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Oral and Dental Diseases: Causes, Prevention and Treatment Strategies 275 Oral and dental diseases: Causes, prevention and treatment strategies 275 Oral and dental diseases: Causes, prevention and treatment strategies NASEEM SHAH DENTAL CARIES Dental caries is an infectious microbiological disease of caries. Malalignment of the teeth such as crowding, abnormal the teeth that results in localized dissolution and destruction spacing, etc. can increase the susceptibility to caries. of the calcified tissues. It is the second most common cause of tooth loss and is found universally, irrespective of age, Saliva5–8 sex, caste, creed or geographic location. It is considered to Saliva has a cleansing effect on the teeth. Normally, 700– be a disease of civilized society, related to lifestyle factors, 800 ml of saliva is secreted per day. Caries activity increases but heredity also plays a role. In the late stages, it causes as the viscosity of the saliva increases. Eating fibrous food severe pain, is expensive to treat and leads to loss of precious and chewing vigorously increases salivation, which helps man-hours. However, it is preventable to a certain extent. in digestion as well as improves cleansing of the teeth. The The prevalence of dental caries in India is 50%–60%. quantity as well as composition, pH, viscosity and buffering capacity of the saliva plays a role in dental caries. Aetiology • Quantity: Reduced salivary secretion as found in xerostomia An interplay of three principal factors is responsible for and salivary gland aplasia gives rise to increased caries this multifactorial disease. activity. • Composition: Inorganic—fluoride, chloride, sodium, • Host (teeth and saliva) magnesium, potassium, iron, calcium and phosphorus • Microorganisms in the form of dental plaque are inversely related to caries. • Substrate (diet) Organic—ammonia retards plaque formation and Thus, caries requires a susceptible host, cariogenic oral neutralizes the acid. flora and a suitable substrate, which must be present for a • pH: A neutral or alkaline pH can neutralize acids formed sufficient length of time. by the action of microorganisms on carbohydrate food substances. Host factors • Antibacterial factors: Saliva contains enzymes such as lactoperoxidase, lypozyme, lactoferrin and immuno- 1–4 Teeth globulin (Ig)A, which can inhibit plaque bacteria. • Composition: Deficiency in fluorine, zinc, lead and iron content of the enamel is associated with increased caries. Dental plaque9–12 • Morphological characteristics: Deep, narrow occlusal Dental plaque is a thin, tenacious microbial film that forms fissures, and lingual and buccal pits tend to trap food on the tooth surfaces. Microorganisms in the dental plaque debris and bacteria, which can cause caries. As teeth get ferment carbohydrate foodstuffs, especially the disaccharide worn (attrition), caries declines. sucrose, to produce acids that cause demineralization of • Position: The interdental areas are more susceptible to dental inorganic substances and furnish various proteolytic enzymes to cause disintegration of the organic substances of the teeth, the processes involved in the initiation and Division of Conservative Dentistry and Endodontics progression of dental caries. The dental plaque holds the Centre for Dental Education and Research acids produced in close contact with the tooth surfaces All India Institute of Medical Sciences, New Delhi 110029 and prevents them from contact with the cleansing action e-mail: [email protected] of saliva. NCMH Background Papers·Burden of Disease in India 276 Shah Table 1. Causes of dental caries Direct Indirect Distant 1. Tooth • Poor contact between the teeth resulting in food • Socioeconomic status • Structure·fluoride content and other trace impaction and caries due to the following • Literacy level elements such as zinc, lead, iron causes • Location·urban, rural • Morphology·deep pits and fissures ·malalignment of the teeth (crowding) • Age • Alignment·crowding ·loss of some teeth and failure to replace them • Sex 2. Microorganisms·dental plaque accumulation • Gingival recession leading to root caries • Dietary habits due to poor oral hygiene • Climatic conditions and soil type 3. Diet • Social and cultural practices • Intake of refined carbohydrates such as • Availability/access to health care facility sucrose, maltose, lactose, glucose, fructose, • Health insurance cooked sticky starch, etc. ·quantity; frequency, physical form; oral clearance rate • Saliva (quantity and quality) ·reduced secretion (xerostomia) increases caries ·Viscosity: more viscous, more caries ·pH: alkaline pH neutralizes acid, less caries ·enzymes: lactoperoxidase, lysozyme lactoferrins ·immunoglobulins IgA Substrate13–16 and after 60 years of age, when the incidence of root caries is higher. The role of refined carbohydrates, especially the disac- • Females develop caries more often than males. charide sucrose, in the aetiology of dental caries is well • Non-vegetarians develop caries more often than vegetarians. established. The total amount consumed as well as the • Availability/access to a health care facility can affect physical form, its oral clearance rate and frequency of utilization of health care services. consumption are important factors in the aetiology. • Lack of oral health insurance promotes oral neglect and Vitamins A, D, K, B complex (B6), calcium, phosphorus, increases disease levels. fluorine, amino acids such as lysine and fats have an inhibitory effect on dental caries. Table 1 summarizes the causes of dental caries. Indirect causes17,18 Prevention and control of dental caries • Loss of some natural teeth and failure to replace them 1. Increase the resistance of the teeth.21–25 results in drifting of the teeth in the edentulous space. Systemic use of fluoride: (i) Fluoridation of water, milk This leads to increased food impaction between the teeth and salt; (ii) fluoride supplementation in the form of tablets and formation of new carious lesions. and lozenges; and (iii) consuming a fluoride-rich diet such • Malalignment of the teeth, especially crowding, does as tea, fish, etc. not allow proper cleaning between the teeth and leads Topical: (i) Use of fluoridated toothpaste and mouth to an increased incidence of caries. wash; (ii) use of fluoride varnishes (in-office application, • Gingival recession, abrasion and abfraction defects at longer duration of action, high fluoride content); (iii) use the neck of the tooth increase root caries. of casein phosphopeptide–amorphous calcium phosphate • Selenium in the soil increases the formation of caries (CPP–ACP), which is available as tooth mousse, helps to while molybdenum and vanadium decrease it. remineralize the soft initial carious, demineralized areas of • A high temperature is associated with a lower prevalence the teeth. of caries. Water has a cleansing effect on the teeth. If the 2. Combat the microbial plaque by physical and chemical fluoride content of the water is at an optimum concen- methods. tration, it will also exert an anticaries effect. (i) Physical methods26–30 19,20 The correct method and frequency of brushing should Distant causes be followed—in the morning and before going to bed and • A low socioeconomic and literacy status is associated preferably after every major meal. with caries. Tongue cleaning and the use of indigenous agents such • Urbanization is linked to an increased incidence of caries. as the bark of neem or mango (where toothbrush and paste • Caries is more common in childhood and adolescence, are unaffordable) should be encouraged. The use of coarse NCMH Background Papers·Burden of Disease in India Oral and dental diseases: Causes, prevention and treatment strategies 277 toothpowder and tobacco-containing dentifrices should be Table 2. Prevention and treatment of dental caries avoided. Medical interventions Non-medical interventions Other interventions The use of various interdental cleaning aids such as dental floss, interdental brush, water pik, etc. supplements the • Use of systemic • Oral health education • Make oral health cleansing effect of a toothbrush. Use of an electronic and topical • Nutrition and diet care more fluorides • Proper methods of accessible and toothbrush in children and persons with decreased manual • Use of pit and maintaining oral hygiene affordable dexterity is recommended. fissure sealants ·use of fluoride tooth- • Improve the (ii) Chemical methods • Preventive paste and brush socioeconomic These include the use of a fluoride-containing toothpaste, restorations ·use of dental floss and and literacy level mouth rinses and 0.2% chlorhexidine and povidine–iodine • Different types of interdental brushes, etc. of the population mouthwash. These should be used on prescription of a restorations and ·antiseptic mouth washes • Include oral health dental surgeon. endodontic (under prescription) care in general treatment health insurance 31–34 3. Modify the diet. • Regular dental Reduce the intake and frequency of refined carbo- check-up hydrates. Avoid sticky foods and replace refined with unrefined natural food. Increase the intake of fibrous food • Using sugar substitutes such as saccharine, xylitol, to stimulate salivary flow, which is protective against caries. mannitol, aspartame, etc. in paediatric medicinal syrups, Consume caries-protective foods such as cheese, nuts, raw bakery products, jams, marmalade, etc. vegetables, fruits, etc. Stimulate salivary flow with sugar- • Making toothbrushes and fluoridated toothpaste available free chewing gum. Xylitol (a sugar substitute)-containing to the masses at low cost.
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