Definition

Definition Causes Dental caries, also known as tooth decay or a cavity, is an infection, usually bacterial in origin that causes demineralization of the hard tissues (enamel, dentin and cementum) and destruction of the organic matter of the tooth, usually by production of acid by hydrolysis of the food debris accumulated on the tooth surface. If demineralization exceeds saliva and other remineralization factors such as from calcium and fluoridated toothpastes, these tissues progressively break down, producing dental caries (cavities, holes in the teeth). The two bacteria most commonly responsible for dental cavities are Streptococcus mutans and Lactobacillus. If left untreated, the disease can lead to pain, tooth loss and infection

 It is one of the most common of all disorders, second only to the common cold. It usually occurs in children and young adults but can affect any person. It is a common cause of tooth loss in younger people. Bacteria are normally present in the mouth. The bacteria convert all foods -- especially sugar and starch -into acids. Bacteria, acid, food debris, and saliva combine in the mouth to form a sticky substance called plaque that adheres to the teeth.

 It is most prominent on the molars, just above the gum line on all teeth, and at the edges of fillings. Plaque begins to build up on teeth within 20 minutes after eating (the time when most bacterial activity occurs). If this plaque is not removed thoroughly and routinely, tooth decay will not only begin, but flourish.

 The acids in plaque dissolve the enamel surface of the tooth and create holes in the tooth (cavities). Cavities are usually painless until they grow very large and affect nerves or cause a tooth fracture. Untreated tooth decay also destroys the internal structures of the tooth (pulp) and ultimately causes the loss of the tooth. Carbohydrates (sugars and starches) increase the risk of tooth decay. Sticky foods are more harmful than non-sticky foods because they remain on the surface of the teeth. Frequent snacking increases the time that acids are in contact with the surface of the tooth.

Clinical sites for caries initiation Pit and fissures of enamel most susceptible site Smooth surface of crown (proximal) Second susceptible site Root surface (cervical region) Third susceptible site Sub gingival area

 Presentation The presentation of caries is highly variable. However the risk factors and stages of development are similar. Initially it may appear as a small chalky area (incipient caries), which may eventually develop into a large cavitation. With continued acid attack the surface changes from being smooth to rough and may become stained.

 Note: once enamel caries penetrates into the dentinoenamel junction, rapid lateral expansion of carious lesion takes place. DEJ has least resistance to caries attack. Progression and morphology of carious lesion is variable depending upon; Site of origin and condition of mouth (oral hygiene).

 Exams and Tests Most cavities are discovered in the early stages during routine checkups. The surface of the tooth may be soft when probed with a sharp instrument. Pain may not be present until the advanced stages of tooth decay. Dental x-rays (radiographs) may show some cavities before they are visible to the eye and are used for less visible areas of teeth and to judge the extent of destruction.

Medical factors associated with increased caries risk Factors risk increasing observation Gender Female > Male Age children and adolescents are more prone Fluoride exposure no or less fluoride in drinking water Smoking risk increases with intake Alcohol risk increases with intake General Health chronic illness and debilitating disease Medication medication w/c lowers salivary flow (e.g., Atropine), Antiepileptic, Pills (hormone)

 Rampant caries Acute and rapid infectious process, usually involving several teeth. It is usually occurred in children or infants. Causes Dietary habits Poor oral hygiene Systemic illness

 Secondary caries It is caries of filled teeth. It may occur due to defective margin of restoration and if caries is not completely removed from the cavity before the procedure and cavity preparation. Arrested Caries Under favorable conditions a lesion become inactive, even regress. Clinically arrested dentine caries has a hard or leathery consistency and is darker in color than soft, yellow active decay. Arrested enamel caries can be stained dark brown.

Prevention: Classically three main approaches are possible: Tooth strengthening or protection Reduction in the availability of microbial substrate. Removal of plaque by physical or chemical means; practically this means dietary advice, fluoride, fissure sealing and regular tooth brushing. The relative value of these varies with age of the individual.

 Saliva Has buffering action (effect) against bacteria and act as intraoral antacid due to its alkali PH at high flow rate Has flushing effect wash away bacteria and decrease plaque accumulation. Produce antimicrobial products such as IgA, lysozyme, lactoferin, agglutins and lactoperioxidase Has remeneralization effect, as it is supersaturated with calcium, phosphate and fluoride ions which give opportunity for remeneralization of enamel.

 Treatment Treatment can help prevent tooth damage from leading to cavities. Treatment may involve: Fillings Crowns Root Canal Treatment (RCT)

 Fillings Dentists fill teeth by removing the decayed tooth material with a drill and replacing it with a material such as silver alloy, gold, porcelain, or composite resin. Porcelain and composite resin more closely match the natural tooth appearance, and may be preferred for front teeth (aesthetics). Many dentists consider silver amalgam (alloy) and gold to be stronger, and these materials are often used on back teeth as they are strong and non aesthetics.

 Crowns Crowns or "caps" are used if tooth decay is extensive and there is limited tooth structure, which may cause weakened teeth. Large fillings and weak teeth increase the risk of the tooth breaking. The decayed or weakened area is removed and repaired. A crown is fitted over the remainder of the tooth. Crowns are often made of gold, porcelain, or porcelain attached to metal.

 Root Canal Treatment (RCT) A root canal treatment is recommended if the nerve in a tooth dies from decay or injury. The center of the tooth, including the nerve and blood vessel tissue (pulp), is removed along with decayed portions of the tooth. The roots are filled with a sealing material. The tooth is filled, and a crown may be placed over the tooth if needed.

 Developmental stages of dental caries Enamel caries no pain Dentine caries maybe sensitive to hot, cold and sweet foods/drinks and eating hard things; there may be pain Pulp involved severe continuous or throbbing pain Abscess deep acute pain which may disappear after a while.

Diseases of pulp and periapical tissues

Definition Disease of the pulp (Pulpitis) Pulpitis - Inflammation of pulp Etiology: Dental caries (primary cause) Tooth fracture; expose dental pulp to oral fluids and bacterias Chemical irritation to pulp; filling Severe thermal change; common in large metallic restoration

 Classification

Pulp hyperemia (Focal Reversible Pulpitis) Earliest form of pulpitis Cause Deep caries Large metallic restoration (especially with no adequate insulation) Restoration with defective margin Clinical features Sensitive to thermal changes, particularly to cold, but disappears upon removal of the stimulus or restoration of normal temperature Treatment Carious lesion should be excised and restored or a defective filling replaced as soon as it is discovered

 Reversible pulpitis Clinical features Fleeting sensitivity / pain to hot, cold or sweet with immediate onset Pain usually sharp and may be difficult to locate Quickly subsides after removal of stimulus (pain <10 min) Treatment Filling by removal of any caries present and place a sedative dressing or Permanent restoration with suitable pulp protection

 Irreversible Pulpitis Clinical features Spontaneous pain which may last several hours (>10 min), be worse at night and is pulsatile in nature Pain elicited by hot and cold at first but in later stages heat is more significant and cold may actually ease symptoms Localization of pain may be difficult initially, but as the inflammation spread to the Periapical tissue the tooth will become more sensitive to pressure Tender to percussion Treatment RCT, treatment of choice Extraction

 Diseases of periapical tissues Once infection has become established in the dental pulp, spread of the process can be in one direction through the root canals and into the periapical region. Progression of irreversible pulpitis ultimately leads to death of the pulp (pulpal necrosis). At this stage the patient may experience relief from pain. If neglected however the bacteria and the pulpal breakdown products leave the root canal system via the apical foramen lead to inflammatory changes and possibly severe pain. Here a number of different tissue reactions may occur, depending on the circumstances

 The periapical lesions dont represent individual and distinct entities, but rather that there is a subtle transformation from one type of lesion into another type in most cases. Note: sensitive to percussion is first evidence that infection has spread beyond the confines of the pulp.

 Apical periodontitis (Periapical granuloma) Granuloma: essentially localized mass of chronic granulation tissue formed in response to infection Clinical features Sensitive to percussion, due to edema, hyperemia and inflammation of apical periodontal ligament. Mild pain occasioned on biting or chewing solid food In some cases tooth feels slightly elongated in its socket and may actually be so Treatment Extraction RCT, under certain condition with or without subsequent apicectomy

Apical periodontal cyst Cyst Pathological cavity lined by epithelium and is often fluid filled APC- is common and developed over long period of time. Cause Sequela of periapical granuloma Necrosis of dental pulp Clinical features The majority is asymptomatic and present no clinical evidence of their presence Seldom painful even sensitive to percussion Long standing may undergo acute exacerbation of inflammatory process and develop rapidly into an abscess may then proceed to a cellulites or draining fistula Treatment Extraction and curette of periapical tissue, carefully RCT and apicectomy with inoculation in some condition

Periapical Abscess (Dentoalveolar Abscess) An acute or chronic suppurative process of the dental periapical region. Clinical features Tooth is extremely painful Slightly extruded from its socket Seldom severe systemic manifestation, regional lymphadenitis and fever may be present Rapid extension to adjacent bone marrow spaces frequently occurs producing an actual osteomyelitis Treatment Drainage by either opening the pulp chamber or extraction RCT, sometimes Note: If not treated leads to osteomyelitis, cellulites, bacteremia and formation fistulous Tract opening to skin or mucosa.