oral cavity after eruption of teeth
require hard, non-desquamating surface;
MS adalah kompetitor yang buruk

03 04 05
Transmisi vertikal
qSome believe in window of infectivity that relievs Acquisition
untukofkolonisasi
MS by Infants - setelah biofilm stabil Sumber : ibunya (>>)
on virgin tooth surfaces for initial colonization; ada, shg kemampuan MS untuk is >70%
berkolonisasi
qMS is poor competitor forberkurang
colonization once Penularan terjadi saat lahir namun MS
qSecond window may open when permanent Bayi yang
stable biofilm mendapatkan
is in place, ability for MS sanguis
to lbh awal dlm jumlah rendah spt di tonsil dan
colonize is reduced
dentition erupts memiliki MS kurang dorsum lidah
qInfants who acquire sanguis early have less MS
Acquisition of MS by Infants
mi(s sanguis mutans
Birth
1 8 11 19 26 33 mos.

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 Other Microorganisms
Lactobacilli sp.

01 02 03 04
Lactobacilli sp. Lactobacilli sp. Lactobacilli sp. Lactobacilli sp.
considered Numbers in cavity Lactobacilli are good
Found in large numbers
opportunistic, not increase after DEJ indicators of total
in some children
initiators invaded carbohydrate intake

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 Dental caries was the highest diet-related disease

10% glucose rinse

Dental
plaque pH

Cri7cal pH for tooth

enamel dissolu7on

Minutes
Jenkins GN. The physiology and biochemistry of the mouth, 4th Edition. Ox
Blackwell Scientific Publications, 1978. Page

s GN. The physiology and biochemistry of the mouth, 4th Edition. Oxford: Blackwell Scientific
ations, 1978. Page 388.

JENKINS GN. THE PHYSIOLOGY AND BIOCHEMISTRY OF THE MOUTH, 4TH EDITION. OXFORD: BLACKWELL SCIENTIFIC PUBLICATIONS,
1978. PAGE 388.
< 16 >
 300 4

200
New
Sugar DMFT
consumed per
gm per day year
100
1

0 0
Liquid 24
Gustafsson et al. (1954). The Vipeholm dental caries toees
study. Acta Odontlogica Scandinavica 11:232-364.

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 The Melbourne Study

Other fact < 18 >

Caries incidence was not related to

total sugar intake nor to frequency
of eating occasions.
Pit and ssure surface caries risk es0mates

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Etiology - Diet Lessons from Vipeholm (Sweden)
Sugar consumption at meals slight increase in caries;
Hopewood House (Australia) 1947 52 determine
Sugar between meals marked increase in caries;
diets devoid of sugar and white flour- extremely low dental caries
prevalence Sugar in sticky candies greatest caries activity;

qVipeholm (Sweden) 1945 52 determined Caries activity differs among individuals

Caries activity declines with withdrawal of sugar-rich
effects of frequency of sugar consumption
effects of consistency (retentiveness) of sugar
foods
sugar at meals vs. in between meals

The role of dietary sugars

Not all sugars are cariogenic.

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 The more common dietary sugars are presented.
The cariogenic potential of carbohydrates are presented too.

The sugars with the most

cariogenicity are sucrose
and glucose (red).

Other carbohydrates
(maltose, lactose, fructose,
and starch) are less
cariogenic.

The sugar alcohols, such as

sorbitol and mannitol, are
the least cariogenic (yellow)

Xylitol has even been

shown to be anticariogenic
(green).
BLOK 18 - KESEHATAN GIGI MASYARAKAT < 21 >
 Sucrose
The disaccharide sucrose One of the strategies in

01 04
and the monosaccharide prevention of caries is to limit
glucose ( a component of access to the more cariogenic
sucrose), are most sugars and substitute them
cariogenic. with the anti-cariogentic ones.

02 05
Not only does their
Frequent ingestion, can
conversion to acid result in
cause severe damage to
enamel dissolution, but they
the tooth.
also encourage the growth of
more virulent cariogenic
bacteria.

03
There is no question that
carbohydrates are the
main etiological reason qGlucose + fructose

for the development of

caries. extracellular polyglucose,
glucan, (from sucrose metabolism only)
creates irreversible attachment

Glucan
qWater soluble metabolized by plaque bacteria
qExtracellular glue
qEnables adhesion to tooth
fructan
reduced susceptibility to mechanical disruption
glucan +
qInhibits diffusion properties of plaque
reduces buffering capacity of saliva
inhibits transport of acid away from tooth
Sucrose
22

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 Role of other Role of refined
sugars Starch
Fruktosa dan glukosa sama efektifnya dengan
Soluble starch and refined starch dapat
sukrosa yang kemampuannya menyebabkan
dipecah dengan amilase pd saliva menjadi gula
penurunan pH;
Refined KH ini menyebabkan penurunan pH
Fruktosa hampir sama dengan sukrosa
bervariasi yang mungkin sama besarnya
( kariogenisitas;)
dengan yang disebabkan oleh sukrosa
Raw starch hanya menyebabkan sedikit dalam
penurunan pH pd plak

Bakteri supragingiva didominasi o/ streptokokus

& lactobacilli yang dapat menurunkan pH plak
shg tjd decalcification

White spot lesion

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 The plaque that is responsible for
caries is generally located
supragingivally and is
Figure shows an illustra0on of dental plaque at acidogenic.
the gingival margin.
People who consume sugars
frequently in their diet increase the
levels of streptococci and lactobacilli

The two bacteria species thought to be

responsible for caries.

These bacteria continue to thrive as

(1) The enamel (e) has plaque biofilm (b) growing at the border of the inflamed
gingival (g). the pH drops.
(2) Same plaque at closer look. There is a white spot lesion (w) developing at
the margin of the gingiva, and brown calculus (c) developing in the sulcus
attached to the tooth.
(3) Close-up view of plaque. Biofilm bacteria, which If the plaque is not removed,
consists of several species of bacteria (cocci, rods, motile spirochetes),
organic material (salivary proteins) and organic matter secreted by the eventually, the enamel starts to
bacteria (yellow-stained)
decalcify and an incipient white
spot lesion ensues.

BLOK 18 - KESEHATAN GIGI MASYARAKAT < 24 >

 Marsh (1994) was able to show, that feeding
of bacteria a meal of glucose can encourage
the growth of cariogenic bacteria when the pH
is allowed to drop .

Repeated glucose rinses encourages SM and LB growth

when plaque acid is not controlled
Fluoride at high concentra9ons inhibits SM , but not LB !!!
Xylitol had inhibitory proper9es for
both cariogenic and periodontal
bacteria. <

> The enamel white spot lesion at the mesial
contact zone of thefirst maxillary right molar .

Sed ut perspiciatis unde omnis iste natus error sit voluptatem accusantium
These white-spot lesions are some1mes lled by
doloremque laudantium, totam rem aperiam, eaque ipsa quae ab illo inventore
veritatis et quasi architecto beatae vitae dicta sunt explicabo. Nemo enim ipsam
den1sts but can be remineralized.
voluptatem quia voluptas sit aspernatur aut odit aut fugit, sed quia consequuntur
magni dolores eos qui ratione voluptatem sequi nesciunt.
 The demineralizationremineralization
balance in caries
Ketebalan plak yang didominasi oleh bakteri kariogenik, dapat secara efektif menjaga agar saliva tidak sampai
ke permukaan email gigi
Selain itu, semakin banyak plak, semakin banyak asam yang dihasilkan.
Asam ini memiliki waktu lebih lama untuk menembus enamel di bawah biofilm tebal - ini memungkinkan gigi
menjadi terdemineralisasi !!
Jika saliva asam, mereka akan dinetralisir oleh buffer saliva - ini memungkinkan gigi untuk mengalami
remineralisasi.
Siklus yang berulang setiap makan terutama yang manis mengandung gula tinggi dapat tjdnya fermentasi
sugars.
Karies terjadi jika frekuensi konsumsi gula dalam sehari yang sering dan tinggi.

The repeated
cycle of sugar
attacks.

BLOK 18 - KESEHATAN GIGI MASYARAKAT < 26 >

 The pH of dental plaque in response to glucose has
been studied using the classic Stephan curve
The diagram illustrates the plaque pH response curves that have been obtained from patients
with different risks for caries.

A high-risk individual, when
given a glucose rinse , will
experience a dramatic drop in
the plaque pH well below the
critical pH of 5.5.
The area under the pH-time qThe person with a high risk for caries
snacks frequently during the day,
curve (AUC)representing the
and the total AUCs clearly are
time spend at pH lower than excessive
the critical pH.
and will not allow remineralization to
The AUC for a high risk occur.

The recovery to neutral pH in individual will be very large. qIf that daily trend continues, the person
the high risk individual will be will experience dental decay.
slow. AUC is a better measure of
total caries risk.

BLOK 18 - KESEHATAN GIGI MASYARAKAT < 27 >

 q The person with moderate caries risk might have
three meals and one snack of moderate cariogenic
potential on a daily basis,
For a caries-resistant and the AUCs below the critical pH might result in a
For a moderate risk
person (green),the initial net loss of mineral.
individual (yellow), the
pH drop of that person s
initial pH drop may only
plaque may
be a little lower than the
critical pH, and the AUC
not even reach the q At this stage, remineralization
critical pH, and the
will be much less. recovery will be very strategies might work.
quick.

he person at low risk may not snack ut it is als

o
tant, b
at all and has three meals of low e r mined th
at:
s tio n that i
s im p
g
o r
ested
.
e t e in
cariogenicity spread apart during the Re s ear chers
have
ly the
d
f r eq uency
of i
carb
n
o
g
h y d rate t
h at is

ot on able
day. it is n
pe of
ferm
e n t
the ty
This allow remineralization to occur.

BLOK 18 - KESEHATAN GIGI MASYARAKAT < 28 >

 Kleinberg et al. (1982) determined
that increasing glucose concentra1ons
results in lower pH drops

1.0% Glucose 1.0% Glucose 50% Glucose

8.0

7.0

6.0

0 20 40 60 80 100

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03
Etiology- Host Factors
< >

Tooth factors unde omnis iste natus

Sed ut perspiciatis Saliva
error sit voluptatem accusantium
quality of
doloremque enamel totam rem aperiam, eaque ipsa quae ab illo inventore
laudantium, pH
presence/depth
veritatis of pitsbeatae
et quasi architecto and vitae dicta sunt explicabo. Nemo enim ipsam
flow rate
fissuresquia voluptas sit aspernatur aut odit aut fugit, sed quia consequuntur
voluptatem
magni dolores eos qui ratione voluptatem sequibuffering
hypoplasia nesciunt.capacity
antimicrobial components
fluoride exposure

Saliva
q Is to teeth what blood is to cells of the body
qComposition
supersaturated with Ca, P
bicarbonate principal buffer
proteins, immunologic/antibacterial components
fluoride
viscosity depends on gland, nervous control of
secretion
pH normally around 7.0; varies from ~5.5-8.0
BLOK 18 - KESEHATAN GIGI MASYARAKAT
The main components of saliva and their func4on
Classica4on Ingredient Func4on
of component
Inorganic Water (99%)
Inorganic, organic Carbonate, Buers acid
phosphate, protein
Organic Amylase, lipase, AnAbacterial
protease,
pyrophosphatase,
lysozyme
Organic Mucins Lubricant, calcium binding
Organic IgA AnAbacterial
< 31 >
 The role of saliva Saliva
Saliva contains antibacterial proteins, electrolytes for remineralization Flow rate Increased by:
and the essential nutrients for bacteria to grow. gustatory stimulants (sugar-free candy)
masticatory stimulants (s-f chewing gum)

The host provides the dietary carbohydrates that are easily converted reduced by:
to energy and acids by the bacteria that leads to dissolution of dental
hard tissues.
medications (antihistamines, antiasthmatics,
others)

disease (degenerative, metaplastic)
Because of its buffering capacity and ability to neutralize acids, dehydration
a simple intervention such as stimulating the saliva radiation
with chewing gum can arrest white spot lesions and prevent age
cavities from forming (Stookey 2008).

BLOK 18 - KESEHATAN GIGI MASYARAKAT < 32 >

SED UT
Pathogenesis of
PERSPICIATIS UNDE
dental caries
OMNIS ISTE NATUS
Mechanism of development of dental caries

ERROR SIT
 Sequence of the mechanism for the development of
dental caries

SED UT
PERSPICIATIS UNDE
1.
Degrada7o Acid Deminerali
2.
Degrada7o Acid next
Proteoly7c 34

OMNIS ISTE NATUS

degrada7o
n of deminerali za7on n of diges7on
n of
inorganic za7on of by organic of organic
organic
ma8er in enamel chelators ma8er ma8er
ma8er
enamel

ERROR SIT
Mechanism of acid demineralization

Carbohydra
tes from

SED UT
food
Release of calcium Plaques
and phosphate ions microorg
anisms

PERSPICIATIS UNDE
Dissolu8on of
enamel crystals acids
next
OMNIS ISTE NATUS
Narrow intercrystal dissocia8

ERROR SIT
spaces of the on
enamel surface
hydrogen
ions
Dissolu'on in the presence of chelators

Amino -Acids Citrates

SED UT
Carboxylic acids Lactates

PERSPICIATIS UNDE next 36

OMNIS ISTE NATUS

ERROR SIT
Bonding the
calcium at the
enamel surface
and extrac'on
Development of caries in the
presence of inhibitors

SED UT
PERSPICIATIS UNDE next 37

OMNIS ISTE NATUS

pyrophosp
hates
diphosphates
calcium
uoride
uorapa2te =
hinder
dissolu2on

ERROR SIT
Mechanism of degrada0on of organic ma1er

SED UT
acid soluble acid insoluble

PERSPICIATIS UNDE
OMNIS ISTE NATUS
Degrada(on in acid

ERROR SIT
proteoly0c enzymes
medium
 SED UT interventions aim
Preventive
to modify the steps in the repeat
PERSPICIATIS
demineralization and
UNDE
OMNIS ISTE
remineralization NATUS
cycles.
ERROR SIT
 Prevention of Dental Caries

01
Neutralize the plaque acids
This can be done by adding
base or adding buffers such as
04 Stimulate saliva
Saliva contains numerous
components(that fight tooth
decay) .
sodium bicarbonate (baking Buffer, remineralizing mineral
soda) to the saliva to boost its AB enzyms, antinbodies
ability to neutralize acids.

Improve Hygiene: Topical Fluorides

02 05
With bacterial levels low, less acid Fluoride added to the
is produced. remineralizing
Plaque layers dont have a chance incipient lesion increases
to grow thick;
the enamel crystals
Saliva can penetrate better to the
resistance to dissolution
enamel surface through thin layers
of plaque by plaque acids.

Introduce antimicrobials Remineralizing strategies

03 06
Since caries is a disease caused by
bacteria, simply eliminating the bacteria
Remineralization can b
or controlling their growth will reduce
promoted with the use of
the caries incidence.
Chlorhexidine, xylitol, ozone : even calcium-phosphate
experimental antibodies, have been complexes such and
used to control bacterial growth. ACP-CPP.

40

BLOK 18 - KESEHATAN GIGI MASYARAKAT < >

Water fluoridation in the
Blue Mountains reduces risk
of tooth decay

RW Evans1, A Hsiau1, PJ Dennison1, A Paterson2,

and B.Jalaludin2 The effect of water
fluoridation
Australian Dental Journal 54: 368-373, 2009

The combined effect of water

fluoridation and fluoridated toothpaste

Victorian 12-year-olds

BLOK 18 - KESEHATAN GIGI MASYARAKAT < 41 >

The Cochrane Database of Systema3c Reviews

Fluoride toothpastes for preven2ng

dental caries in children and adolescents

Marinho VCC, Higgins JPT, Sheiham A, Logan S

Date of Most Recent Substan3ve Update:
3 September 2002

Better use of fluorides

Better oral
hygiene

Dietary
challenge Caries
risk
Better access to saliva

For a given dietary challenge, risk of caries at any tooth site will depend
on (1) fluoride exposure, (2) plaque bulk, and (3) access to saliva.
Loveren C van, Duggal MS. The role of diet in caries
prevention. International Dental Journal 51:399-406,2001.

BLOK 18 - KESEHATAN GIGI MASYARAKAT < 42 >

Better use of fluorides

Betteroral
Better
hygiene

For reduced
dietary
challenge

Betteraccess
Better accessto
tosaliva
saliva

For a given dietary challenge, risk of caries at any tooth site will depend
on (1) fluoride exposure, (2) plaque bulk, and (3) access to saliva.
Loveren C van, Duggal MS. The role of diet in caries
prevention. International Dental Journal 51:399-406,2001.

BLOK 18 - KESEHATAN GIGI MASYARAKAT < 43 >

 Better use
Better use of fluorides

Betteroral
Better
hygiene

For reduced
Scope to
dietary
reduce caries
challenge
risk is limited
Betteraccess
Better accessto
tosaliva
saliva

For a given dietary challenge, risk of caries at any tooth site will depend
on (1) fluoride exposure, (2) plaque bulk, and (3) access to saliva.
Loveren C van, Duggal MS. The role of diet in caries
prevention. International Dental Journal 51:399-406,2001.

BLOK 18 - KESEHATAN GIGI MASYARAKAT < 44 >

Thank You