l C il C iDental Caries Dental Caries i th N Mill ii th N Mill iin the New Millennium:in the New Millennium:

AetilogyAetilogy and Rationaleand RationaleAetilogyAetilogy and Rationaleand Rationale

ObjectivesObjectivesjjTemporal objectivesTemporal objectives

Understand caries is a transmissible infectionUnderstand caries is a transmissible infectionRecognize mediating factors in the infection Recognize mediating factors in the infection processprocessprocessprocessRecognize risk factorsRecognize risk factors

Practical objectivesPractical objectivesjjApply medical model of caries control in your Apply medical model of caries control in your officeofficeMonitor your patients’ progressMonitor your patients’ progress

Caries: An Ancient DiseaseCaries: An Ancient Disease

Neanderthal ~35 000 B CNeanderthal ~35 000 B CNeanderthal 35,000 B.C.Neanderthal 35,000 B.C.CroCro--Magnon ~25,000 B.C.Magnon ~25,000 B.C.Neolithic ~9000 B.C.Neolithic ~9000 B.C.

A A CoppaCoppa, L , L BondioliBondioli, A , A CucinaCucina, D W , D W FrayerFrayer, C , C JarrigeJarrige, , d ld l ddJJ--F F JarrigeJarrige, G , G QuivronQuivron M Rossi, M M Rossi, M VidaleVidale and R and R

MacchiarelliMacchiarelliPalaeontologyPalaeontology: Early Neolithic tradition of dentistry: Early Neolithic tradition of dentistrygygy y yy yNatureNature 440, 755440, 755--756 (6 April 2006)756 (6 April 2006)

““Until the great takeoff, millions of people died Until the great takeoff, millions of people died from tooth decay. You see, cavities kill if they are from tooth decay. You see, cavities kill if they are not treated. During the Middle Ages, a not treated. During the Middle Ages, a demographer named Johndemographer named John GrauntGraunt found that 5% offound that 5% ofdemographer named John demographer named John GrauntGraunt found that 5% of found that 5% of the deaths in London were due to tooth decay. My the deaths in London were due to tooth decay. My wife's grandmother died of tooth decay. But to us wife's grandmother died of tooth decay. But to us g yg ytoday, tooth decay is a minor nuisance. We rarely today, tooth decay is a minor nuisance. We rarely think about it unless we see a TV commercial about think about it unless we see a TV commercial about

h ”h ”toothpaste.”toothpaste.”

The Coming Great WarThe Coming Great WarHow It Will Affect Your InvestmentsHow It Will Affect Your InvestmentsHow It Will Affect Your Investments How It Will Affect Your Investments

Richard J. Richard J. MayburyMaybury19981998

Today’s Reality Today’s Reality –– CDC DataCDC Datay yy ySecond to the common cold as the most prevalent Second to the common cold as the most prevalent disease in humansdisease in humansMost common chronic disease of children aged 5 to Most common chronic disease of children aged 5 to 17 years 17 years –– 4 times more common than asthma (42% 4 times more common than asthma (42% versus 9.5%)versus 9.5%)%)%)Poor children are nearly 12 times more likely to miss Poor children are nearly 12 times more likely to miss school because of dentalschool because of dental--related illness than children related illness than children f hi hf hi h i f ilii f ilifrom higherfrom higher--income familiesincome familiesMany adults also have untreated dental caries (e.g., Many adults also have untreated dental caries (e.g., 27% of those 20 to 39 years, 21% of those 40 to 59 27% of those 20 to 39 years, 21% of those 40 to 59 y ,y ,years, and 19% of those 60 years and older)years, and 19% of those 60 years and older)

?? ?? ??QUESTIONQUESTION?? ?? ?? ?? ??QUESTIONQUESTION?? ??

SS?? ??SS???? ???? ???? ????

What is dental caries?What is dental caries?What is dental caries?What is dental caries?

Dental caries is…Dental caries is…1.1. an infection caused by specific an infection caused by specific

b ib ibacteria.bacteria.2.2. a a multifactorialmultifactorial disease process of disease process of

continuous demineralization and continuous demineralization and remineralizationremineralization..

3.3. a reversible disease process until a reversible disease process until cavitationcavitation occurs.occurs.

4.4. a chronic disease process having a chronic disease process having episodes of activity and inactivity.episodes of activity and inactivity.

What causes dental caries?What causes dental caries?What causes dental caries?What causes dental caries?

AetiologyAetiologyAetiologyAetiology

Keyes’ TriadKeyes’ Triadyy

PlaquPlaquee

FermentableFermentableSusceptiblSusceptiblCarieCarie

Fermentable Fermentable carbohydratcarbohydratee

SusceptiblSusceptible toothe tooth

ss

Fourth DimensionFourth Dimension

Treatment Must Be Treatment Must Be Based on Based on AetiologyAetiology

AetiologicAetiologic FactorsFactorsggHostHostBacterialBacterialEnvironmental (diet)Environmental (diet)Environmental (diet)Environmental (diet)TimeTime

Case Study Case Study -- DeborahDeborahyy5454--yearyear--old nurseold nurseSwing shift scheduleSwing shift scheduleNonNon--smokersmokerHistory of extensive dental treatmentHistory of extensive dental treatmentMultiple medications, includingMultiple medications, including

HCTZHCTZClaritin DClaritin D

DeborahDeborah

DeborahDeborah

Host FactorsHost FactorsNonNon--modifiablemodifiable

GenesGenesImmune systemImmune systemSalivary flow and chemistrySalivary flow and chemistry

ModifiableModifiableModifiableModifiableImmune system (???)Immune system (???)Salivary flow and chemistry (???)Salivary flow and chemistry (???)Salivary flow and chemistry (???)Salivary flow and chemistry (???)

Bacterial FactorsBacterial FactorsMS counts (quantity)MS counts (quantity)

Streptococcus Streptococcus mutansmutansStreptococcus Streptococcus sobrinussobrinuspp

Virulence (quality)Virulence (quality)

Environmental FactorsEnvironmental FactorsWhat you eat and drinkWhat you eat and drinkHow often you eat and drinkHow often you eat and drink

TiTiTimeTime

Host FactorsHost Factors

SalivaSalivaSalivaSaliva

“don’t it always seem to go“don’t it always seem to gothat you don’t know what you’ve gotthat you don’t know what you’ve got

till it’s gone…”till it’s gone…”( l i J i Mi h ll)( l i J i Mi h ll)(apologies to Joni Mitchell)(apologies to Joni Mitchell)

Saliva’s AntiSaliva’s Anti--caries Activitycaries ActivityyyClearance of food and bacteriaClearance of food and bacteriaCalcium phosphate salts promote Calcium phosphate salts promote remineralizationremineralizationBicarbonates neutralize acidsBicarbonates neutralize acids

Assessing Dry MouthAssessing Dry Mouthg yg yNormal salivationNormal salivationHyposalivationHyposalivationXerostomiaXerostomiaXerostomiaXerostomia

Normal SalivationNormal Salivation1.5 liter per day (~1mL/minute)1.5 liter per day (~1mL/minute)>0.2mL/minute >0.2mL/minute unstimulatedunstimulated whole whole salivasalivaMajor glands supply most saliva in Major glands supply most saliva in response to exogenous stimuliresponse to exogenous stimuliresponse to exogenous stimuliresponse to exogenous stimuliMinor glands provide continual Minor glands provide continual h d i d l b i ih d i d l b i ihydration and lubricationhydration and lubrication

HyposalivationHyposalivationypypDecreased volume (flow)Decreased volume (flow)<0.2mL/minute <0.2mL/minute unstimulatedunstimulated whole whole salivasalivaMay not be associated with May not be associated with complaints or altered disease patternscomplaints or altered disease patternscomplaints or altered disease patternscomplaints or altered disease patterns

XerostomiaXerostomia<0.16mL/minute <0.16mL/minute unstimulatedunstimulatedwhole salivawhole salivaAssociated with complaints or altered Associated with complaints or altered ppdisease patternsdisease patterns0 04mL/minute differentiates0 04mL/minute differentiates0.04mL/minute differentiates 0.04mL/minute differentiates between symptoms or no symptomsbetween symptoms or no symptoms

Discriminate Analysis FormulaDiscriminate Analysis Formula

Flow Rate = Flow Rate = --0.345*LD + 2.242*BMD + 0.345*LD + 2.242*BMD + 0 267*0 267*tDMFTtDMFT + 4 426*MSGP+ 4 426*MSGP –– 8 8918 8910.2670.267 tDMFTtDMFT + 4.426 MSGP + 4.426 MSGP 8.8918.891

SO WHAT?!?!?!SO WHAT?!?!?!SO WHAT?!?!?!SO WHAT?!?!?!

Practical Clinical AssessmentPractical Clinical AssessmentTongue bladesTongue bladesGauze, fingers and eyesGauze, fingers and eyes

Diseases and Medical Therapies Diseases and Medical Therapies that Cause that Cause XerostomiaXerostomia

SjSjöögren’sgren’s s ndromes ndromeSjSjöögren sgren s syndromesyndromeHypertensionHypertensionDiabetes mellitusDiabetes mellitusRadiation therapyRadiation therapyRadiation therapyRadiation therapyChemotherapyChemotherapyM di i !!!M di i !!!Medications!!!Medications!!!

Medications (over 400)Medications (over 400)( )( )AnalgesicsAnalgesicsA ti l tA ti l tAnticonvulsantsAnticonvulsantsAntidepressants Antidepressants AntihistaminesAntihistaminesAntihistaminesAntihistaminesAntihypertensivesAntihypertensivesAntiretroviralsAntiretroviralsAntiretroviralsAntiretroviralsCytotoxicsCytotoxicsSedativesSedatives

Salivary ChemistrySalivary Chemistry

pH and other thingspH and other things

pHpHppResting oral pHResting oral pHStephan CurveStephan CurveCritical pHCritical pHCritical pHCritical pH

Stephan CurveStephan CurveppShows change in dental plaque pH Shows change in dental plaque pH following a “challenge”following a “challenge”Initial rapid drop in pH (<5 minutes)Initial rapid drop in pH (<5 minutes)p p p ( )p p p ( )Slower rise back to resting pH (15Slower rise back to resting pH (15--40 40 minutes)minutes)minutes)minutes)Plaque pH affects oral pHPlaque pH affects oral pH

The lowest pH achieved depends The lowest pH achieved depends ononon…on…

1.1. the resting the resting pH.pH.2.2. the microbial composition of the dental the microbial composition of the dental

plaque.plaque.3.3. the nature of the fermentable the nature of the fermentable

carbohydrate source.carbohydrate source.4.4. the rate of diffusion of substrates and the rate of diffusion of substrates and

metabolites into and out of the plaque.metabolites into and out of the plaque.

Effect of Saliva on Return to Resting pHEffect of Saliva on Return to Resting pH

Salivary flow rateSalivary flow rateBicarbonateBicarbonate--mediated acid neutralizationmediated acid neutralization

Accelerated by salivary carbonic Accelerated by salivary carbonic anhydraseanhydrase

A Day in Port ElizabethA Day in Port Elizabethyy

When should you brush your teeth?When should you brush your teeth?y yy y

Bacterial FactorsBacterial Factors

M t St 100 000 C l F i U itMutans Strep ≥ 100,000 Colony Forming Units

Lactobacillus ≥100,000 Colony Forming Units

Environmental FactorsEnvironmental Factors

DietDietSucroseSucroseFructoseFructoseRefined carbohydratesRefined carbohydratesRefined carbohydratesRefined carbohydratesStickinessStickinessFrequency of intakeFrequency of intake

pH of Various BeveragespH of Various Beverages

Beverage pH

Pure water 7.2Coke 2.6

Diet Coke 3.4Sprite 3.4

Diet Sprite 3.7Gatorade 2.9

Surge 3.0Orange juice 3.6

Beer 4.128-year-old single-barrel 5.38 yea o d s g e ba e

bourbon5.3

Gastric acid 2.2