Dental caries

Dental caries, also known as , cavities, 1 Signs and symptoms or caries, is a breakdown of teeth due to activities of bacteria.[1] The cavities may be a number of different colors from yellow to black.[2] Symptoms may include pain and difficulty with eating.[2][3] Complications may include inflammation of the tissue around the tooth, , and infection or abscess formation.[4][2] The cause of caries is bacterial break down of the hard tissues of the teeth (enamel, and ). This occurs due to acid made from food debris or sugar on the tooth surface. Simple sugars in food are these bacte- ria’s primary energy source and thus a diet high in simple sugar is a risk factor. If mineral breakdown is greater than build up from sources such as , caries results. Risk factors include conditions that result in less saliva such as: diabetes mellitus, Sjogren’s syndrome and some med- ications. Medications that decrease saliva production in- clude antihistamines and antidepressants among others.[5] Caries is also associated with poverty, poor cleaning of the mouth, and receding resulting in exposure of (A) A small spot of decay visible on the surface of a tooth. (B) the roots of the teeth.[1][6] The radiograph reveals an extensive region of demineralization Prevention includes: regular cleaning of the teeth, a diet within the dentin (arrows). (C) A hole is discovered on the side of the tooth at the beginning of decay removal. (D) All decay low in sugar, and small amounts of fluoride.[3][5] Brush- removed. ing the teeth two times per day and flossing between the [1][5] teeth once a day is recommended by many. Fluo- A person experiencing caries may not be aware of the ride may be from water, salt or among other disease.[10] The earliest sign of a new carious lesion is the [3] sources. Treating a mother’s dental caries may de- appearance of a chalky white spot on the surface of the crease the risk in her children by decreasing the num- tooth, indicating an area of demineralization of enamel. [5] bers of certain bacteria. Screening can result in earlier This is referred to as a white spot lesion, an incipient car- [1] detection. Depending on the extent of destruction, var- ious lesion or a “microcavity”.[11] As the lesion contin- ious treatments can be used to restore the tooth to proper ues to demineralize, it can turn brown but will eventu- [1] function or the tooth may be removed. There is no ally turn into a cavitation (“cavity”). Before the cavity [7] known method to grow back large amounts of tooth. forms, the process is reversible, but once a cavity forms, The availability of treatment is often poor in the develop- the lost tooth structure cannot be regenerated. A lesion [3] ing world. Paracetamol (acetaminophen) or ibuprofen that appears dark brown and shiny suggests dental caries [1] may be taken for pain. were once present but the demineralization process has Worldwide, approximately 2.43 billion people (36% of stopped, leaving a stain. Active decay is lighter in color the population) have dental caries in their permanent and dull in appearance.[12] [8] teeth. The World Health Organizations estimates that As the enamel and dentin are destroyed, the cavity be- nearly all adults have dental caries at some point in comes more noticeable. The affected areas of the tooth [3] time. In baby teeth it affects about 620 million people change color and become soft to the touch. Once the de- [8] or 9% of the population. They have become more com- cay passes through enamel, the dentinal tubules, which [9] mon in both children and adults in recent years. The have passages to the nerve of the tooth, become exposed, disease is most common in the developed world and less resulting in pain that can be transient, temporarily wors- common in the developing world due to greater simple ening with exposure to heat, cold, or sweet foods and [1] [4] sugar consumption. Caries is Latin for “rottenness”. drinks.[13] A tooth weakened by extensive internal decay can sometimes suddenly fracture under normal chewing forces. When the decay has progressed enough to allow the bacteria to overwhelm the pulp tissue in the center of

1 2 2 CAUSE

the tooth a toothache can result and the pain will become more constant. Death of the pulp tissue and infection are common consequences. The tooth will no longer be sen- sitive to hot or cold, but can be very tender to pressure. Dental caries can also cause bad breath and foul tastes.[14] In highly progressed cases, infection can spread from the tooth to the surrounding soft tissues. Complications such as cavernous sinus thrombosis and Ludwig angina can be life-threatening.[15][16][17]

2 Cause A gram stain image of Streptococcus mutans.

2.1 Bacteria

The bacteria most responsible for dental cavities are the mutans streptococci, most prominently Streptococcus mu- tans and Streptococcus sobrinus, and lactobacilli. If left untreated, the disease can lead to pain, tooth loss and infection.[23] The mouth contains a wide variety of oral bacteria, but only a few specific species of bacteria are be- lieved to cause dental caries: Streptococcus mutans and Lactobacillus species among them. These organisms can produce high levels of lactic acid following fermentation of dietary sugars, and are resistant to the adverse effects Diagrammatic representation of acidogenic theory of causation of low pH, properties essential for cariogenic bacteria.[20] of dental caries. Four factors, namely, a suitable carbohydrate As the cementum of root surfaces is more easily deminer- substrate (1), micro-organisms in dental plaque (2), a susceptible alized than enamel surfaces, a wider variety of bacteria tooth surface (3) and time (4); must be present together for dental can cause root caries including Lactobacillus acidophilus, caries to occur (5). Saliva (6) and fluoride (7) are modifying Actinomyces spp., Nocardia spp., and Streptococcus mu- factors tans. Bacteria collect around the teeth and gums in a sticky, creamy-coloured mass called plaque, which serves as a biofilm. Some sites collect plaque more commonly There are four main criteria required for caries formation: than others, for example sites with a low rate of salivary a tooth surface (enamel or dentin), caries-causing bac- flow (molar fissures). Grooves on the occlusal surfaces teria, fermentable carbohydrates (such as sucrose), and of molar and premolar teeth provide microscopic reten- [18] time. However, it is also known that these four cri- tion sites for plaque bacteria, as do the interproximal sites. teria are not always enough to cause the disease and a Plaque may also collect above or below the gingiva where sheltered environment promoting development of a cari- it is referred to as supra- or sub-gingival plaque, respec- ogenic biofilm is required. The caries process does not tively. have an inevitable outcome, and different individuals will be susceptible to different degrees depending on the These bacterial strains, most notably S. mutans can be in- shape of their teeth, habits, and the buffering herited by a child from a caretaker’s kiss or through feed- [24] capacity of their saliva. Dental caries can occur on any ing premasticated food. surface of a tooth that is exposed to the oral cavity, but not the structures that are retained within the bone.[19] 2.2 Dietary sugars Tooth decay is caused by specific types of bacteria that produce acid in the presence of fermentable Bacteria in a person’s mouth convert glucose, fructose, carbohydrates such as sucrose, fructose, and [20][21] and most commonly sucrose (table sugar) into acids glucose. such as lactic acid through a glycolytic process called Caries occur more often in people from the lower end of fermentation.[21] If left in contact with the tooth, these the socioeconomic scale than people from the upper end acids may cause demineralization, which is the disso- of the socioeconomic scale.[22] lution of its mineral content. The process is dynamic, 2.4 Teeth 3 however, as remineralization can also occur if the acid is cementum enveloping the root surface is not nearly as neutralized by saliva or mouthwash. Fluoride toothpaste durable as the enamel encasing the , root caries or dental varnish may aid remineralization.[25] If dem- tends to progress much more rapidly than decay on other ineralization continues over time, enough mineral content surfaces. The progression and loss of mineralization on may be lost so that the soft organic material left behind the root surface is 2.5 times faster than caries in enamel. disintegrates, forming a cavity or hole. The impact such In very severe cases where oral hygiene is very poor and sugars have on the progress of dental caries is called cario- where the diet is very rich in fermentable carbohydrates, genicity. Sucrose, although a bound glucose and fructose caries may cause cavities within months of tooth eruption. unit, is in fact more cariogenic than a mixture of equal This can occur, for example, when children continuously parts of glucose and fructose. This is due to the bacte- drink sugary drinks from baby bottles (see later discus- ria utilising the energy in the saccharide bond between sion). the glucose and fructose subunits. S.mutans adheres to the biofilm on the tooth by converting sucrose into an ex- tremely adhesive substance called dextran polysaccharide 2.4 Teeth by the enzyme dextransucranase.[26] There are certain diseases and disorders affecting teeth that may leave an individual at a greater risk for cavi- 2.3 Exposure ties. , which occurs between 1 in 718 and 1 in 14,000 individuals, is a disease in which the enamel does not fully form or forms in insufficient amounts and can fall off a tooth.[30] In both cases, teeth may be left more vulnerable to decay because the enamel is not able to protect the tooth.[31] In most people, disorders or diseases affecting teeth are not the primary cause of dental caries. Approximately 96% of is composed of minerals.[32] These minerals, especially hydroxyapatite, will become soluble when exposed to acidic environments. Enamel begins to demineralize at a pH of 5.5.[33] Dentin and cementum are more susceptible to caries than enamel because they have lower mineral content.[34] Thus, when root surfaces of teeth are exposed from gingival recession or periodon- tal disease, caries can develop more readily. Even in a healthy oral environment, however, the tooth is suscepti- “Stephan curve”, showing sudden decrease in plaque pH follow- ble to dental caries. ing glucose rinse, which returns to normal after 30-60 min. Net The evidence for linking and/or crowding demineralization of dental hard tissues occurs below the critical to the dental caries is weak;[35][36] however, the anatomy pH (5.5), shown in yellow. of teeth may affect the likelihood of caries formation. Where the deep developmental grooves of teeth are more The frequency of which teeth are exposed to cariogenic numerous and exaggerated, pit and fissure caries is more (acidic) environments affects the likelihood of caries likely to develop (see next section). Also, caries is more development.[27] After meals or snacks, the bacteria in likely to develop when food is trapped between teeth. the mouth metabolize sugar, resulting in an acidic by- product that decreases pH. As time progresses, the pH returns to normal due to the buffering capacity of saliva 2.5 Other factors and the dissolved mineral content of tooth surfaces. Dur- ing every exposure to the acidic environment, portions of Reduced salivary flow rate is associated with increased the inorganic mineral content at the surface of teeth dis- [28] caries since the buffering capability of saliva is not solves and can remain dissolved for two hours. Since present to counterbalance the acidic environment cre- teeth are vulnerable during these acidic periods, the de- ated by certain foods. As a result, medical condi- velopment of dental caries relies heavily on the frequency tions that reduce the amount of saliva produced by of acid exposure. salivary glands, in particular the submandibular gland The carious process can begin within days of a tooth’s and parotid gland, are likely to dry mouth and thus to erupting into the mouth if the diet is sufficiently rich widespread tooth decay. Examples include Sjögren’s in suitable carbohydrates. Evidence suggests that the syndrome, diabetes mellitus, diabetes insipidus, and introduction of fluoride treatments have slowed the sarcoidosis.[37] Medications, such as antihistamines and process.[29] Proximal caries take an average of four years antidepressants, can also impair salivary flow. Stim- to pass through enamel in permanent teeth. Because the ulants, most notoriously methylamphetamine (“meth 4 3 PATHOPHYSIOLOGY mouth”), also occlude the flow of saliva to an extreme degree. Tetrahydrocannabinol, the active chemical sub- stance in cannabis, also causes a nearly complete occlu- sion of salivation, known in colloquial terms as “cotton mouth”. Moreover, 63% of the most commonly pre- scribed medications in the United States list dry mouth as a known side-effect.[37] Radiation therapy of the head and neck may also damage the cells in salivary glands, some- what increasing the likelihood of caries formation.[38][39] Susceptibility to caries can be related to altered in the tooth, in particular to fluid flow in the dentin. Experiments on rats have shown that a high- sucrose, cariogenic diet “significantly suppresses the rate of fluid motion” in dentin.[40] The use of tobacco may also increase the risk for caries formation. Some brands of smokeless tobacco contain high sugar content, increasing susceptibility to caries.[41] Tobacco use is a significant risk factor for , which can cause the gingiva to recede.[42] As the gingiva loses attachment to the teeth due to gingival reces- sion, the root surface becomes more visible in the mouth. If this occurs, root caries is a concern since the cementum covering the roots of teeth is more easily demineralized by acids than enamel.[43] Currently, there is not enough evidence to support a causal relationship between smok- ing and coronal caries, but evidence does suggest a re- lationship between smoking and root-surface caries.[44] Exposed of children to secondhand tobacco smoke is as- sociated with tooth decay.[45] Intrauterine and neonatal lead exposure promote tooth decay.[46][47][48][49][50][51][52] Besides lead, all atoms with electrical charge and ionic radius similar to bivalent The progression of pit and fissure caries resembles two triangles calcium,[53] such as cadmium, mimic the calcium ion and with their bases meeting along the junction of enamel and dentin. therefore exposure may promote tooth decay.[54] Poverty is also a significant social determinant for oral health.[55] Dental caries have been linked with lower pens when there is an ecologic shift within the dental socio-economic status and can be considered a disease biofilm, from a balanced population of micro-organisms of poverty.[56] to a population that produce acids and can survive in an acid environment.[59] Forms are available for risk assessment for caries when treating dental cases; this system using the evidence-based Caries Management by Risk Assessment 3.1 Enamel (CAMBRA).[57] It is still unknown if the identification of high-risk individuals can lead to more effective long- Enamel is a highly mineralized acellular tissue, and caries term patient management that prevents caries initiation act upon it through a chemical process brought on by the and arrests or reverses the progression of lesions.[58] acidic environment produced by bacteria. As the bacteria consume the sugar and use it for their own energy, they produce lactic acid. The effects of this process include 3 Pathophysiology the demineralization of crystals in the enamel, caused by acids, over time until the bacteria physically penetrate Teeth are bathed in saliva and have a coating of bacte- the dentin. Enamel rods, which are the basic unit of the ria on them (biofilm) that continually forms. The min- enamel structure, run perpendicularly from the surface of erals in the hard tissues of the teeth (enamel, dentin the tooth to the dentin. Since demineralization of enamel and cementum) are constantly undergoing processes of by caries, in general, follows the direction of the enamel demineralization and remineralisation. Dental caries re- rods, the different triangular patterns between pit and fis- sults when the demineralization rate is faster than the sure and smooth-surface caries develop in the enamel be- remineralisation and there is net mineral loss. This hap- cause the orientation of enamel rods are different in the 3.2 Dentin 5

two areas of the tooth.[60] As the enamel loses minerals, and dental caries pro- gresses, the enamel develop several distinct zones, visible under a light microscope. From the deepest layer of the enamel to the enamel surface, the identified areas are the: translucent zone, dark zones, body of the lesion, and sur- face zone.[61] The translucent zone is the first visible sign of caries and coincides with a one to two percent loss of minerals.[62] A slight remineralization of enamel occurs in the dark zone, which serves as an example of how the development of dental caries is an active process with al- ternating changes.[63] The area of greatest demineraliza- tion and destruction is in the body of the lesion itself. The surface zone remains relatively mineralized and is present until the loss of tooth structure results in a cavitation.

3.2 Dentin

Unlike enamel, the dentin reacts to the progression of dental caries. After tooth formation, the ameloblasts, which produce enamel, are destroyed once enamel for- mation is complete and thus cannot later regenerate enamel after its destruction. On the other hand, dentin is produced continuously throughout life by odontoblasts, which reside at the border between the pulp and dentin. Since odontoblasts are present, a stimulus, such as caries, can trigger a biologic response. These defense mech- anisms include the formation of sclerotic and tertiary dentin.[64] In dentin from the deepest layer to the enamel, the distinct areas affected by caries are the advancing front, the zone of bacterial penetration, and the zone of destruction.[60] The faster spread of caries through dentin creates this triangular The advancing front represents a zone of demineralised appearance in smooth surface caries. dentine due to acid and has no bacteria present. The zones of bacterial penetration and destruction are the locations of invading bacteria and ultimately the decomposition of tubules also allow caries to progress faster. dentin. The zone of destruction has a more mixed bacte- In response, the fluid inside the tubules bring rial population where proteolytic enzymes have destroyed immunoglobulins from the immune system to fight the organic matrix. The innermost dentine caries has the bacterial infection. At the same time, there is an been reversibly attacked because the collage matrix is not increase of mineralization of the surrounding tubules.[67] severely damaged, giving it potential for repair. The outer This results in a constriction of the tubules, which is an more superficial zone is highly infected with proteolytic attempt to slow the bacterial progression. In addition, degradation of the collagen matrix and as a result the den- as the acid from the bacteria demineralizes the hydrox- tine is irreversibly demineralised. yapatite crystals, calcium and phosphorus are released, allowing for the precipitation of more crystals which fall 3.2.1 Sclerotic dentin deeper into the dentinal tubule. These crystals form a barrier and slow the advancement of caries. After these The structure of dentin is an arrangement of microscopic protective responses, the dentin is considered sclerotic. channels, called dentinal tubules, which radiate outward According to hydrodynamic theory, fluids within dentinal from the pulp chamber to the exterior cementum or tubules are believed to be the mechanism by which pain enamel border.[65] The diameter of the dentinal tubules is receptors are triggered within the pulp of the tooth.[68] largest near the pulp (about 2.5 μm) and smallest (about Since sclerotic dentin prevents the passage of such fluids, 900 nm) at the junction of dentin and enamel.[66] The pain that would otherwise serve as a warning of the in- carious process continues through the dentinal tubules, vading bacteria may not develop at first. Consequently, which are responsible for the triangular patterns resulting dental caries may progress for a long period of time with- from the progression of caries deep into the tooth. The out any sensitivity of the tooth, allowing for greater loss 6 4 DIAGNOSIS of tooth structure.

3.2.2 Tertiary dentin

In response to dental caries, there may be production of more dentin toward the direction of the pulp. This new dentin is referred to as tertiary dentin.[66] Tertiary dentin is produced to protect the pulp for as long as possible from the advancing bacteria. As more tertiary dentin is produced, the size of the pulp decreases. This type of dentin has been subdivided according to the presence or absence of the original odontoblasts.[69] If the odonto- blasts survive long enough to react to the dental caries, then the dentin produced is called “reactionary” dentin. If the odontoblasts are killed, the dentin produced is called “reparative” dentin. In the case of reparative dentin, other cells are needed to assume the role of the destroyed odontoblasts. Growth factors, especially TGF-β,[69] are thought to initiate the production of reparative dentin by fibroblasts and mesenchymal cells of the pulp.[70] Reparative dentin is produced at an average of 1.5 μm/day, but can be in- creased to 3.5 μm/day. The resulting dentin contains ir- regularly shaped dentinal tubules that may not line up with existing dentinal tubules. This diminishes the ability for dental caries to progress within the dentinal tubules.

3.3 Cementum

The incidence of cemental caries increases in older adults as gingival recession occurs from either trauma or peri- odontal disease. It is a chronic condition that forms a large, shallow lesion and slowly invades first the root’s cementum and then dentin to cause a chronic infection of the pulp (see further discussion under classification by affected hard tissue). Because dental pain is a late finding, many lesions are not detected early, resulting in restora- tive challenges and increased tooth loss.[71] The tip of a dental explorer, which is used for caries diagnosis. 4 Diagnosis explorer. Dental radiographs (X-rays) may show dental The presentation of caries is highly variable. However, caries before it is otherwise visible, in particular caries the risk factors and stages of development are similar. between the teeth. Large dental caries are often apparent Initially it may appear as a small chalky area (smooth sur- to the naked eye, but smaller lesions can be difficult to face caries), which may eventually develop into a large identify. Visual and tactile inspection along with radio- cavitation. Sometimes caries may be directly visible. graphs are employed frequently among dentists, in par- However other methods of detection such as X-rays are ticular to diagnose pit and fissure caries.[72] Early, uncav- used for less visible areas of teeth and to judge the extent itated caries is often diagnosed by blowing air across the of destruction. Lasers for detecting caries allow detection suspect surface, which removes moisture and changes the without ionizing radiation and are now used for detection optical properties of the unmineralized enamel. of interproximal decay (between the teeth). Disclosing Some dental researchers have cautioned against the use solutions are also used during tooth restoration to mini- of dental explorers to find caries,[73] in particular sharp mize the chance of recurrence. ended explorers. In cases where a small area of tooth has Primary diagnosis involves inspection of all visible tooth begun demineralizing but has not yet cavitated, the pres- surfaces using a good light source, dental mirror and sure from the dental explorer could cause a cavity. Since 4.2 7 the carious process is reversible before a cavity is present, it may be possible to arrest the caries with fluoride and remineralize the tooth surface. When a cavity is present, a restoration will be needed to replace the lost tooth struc- ture. At times, pit and fissure caries may be difficult to de- tect. Bacteria can penetrate the enamel to reach dentin, but then the outer surface may remineralize, especially if fluoride is present.[74] These caries, sometimes referred to as “hidden caries”, will still be visible on x-ray radio- graphs, but visual examination of the tooth would show the enamel intact or minimally perforated. The differential diagnosis for dental caries includes dental fluorosis and developmental defects of the tooth includ- ing hypomineralization of the tooth and hypoplasia of the tooth.[75]

Rampant caries caused by abuse. 4.1 Classification 4.2 Early childhood caries

Early childhood caries (ECC) or "Baby bottle caries,” "baby bottle tooth decay,” or “Bottle Rot” is a pattern of decay found in young children with their deciduous (baby) teeth. The teeth most likely affected are the max- illary anterior teeth, but all teeth can be affected.[77] The name for this type of caries comes from the fact that the decay usually is a result of allowing children to fall asleep with sweetened liquids in their bottles or feeding children G.V. Black Classification of Restorations sweetened liquids multiple times during the day.[78]

Caries can be classified by location, etiology, rate of pro- Another pattern of decay is “rampant caries”, which sig- gression, and affected hard tissues.[76] These forms of nifies advanced or severe decay on multiple surfaces of [79] classification can be used to characterize a particular case many teeth. Rampant caries may be seen in individ- of tooth decay in order to more accurately represent the uals with , poor oral hygiene, stimulant use [80] condition to others and also indicate the severity of tooth (due to drug-induced dry mouth ), and/or large sugar destruction. In some instances, caries are described in intake. If rampant caries is a result of previous radiation other ways that might indicate the cause. G.V. Black clas- to the head and neck, it may be described as radiation- sification: induced caries. Problems can also be caused by the self- destruction of roots and whole when new teeth erupt or later from unknown causes. • Class I - occlusal surfaces of posterior teeth, buccal or lingual pits on molars, lingual pit near cingulum of maxillary 4.2.1 Rate of progression

• Class II - proximal surfaces of posterior teeth Temporal descriptions can be applied to caries to indicate the progression rate and previous history. “Acute” sig- • Class III - interproximal surfaces of anterior teeth nifies a quickly developing condition, whereas “chronic” without incisal edge involvement describes a condition that has taken an extended time to develop, in which thousands of meals and snacks, many • Class IV - interproximal surfaces of anterior teeth causing some acid demineralization that is not remineral- with incisal edge involvement ized, eventually results in cavities. Recurrent caries, also described as secondary, are caries • Class V - cervical third of facial or lingual surface that appears at a location with a previous history of caries. of tooth This is frequently found on the margins of fillings and other dental restorations. On the other hand, incipient • Class VI - incisal or occlusal edge worn away due to caries describes decay at a location that has not experi- enced previous decay. Arrested caries describes a lesion 8 5 PREVENTION on a tooth that was previously demineralized but was rem- the depth of sulcus has not been compromised. Other ad- ineralized before causing a cavitation. Fluoride treatment junct oral hygiene aids include interdental brushes, water can help recalcification of tooth enamel as well as use of picks, and mouthwashes. Amorphous calcium phosphate. However oral hygiene is probably more effective at pre- venting gum disease (periodontal disease) than tooth de- cay. Food is forced inside pits and fissures under chewing 4.2.2 Affected hard tissue pressure, leading to carbohydrate-fueled acid demineral- isation where the brush, fluoride toothpaste, and saliva Depending on which hard tissues are affected, it is pos- have no access to remove trapped food, neutralise acid, sible to describe caries as involving enamel, dentin, or or remineralise demineralised tooth like on other more cementum. Early in its development, caries may affect accessible tooth surfaces food to be trapped. (Occlusal only enamel. Once the extent of decay reaches the deeper caries accounts for between 80 and 90% of caries in chil- layer of dentin, “dentinal caries” is used. Since cementum dren (Weintraub, 2001).) Chewing fibre like celery af- is the hard tissue that covers the roots of teeth, it is not of- ter eating forces saliva inside trapped food to dilute any ten affected by decay unless the roots of teeth are exposed carbohydrate like sugar, neutralise acid and remineralise to the mouth. Although the term “cementum caries” may demineralised tooth. The teeth at highest risk for carious be used to describe the decay on roots of teeth, very rarely lesions are the permanent first and second molars due to does caries affect the cementum alone. Roots have a very length of time in oral cavity and presence of complex sur- thin layer of cementum over a large layer of dentin, and face anatomy. thus most caries affecting cementum also affects dentin. Professional hygiene care consists of regular dental exam- inations and professional prophylaxis (cleaning). Some- times, complete plaque removal is difficult, and a den- 5 Prevention tist or dental hygienist may be needed. Along with oral hygiene, radiographs may be taken at dental visits to de- tect possible dental caries development in high risk areas of the mouth (e.g. "bitewing" x-rays which visualize the crowns of the back teeth).

5.2 Dietary modification

For dental health, frequency of sugar intake is more im- portant than the amount of sugar consumed.[27] In the presence of sugar and other carbohydrates, bacteria in the mouth produce acids that can demineralize enamel, dentin, and cementum. The more frequently teeth are exposed to this environment the more likely dental caries are to occur. Therefore, minimizing snacking is recom- mended, since snacking creates a continuous supply of Toothbrushes are commonly used to clean teeth. nutrition for acid-creating bacteria in the mouth. Also, chewy and sticky foods (such as dried fruit or candy) tend to adhere to teeth longer, and, as a consequence, are 5.1 Oral hygiene best eaten as part of a meal. For children, the American Dental Association and the European Academy of Paedi- Personal hygiene care consists of proper brushing and atric Dentistry recommend limiting the frequency of con- sumption of drinks with sugar, and not giving baby bot- flossing daily. The purpose of oral hygiene is to mini- [82][83] mize any etiologic agents of disease in the mouth. The tles to infants during sleep (see earlier discussion). primary focus of brushing and flossing is to remove and Mothers are also recommended to avoid sharing utensils and cups with their infants to prevent transferring bacteria prevent the formation of plaque or dental biofilm. Plaque [84] consists mostly of bacteria.[81] As the amount of bacte- from the mother’s mouth. rial plaque increases, the tooth is more vulnerable to den- It has been found that milk and certain kinds of cheese tal caries when carbohydrates in the food are left on teeth like cheddar cheese can help counter tooth decay if eaten after every meal or snack. A toothbrush can be used to re- soon after the consumption of foods potentially harmful move plaque on accessible surfaces, but not between teeth to teeth.[27] Also, chewing gum containing xylitol (a sugar or inside pits and fissures on chewing surfaces. When alcohol) is widely used to protect teeth in many countries used correctly, dental floss removes plaque from areas now. Xylitol’s effect on reducing dental biofilm is, it is that could otherwise develop proximal caries but only if presumed, due to bacteria’s inability to utilize it like other 9 sugars.[85] Chewing and stimulation of flavor receptors on varnish.[90] After brushing with fluoride toothpaste, rins- the tongue are also known to increase the production and ing should be avoided and the excess spat out.[91] This release of saliva, which contains natural buffers to pre- leaves a greater concentration of fluoride residue on the vent the lowering of pH in the mouth to the point where teeth. Many dental professionals include application of enamel may become demineralized.[86] topical fluoride solutions as part of routine visits and rec- ommend the use of xylitol and amorphous calcium phos- phate products. Silver diamine fluoride may work better 5.3 Other measures than fluoride varnish to prevent cavities.[92] Vaccines are also under development.[93]

6 Treatment

See also: Dental restoration and Tooth extraction Most importantly, whether the carious lesion is cavitated

Common dentistry trays used to deliver fluoride.

An amalgam used as a restorative material in a tooth.

or noncavitated dictates the management. Clinical assess- ment of whether the lesion is active or arrested is also Fluoride is sold in tablets for cavity prevention. important. Noncavitated lesions can be arrested and rem- ineralization can occur under the right conditions. How- The use of dental sealants is a means of prevention.[87] A ever, this may require extensive changes to the diet (re- sealant is a thin plastic-like coating applied to the chewing duction in frequency of refined sugars), improved oral hy- surfaces of the molars to prevent food from being trapped giene (toothbrushing twice per day with fluoride tooth- inside pits and fissures. This deprives resident plaque bac- paste and daily flossing), and regular application of top- teria carbohydrate preventing the formation of pit and fis- ical fluoride. Such management of a carious lesion is sure caries. Sealants are usually applied on the teeth of termed “non-operative” since no drilling is carried out children, as soon as the tooth erupt but adults are receiv- on the tooth. Non-operative treatment requires excellent ing them if not previously performed. Sealants can wear understanding and motivation from the individual, other- out and fail to prevent access of food and plaque bacteria wise the decay will continue. inside pits and fissures and need to be replaced so they Once a lesion has cavitated, especially if dentin is in- must be checked regularly by dental professionals. volved, remineralization is much more difficult and a Calcium, as found in food such as milk and green veg- dental restoration is usually indicated (“operative treat- etables, is often recommended to protect against dental ment”). Before a restoration can be placed, all of caries. Fluoride helps prevent decay of a tooth by binding the decay must be removed otherwise it will continue to the hydroxyapatite crystals in enamel.[88] The incorpo- to progress underneath the filling. Sometimes a small rated calcium makes enamel more resistant to deminer- amount of decay can be left if it is entombed and the there alization and, thus, resistant to decay.[89] Topical fluoride is a seal which isolates the bacteria from their substrate. is more highly recommended than systemic intake such This can be likened to placing a glass container over a as by tablets or drops to protect the surface of the teeth. candle, which burns itself out once the oxygen is used This may include a fluoride toothpaste or mouthwash or up. Techniques such as stepwise caries removal are de- 10 7 EPIDEMIOLOGY

signed to avoid exposure of the dental pulp and overall re- and making their environment less favorable for them. It duction of the amount of tooth substance which requires is a minimally invasive method of managing decay in chil- removal before the final filling is placed. Often enamel dren and does not require injections in the which overlies decayed dentin must also be removed as it mouth. is unsupported and susceptible to fracture. The modern decision-making process with regards the activity of the lesion, and whether it is cavitated, is summarized in the table.[94] Destroyed tooth structure does not fully regenerate, al- though remineralization of very small carious lesions may occur if dental hygiene is kept at optimal level.[13] For the small lesions, topical fluoride is sometimes used to en- courage remineralization. For larger lesions, the progres- sion of dental caries can be stopped by treatment. The goal of treatment is to preserve tooth structures and pre- vent further destruction of the tooth. Aggressive treat- ment, by filling, of incipient carious lesions, places where A tooth with extensive caries eventually requiring extraction. there is superficial damage to the enamel, is controversial In certain cases, endodontic therapy may be necessary for as they may heal themselves, while once a filling is per- [99] formed it will eventually have to be redone and the site the restoration of a tooth. Endodontic therapy, also serves as a vulnerable site for further decay.[11] known as a “root canal”, is recommended if the pulp in a tooth dies from infection by decay-causing bacteria or In general, early treatment is quicker and less expensive from trauma. During a root canal, the pulp of the tooth, than treatment of extensive decay. Local anesthetics, including the nerve and vascular tissues, is removed along nitrous oxide (“laughing gas”), or other prescription med- with decayed portions of the tooth. The canals are instru- ications may be required in some cases to relieve pain mented with endodontic files to clean and shape them, during or following treatment or to relieve anxiety dur- and they are then usually filled with a rubber-like mate- [95] ing treatment. A dental handpiece (“drill”) is used to rial called gutta percha.[100] The tooth is filled and a crown remove large portions of decayed material from a tooth. can be placed. Upon completion of a root canal, the tooth A spoon, a dental instrument used to carefully remove is now non-vital, as it is devoid of any living tissue. decay, is sometimes employed when the decay in dentin reaches near the pulp.[96] Once the decay is removed, the An extraction can also serve as treatment for dental caries. missing tooth structure requires a dental restoration of The removal of the decayed tooth is performed if the some sort to return the tooth to function and aesthetic tooth is too far destroyed from the decay process to ef- condition. fectively restore the tooth. Extractions are sometimes considered if the tooth lacks an opposing tooth or will Restorative materials include dental amalgam, composite probably cause further problems in the future, as may be [97] resin, porcelain, and gold. Composite resin and porce- the case for wisdom teeth.[101] Extractions may also be lain can be made to match the color of a patient’s natural preferred by people unable or unwilling to undergo the teeth and are thus used more frequently when aesthetics expense or difficulties in restoring the tooth. are a concern. Composite restorations are not as strong as dental amalgam and gold; some dentists consider the latter as the only advisable restoration for posterior ar- 7 Epidemiology eas where chewing forces are great.[98] When the decay is too extensive, there may not be enough tooth structure re- maining to allow a restorative material to be placed within the tooth. Thus, a crown may be needed. This restoration appears similar to a cap and is fitted over the remainder of the natural crown of the tooth. Crowns are often made of gold, porcelain, or porcelain fused to metal. For children, preformed crowns are available to place over the tooth. These are usually made of metal (usually stainless steel but increasingly there are aesthetic materi- als). Traditionally teeth are shaved down to make room Disability-adjusted life year for dental caries per 100,000 for the crown but, more recently, stainless steel crowns inhabitants in 2004.[102] have been used to seal decay into the tooth and stop it progressing. This is known as the Hall Technique and works be depriving the bacteria in the decay of nutrients Worldwide, approximately 2.43 billion people (36% of the population) have dental caries in their permanent 11

teeth.[8] In baby teeth it affects about 620 million peo- ple or 9% of the population.[8] The disease is most com- mon in Latin American countries, countries in the Middle East, and South Asia, and least prevalent in China.[103] In the United States, dental caries is the most common chronic childhood disease, being at least five times more common than asthma.[104] It is the primary pathological cause of tooth loss in children.[105] Between 29% and 59% of adults over the age of fifty experience caries.[106] The number of cases has decreased in some developed countries, and this decline is usually attributed to increas- ingly better oral hygiene practices and preventive mea- sures such as fluoride treatment.[107] Nonetheless, coun- tries that have experienced an overall decrease in cases of tooth decay continue to have a disparity in the distri- bution of the disease.[106] Among children in the United States and Europe, twenty percent of the population en- dures sixty to eighty percent of cases of dental caries.[108] A similarly skewed distribution of the disease is found An image from Omne Bonum (14th century) depicting a dentist throughout the world with some children having none or extracting a tooth with forceps. very few caries and others having a high number.[106] Australia, Nepal, and Sweden (where children receive dental care paid for by the government) have a low inci- with the increase in dependence on rice agriculture.[115] dence of cases of dental caries among children, whereas A Sumerian text from 5000 BC describes a “tooth worm” [109] cases are more numerous in Costa Rica and Slovakia. as the cause of caries.[116] Evidence of this belief has also The classic DMF (decay/missing/filled) index is one of been found in India, Egypt, Japan, and China.[112] Un- the most common methods for assessing caries preva- earthed ancient skulls show evidence of primitive dental lence as well as dental treatment needs among popula- work. In Pakistan, teeth dating from around 5500 BC to tions. This index is based on in-field clinical examination 7000 BC show nearly perfect holes from primitive dental of individuals by using a probe, mirror and cotton rolls. drills.[117] The Ebers Papyrus, an Egyptian text from 1550 Because the DMF index is done without X-ray imag- BC, mentions diseases of teeth.[116] During the Sargonid ing, it underestimates real caries prevalence and treatment dynasty of Assyria during 668 to 626 BC, writings from needs.[74] the king’s physician specify the need to extract a tooth due to spreading inflammation.[112] In the Roman Em- Bacteria typically associated with dental caries have been pire, wider consumption of cooked foods led to a small isolated from vaginal samples who have bacterial vagi- increase in caries prevalence.[108] The Greco-Roman civ- nosis.[110] ilization, in addition to the Egyptian, had treatments for pain resulting from caries.[112] The rate of caries remained low through the Bronze Age 8 History and Iron Age, but sharply increased during the Middle Ages.[111] Periodic increases in caries prevalence had There is a long history of dental caries. Over a mil- been small in comparison to the 1000 AD increase, when lion years ago, hominins such as Australopithecus suf- sugar cane became more accessible to the Western world. [111] Treatment consisted mainly of herbal remedies and fered from cavities. The largest increases in the [118] prevalence of caries have been associated with di- charms, but sometimes also included bloodletting. [111][112] The barber surgeons of the time provided services that in- etary changes. Archaeological evidence shows [112] that tooth decay is an ancient disease dating far into cluded tooth extractions. Learning their training from prehistory. Skulls dating from a million years ago through apprenticeships, these health providers were quite suc- the neolithic period show signs of caries, including those cessful in ending tooth pain and likely prevented sys- from the Paleolithic and Mesolithic ages.[113] The in- temic spread of infections in many cases. Among Ro- crease of caries during the neolithic period may be at- man Catholics, prayers to Saint Apollonia, the patroness of dentistry, were meant to heal pain derived from tooth tributed to the increased consumption of plant foods con- [119] taining carbohydrates.[114] The beginning of rice cultiva- infection. tion in South Asia is also believed to have caused an in- There is also evidence of caries increase in North Ameri- crease in caries. Although there is also some evidence can Indians after contact with colonizing Europeans. Be- from sites in Thailand, such as Khok Phanom Di, that fore colonization, North American Indians subsisted on shows a decrease in overall percentage of dental caries hunter-gatherer diets, but afterwards there was a greater 12 12 REFERENCES

reliance on maize agriculture, which made these groups the plural form of any singular form cary meaning hole more susceptible to caries.[111] or cavity. Nonetheless, the idea that it is such a plural is a During the European Age of Enlightenment, the belief reanalysis that naturally occurs to most English speakers, that a “tooth worm” caused caries was also no longer ac- and the reanalyzed sense is common enough to be entered cepted in the European medical community.[120] Pierre in various dictionaries and to exist in respectable usage. Fauchard, known as the father of modern dentistry, was It still shows a hint of its reanalyzed origins in that it re- one of the first to reject the idea that worms caused tooth mains idiomatically limited to a plurale tantum sense— decay and noted that sugar was detrimental to the teeth that is, like scissors or glasses, one speaks of plural caries obligately in the plural—not of one scissor, glass, or cary. and gingiva.[121] In 1850, another sharp increase in the prevalence of caries occurred and is believed to be a re- (This is why one can look for a singular count-noun form of dental cary in any of a dozen major medical and gen- sult of widespread diet changes.[112] Prior to this time, cervical caries was the most frequent type of caries, but eral dictionaries and not find it listed.) Many still use it in the traditional sense (mass, singular), which is why they increased availability of sugar cane, refined flour, bread, and sweetened tea corresponded with a greater number speak of carious lesions rather than just caries when they intend the plural count sense. of pit and fissure caries. In the 1890s, W.D. Miller conducted a series of stud- ies that led him to propose an explanation for dental 9 Society and culture caries that was influential for current theories. He found that bacteria inhabited the mouth and that they produced acids that dissolved tooth structures when in the pres- It is estimated that untreated dental caries results in ence of fermentable carbohydrates.[122] This explanation worldwide productivity losses in the size of about US$27 [127] is known as the chemoparasitic caries theory.[123] Miller’s billion yearly. contribution, along with the research on plaque by G.V. Black and J.L. Williams, served as the foundation for the current explanation of the etiology of caries.[112] Several 10 Research of the specific strains of lactobacilli were identified in 1921 by Fernando E. Rodriguez Vargas. Cariology is the study of dental caries. In 1924 in London, Killian Clarke described a spherical bacterium in chains isolated from carious lesions which he called Streptococcus mutans. Although Clarke pro- 11 Other animals posed this organism was the cause of caries the discov- ery was not followed up. Later, in the 1950s in the USA, Main article: Dental caries (non-human) Keyes and Fitzgerald working with hamsters showed that caries was transmissible and caused by an acid-producing Streptococcus. It was not until the late 1960s that it be- Dental caries is uncommon among companion [128] came generally accepted that the Streptococcus isolated animals. from hamster caries was the same as S. mutans described by Clarke.[124] 12 References Tooth decay has been present throughout human history, from early hominids millions of years ago, to modern humans.[125] The prevalence of caries increased dramat- [1] Silk, H (March 2014). “Diseases of the mouth.”. Primary care 41 (1): 75–90. doi:10.1016/j.pop.2013.10.011. ically in the 19th century, as the Industrial Revolution PMID 24439882. made certain items, such as refined sugar and flour, read- ily available.[112] The diet of the “newly industrialized En- [2] Laudenbach, JM; Simon, Z (November 2014). “Common glish working class”[112] then became centered on bread, Dental and Periodontal Diseases: Evaluation and Man- jam, and sweetened tea, greatly increasing both sugar agement.”. The Medical clinics of North America 98 (6): consumption and caries. 1239–1260. doi:10.1016/j.mcna.2014.08.002. PMID 25443675.

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13 External links

• Dental caries at DMOZ

• Centers for Disease Control, Dental Caries at http://www.cdc.gov/healthywater/hygiene/disease/ dental_caries.html 18 14 TEXT AND IMAGE SOURCES, CONTRIBUTORS, AND LICENSES

14 Text and image sources, contributors, and licenses

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