1.

PREVENTIVE AND COMMUNITY DENTISTRY I

EPIDEMIOLOGY OF ORAL DISEASES:
DENTAL CARIES

Dr. Caroline Piske de A. Mohamed

OBJECTIVES

Students should be able to explain and discuss:

1.

Epidemiology of dental caries

2.

How do you measure dental caries?

Epidemiology of dental caries A HISTORICAL PERSPECTIVE
Dental caries and disparities
Factors affecting the epidemiology of dental caries
RISK FACTORS AND INDICATORS
Nutrition and caries
DIET AND CARIES
Environmental factors that may affect caries

3.
4.
5.
6.
7.
8.
9.

HOW DO YOU MEASURE DENTAL CARIES?

Dental caries is an universal disease affecting all
geographic regions, races, both the sexes
and all ages groups.
The prevalence of dental caries is generally
estimated at the ages of 5, 12, 15, 35 to 44 and
65 to 74 years for global monitoring of
trends and international comparisons.
The prevalence is expressed in terms of point
prevalence ( percentage of population affected
at any given point of time) as well as DMFT
index ( number of decayed, missing and filled
teeth in an individual and in a population)

MEASURING DENTAL CARIES

WHO oral health surveys manual means of DMFT Index:

Very

low

Low
Medium
High
Very

high

=
=
=
=
=

0.0 1.0
1.2 2.6
2.7 4.4
4.4 6.5
6.5 or more

 The

levels of dental caries are high

in many countries and populations,
was it the same in ancient times?

EPIDEMIOLOGY OF DENTAL CARIES

A HISTORICAL PERSPECTIVE
Dental caries was very uncommon amongst
fossil hominids into the Paleolithic and
Mesolithic era. The incidence of caries was less
than 1%.
From the Australopithecines (over a million years
ago) to the Neolithic (since 10,000 years ago),
carious lesions have been found in almost
every population studied.

FROM HUNTERS TO CROPERS

MORE CARIES....
Several studies have shown an increase in
caries rate associated with the change from a
hunter-gatherer diet with meat and low
carbohydrate to a diet heavy with starchrich cereal.
With maize agriculture, the dominant pattern
was root surface caries or lesions at the
cemento-enamel
junction
initiated
in
adulthood.
Where sugars have been introduced into the
diet, fissure and proximal surface cavities,
particularly in children, became dominant.

ANCIENT EGYPT
What do Egyptian dental patterns reveal
about their lives and how to they compare
to living populations today?
Dental caries were far less frequently seen
amongst ancient Egyptians and Nubians than in
today's populations. Two reasons are cited.
First, rapid wear literally wore away the
sites of pit and fissure cavities. Second, was
the lack of refined carbohydrates in their
diet.

Ancient Egyptians and Nubians rarely had the

dental crowding and abnormal molar
relationships that are observed throughout
the world today.
Many anthropologists and some orthodontists
suggest that vigorous chewing encourages
development of robust, full sized lower jaws
and some degree of wear minimized joint
pain and crowding that are prevalent
today.

In ancient Egypt, the greatest single problem was

attrition, specifically the wear of the occlusal
and proximal surfaces.
The teeth were rapidly worn down throughout
life by the consumption of a course diet. This
was true for both pharaohs and commoners.

In time, the wear became so extensive that

enamel and dentin were worn away, exposing the
pulp.
Painful chronic infection was the result. Dental
surgeons of that time would drain the abscesses
with the use of a hollow reed and had worked in
teeth restoration and prostheses..
High level of calculus accumulation were found
and tooth loss for periodontal disease was
moderately prevalent.

In European material, there is a gradual increase

from very low rates through the Paleolithic,
Neolithic, Bronze and Iron Age, to a rapid rise
through Medieval and modern times.

GOING TO MODERN TIMES AND DENTAL

CARIES AS AN ENDEMIC DISEASE
5th to 6th centuries: MODERATE caries
experience. More attrition, cervical & root caries.
16 th century: MODERN pattern ( fissures &
proximal surfaces caries), in HIGH-INCOME
nations. ( Sugar crop at colonies)

DENTAL CARIES AS AN ENDEMIC DISEASE

18 th century: dietary changes, increase in caries

prevalence until 70s.
The only break in this increase came during the mid 40s
and early 50s and this coincided with the reduced
availability of sucrose as a result of food rationing
imposed during the World War II.
19 th century: dental caries endemic disease.

NUMBER OF CARIOUS TEETH PER 100 TEETH

IN FOUR EUROPEAN POPULATIONS, ADAPTED
FROM KEAN, 1980

 Increase

in the number of caries is

related to the:
1. improvement
of productivity (
industrialization),
2. the development of agriculture and
3. food processing industry and
4. increase of sugar intake amount.

ANCIENT X MODERN PEOPLE IN

RELATION TO DENTAL CARIES

Ancient people

Modern people

Proximal caries

Occlusal pit &

fissures caries

Poor production
tools and coarse
food

Industrialized
refined food

Low sugar
comsumption

High sugar
comsuption

EPIDEMIOLOGY OF DENTAL CARIES

GOING THROUGH THE 20S AND AFTER
II WORLD WAR

Most obvious reason: DIET

For most of the 20 th century dental caries:
Disease of the HIGH-INCOME countries
Low prevalence in poorer countries
By the late 20 century happened:
Sharply RISING caries in some LOW INCOME
countries after world war ( 1939-1945) especially
urban areas.
Significant caries reduction in HIGH-INCOME
countries. Marked reduction among children and
young adults eventhough caries remains the most
common common chronic childhood disease.
Most data: DMFT

CHANGING TRENDS IN DENTAL CARIES [DMFT

OF 12 YR OLDS] IN DEVELOPED & DEVELOPING
COUNTRIES

WHAT WERE THE CAUSES

OF THE CHANGE OF
DENTAL CARIES PATTERN
IN THE LATE 20S IN

DEVELOPED AND
UNDEVELOPED
COUNTRIES?

THIS WAS ATTRIBUTED TO:

Dietary changes
Fluorides
Preventive programs
(better oral hygiene)

file:///C:/Users/sony/Downloads/a01f01.gif

NUMBERS....

Worldwide, approximately 2.43 billion people (36% of the

population) have dental carries in their permanent teeth. In
baby teeth it affects about 620 million people or 9% of

the population.

The disease is most prevalent in Latin American

countries, countries in the Middle East, and South Asia,
and least prevalent in China.

Countries

good
decreased DMFT
with

oral

health

programs

( Brazil- Water fluoridation- Brazil

Sorridente Oral Health Program)

In the United States, dental caries is the most common

chronic childhood disease, being at least five times

more common than asthma.

It is the primary pathological cause of tooth
loss in children. Between 29 and 59% of adults over
the age of fifty experience dental caries.

Caries continues to affects millions of

adolescents and adults.
Almost 94% of dentate adults showed
evidence of coronal caries, and almost 23%
root caries.

The

prevalence of caries in adults

increase with age.

DENTAL CARIES AND DISPARITIES

Developed countries (North America, Australia,
Europe and Japan)......decreasing caries rate in
children and increased number of retained
teeth in older adults.
There are disparities in this situation
(developed countries) for:
1. Developmentally disabled
2. Mentally retarded
3. Immigrant groups
4. Low socioeconomic group individuals

They present high levels of decay.

POLARIZATION

Dental caries, in those countries, are largely a disease

affecting the deprived section of the society.
In many communities 60 to 80% of dental caries is
occuring in 20 % of the population.
of all affected teeth are found in of the
population, constituting a small amount of people
with the greatest severity of decay - polarization.

SIGNIFICANT CARIES INDEX SIC FOR 12

YEAR OLD CHILDREN IN GERMANY

DENTAL CARIES, AN PANDEMIC DISEASE

B.L. Edelstein (2006)

Because:
1.

those who are affected by caries and have litlle or no

access to care number in the

millions,
2.

3.

hundreds of

all continents and in

most societies,
and experience significant consequences of pain
and dysfunction that impair
their most basic functions of eating,
reside on

sleeping, speaking, being productive and enjoying

general health as defined by the WHO.

FACTORS AFFECTING THE

EPIDEMIOLOGY OF DENTAL CARIES

Keyes triad ( carbohydrate (diet); bacteria ( dental

plaque); susceptible teeth( the host)
Modifying factors:
Saliva, immune system, time, socioeconomical
status, level of education, lifestyle behaviors,
and the use of fluorides.
The caries process can be described as loss of
mineral (demineralization) when the pH of
plaque drops below the critical value of 5.5.
Redisposition of mineral ( remineralization) occurs
when the pH of plaque rises.
The presence of fluoride reduces the critical pH by 0.5
pH units, thus exerting its protective effect.

Dr.Caroline Mohamed

33

HOST
Susceptibility
1.
2.
3.

4.

5.

of different teeth:

Mandibular first and second molar

Maxillary first and second molar
Mandibular second bicuspids, maxilar
first and second bicuspids, maxillary
central and lateral incisors.
Maxillary canines and mandibular first
bicuspid.
Mandibular central and lateral incisors,
mandibular canines.

DEVELOPMENT OF CARIES WITHIN THE

MOUTH/PERMANENT DENTITION
First

lesions: pits and fissures soon

after eruption.

The rapid onset of pit and fissures caries is

expected because of the morphology of those
pits and fissures where food debris is retained,
and the enamel at the very depth of the fissures
is often very thin or even absent.

IN

CONTRAST,

PROXIMAL

CARIES

SURFACES

OF

ARE

SELDOM CLINICALLY EVIDENT

UNTIL THE AFFECTED TOOTH
HAS BEEN ERUPTED FOR TWO
OR MORE YEARS.

CARIES OF CERVICAL
AREAS
OF
TOOTH
WHERE

CEMENTUM

HAS BEEN EXPOSED

IS
RELATED
TO
PROGRESSIVE
CHANGE
IN

THE

FREE
MARGIN
OF
THE GINGIVA WHICH
INCREASE
SUSCEPTIBILITY TO
PLAQUE FORMATION.

I. DEMOGRAPHIC RISK FACTORS

1) AGE
Mean DMF scores increase with age.
The increase with age for children comes largely
from an increase in number of restored teeth.(
developed countries)
Developing countries ( high levels of D, low levels of
F). For the adult most of increase comes from
missing teeth.

THE RELATION OF AGE AND CARIES

In the past caries used to be considered a childhood

disease ( as most susceptible surfaces were usually
affected by the time the child reached adulthood).
NOW ( developed countries) younger people reach
adulthood with many surfaces free of caries, the
carious attack is spread out more throughout life.
Adults of ages can develop new coronal lesions, and
caries has to be viewed as a lifetime disease.

2) GENDER
Females

usually demonstrate higher

DMF scores than males of the same
age.

WHY?

Women produce less saliva than do men,

reducing the removal of food residue from the
teeth, and during pregnancies the chemical
composition changes, reducing salivas
antimicrobial capacity.
Food cravings, aversions (women crave highenergy, sweet foods related to pregnancy and in
periodical hormonal changes).
Undeveloped countries women normally
have more pregnancies, less quality in
nutrition, more caries.

THE RELATION BW GENDER AND DENTAL CARIES

In children the different due to earlier eruption
of the teeth in girls.
In adults the treatment factor is more likely to
be affecting the differences.
In national surveys, males usually have more
untreated decayed surfaces (D), and females
have more restored teeth (F).
The females are not more susceptible to
caries than males, a combination of earlier
tooth eruption plus, habits, hormonal
changes and treatment factor is a more
likely explanation for the observed
difference.

WOMEN LOOK FOR TREATMENT MORE

THAN MEN.

3. RACE AND ETHNICITY

Old observations showed that non-European
races, such as those in Africa and India, enjoyed
a greater freedom from caries.
This
global variation result more from
environment rather than racial factors.
Certain racial groups thought to be caries
resistant, quicly developed caries when
they migrate to areas with different culture
and dietary pattern.

THE RELATION BW RACE & ETHNICITY AND

DENTAL CARIES

In the past there were wide DMF difference

between whites and African-Americans ( W>AF),
although the latter usually had more decayed
teeth (D) as a result of lack to access to care.
Now there is little difference in the total DMFs,
although whites still had a higher filled (F)
component and lower scores for decayed
( D) and missing surfaces (M).

THE RELATION BW RACE & ETHNICITY AND

DENTAL CARIES

There are NO inherent differences in susceptibility to

dental caries bw different racial groups.
Socio-economic differences ( i. e. Differences in
education, self care practices, attitudes, value,
income, and access to health care ) appear to be far
more important.

4. SOCIO-ECONOMIC STATUS SES

SES is a broad measure of an individuals background in

terms of such factors as education, income, occupation
and attitude &values.
SES usually measured by the annual income or years of
education.

SES is inversely related to the status of

many diseases and to characteristics
though to affect health.
Lower SES groups had higher values of D and M,
lower for F.

THE RELATION BW SES AND DENTAL CARIES

Although fluoridation of water supplies reduces the

difference bw the social classes, it doesnt entirely
remove it.

greatest reduction in caries experience

has been enjoyed by the upper social groups,

The

where reduction is less in lower social groups.

When
planning
treatment
programs,
caries
experience expected to be more extensive and sever
among low SES population.

5) FAMILIAL AND GENETIC PATTERN

Familial tendencies ( bad teeth run in families) are seen by

many dentists and have been demonstrated by research.
Such tendencies may have genetic basis such as:
deep and narrow pits and fissures, and
special arch form ( crowding) and/or
salivary flow and composition
or from bacterial transmission or continuing familial
dietary or behavioral traits.

THE RELATION BW FAMILIAL AND GENETIC

PATTERN AND DENTAL CARIES

Intrafamilial transmission of cariogenic flora

especially from mother to infants is accepted as
primary way for cariogenic bacteria to
become established in children.
Studies with identical twins concluded that
whereas genetic factors could affect caries
experience to some extent, the environmental
variables were stronger.

WEB OF TRANSMISSION/
PARENTS EDUCATION
Dr.Caroline Mohamed

53

II. RISK FACTORS AND INDICATORS

THE AGENT

1) Bacterial infection
Dental caries is a bacterial disease, bacteria is
necessary for the disease to occur.
The most important bacteria involved are:
streptococos mutans and lactobacilli.
These bacteria are normally present in the oral
flora, so caries may be considered as an ecologic
imbalance rather than an exogenous infection.
Caries is described as a carbohydrate-modified
bacterial infectious disease, in which cariogenic diet
selectively favors cariogenic bacteria.
Because infection with cariogenic bacteria is
necessary condition for caries to occur, its considered as a
risk factor for caries.

2)NUTRITION AND CARIES

Diet is the total oral intake of substances that provide nourishment and
energy.
Nutrition: refers to the absorption of nutrients.

Inadequate Calcium intake for a prolonged period;

Vitamin A, C and D deficiency,
Iodine,
fluoride,
protein-energy malnutrition ( inadequate intake of
protein, calories and micronutrients)
have been associated to
delays in tooth eruption,
hypoplasia of the enamel,
atrophy of the salivary glands, and
impaired salivary antimicrobial activity;
conditions that determine a greater susceptibility to
caries and are causative factors in hypoplasia.

A specific type of enamel hypoplasia of primary

teeth called linear enamel hypoplasia (LEH) is
common
in
some
economically
underdeveloped countries.
In children, who have signs of severe
malnutrition (related to mal absorption,
gastrointestinal disease and infection that
may
lead
to
hypocalcaemia),
linear
hypoplasia was present in up to 73% of the
population.

VITAMIN D DEPENDENT RICKETS

The structural damage can testify to the period
in which the lack of nutrition occurred.
The rate of enamel hypoplasia in primary teeth of
children born prematurely is more than two fold (
2X) that of controls.

Caries is found in countries where malnutrition

during early childhood is common but where
there is later exposure to cariogenic food; the
malnutrition itself DOESNT produce dental
caries whithout the later cariogenic challenge.

Hypoplasia and pits on the surface of the

enamel correlate to a lack of vitamin A.

3) DIET AND CARIES

In contrast with nutrition dietary factors have a
clear influence on caries development.
The relation bw the intake of refined CHO, and
the prevalence and severity of caries is so strong
that sugars are clearly a major etiologic
factor in the causation of caries.
Although the evidence that consumption of
sugars is a major risk factor for caries, sugar
arent the only food sources likely to be
involved in the carious process.

Cooked or milled starches can be broken

down to low molecular weight carbohydrates
by the salivary amylase and thus act as a
substrate for cariogenic bacteria.
Large molecular weight CHO in uncooked or
lightly cooked wegetables are considered noncariogenic because little brekdown of these
foods occurs in the mouth.

THE VIPEHOLM STUDY

The Vipeholm Study was a study that dental researchers

conducted on a group of mentally challenged residents of
the Vipeholm Institution.
Dental researchers fed mentally handicapped people

lots of sugar for the purpose of studying tooth

decay. Unfortunately, many of these patients ended up
losing their teeth to cavities.
Although the study is tragic and wouldn't be allowed
to be done today due to ethics concerns, we
learned a great deal about how foods cause cavities from
this study.
The participants in the study were all fed the same basic
diet. The participants were divided up into seven
groups to compare how subtle changes in the
timing and quantity of sugar consumption
affected their dental health.

THREE KEY GROUPS IN THE VIPEHOLM

STUDY

There are three key groups in the Vipeholm study that helped us understand
more about how food affects the formation of a cavity on a tooth:

1 - One group ate the original diet with an extra 300 grams

of sugar dissolved in solution during their

meals. That's the equivalent of drinking about five bottles of coke
per day during meals!

extra 50
grams of sugar mixed into their bread that
they ate during mealtime.
3 - The last group ate the basic diet, in between meals,
this group also ate snacks of sugary toffee and
candy.
2 - Another group ate the basic diet with an

WHICH GROUP ENDED UP

GETTING THE MOST CAVITIES
AND LOSING THE MOST
TEETH?

The third group.

When the sugar was consumed in between
meals, it gave the bacteria more opportunities
throughout the day to form cavities on the
teeth.

http://www.medicinhistoriskasyd.se/SMHS_bilder/thumbnail
s.php?album=25&page=3

VIPEHOLM STUDY,( 1952), CONCLUDED THAT:

1.
2.

3.

4.

5.

6.

Sugar consumption increase caries activity.

The risk of increased caries activity is greater if the sugar
is in a sticky form.
The risk is greater if taken bw the meals and sticky
form.
The increase in caries under uniform conditions shows
great individual variation.( 20 to 30% of the
patients didnt have any caries although they
consumed tofees bw meals)
The increase in caries disappears upon withdrawl of
sticky foodstuffs from the diet.
Caries can still occur in the absence of refined sugar,
natural sugars and total dietary CHO.

SUGAR CARIES RELATIONSHIP

Are all the caries free

children not consuming
sugar or do other factors
have a major influence?

SUGAR CARIES RELATIONSHIP

Oral hygiene is an important co-variable in the
sugar caries relationship.
Consumption of sugars is not a major risk factor
for many children ( those who were caries free
and still ate a lot of sugar), but it is for these
who are still clearly susceptible to caries (
those presenting proximal caries)
The caries is a multifactorial disease, and
the caries risk is not always related to
sugar consumption.

ENVIRONMENTAL FACTORS THAT MAY

AFFECT CARIES
I) Climatological factors:
Sunshine, temperature, relative humidity.
Geographical
disposition of developed and
underdevelopment countries in temperate and
tropical zones leads to this type of hypothesis.

Non-climatological factors:
1) Fluoride
The geologic formation as well as the distance
from the sea coast affect the fluoride
concentration in water supplies.
2) Total water hardness
It is measured in terms of calcium carbonate.
There is inverse relationship bw caries and total
water hardness.
3) Trace elements
They are elements found in water supplies and in
common food. Such as Selenium which is a
micronutrient element and it is capable of
increasing caries particularly when consumed
during the developmental period of teeth.

An overwhelming number of scientific studies

conclude that cavity levels are falling
worldwide even in countries which dont
fluoridate water related possibly to good oral
hygiene habits, fluoridated toothpaste and
community OH programs.

Fluoridate or not fluoridate,

thats the question
To

ACTIVITIES
Make a resume about: The Vipeholm Dental
Caries Study: recollections and reflections 50
years later.
How to find it:
The Vipeholm Dental Caries Study: recollections
and reflections 50 ...
www.researchgate.net/.../11439564_The_Vipehol
m_... Right side of page click
VIEW
Read and make a 1 page resume.

THANK YOU