Dental caries

from Wikipedia, the free encyclopedia
Classification according to ICD-10
K02.- Dental caries
ICD-10 online (WHO version 2019)
Development of caries with presentation of the symptoms
A) Probing caries
B) Radiological diagnostics
C) Opening of the cavity
D) Caries profunda with opening of the pulp

The dental caries (from Latin caries , rottenness', 'rot') or short caries is a multifactorial disease of destructive dental hard tissue , enamel and dentin . It arises with the participation of microorganisms and is based on the tooth surface being " decalcified " by the action of acid . Other names are also tooth decay or tooth decay (Latin technical term: Caries dentium ).

At a symposium in the run-up to the congress of the European Association for Caries Research (ORCA) it was established that caries is a noncommunicable disease.

etiology

There are several theories about how tooth decay develops. The starting point for modern caries theories was the chemoparasitic theory according to Willoughby D. Miller (1890), according to which lactobacilli (in interaction with carbohydrates and saliva) were considered to be the cause until the 1960s. As a result, the specific plaque hypothesis developed , followed by a paradigm shift that led to the ecological plaque hypothesis . Accordingly, several pathogenic factors lead to the destruction of the hard tooth tissue in several stages.

Caries is caused by a disruption of the homeostasis of the oral microflora , namely by a selective favoring of potentially pathogenic microorganisms, such as Streptococcus mutans , and by a diet rich in sugar. It is therefore not an exogenous infection that leads to the disease. Even in healthy people, the bacteria are part of the physiological endogenous flora , which can become pathological through changes in certain factors. In rare cases, Streptococcus mutans, one of the most important caries-causing pathogens, is not part of the oral flora or is only very weakly represented, which makes the disease less likely. If an acidogenic and aciduric species is favored and their metabolic activity forms organic acids through frequent sugar consumption, this in turn promotes the demineralization of the hard tooth substances and thus caries.

The oral cavity of an unborn baby is initially sterile; the first contact with vaginal and fecal microorganisms occurs at birth. A natural bacterial flora similar to that of adults develops within a short time. The cariogenic pathogens are transmitted through saliva contact. Colonization with the most important cariogenic germ Streptococcus mutans takes place in some cases only after the milk teeth have erupted. The most common transmission takes place via the milk bottle teat between mother and child (licking a spoon or pacifier, initial tasting, temperature check of the milk), but also through other transmission channels such as kissing, sharing dishes, coughing.

There are rare inherited diseases. For example, amelogenesis imperfecta , a congenital disorder of tooth enamel formation, which is associated with an increased susceptibility to caries.

Biological foundations

The teeth are surrounded by a biofilm (plaque) that contains numerous microorganisms . Some of these can metabolize low molecular weight carbohydrates from food into organic acids and lead to a lowering of the pH value . If the pH value on the tooth falls below a critical pH value (5.2–5.7 for tooth enamel or 6.2–6.7 for tooth cement and root dentine), minerals such as calcium phosphates can be extracted from the hard tooth substances; the tooth is demineralized. If this process is not stopped or reversed, the demineralization of the enamel leads to the formation of a carious lesion . Caries is the result of an ecological change in the biofilm. It can therefore be defined as a shift in the dynamic equilibrium between the mineral salts bound in the hard tooth substance and those dissolved in the biofilm or saliva.

You can get caries when four main factors work together:

  • Susceptibility to disease of the tooth
  • Plaque with cariogenic bacteria
  • low molecular weight carbohydrates (especially found in sugar and sugary foods)
  • enough time

In addition to these main factors, there are various secondary factors: tooth position, tooth malformations, saliva flow and composition, genetic factors and the composition of the diet.

Lactobacilli and various types of streptococcus settle in the plaque . Streptococcus mutans is outstanding . These bacteria break down sugar from food into lactic acid . Only microorganisms that control this metabolic process (acidogenic microorganisms) and can survive in a strongly acidic environment (aciduric microorganisms) then continue to multiply. Dental plaque from people who consume a lot and often sugar therefore have a different microbiota.

Recent research has shown that there is an interaction between Streptococcus mutans and the fungus Candida albicans , which causes the bacterium to change its virulence. The fungus produces signaling molecules that stimulate the bacterium's genes to produce antibiotics in the cell. Furthermore, the bacterium can absorb foreign genetic material through the fungus. The production of sticky substances, an important prerequisite for the adhesion of S. mutans to the tooth, is also supported by the fungus.

If the acid effect was not caused microbially, but through the intake of fruit acids , for example, this is also damaging to the teeth, but is more likely to result in the clinical picture of tooth erosion .

Stages

Formation of fissure caries
Development of surface caries

Caries stages range from initial caries to dentin caries and caries penetrans . They are diagnosed using special probes .

Initial caries

As a preliminary stage of caries ( initial caries ), decalcification forms first. These are macroscopically recognizable as white spots ( English white spot , Latin macula alba ). Due to the accumulation of color pigments from food, these spots often become dark (lat. Macula fusca ).

Caries, which is only limited to the enamel, does not have to be treated in every case. As long as the enamel layer is only attacked, but still intact overall, the lesion can be remineralized through suitable fluoridation measures and a change in diet (after nutritional advice ), the hydroxide ions in the apatite are replaced by the fluoride to form fluorapatite .

If tooth decay is at an early stage, i. H. As long as the tooth enamel ( superficial caries ) is affected, not remineralized, it penetrates into the dentin (dentin). These dentine caries ( caries media ) can already lead to toothache .

Since dentin is much softer than tooth enamel, the caries spreads out below the enamel-dentin boundary. The thus undermined tooth enamel at the edges of the carious defect breaks in after a certain time while chewing. The tooth decay is often noticed for the first time, although it has existed for a long time.

Approximal caries is a caries that occurs at the contact points between adjacent teeth, i.e. in the interdental space.

Caries profunda

With caries profunda ( Latin for deep dental caries), the caries lesion has penetrated over 2/3 of the dentin layer towards the pulp . The lesion then persists

  • from the destruction layer in which bacteria have not only dissolved minerals but also decomposed the protein matrix,
  • the zone of bacterial penetration, where bacteria have penetrated the dentinal tubules ,
  • the demineralization zone (loss of mineral due to acid exposure)
  • and the transparency zone. In this, the odontoblasts have deposited more mineral in the dentinal tubules in order to delay the progress of the caries. In a microscopic thin section, this layer appears transparent, as the optical interfaces (mineralized dentin and canal contents) have disappeared due to the mineral deposits.

Caries penetrans

In caries penetrans (penetrating tooth decay), the defect has reached the pulp (popularly: "tooth nerve") through the dentine, creating a connection between the oral cavity and the pulp cavity (the cavity in which the pulp is located).

diagnosis

X-ray of a tooth with amalgam filling

The presentation of tooth decay is very variable, however the risk factors and stages of most of the appearances are identical. Depending on the location, the caries is either directly visible or can only be made visible using diagnostic tools (X-ray, probes, laser). The primary diagnosis at the dentist is primarily through inspection with a strong light source, a dental mirror and a probe in combination with compressed air. The results of the inspection are compared with X-rays, which can make caries visible in the inaccessible areas of the teeth (fissures, contact points between the teeth). For this, bitewing recordings are made. The use of probes for diagnosing caries, especially those with pointed ends, is controversially discussed in the specialist literature. Caries in the early stages can be stopped by using fluorides as long as a cavity has not yet formed. Such areas could break through with pointed probes, so that the diseased area can no longer be remineralized by fluoridation alone.

distribution

Dental caries is considered to be the most common disease in humans. In Germany only about one percent of adults are caries-free. The Fourth German Oral Health Study (DMS IV; 2010) showed that 70.1% of children (12 years) and 46.1% of adolescents (15 years) have teeth without any experience of caries. Comparable to other countries, the incidence of tooth decay decreases with belonging to a higher social class.

Diet (especially sugar ) and poor dental care are primarily responsible for tooth decay, but a person's genetic makeup has no significant influence. Even if the composition of the human oral microbiome is influenced by the genetic background, potentially cariogenic bacterial strains are independent of genetic factors. The relationship between the human oral microbiome and a person's genetic background continues to decrease with age.

Caries after radiation therapy

If patients develop malignant tumors in the head and neck area , ionizing radiation is used to eliminate the tumor in around 50 percent of cases ( radiation therapy ). Although fractionated irradiation, which is common today, somewhat limits the effects of radiation therapy on the salivary glands, there is currently no reliable method of controlling radiation in such a way that side effects can be completely excluded. The skin and mucous membrane, muscles, salivary glands, bones and teeth are affected. Damage to the salivary glands leads to dry mouth , also known as radiogenic xerostomia, which can lead to an often very painful inflammation of the oral mucosa ( mucositis ). The risk of so-called radiation caries (Caries radiatio) increases extremely in these patients due to the loss of the neutralizing and remineralizing effect of the saliva.

In order to reduce the risk of radiation caries, a complete renovation of the dentition should be carried out before starting radiotherapy. In addition, dental care and the patient's willingness to cooperate should already be improved in this phase through extensive and repeated oral hygiene instructions. Professional mouth cleaning must be carried out daily during the irradiation phase. In order to reduce radiation damage to the oral mucosa may Radiation Protection rails are used. But oral hygiene measures alone cannot prevent radiation caries from occurring. Saliva substitutes are a valuable remedy for dry mouth, but they have no caries prophylactic effect. They can even cause damage to the hard tooth structure, as some of them have a low pH value and thus have an erosive effect. Regular local fluoridation during and after radiation is a key complementary therapy for head and neck radiation patients.

Consequences and complications

As the caries lesion approaches the pulp, bacterial endotoxins can lead to pulp inflammation. The patient perceives this through increased sensitivity to cold and heat, as the endotoxins lower the stimulus threshold of the nerve fibers. At this stage, the inflammation can be reversed through dental treatment (removal of the caries, application of a bacteria-inhibiting underfilling (based on Ca (OH) 2 ) and a tight restoration). If the inflammatory process is not interrupted, the pulp can be irreversibly attacked (irreversible pulpitis ), resulting in spontaneous, sometimes severe pain from an odontogenic infection . If the bacteria reach the pulp, local abscesses develop and the pulp dies (pulp gangrene ). In this case, only a root canal treatment or, if the tooth can no longer be restored, extraction .

If caries forms again in areas that have already been treated (filled), one speaks of caries recurrence or secondary caries . Secondary caries is a carious disease caused by any restorative measure, for example on a protruding, unpolished or damaged filling or crown margin.

prevention

Diet and neutralization of acids

The best way to prevent tooth decay is to limit your sugar intake. This prevents the change in the oral flora in the direction of cariogenic plaque. The American Dental Association and the European Academy of Children's Dentists recommend limiting the consumption of sugary beverages and not giving infants and young children any sugary liquids to help them fall asleep.

Of great importance for dental health are sufficient breaks between meals (or drinking sugary drinks), during which the saliva can neutralize the acids and remineralize the damaged tooth substance . So it is not so much the amount of sugar consumed that matters, but above all the frequency and duration of sugar consumption. A dose of a sugary soft drink distributed throughout the day increases the risk of tooth decay considerably, as it deprives the enamel of the regeneration phases. Not only sugar, but also fruit acids pose a danger to the teeth, whereby this is reflected primarily as tooth erosion . Adequate saliva flow is essential for keeping teeth and oral mucous membranes healthy. Any impairment of the saliva flow means, in addition to a large number of unpleasant side effects, an increase in the risk of caries. A complete cessation of the flow of saliva can lead to carious destruction of the teeth within a very short time.

Brush teeth

Toothbrush with toothpaste

One way of reliably removing plaque is to clean the teeth with a toothbrush and in the interdental spaces with dental floss or, in the case of larger gaps between the teeth, with an interdental brush . Mouth rinses, including chlorhexidine digluconate , can delay the formation of new plaque, but not prevent it. Thorough removal of plaque can prevent demineralization . It is often recommended not to brush your teeth immediately after meals, as the enamel is already loosened and can be more easily removed by cleaning. However, the latest research indicates that waiting to brush your teeth after a meal can even be counterproductive and is therefore not recommended.

Fluorides, xylitol and polyphenols

Prophylaxis with fluoride is seen as a good way of preventing tooth decay . Fluoride promotes remineralization , hardens the top layer of enamel and inhibits bacterial growth. A Cochrane meta-analysis found that children aged 5–16 who brushed their teeth with a fluoride-containing toothpaste at least once a day had fewer tooth decay. After three years of use, the children not only had less tooth decay, but also fewer sealed and missing permanent teeth, regardless of whether they drank fluoridated water or not. It was advantageous if the children brushed their teeth twice a day.

Fluoridation , especially tap water, is the subject of controversial discussion from various angles . The addition of fluorides to table salt is also used. Nowadays the focus is on the local administration of fluorides for caries prophylaxis and no longer on the administration of fluoride tablets. The latter should only be sucked to create the local effect.

In Finland, among others, the use of xylitol has been systematically researched since the 1970s . It was proven that xylitol not only inhibits the formation of caries in the long term, but can also lead to remineralization of the affected tooth areas. The anti-cariogenic effect is explained by the fact that the cariogenic Streptococcus mutans cannot metabolize the xylitol and thus die. Furthermore, they are also prevented from adhering to the tooth surface as plaque bacteria. In the Finnish studies, an amount of xylitol between 5 and 10 grams per day in several servings was found to be optimal. This can be done using chewing gum or lozenges. In addition, xylitol stimulates the production of saliva and promotes the formation of complexes with calcium and saliva proteins in the oral cavity, which leads to a remineralization of tooth structure. A meta-study by the Cochrane Collaboration from 2015 sees evidence of a 13% reduction in tooth decay in children by using fluoride toothpaste with xylitol (compared to toothpaste containing only fluoride). Conclusions about a preventive effect of other xylitol-containing products are not possible due to the study situation. Overall, the quality of the documents is rated as low to very low.

Polyphenols from red grapes inhibit the type of bacteria Streptococcus mutans , which contributes to the build-up of plaque and so-called biofilms on the teeth. With their bactericidal effect, polyphenols inhibit the harmful effects of bacteria and thus also have a preventive effect against dental caries.

Microbial Aspects

A study by the University of Pennsylvania also showed that the yeast Candida albicans to promote plaque production results and increases the risk of caries. Experiments with rats showed an increase in tooth damage caused by the combination of yeast and streptococci .

Another new development is the use of special lactic acid bacteria, for example as the main ingredient of toothpaste: the Lactobacillus paracasei against caries pathogens. These are able to specifically recognize caries bacteria, attach to them and then easily remove them.

Infection prevention in infants and young children

Some parents clean the pacifier by licking it off or sucking it off, for example if the pacifier has fallen on the floor. The temperature of the milk in milk bottles is sometimes checked by the parents using preliminary costs. This makes it possible for the child to be infected with caries-causing oral bacteria. The most common transmission occurs via the pacifier and the milk bottle teat between mother and toddler. Other ways of transmission can also be considered, for example through toys that are put into the mouth by children in playgroups or in kindergarten , thereby causing the transmission of bacteria. A transmission, i.e. infection, can also take place through jointly used cutlery, jointly used toothbrushes or through kissing. The level of the concentration of Streptococcus mutans in saliva correlates closely with the risk of tooth decay.

Visit to the dentist

The preventive check-up for the early detection of pathological conditions should take place twice a year. The group prophylaxis affects selected larger population groups (e.g. examinations of school children by school dentists), while the individual prophylaxis only applies to individuals.

For legally insured persons in Germany, the practitioner confirms in a bonus booklet that the patient has attended the regular preventive medical check-up. Patients who are over 18 years of age must be able to document a visit to the dentist in their bonus booklet once a year. Children and adolescents up to the age of 18 should go to the dentist for preventive medical checkups twice a year. Those who can document all the necessary preventive examinations in their bonus booklet within a period of five years will receive a 20 percent increase in the fixed allowance for dentures. After ten years, the fixed grant will be increased to 30 percent. The legal basis is § 22 SGB ​​V.

therapy

Decalcification (" macula alba ") as a preliminary stage of caries can be remineralized through intensive fluoridation with special fluoride preparations and thus made to disappear.

Caries infiltration

Caries infiltration can be used for early caries and up to the first third of the dentine (D1)

A new type of treatment method, caries infiltration, is intended to stop incipient approximal caries or incipient surface caries without “drilling”. The principle of caries infiltration is based on the penetration of a low-viscosity plastic (infiltrant) into the lesion body of a caries. After hardening, the infiltrant closes the lesion pores and thus represents a diffusion barrier for acids and low molecular weight carbohydrates.

Conservative forms of therapy

Later stages of caries, which are associated with a cavity ("hole"), have to be treated differently: The affected hard tooth substance has to be cleared out and the tooth has to be provided with a filling material ( e.g. glass ionomer cement , composite , amalgam , inlay ).

If the tooth is more severely damaged, an onlay or crowning is possible, and if the bacteria have already reached the pulp, a root canal treatment or removal of the tooth is possible. The removed tooth should be replaced as soon as possible (bridge or implant) in order to prevent changes in the jaw or the position of the teeth.

Leave carious residual dentin

After one hundred years, in which the complete removal of carious dentin was considered state-of-the-art , more recent studies have shown that it is preferred to leave carious residual dentin in the area near the pulp. The focus of the treatment of defects near the pulp is the preservation of the closed pulp. A complete caries removal leads to the opening of the pulp more often than leaving residual caries. The dentin near the pulp is given the opportunity to form tertiary dentin. Dentin near the pulp is covered with calcium hydroxide or glass ionomer cement. The procedure is referred to as minimally invasive - often for marketing reasons . In order to be able to excavate carious dentin to the necessary extent, there are numerous self-limiting procedures.

These either work with active feedback :

or with passive feedback:

Active feedback methods are preferred, as the desired end point of the excavation can be set and the condition of the remaining dentine can be taken into account. According to a current study with high evidence, the prognosis of the pulp is improved by incomplete caries removal in one step, i.e. with subsequent definitive cavity closure .

See also

Portal: Dentistry  - Overview of Wikipedia content on dentistry

literature

Web links

Portal: Dentistry  - Overview of Wikipedia content on dentistry
Wiktionary: Karies  - explanations of meanings, word origins, synonyms, translations
Commons : Dental Caries  - Collection of pictures, videos and audio files

Individual evidence

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