Good afternoon, good morning, good evening, wherever you are in the world.

My name is John Featherstone and this course is entitled Caries Management by Risk Assessment, otherwise known as CAMBRA and you can see that these letters fit with the title, and I'm going to be talking about how to implement it in your practice. In the broader sense which might include implementing it for yourself also. So this is part one of the first week and I'm going to give you an introduction and the course outline and let you know what's coming in the subsequent weeks. Firstly, a disclaimer. This course is designed for educational purposes only. Its not intended as medical advice or medical services for you as individuals. The information provided in this course should not be used for diagnosing or treating A health problem or a disease, nor does it qualify you as a healthcare provider. It is not a substitute for professional care and if you have or suspect you have a health problem, you should consult your healthcare provider. And for the healthcare providers who are tuned into this course, this is information That you will be able to use in your own practice. A little about myself. I'm a distinguished professor of preventive and restorative dentistry at the University of California San Francisco School of Dentistry. Believe it or not, in San Francisco, USA. I'm also the dean of the school. And I continue to conduct research in the area of caries and cariology. I've been involved with this research and clinical applications of it for a total now of a little over 38 years. So, I've been around. I've published over 230 articles and book chapters relating to my research and the key items of that research and the application are in this course. So have fun for the next few weeks. And stay with me. Course objectives, threefold. Firstly, to understand the process of dental caries, as an infectious, and transmissible disease.

And I'm going to define dental caries in a moment. Secondly, to learn about pathological and protective factors related to caries initiation, progression and prevention. And thirdly, to understand the principles of clinical intervention in the caries process, and how to put this into dental practice. Or into your own life. Who's the audience? We have thousands of people signed up for this course. Dental professionals, that's dentists, hygienists, dental assistants, dental therapists or whatever you may be called and whatever part of the world You are. Secondly, allied health professional, such as, pediatricians, nurse practitioners, family medicine docs, physicians assistants, et cetera. And we hope that you'll learn something from this and be able to put it into practice in your part of medicine and dentistry. From what you've learned here. And lastly, it's open for educated lay people who wish to learn more about dental decay, and how this knowledge applies to themselves, or to their families. It wouldn't be a normal presentation without another disclosure. I have no personal financial interest in any company relevant to this presentation. I will be providing you with examples of products, and I will be describing how products are put together and how they work. And in no way will I be providing you with a comprehensive list of products. The products that I show you will be examples only, and I'm not here to endorse any company. And I would like to also disclose that I have consulted for, or have done research funded by or supported by a bunch of companies. Arm and Hammer, Beecham, Cadbury, Glaxosmithkline, KaVo, Novamin, etcetera, etcetera. And you can read the list. Pretty well all of the dental health care. Companies in the majority of the world. So folks to the course, what is dental caries? Some of you live with dental caries all

the time everyday. Others of you it may be an unusual word for you. Dental caries is simply defined as tooth decay. But it's not as simple as that. It's a disease, it's not a hole in the tooth. The hole in the tooth is the last manifestation of the disease that we call tooth decay. And I'll be showing you numerous examples as the weeks go on. Firstly, specific bacteria are involved. The streptococcus mutans. Streptococcus sobrinus. Lactobacilli. And several more that are on the tooth surface, and they feed on carbohydrates and make acids. As waste products. These acids travel into the tooth and dissolve the minereal of the tooth. And if this mineral loss is not halted or reversed, a cavity is formed. And lastly, dental carries is a transmissible bacterial infection. Interestingly enough, an outline of this process was published in 1890. Not 1990, folks, 1890. By a man called W.D. Miller. And he demonstrated that bacteria from the mouth fed upon carbohydrates and produced acids that dissolved the teeth. It's well over a hundred years since that time. And how far have we advanced? We've still got people with decay. In fact, a much higher percentage now than, in W.D. Miller's time. So I'm going to give you some cold, hard facts about dental caries, that you need to know. And each week, I will add some more. Facts about dental caries and the science that goes behind it. And in case you're interested, this photograph I took in the Antarctic. Why am I showing it? It's somewhat like a decayed tooth in the early stages. It has this intact surface, just like a tooth. And underneath, there are decayed areas. And I'm going to describe how that works during the dental decay process. It's an interesting phenomenon.

And eventually, cavitation occurs in the tooth. We can avoid that. We can stop that. We can intervene and reverse it. So folks, demineralization. That means loss of mineral. That's step one in the dental carries process. We have our cariogenic bacteria. And the cariogenic bacteria means they are bacteria that cause dental carries, hence the name cariogentic. Most of you will have heard of strep mutans. Most of you will not have heard of strep sobrinus. Streptococcus sobrinus is related very closely to strep mutans. It's a species that is particularly virulent, as we call it, produces lots of acid and is present in many people with high levels of decay. And then we have lactobacilli which are bacteria that everyone is familiar with most likely, appears in various form in our everyday life and also appears in the plaque bio-film in the mouth, plus, and I'll describe those in a little bit, numerous other bacteria. Any bacteria that produce acid by feeding upon fermentable carbohydrates. We as humans need fermentable carbohydrates to live. And, we like the taste. What are they? The most common one is sucrose, sugar. Glucose. You're all familiar with glucose and fructose. Fructose is interesting, because in the US it comes from high fructose corn syrup. And then we have cooked starch. So complex starch is not able to be metabolized by these cariogenic bacteria. However, when we take starch and cook it, it breaks down the complex carbohydrate, and turns it into simple carbohydrates that our cariogenic bacteria can feed upon. And once the bacteria feed upon any of these fermentable carbohydrates, they produce organic acids. And those organic acids penetrate into the tooth, through the

enamel, through the dentin, and I'm going to describe later what enamel and dentin are, and those acids dissolve the tooth mineral, partly, and that calcium and phosphate flows out of the tooth and that's what we call demineralization, or loss of mineral. The second stage of demineralization is when our dental mineral here on the left, which is called a carbonated hydroxyapatite. I'm going to describe what that means in a little bit, also. That carbonated hydroxyapatite is acid-soluble, And it's dissolved by these organic acids that came from this fermentation. And those organic acids. which I will describe in a little more detail later. Readily dissolved the calcium and the phosphate out of the tooth. It comes into solution in the plaque on the tooth's surface and is flushed away by the saliva. So if demineralization continues, it produces what we call decalcified areas. And if that continues, those decalcified areas show up as cavities. Here's the first example of an early stage of tooth decay, and what we see here, circled in blue and now circled in green is a white spot lesion. It's called a white spot because it looks like a white spot and indeed it is. So here's a regular tooth. Another tooth next door. And so on. And this area here. That's the white spot has shown up because the tooth between this one and this one, what we call exfoliated. It was a deciduous tooth that came out, from here, leaving a gap,allowing us to see this white spot lesion. And that white spot lesion is early decay, early demineralization, that's not yet cavitated. In other words, it's not yet a hole in the tooth. If we leave it long enough and don't intervene, it will become a hole in the tooth. It will become a cavity. It will have to be drilled and filled or

it might go beyond that. Leading to infection and the tooth either having to be extracted. Or being drilled out and a root canal being filled. If this white spot lesion continues. In this case, in the occlusal or biting surface of the tooth, we end up with what we call frank, or obvious, dental decay. That's a huge cavity, right here in this tooth. Difficult to understand how this person was walking around and able to just continue to function with this cavity. We can't reverse this chemically, we have to drill and fill it and put a filling in or, otherwise known as a restoration, and all of my dental professional audience will understand and know and do this every day of the week. So if we go back one slide, this early white spot lesion, if it's in here, ends up right here. This slide is a photograph taken by my colleague, Dr. Ling Zhan, in the operating room. It's a child with decay throughout her mouth. And you can see particularly these upper teeth are way decayed. Almost gone. And in the lower teeth you'll see areas of severe decay. If this was decay in a younger child, this, this child's about nine years old, the younger child would be called early childhood caries. Here, we call it childhood caries. Doesn't matter, it's dental decay, it's severe decay, and this child's being treated in the operation room under general anesthetic for about three hours while the mouth is reconstructed. Costs many thousands of dollars. It's all avoidable, and it's all the same process that I'm describing to you as today, and the coming weeks go on. This slide is root caries. That's decay of the tooth root.

So here's the enamel and here's the tooth root which is underneath the gingiva underneath the gums. And you'll see we've got decay of each of these roots showing up in this particular patient. It's the same process, fermentable carbohydrates plus bacteria-producing organic acids dissolving the mineral. And I'm going to describe to you in more detail root caries in the coming weeks. The therapy is similar, and I'll also describe the therapy, how we can prevent root caries. Here we have, courtesy of another of my colleagues at UC San Francisco. A totally destroyed mouth. Well, not totally destroyed, but very close. Dr. Curtis is a prostedontist who did a full mouth reconstruction of this patient. But before he did that he took all of the decay that you'll see here. In fact, there's too much for me to highlight it. Every one of these tooth, teeth is loaded with bacteria. Those bacteria are again producing organic acids dissolving the teeth. How this patient can walk around with his mouth in this condition is quite amazing. But, he came to Dr. Curtis, was referred to Dr. Curtis, who firstly got his decay under control. And then dealt with all the prosthodontic work to turn this mouth into a mouth of teeth that the patient really wanted to have. Here we have a radiograph, radiographic images of a couple of the teeth in the mouth of this patient. And you 'll see, we've got some root canals, and we've got some decayed areas showing up right here. So, it's very easy to tell that this patient is way from under control. He's got decay continuing. His risk of decay continuing is extremely high. And I'm going to talk a lot more about caries risk assessment as the weeks go on. But we'll have to learn some of the fundamental. Science behind it before we get to that

point. Caries risk assessment is the basis for caries management. Caries management is not just drilling and filling. In fact, we must manage the disease before we go to restorative work. You will learn the science behind dental caries enough to use in your practice, and you'll be able to understand the disease that you see everyday. In many of your patients in your practice. You will learn how to assess the risk of the patient having new carious lesions. A carious lesion is a demineralized area, or a cavity, in the future. You will learn what chemical therapy to use to reduce the risk level and to prevent progression, or even reverse the early lesions. So folks, there's a lot more in store for you. So, now at the end of this segment, I have a multiple choice question for you. You don't have to write the answer down. You don't have to send it in. This is just to help you think about what you've hear in the last few minutes. And the question is, what is the basis for demineralization during the caries process. During this disease we call dental caries. Firstly, bacteria on the surface of the teeth feed upon proteins and fats from our diets, producing acids that diffuse into the tooth and dissolve the mineral. Is it that, or acids in the diet and in beverages Are helped by the bacteria to diffuse into the teeth and dissolve the mineral. Think about that. That might be acidic drinks. It might be an apple. And oral bacteria helping those acids to go into the teeth. [INAUDIBLE] . Or thirdly, specific bacteria on the surface of the tooth ferment carbohydrates. Producing acids that dissolve the tooth mineral. I'll let you ponder for a couple of seconds on this. Just think about which one is correct. Based upon what you just heard. There it is, that's the correct answer, folks. Specific bacteria ferment carbohydrates,

producing acid that diffuses into the tooth, and dissolves the tooth mineral. So folks, section one now complete. Take a break and come back and see section two.