Caries

:toc:

= Classification of dental caries . According to location . Pit-and-fissure caries:: A caries lesion on a pit-and-fissure area . Smooth-surface caries:: A caries lesion on a smooth tooth surface . Root caries:: A caries lesion in the root surface

II. According to clinical management strategy i. Initial Caries Lesion/Non-cavitated caries lesion/White Spot Lesion:: A caries lesion that has not been cavitated. In enamel caries, non-cavitated lesions are also referred to as ‘white spot’ lesions. (Clinically, the distinction between a cavitated and a non-cavitated caries lesion is not as simple as it may seem. Although historically any roughness detectable with a sharp explorer has been considered a cavitated lesion, more recent caries detection guidelines establish that only lesions in which a blunt probe (e.g. WHO [World Health Organization]/ CPI [Community Periodonatal Index]/PSR [Periodontal Screening and Recording] probe) penetrates are to be considered cavitated. This distinction has important implications on lesion management because most initial caries lesions can be arrested or remineralized without any restorative intervention ii. Cavitated caries lesion:: A caries lesion that results in the breaking of the integrity of the tooth, or a cavitation. All cavitated lesions would require restorative intervention

III. According to rate of activity i. Active caries lesion:: A caries lesion that is considered to be biologically active, that is, lesion in which tooth demineralization is in frank activity at the time of examination a. Moderate caries lesion: An active caries lesion that may or may not have cavitated but that has not reached the inner one-third of dentin is considered as a moderate caries lesion. This can be observed clinically by microcavitations in the enamel or a grey shadow b. Advanced (deep) caries lesion: A definitely cavitated active caries lesion exposing dentin and that has reached the inner one-third of dentin will be considered an advanced (deep) caries lesion. ii. Inactive caries lesion:: A caries lesion that is considered to be biologically inactive at the time of examination, that is, in which tooth demineralization caused by caries may have happened in the past but has stopped and is currently stalled. Also referred to as arrested caries, meaning that the caries process has been arrested but that the clinical signs of the lesion itself are still present iii. Rampant caries:: Term used to describe the presence of extensive and multiple cavitated and active caries lesions in the same person. Typically used in association with ‘baby bottle caries’, ‘radiation therapy caries’ or ‘meth-mouth caries’. These terms refer to the etiology of the condition.

IV. According to occurrence i. Primary caries:: A caries lesion not adjacent to an existing restoration or crown ii. Secondary caries:: A caries lesion adjacent to an existing restoration, crown or sealant. Other term used is caries adjacent to restorations and sealants (CARS). Also referred to as recurrent caries, implying that a primary caries lesion was restored but that the lesion reoccurred iii. Residual caries:: Refers to carious tissue that was not completely excavated prior to placing a restoration. Sometimes residual caries can be difficult to differentiate from secondary caries

V. According to depth of lesion i. Enamel caries:: A caries lesion in enamel, typically indicating that the lesion has not penetrated into dentin. (Note that many lesions detected clinically as enamel caries may very well have extended into dentin histologically.) ii. Dentin caries:: A caries lesion extending into dentin

According to occurrence

= Primary caries A caries lesion not adjacent to an existing restoration or crown

= Secondary caries A caries lesion adjacent to an existing restoration, crown or sealant. Other term used is caries adjacent to restorations and sealants (CARS). Also referred to as recurrent caries, implying that a primary caries lesion was restored but that the lesion reoccurred or missing tooth

= Residual caries Refers to carious tissue that was not completely excavated prior to placing a restoration. Sometimes residual caries can be difficult to differentiate from secondary caries

According to location

= pit and fissure caries

//location Pit and fissure caries of the primary type develop on the occlusal surface of molars and premolars, the buccal and lingual surface of the molars, and the palatal surface of the maxillary incisors.

//cause Pits and fissures with high steep walls and narrow bases are those most prone to develop caries due to their poor self-cleansing features. Deep and narrow pits and fissures favor the retention of food debris along with microorganisms, and caries may result from fermentation of this food and the formation of acid.

clinical features

//occurence Pits and fissures affected by early caries footnote:[first caries in human approximately at 18 in n6 first molar occlusal]

//Appearance pit and fissure caries may appear brown or black and will feel slightly soft and “catch” to a fine explorer point . The enamel directly bordering the pit or fissure may appear opaque bluish white as it becomes undermined.footnote:[bluish white to brown or black and soft catchy cavitated to a file explorer].

//Progress This undermining occurs through the lateral spread of the caries at the dentinoenamel junction, and it may be a rapid process if the enamel in the base of the pit or fissure is thin.footnote:[caries progress is rapid].

//frank cavity formation The lateral spread of caries at the dentinoenamel junction as well as penetration into the dentin along the dentinal tubules may be extensive without fracturing away the overhanging enamel. Thus, there may be a large carious lesion with only a tiny point of opening. This undermined enamel may suddenly give way under the stress of mastication or the dentist may suddenly open into a large cavity when excavating the pit or fissure. It should not be inferred that all pit and fissure caries begin with a narrow penetration point and develop a large cavitation with overhanging enamel. In many cases, the lesion begins as an open cavity and becomes progressively larger. In this type, caries progression is usually much slower and pulp involvement is often delayed.footnote:[frank cavity formation]

//Comparing with other caries The carious process in pits and fissures does not differ in nature from smooth surface caries except for its anatomical and histological variations. The occlusal fissures are deep invaginations of enamel that have been described as broad or narrow funnels, constricted hourglasses, multiple invaginations with inverted Y-shaped divisions, and irregularly shaped.

The carious lesion starts along the fissure walls rather than at the base, and visual changes such as ** chalkiness or yellow, brown, or black discoloration may be seen**.footnote:[v] If the enamel in the bottom of the pit or fissure is thin, early dentin involvement frequently occurs. When caries occurs in a pit and fissure, it follows the direction of the enamel rods and characteristically forms a triangular or cone-shaped lesion with its apex at the outer surface and base toward the dentinoenamel junction (Figure 11.21 ). It should be noted that the general shape of the lesion here is just the opposite of that occurring in the smooth surface. Because of this, greater numbers of dentinal tubules are involved when the lesion reaches the dentinoenamel junction.

The pit and fissure caries usually produces greater cavitation than the smooth surface caries.

The carious lesion is more prone to be stained with a **brown pigment**in pits and fissures. In newly erupted teeth, a brown stain is indicative of underlying decay, while in teeth of older individuals it may be due to arrested lesions. Occasionally, enamel lamellae are found at the base of pits and fissures that may be important as caries pathway (Figure 11.22 ).

The histological features of the initial carious lesion in enamel have been described by a number of workers. Evidence support the concept that in early stages, caries causes minimal damage to the outer smooth surface but considerable demineralization below the surface. The initial lesion has been divided into different zones based on its histological appearance when longitudinal ground sections are examined with the light microscope. Four zones are clearly distinguishable, starting from the inner advancing front of the lesion. These are the (1) translucent zone, (2) dark zone, (3) body of the lesion, and (4) surface layer.

= Smooth surface caries

//location Smooth surface caries (Figure 11.9 A) of the primary type is caries that develops on the proximal surfaces of the teeth or on the gingival third of the buccal and lingual surfaces.

//cause Seldom does caries occur on other areas of the teeth, except in cases of malposed or malformed teeth, because of the self-cleansing properties of these areas. Unlike pit or fissure caries, which is not dependent on the development of a definite, grossly recognizable plaque for the initiation of caries, smooth surface caries is generally preceded by the formation of a microbial plaque. This ensures the retention of carbohydrate and microorganisms on the tooth surface in an area not habitually cleansed and subsequent formation of acid to initiate the caries process.

Proximal caries usually begins just below the contact point and appears in the early stage as a faint white opacity of the enamel without apparent loss of continuity of the enamel surface .In some cases, it appears as a yellow or brown pigmented area, but in either event is usually rather well demarcated. The early white chalky spot becomes slightly roughened owing to superficial decalcification of the enamel. As the caries penetrates the enamel, the enamel surrounding the lesion assumes a bluish white appearance similar to that seen sometimes around carious pits or fissures. This is particularly apparent as the lateral spread of caries occurs at the dentinoenamel junction. The more rapid type of caries usually produces a small area penetration; the slower forms an open and shallow cavity. It is not uncommon for proximal caries to extend both buccally and lingually,but seldom does the cavity encroach upon areas accessible to excursion of food or to the toothbrush.

The earliest macroscopic evidence of incipient caries on the smooth surface is the appearance of an area of decalcification beneath the dental plaque, which resembles a smooth chalky white area (Figure 11.16 ). It is best observed on an extracted tooth, usually at the cervical margin of the interdental facet referred to as white spot. The enamel surface overlying the white spot is hard and shiny and cannot be distinguished from the surface of adjacent sound enamel using a sharp explorer point. Intact surface lesions may also appear brownish when they are described as brown spots. This largely depends on the degree of exogenous material adsorbed by the porous region.footnote:[white or sometimes brown has no enamel break down so cavity]].

= Cervical caries

//location This type of caries occurs on buccal, lingual, or labial surfaces and usually extends from the area opposite the gingival crest occlusally to the convexity of the tooth surface.footnote:[locations are buccal,lingual,labial]

It extends laterally toward the proximal surfaces and, on occasions, extends beneath the free margin of the gingiva. Thus, the typical cervical carious lesion is a crescent-shaped cavity beginning as a slightly roughened chalky area which gradually becomes excavated. Cervical caries is almost always an open cavity and does not present the narrow point of penetration seen commonly in the pit or fissure caries and proximal caries. Cervical caries occurs on any tooth without predilection and is directly related to lack of oral hygiene. Of all forms of dental caries on different areas of the tooth,there is least excuse for cervical caries, since it can be prevented in nearly every instance by proper toothbrushing.

= Root caries

//Location At one time, it was also referred to as** “caries of cementum.”** Root caries is defined as “a soft, progressive lesion that is found anywhere on the root surface that has lost connective tissue attachment and is exposed to the oral environment.”footnote::[location is on root]

//Occurence This type of caries is predominantly found in dentitions of the older age groups with significant gingival recession and exposed root. It is also called senile caries (Figure 11.9 C and D).

//Cause Prevalence of root caries is not known exactly. However, it is generally recognized that the longer life span of persons today, with the retention of teeth into the later decades of life, has increased the number of people in the population exhibiting gingival recession with clinical exposure of cemental surfaces and, thereby, probably increasing the prevalence of root caries.

Enamel may become involved if it is undermined during the progression of the lesion. Dental plaque and microbial invasion are an essential part of the cause and progression of this lesion. However, there is some evidence that the microorganisms involved in root caries are different from those involved in coronal caries, being filamentous rather than coccal.

Microorganisms appear to invade the cementum either along Sharpey’s fibers or between bundles of fibers, in a manner comparable to invasion along dentinal tubules. Since cementum is formed in concentric layers and presents a lamellated appearance, the microorganisms tend to spread laterally between the various layers. Irregular mineralization on this cemental surface may often be seen at the same time, probably representing the beginning of calculus formation. After decalcification of the cementum, destruction of the remaining matrix occurs similar to the process in dentin, with ultimate softening and destruction of this tissue. As the caries process continues, there is invasion of microorganisms into underlying dentinal tubules, subsequent matrix destruction, and finally pulpal involvement.

Most investigators have felt that once caries involves the dentin, the process is identical with coronal dentinal caries. However, it has been pointed out that since there are more dentinal tubules per unit area in the crown than in the root of the tooth and dentinal sclerosis is present, one may expect differences in the rate of caries progression. The intraoral distribution patterns for root caries revealed that the teeth most frequently affected were the mandibular molars, the mandibular premolars, and the maxillary canines in descending order. The mandibular incisors were the least frequently affected teeth. It was also noted that the interproximal surfaces were affected most frequently in the maxillary arch, while the buccal surfaces were attacked most frequently in the mandibular arch.

=== Time

== Acute dental caries Dental caries is the form of caries which runs a rapid clinical course and results in early pulp involvement by the carious process. It occurs most frequently in ** children and young adults, presumably because the dentinal tubules are open and show no sclerosis**. The process is usually so rapid that there is little time for the deposition of reparative dentin. The initial entrance of the carious lesion remains small, while the rapid spread of the process at the dentinoenamel junction and diffuse involvement of the dentin produces a large internal excavation. It has been suggested that saliva does not easily penetrate the small opening to the carious lesion so that, as acids are formed, there is little opportunity for buffering or neutralization. In acute caries, the dentin is usually stained light yellow rather than the darker brown of chronic caries (Figure 11.11 ). Pain is more apt to be a feature of acute caries than of chronic caries, but this is not an invariable finding. footnote:[young,rapid,small narrow,large internal excavation,little buffering,yellow rather than brown, painful]

== Chronic dental caries Chronic dental caries progresses slowly**and **tends to involve the pulp much later than acute caries. It is most common in adults. The entrance to the lesion is almost invariably larger.Because of this, there is not only less food retention but also greater access of saliva.

//why chronic are dark brown The slow progress of the lesion allows sufficient time for both sclerosis of the dentinal tubules and deposition of reparative dentin in response to adverse irritation. The carious dentin is often stained dark brown. Although there is a considerable surface destruction of tooth substance, the cavity is generally a shallow one with a minimum softening of dentin. There is little undermining of enamel and only lateral spread of caries at the dentinoenamel junction.** Pain is not a common feature of chronic caries because of the protection afforded to the pulp by the formation of secondary dentin or reparative dentin**.footnote:[slow,pulpal,adult,large,dark brown,painless]

= Enamel Caries == Non-cavitated Enamel Caries/White Spot Lesion/Initial Caries Lesion Non-cavitated caries lesion or white spot lesion (WSL) or incipient caries lesion is the first evidence of caries activity in enamel and appear as chalky white opaque areas on enamel when air-dried and seems to disappear when the tooth is rehydrated or made wet (Fig. 2.21). • This lesion may be characterized as reversible, and the enamel surface is fairly hard, intact and smooth to the touch. • These areas of enamel lose their translucency because of the extensive subsurface porosity caused by demineralization. • These lesions usually are observed on the facial and lingual surfaces of teeth. They can also occur in the proximal surfaces but are difficult to detect. • Care must be exercised in distinguishing white spots of initial caries lesions from developmental white spot hypocalcifications or other developmental defects of enamel. Initial (white spot) caries lesions partially or totally disappear visually when the enamel is hydrated (wet), whereas hypocalcified enamel is affected less by drying and wetting (Table 2.5). Hypocalcified enamel does not represent a clinical problem except for its potential esthetically objectionable appearance. • Non-cavitated enamel lesions sometimes can be seen on radiographs as a faint radiolucency that is limited to the superficial enamel. • Initial lesions can also occur on the proximal smooth surfaces, although their detection by visual examination is more challenging. Tooth separation with orthodontic separators can facilitate visual examination of proximal tooth surfaces. • When a proximal lesion is clearly visible radiographically, the lesion may have advanced significantly, and histologic alteration of the underlying dentin probably already has occurred, whether the lesion is cavitated or not.

Zones of Enamel Caries

Progression of lesion

= Cavitated Enamel Caries • Cavitated enamel lesions can be initially detected as subtle breakdown of the enamel surface. More advanced cavitated enamel lesions are more obviously detected as gross enamel breakdown (Fig. 2.24). • These lesions are very sensitive to probing and can be easily enlarged by using sharp explorers and excessive probing force. • In cavitated caries, the enamel surface is broken (not intact), and usually the lesion has advanced into dentin. Although some cavitated enamel lesions can be arrested and may not progress to larger lesions, most cavitated caries lesions require restorative treatment. • The cavitation of the tooth surface produces a synergistic acceleration of the growth of the cariogenic biofilm community and the expansion of the demineralization with ensuing expanded cavitation. sheltered, highly acidic and anaerobic environment provides an ideal niche for cariogenic bacteria. This situation results in a rapid and progressive destruction of the tooth structure.

Dentin Caries Lesions Progression of Caries in Dentin • Progression of dental caries in dentin is different from progression in enamel because of the structural differences of dentin. Caries advances more rapidly in dentin than in enamel because j Chapter | 2 | Dentin provides much less resistance to acid attack owing to less mineralized content. j Dentin possesses microscopic tubules that provide a pathway for the ingress of bacteria and egress of minerals (Fig. 2.25). Increasing demineralization of the body of the enamel lesion results in the weakening and eventual collapse of the surface enamel. The resulting cavitation provides an even more protective and retentive habitat for the cariogenic biofilm, accelerating the progression of the lesion (Fig. 2.26). • When enamel demineralization advances to the DEJ, rapid lateral expansion of the caries lesion along the DEJ may occur if there is bacterial contamination. The lateral spread of caries at the DEJ has been attributed to j DEJ’s lower mineral content compared to primary dentin.25 j More recently, it has been shown that a high concentration of MMPs is found at the DEJ. MMPs are implied in dentin caries lesion progression, although this may be a host defence mechanism and not necessarily linked to an increase in caries susceptibility.26

Clinical Symptoms • Episodes of short-duration sensitivity or mild discomfort may be felt occasionally during earlier stages of dentin caries. The pain is caused by stimulation of pulp tissue by the movement of fluid through the dentinal tubules that have been opened to the oral environment by cavitation. • When bacterial invasion of the dentin is close to the pulp, toxins and possibly a few bacteria enter the pulp, resulting in inflammation of the pulpal tissues and, thus, pulpal pain.

Dentinal Reaction to Caries The three levels of dentinal reaction to caries that can be recognized are as follows: I. Reaction to a long-term, low-level acid demineralization associated with a slowly advancing lesion: sclerotic dentin II. Reaction to a moderate-intensity attack: reparative dentin III. Reaction to severe, rapidly advancing caries characterized by very high acid levels: pulpal necrosis

Zones of Dentin Caries Lesions

= Inactive Caries Lesion/Arrested Caries • Inactive caries lesions are remineralized (arrested) lesions that may be observed clinically as either intact, smooth white lesions or discoloured, usually brown or black, spots (Fig. 2.29). • The change in colour is presumably caused by trapped organic debris and metallic ions within the enamel. • These discoloured, remineralized, arrested caries lesion areas are more resistant to subsequent caries activity than the adjacent unaffected enamel. • They should not be restored unless they are esthetically objectionable.

= Rampant Caries Rampant (or acute) caries is a rapidly developing caries process usually involving several teeth and is a sign of gross dietary inadequacy, a complete absence of oral hygiene practice, systemic illness or a combination of these pathologic factors (Fig. 2.30A–C). Rampant caries that is present primarily on proximal surfaces may point more to diet as the main driving factor, whereas rampant caries in the cervical and interproximal areas may point to diet and hygiene as the driving factors. The presence of rampant caries indicates the need for comprehensive patient evaluation.

= Diagnosis - acute pit and fissure caries - chronic pit and fissure caries

• Diet related Active acute non-cavitated occlusal pit and fissure caries

• caries

= Treatment plan

= Findings

According to G.V black I - Posterior restoration contained within the occlusal surface II -Posterior restoration including an approximal surface III-Anterior restoration including an approximal surface IV- only Anterior incisal edge restoration V- Buccal cervical surface restoration

LOCATIONS Posterior buccal,mesial,distal,occlusal,lingual

cervical,cuspal,root

Anterior Labial,mesial,distal,lingual

Posterior combinatiors buccal,mesial,distal,occlusal,lingual

Anterior combinators Labial,mesial,distal,lingual

== Combinators of caries

POSTERIOR LOCATION Pit and fissure caries(buccal, occlusal, lingual) 1 surface - buccal pit and fissure - lingual pit and fissure - Occlusal pit and fissure 2 surfaces - buccal-occlusal pit and fissure - lingual-occlusal pit and fissure

Proximal caries(mesial, occlusal,distal) 1 surface - mesial proximal caries - distal proximal caries 2 surfaces - mesio-occlusal proximal caries - disto-occlusal proximal caries - mesio-distal proximal caries 3 surfaces mesio-occlusal-distal

4 surface - mesio-occlusal-distal-buccal proximal caries - mesio-occlusal-distal-lingual caries

• cervical caries

• cuspal tip

ANTERIOR LOCATION - lingual pit and fissure

• mesial-lingual
• distal-lingual
• mesial-buccal

• distal-buccal

• mesial-incisal

• Disto-incisial

• cervical caries

• incisal

Posterior - pit and fissure => class 1 - proximal => class 2

Anterior - pit and fissure=> class 1

• non-incisal => class 3
• incisal => class 4

Both - cervical caries => class 5 - attrition tips => class 6 - root caries?

image::../../assets/blackman.png[]

No.of tooth involved Parameters of Lesion [[location]] [[Colour]] [[depth]] = progression cavity catchy probe

[[Size]] = small,large

[[Pain]] = th

{small,painful} ,{larger,painless}

(If the caries is diet-induced, incipient, acute, and located in pits and fissures, then it is classified as Class I

For classes L is enough

E1 ∧ D1 ∧ P1 ∧ L1 → C1

0 Location =

Acute Chronic

1 intial dental caries

3 dentinal caries

Diagnosis= time future and past and next consequences

Propositions

More than 3 satisfied

Dental caries can be classified based on different criteria, including their location, extent, progression, and etiology. Here are the main classification systems used in dentistry:

1. Based on Location (Black’s Classification)

Introduced by G.V. Black, this system categorizes cavities based on their location on the tooth surface:

Class I – Pits and fissures of molars, premolars, and lingual surfaces of anterior teeth.

Class II – Proximal surfaces of premolars and molars.

Class III – Proximal surfaces of anterior teeth without involving the incisal edge.

Class IV – Proximal surfaces of anterior teeth involving the incisal edge.

Class V – Cervical third of all teeth (buccal or lingual).

Class VI – Cusp tips of molars, premolars, and canines.

Class I Preparations All preparations required to treat pit-and-fissure caries are termed Class I preparations. These include preparations on: I. occlusal surfaces of premolars and molars, II. occlusal two-thirds of the facial and lingual surfaces of molars and III. the lingual surfaces of maxillary incisors. Class II Preparations Preparations required to correct caries lesions that develop in the proximal surfaces of posterior teeth are termed Class II preparations. Class III Preparations Preparations required to correct caries lesions that develop in the proximal surfaces of anterior teeth that do not include the incisal edge are termed Class III preparations. Class IV Preparations Preparations required to correct caries lesions or other defects that develop in the proximal surfaces of anterior teeth that include the incisal edge are termed Class IV preparations. Class V Preparations Preparations required to correct caries lesions or other defects that develop in the gingival third of the facial or lingual surfaces of all teeth are termed Class V preparations. Class VI Preparations Preparations required to correct caries lesions or other defects that develop in the incisal edges of anterior teeth or the occlusal cusp tips of posterior teeth are termed Class VI preparations.

1. Based on Extent (Depth of Caries)

Incipient caries – Limited to enamel (White spot lesion).

Superficial caries – Extending just into dentin.

Moderate caries – Deeper into dentin but not near the pulp.

Deep caries – Close to or exposing the pulp.

Non-cavitated Enamel Dentin

1. Based on Progression

Acute (Rampant) caries – Rapidly spreading, common in young individuals.

Chronic caries – Slow progression, found in older individuals.

Arrested caries – Inactive and remineralized caries.

1. Based on Etiology (Cause)

Early Childhood Caries (ECC) – Seen in infants due to bottle-feeding habits.

Radiation caries – Caused by reduced salivary flow after radiotherapy.

Diet-related caries – Caused by high sugar intake.

Fluoride-related caries – Due to fluoride deficiency.

1. Based on Affected Surfaces

Pit and fissure caries – Found in occlusal surfaces.

Smooth surface caries – Found on buccal, lingual, or interproximal areas.

Root caries – Found on the exposed root surface.

Would you like a classification specific to your odontogram project?

Formula

Location

Colour 0 = no colour 1 = white spot 2 = brown

Depth 0 = no depth 1 = catchy 2 = cavity

Pain 0 = no pain 1 = history of pain 2 = painful

Colour,depth,no pain = caries Matrix

0×2 = 0

<>

xref:caries-description[Brown or black]

[[location]]ram is a good

Occurence=

Age Earlier = pit and fissure caries Old age = root caries

Tooth shape

Plaque or brushing

= Reference books * Shafers * Sturdvents

Acute,chronic 1. young,adult 2. Rapid,slow 3. Narrow,large 4. More excavation,less excavation 5. Little buffering,more buffering 6. Yellow, brown 7. Painful,painless

Non-cavitated Enamel Caries/cavitated enamel caries White,brown

Active /inactive/rampant

Brushing

Pit and fissure/Smooth/Cervical/Root Early,mid,any,old large,,, Cervical shaped Cause:

Non Cavity -> Cavity -> pulpitis

Primary Active acute non-cavitated occlusal pit and fissure caries in {tooth}

Active: The caries is progressing. Acute: The decay is rapid. Non-cavitated: The lesion hasn't progressed to an actual cavity. Occlusal pit and fissure: The specific location on the tooth surface. Caries: Confirms it's a decay process.