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{{Short description|Deformation of teeth due to acids produced by bacteria}}{{cs1 config|name-list-style=vanc}}{{For|caries of bone|Osteolysis}}

factoids

| symptoms = Pain, tooth loss, difficulty eatingperiodontal disease>Inflammation around the tooth, tooth loss, infection or abscess formation| onset = | duration = Long term| causes = Bacteria producing acid from food debris| risks = Diet high in simple sugar, diabetes mellitus, Sjögren syndrome, medications that decrease saliva| diagnosis = | differential = simple sugar>sugar diet, tooth brushing, fluoride, flossing| treatment = | medication = Paracetamol (acetaminophen), ibuprofen| frequency = 3.6 billion (2016)| deaths = }}Tooth decay, also known as cavities or caries, is the breakdown of teeth due to acids produced by bacteria.JOURNAL, Silk, H, Diseases of the mouth, Primary Care: Clinics in Office Practice, March 2014, 41, 1, 75–90, 24439882, 10.1016/j.pop.2013.10.011, 9127595, The cavities may be a number of different colors, from yellow to black.JOURNAL, Laudenbach, JM, Simon, Z, Common Dental and Periodontal Diseases: Evaluation and Management, The Medical Clinics of North America, November 2014, 98, 6, 1239–1260, 25443675, 10.1016/j.mcna.2014.08.002, Symptoms may include pain and difficulty eating. Complications may include inflammation of the tissue around the tooth, tooth loss and infection or abscess formation. Tooth regeneration is an on-going stem cell based field of study that is trying to reverse the effects of decay, unlike most current methods which only try to make dealing with the effects easier.The cause of cavities is acid from bacteria dissolving the hard tissues of the teeth (enamel, dentin and cementum). The acid is produced by the bacteria when they break down food debris or sugar on the tooth surface. Simple sugars in food are these bacteria's primary energy source and thus a diet high in simple sugar is a risk factor. If mineral breakdown is greater than buildup from sources such as saliva, caries results. Risk factors include conditions that result in less saliva, such as diabetes mellitus, Sjögren syndrome and some medications. Medications that decrease saliva production include antihistamines and antidepressants.JOURNAL, SECTION ON ORAL, HEALTH, SECTION ON ORAL, HEALTH, Maintaining and improving the oral health of young children, Pediatrics, December 2014, 134, 6, 1224–9, 25422016, 10.1542/peds.2014-2984, 32580232, free, Dental caries are also associated with poverty, poor cleaning of the mouth, and receding gums resulting in exposure of the roots of the teeth.JOURNAL, Schwendicke, F, Dörfer, CE, Schlattmann, P, Page, LF, Thomson, WM, Paris, S, Socioeconomic Inequality and Caries: A Systematic Review and Meta-Analysis, Journal of Dental Research, January 2015, 94, 1, 10–18, 25394849, 10.1177/0022034514557546, 24227334, Prevention of dental caries includes regular cleaning of the teeth, a diet low in sugar, and small amounts of fluoride. Brushing one's teeth twice per day, and flossing between the teeth once a day is recommended. Fluoride may be acquired from water, salt or toothpaste among other sources. Treating a mother's dental caries may decrease the risk in her children by decreasing the number of certain bacteria she may spread to them. Screening can result in earlier detection. Depending on the extent of destruction, various treatments can be used to restore the tooth to proper function, or the tooth may be removed. There is no known method to grow back large amounts of tooth.JOURNAL, Otsu, K, Kumakami-Sakano, M, Fujiwara, N, Kikuchi, K, Keller, L, Lesot, H, Harada, H, Stem cell sources for tooth regeneration: current status and future prospects, Frontiers in Physiology, 2014, 5, 36, 24550845, 10.3389/fphys.2014.00036, 3912331, free, The availability of treatment is often poor in the developing world. Paracetamol (acetaminophen) or ibuprofen may be taken for pain.Worldwide, approximately 3.6 billion people (48% of the population) have dental caries in their permanent teeth as of 2016.WEB,weblink Oral health, World Health Organization, en, 2019-09-14, The World Health Organization estimates that nearly all adults have dental caries at some point in time.WEB, Oral health Fact sheet N°318,weblink World Health Organization, 10 December 2014, April 2012, dead,weblink" title="web.archive.org/web/20141208132427weblink">weblink 8 December 2014, In baby teeth it affects about 620 million people or 9% of the population.JOURNAL, Vos, T, Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010, The Lancet, Dec 15, 2012, 380, 9859, 2163–96, 23245607, 6350784, 10.1016/S0140-6736(12)61729-2, They have become more common in both children and adults in recent years.JOURNAL, Bagramian, RA, Garcia-Godoy, F, Volpe, AR, The global increase in dental caries. A pending public health crisis, American Journal of Dentistry, February 2009, 22, 1, 3–8, 19281105, The disease is most common in the developed world due to greater simple sugar consumption, but less common in the developing world. Caries is Latin for "rottenness".BOOK, Taber's cyclopedic medical dictionary, 2013, F.A. Davis Co., Philadelphia, 978-0-8036-3909-6, 401, Ed. 22, illustrated in full color,weblink live,weblink 2015-07-13, {{TOC limit|3}}

Signs and symptoms

File:ToothMontage3.jpg|thumb|right|alt=Montage of four pictures: three photographs and one radiograph of the same tooth.|(A) A small spot of decay visible on the surface of a tooth. (B) The radiograph reveals an extensive region of demineralization within the dentin (arrows). (C) A hole is discovered on the side of the tooth at the beginning of decay removal. (D) All decay removed; ready for a filling.]]A person experiencing caries may not be aware of the disease.Health Promotion Board: Dental Caries {{Webarchive|url=https://web.archive.org/web/20100901014808weblink |date=2010-09-01 }}, affiliated with the Singapore government. Page accessed August 14, 2006. The earliest sign of a new carious lesion is the appearance of a chalky white spot on the surface of the tooth, indicating an area of demineralization of enamel. This is referred to as a white spot lesion, an incipient carious lesion, or a "micro-cavity".NEWS, A Closer Look at Teeth May Mean More Fillings,weblink November 30, 2011, The New York Times, November 28, 2011, Richie S. King, An incipient carious lesion is the initial stage of structural damage to the enamel, usually caused by a bacterial infection that produces tooth-dissolving acid., live,weblink" title="web.archive.org/web/20111129223056weblink">weblink November 29, 2011, As the lesion continues to demineralize, it can turn brown but will eventually turn into a cavitation ("cavity").  Before the cavity forms, the process is reversible, but once a cavity forms, the lost tooth structure cannot be regenerated.A lesion that appears dark brown and shiny suggests dental caries were once present, but the demineralization process has stopped, leaving a stain. Active decay is lighter in color and dull in appearance.Johnson, Clarke. "Biology of the Human Dentition {{webarchive|url=https://web.archive.org/web/20151030052831weblink |date=2015-10-30 }}." Page accessed July 18, 2007.As the enamel and dentin are destroyed, the cavity becomes more noticeable. The affected areas of the tooth change color and become soft to the touch. Once the decay passes through the enamel, the dentinal tubules, which have passages to the nerve of the tooth, become exposed, resulting in pain that can be transient, temporarily worsening with exposure to heat, cold, or sweet foods and drinks.{{MedlinePlusEncyclopedia|001055|Dental Cavities}} 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 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 sensitive to hot or cold but can be very tender to pressure.Dental caries can also cause bad breath and foul tastes.weblink" title="web.archive.org/web/20180630212354weblink">Tooth Decay, hosted on the New York University Medical Center website. Page accessed August 14, 2006. In highly progressed cases, an infection can spread from the tooth to the surrounding soft tissues. Complications such as cavernous sinus thrombosis and Ludwig angina can be life-threatening.Cavernous Sinus Thrombosis {{webarchive|url=https://web.archive.org/web/20080527163130weblink |date=2008-05-27 }}, hosted on WebMD. Page accessed May 25, 2008.{{MedlinePlusEncyclopedia|001047|Ludwig's Anigna}}Hartmann, Richard W. Ludwig's Angina in Children {{webarchive|url=https://web.archive.org/web/20080709045030weblink |date=2008-07-09 }}, hosted on the American Academy of Family Physicians website. Page accessed May 25, 2008.

Cause

(File:Dental caries etiology diagram.png|thumb|Diagrammatic representation of acidogenic theory of causation of dental caries. Four factors, namely, a suitable carbohydrate substrate (1), micro-organisms in dental plaque (2), a susceptible tooth surface (3) and time (4); must be present together for dental caries to occur (5). Saliva (6) and fluoride (7) are modifying factors.)Four things are required for caries to form: a tooth surface (enamel or dentin), caries-causing bacteria, fermentable carbohydrates (such as sucrose), and time.BOOK, Southam JC, Soames JV, 2. Dental Caries, Oral pathology, Oxford Univ. Press, Oxford, 1993, 978-0-19-262214-3, 2nd, This involves adherence of food to the teeth and acid creation by the bacteria that makes up the dental plaque.JOURNAL, Wong, Allen, Young, Douglas A., Emmanouil, Dimitris E., Wong, Lynne M., Waters, Ashley R., Booth, Mark T., 2013-06-01, Raisins and oral health, Journal of Food Science, 78, Suppl 1, A26–29, 10.1111/1750-3841.12152, 1750-3841, 23789933, free, However, these four criteria are not always enough to cause the disease and a sheltered environment promoting development of a cariogenic biofilm is required. The caries disease process does not have an inevitable outcome, and different individuals will be susceptible to different degrees depending on the shape of their teeth, oral hygiene habits, and the buffering capacity of their saliva. Dental caries can occur on any surface of a tooth that is exposed to the oral cavity, but not the structures that are retained within the bone.BOOK, Smith B, Pickard HM, Kidd EA, 1. Why restore teeth?, Pickard's manual of operative dentistry, Oxford University Press, 1990, 978-0-19-261808-5, 6th, Tooth decay is caused by biofilm (dental plaque) lying on the teeth and maturing to become cariogenic (causing decay). Certain bacteria in the biofilm produce acids, primarily lactic acid, in the presence of fermentable carbohydrates such as sucrose, fructose, and glucose.BOOK, Soro SA, Lamont RJ, Egland PG, Koo H, Liu Y, Molecular Medical Microbiology, Chapter 44-Dental caries, Elsevier, 2024, 978-0-12-818619-0, 10.1016/b978-0-12-818619-0.00036-8, 915–930, JOURNAL, Hardie JM, The microbiology of dental caries, Dental Update, 9, 4, 199–200, 202–4, 206–8, May 1982, 6959931, JOURNAL, Holloway PJ, The role of sugar in the etiology of dental caries, Journal of Dentistry, 11, 3, 189–213, September 1983, 10.1016/0300-5712(83)90182-3, Moore, W.J., 6358295, Caries occur more often in people from the lower end of the socio-economic scale than people from the upper end of the socio-economic scale, due to lack of education about dental care, and lack of access to professional dental care which may be expensive.Watt RG, Listl S, Peres MA, Heilmann A, editors. Social inequalities in oral health: from evidence to action {{webarchive|url=https://web.archive.org/web/20150619131928weblink |date=2015-06-19 }}. London: International Centre for Oral Health Inequalities Research & Policy; www.icohirp.com

Bacteria

File:Streptococcus mutans 01.jpg|right|thumb|alt=Refer to caption|A Gram stainGram stain{{See also|Oral ecology}}The most common bacteria associated with dental cavities are the mutans streptococci, most prominently Streptococcus mutans and Streptococcus sobrinus, and lactobacilli. However, cariogenic bacteria (the ones that can cause the disease) are present in dental plaque, but they are usually in too low concentrations to cause problems unless there is a shift in the balance.JOURNAL, Marsh, Philip D., Head, David A., Devine, Deirdre A., 2015, Dental plaque as a biofilm and a microbial community—Implications for treatment,weblink Journal of Oral Biosciences, 57, 4, 185–191, 10.1016/j.job.2015.08.002, 86407760,weblink 29 August 2021, Alt URL This is driven by local environmental change, such as frequent sugar intake or inadequate biofilm removal (toothbrushing).JOURNAL, Marsh, P, 1994, Microbial ecology of dental plaque and its significance in health and disease, Advances in Dental Research, 8, 2, 263–71, 10.1177/08959374940080022001, 7865085, 32327358, If left untreated, the disease can lead to pain, tooth loss and infection.Cavities/tooth decay {{webarchive|url=https://web.archive.org/web/20080315144137weblink |date=2008-03-15 }}, hosted on the Mayo Clinic website. Page accessed May 25, 2008.The mouth contains a wide variety of oral bacteria, but only a few specific species of bacteria are believed to cause dental caries: Streptococcus mutans and Lactobacillus species among them. Streptococcus mutans are gram-positive bacteria which constitute biofilms on the surface of teeth. These organisms can produce high levels of lactic acid following fermentation of dietary sugars and are resistant to the adverse effects of low pH, properties essential for cariogenic bacteria. As the cementum of root surfaces is more easily demineralized than enamel surfaces, a wider variety of bacteria can cause root caries, including Lactobacillus acidophilus, Actinomyces spp., Nocardia spp., and Streptococcus mutans. 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 than others, for example, sites with a low rate of salivary flow (molar fissures). Grooves on the occlusal surfaces of molar and premolar teeth provide microscopic retention sites for plaque bacteria, as do the interproximal sites. Plaque may also collect above or below the gingiva, where it is referred to as supra- or sub-gingival plaque, respectively.These bacterial strains, most notably S. mutans, can be inherited by a child from a caretaker's kiss or through feeding pre-masticated food.{{citation |journal=Pediatric Dentistry|date=Sep–Oct 2008 |volume=30 |number=5 |pages=375–87 |title=Association of mutans streptococci between caregivers and their children |last1=Douglass |first1=JM |last2=Li |first2=Y |last3=Tinanoff |first3=N.|pmid=18942596 }}

Dietary sugars

Bacteria in a person's mouth convert glucose, fructose, and most commonly sucrose (table sugar) into acids, mainly lactic acid, through a glycolytic process called fermentation. If left in contact with the tooth, these acids may cause demineralization, which is the dissolution of its mineral content. The process is dynamic, however, as remineralization can also occur if the acid is neutralized by saliva or mouthwash. Fluoride toothpaste or dental varnish may aid remineralization.JOURNAL, Silverstone LM, Remineralization and enamel caries: new concepts, Dental Update, 10, 4, 261–73, May 1983, 6578983, If demineralization continues over time, enough mineral content may be lost so that the soft organic material left behind disintegrates, forming a cavity or hole. The impact such sugars have on the progress of dental caries is called cariogenicity. Sucrose, although a bound glucose and fructose unit, is in fact more cariogenic than a mixture of equal parts of glucose and fructose. This is due to the bacteria using the energy in the saccharide bond between the glucose and fructose subunits. S.mutans adheres to the biofilm on the tooth by converting sucrose into an extremely adhesive substance called dextran polysaccharide by the enzyme dextran sucranase.Madigan M.T. & Martinko J.M. Brock â€“ Biology of Microorganisms. 11th Ed., 2006, Pearson, USA. pp. 705

Exposure

(File:Stephan curve.png|thumb|"Stephan curve", showing sudden decrease in plaque pH following glucose rinse, which returns to normal after 30–60 min. Net demineralization of dental hard tissues occurs below the critical pH (5.5), shown in yellow.)The frequency with which teeth are exposed to cariogenic (acidic) environments affects the likelihood of caries development.{{citation needed|date=February 2020}} After meals or snacks, the bacteria in 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 and the dissolved mineral content of tooth surfaces. During every exposure to the acidic environment, portions of the inorganic mineral content at the surface of teeth dissolve and can remain dissolved for two hours.Dental Caries {{webarchive|url=https://web.archive.org/web/20060630205712weblink |date=2006-06-30 }}, hosted on the University of California Los Angeles School of Dentistry website. Page accessed August 14, 2006. Since teeth are vulnerable during these acidic periods, the development of dental caries relies heavily on the frequency of acid exposure.The carious process can begin within days of a tooth's erupting into the mouth if the diet is sufficiently rich in suitable carbohydrates. Evidence suggests that the introduction of fluoride treatments has slowed the process.Summit, James B., J. William Robbins, and Richard S. Schwartz. "(iarchive:fundamentalsofop0002unse/page/75/mode/2up|Fundamentals of Operative Dentistry: A Contemporary Approach.)" 2nd edition. Carol Stream, Illinois, Quintessence Publishing Co, Inc, 2001, p. 75. {{ISBN|0-86715-382-2}}. Proximal caries take an average of four years to pass through enamel in permanent teeth. Because the cementum enveloping the root surface is not nearly as durable as the enamel encasing the crown, root caries tend to progress much more rapidly than decay on other surfaces. The progression and loss of mineralization on the root surface is 2.5 times faster than caries in enamel. In very severe cases where oral hygiene is very poor and where the diet is very rich in fermentable carbohydrates, caries may cause cavities within months of tooth eruption. This can occur, for example, when children continuously drink sugary drinks from baby bottles (see later discussion).

Teeth

(File:Blausen 0864 ToothDecay.svg|thumb|300px|Tooth decay)There are certain diseases and disorders affecting teeth that may leave an individual at a greater risk for cavities.Molar incisor hypo-mineralization seems to be increasingly common.JOURNAL, Mast P, Rodrigueztapia MT, Daeniker L, Krejci I, Understanding MIH: definition, epidemiology, differential diagnosis and new treatment guidelines, Sep 2013, European Journal of Paediatric Dentistry, 14, 3, 204–8,weblink 24295005, Review, live,weblink" title="web.archive.org/web/20161005114609weblink">weblink 2016-10-05, While the cause is unknown it is thought to be a combination of genetic and environmental factors.JOURNAL, Silva, Mihiri J., Scurrah, Katrina J., Craig, Jeffrey M., Manton, David J., Kilpatrick, Nicky, August 2016, Etiology of molar incisor hypomineralization â€” A systematic review, Community Dentistry and Oral Epidemiology, 44, 4, 342–353, 10.1111/cdoe.12229, 1600-0528, 27121068, 11343/291225, free, Possible contributing factors that have been investigated include systemic factors such as high levels of dioxins or polychlorinated biphenyl (PCB) in the mother's milk, premature birth and oxygen deprivation at birth, and certain disorders during the child's first 3 years such as mumps, diphtheria, scarlet fever, measles, hypoparathyroidism, malnutrition, malabsorption, hypo-vitaminosis D, chronic respiratory diseases, or undiagnosed and untreated coeliac disease, which usually presents with mild or absent gastrointestinal symptoms.JOURNAL, William V, Messer LB, Burrow MF, Molar incisor hypomineralization: review and recommendations for clinical management, 2006, Pediatric Dentistry, 28, 3, 224–32,weblink 16805354, Review, live,weblink" title="web.archive.org/web/20160306130920weblink">weblink 2016-03-06, WEB,weblink Dental Enamel Defects and Celiac Disease, National Institute of Health (NIH), Mar 7, 2016, Tooth defects that result from celiac disease may resemble those caused by too much fluoride or a maternal or early childhood illness. Dentists mostly say it's from fluoride, that the mother took tetracycline, or that there was an illness early on, live,weblink" title="web.archive.org/web/20160305124250weblink">weblink 2016-03-05, JOURNAL, Ferraz EG, Campos Ede J, Sarmento VA, Silva LR, The oral manifestations of celiac disease: information for the pediatric dentist, 2012, Pediatric Dentistry, 34, 7, 485–8, 23265166, Review, The presence of these clinical features in children may signal the need for early investigation of possible celiac disease, especially in asymptomatic cases. (...) Pediatric dentists must recognize typical oral lesions, especially those associated with nutritional deficiencies, and should suspect the presence of celiac disease, which can change the disease's course and patient's prognosis., JOURNAL, Rashid M, Zarkadas M, Anca A, Limeback H, Oral manifestations of celiac disease: a clinical guide for dentists, 2011, Journal of the Canadian Dental Association, 77, b39,weblink 21507289, Review, live,weblink" title="web.archive.org/web/20160308090224weblink">weblink 2016-03-08, JOURNAL, Giuca MR, Cei G, Gigli F, Gandini P, Oral signs in the diagnosis of celiac disease: review of the literature, 2010, Minerva Stomatologica, 59, 1–2, 33–43, 20212408, Review, Amelogenesis imperfecta, which occurs in 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.Neville, B.W., Damm, Douglas; Allen, Carl and Bouquot, Jerry (2002). "Oral & Maxillofacial Pathology." 2nd edition, p. 89. {{ISBN|0-7216-9003-3}}. In both cases, teeth may be left more vulnerable to decay because the enamel is not able to protect the tooth.Neville, B.W., Damm, Douglas; Allen, Carl and Bouquot, Jerry (2002). "Oral & Maxillofacial Pathology." 2nd edition, p. 94. {{ISBN|0-7216-9003-3}}.In most people, disorders or diseases affecting teeth are not the primary cause of dental caries. Approximately 96% of tooth enamel is composed of minerals.Nanci, p. 122 These minerals, especially hydroxyapatite, will become soluble when exposed to acidic environments. Enamel begins to demineralize at a pH of 5.5.JOURNAL, Dawes C, What is the critical pH and why does a tooth dissolve in acid?, Journal of the Canadian Dental Association, 69, 11, 722–4, December 2003, 14653937,weblink live,weblink" title="web.archive.org/web/20090714130336weblink">weblink 2009-07-14, Dentin and cementum are more susceptible to caries than enamel because they have lower mineral content.JOURNAL, Mellberg JR, Demineralization and remineralization of root surface caries, Gerodontology, 5, 1, 25–31, 1986, 10.1111/j.1741-2358.1986.tb00380.x, 3549537, Thus, when root surfaces of teeth are exposed from gingival recession or periodontal disease, caries can develop more readily. Even in a healthy oral environment, however, the tooth is susceptible to dental caries.The evidence for linking malocclusion and/or crowding to dental caries is weak;JOURNAL, 10.3109/00016357.2010.516732, Borzabadi-Farahani, A, Eslamipour, F, Asgari, I, Association between orthodontic treatment need and caries experience, Acta Odontologica Scandinavica, 69, 2–11, 2011, 20923258, 1, 25095059, JOURNAL, 22999666, 2012, Dental crowding as a caries risk factor: A systematic review, American Journal of Orthodontics and Dentofacial Orthopedics, 142, 4, 443–50, 10.1016/j.ajodo.2012.04.018, Hafez, HS, Shaarawy, SM, Al-Sakiti, AA, Mostafa, YA, however, the anatomy of teeth may affect the likelihood of caries formation. Where the deep developmental grooves of teeth are more numerous and exaggerated, pit and fissure caries is more likely to develop (see next section). Also, caries is more likely to develop when food is trapped between teeth.

Other factors

Reduced salivary flow rate is associated with increased caries since the buffering capability of saliva is not present to counterbalance the acidic environment created by certain foods. As a result, medical conditions that reduce the amount of saliva produced by salivary glands, in particular the submandibular gland and parotid gland, are likely to lead to dry mouth and thus to widespread tooth decay. Examples include Sjögren syndrome, diabetes mellitus, diabetes insipidus, and sarcoidosis.Neville, B. W., Douglas Damm, Carl Allen, Jerry Bouquot. Oral & Maxillofacial Pathology 2nd edition, 2002, p. 398. {{ISBN|0-7216-9003-3}}. Medications, such as antihistamines and antidepressants, can also impair salivary flow. Stimulants, most notoriously methylamphetamine, also occlude the flow of saliva to an extreme degree. This is known as meth mouth. Tetrahydrocannabinol (THC), the active chemical substance in cannabis, also causes a nearly complete occlusion of salivation, known in colloquial terms as "cotton mouth". Moreover, 63% of the most commonly prescribed medications in the United States list dry mouth as a known side-effect. Radiation therapy of the head and neck may also damage the cells in salivary glands, somewhat increasing the likelihood of caries formation.Oral Complications of Chemotherapy and Head/Neck Radiation {{webarchive|url=https://web.archive.org/web/20081206081959weblink |date=2008-12-06 }}, hosted on the National Cancer Institute {{webarchive|url=https://web.archive.org/web/20150312111454weblink |date=2015-03-12 }} website. Page accessed January 8, 2007.See Common effects of cancer therapies on salivary glands at WEB,weblink ADA â€” EBD::Systematic Reviews, 2013-07-30, dead,weblink" title="web.archive.org/web/20131202230733weblink">weblink 2013-12-02, Susceptibility to caries can be related to altered metabolism 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.Ralph R. Steinman & John Leonora (1971) "Relationship of fluid transport through dentation to the incidence of dental caries", Journal of Dental Research 50(6): 1536 to 43The use of tobacco may also increase the risk for caries formation. Some brands of smokeless tobacco contain high sugar content, increasing susceptibility to caries.Neville, B.W., Douglas Damm, Carl Allen, Jerry Bouquot. Oral & Maxillofacial Pathology 2nd edition, 2002, p. 347. {{ISBN|0-7216-9003-3}}. Tobacco use is a significant risk factor for periodontal disease, which can cause the gingiva to recede.Tobacco Use Increases the Risk of Gum Disease {{webarchive|url=https://web.archive.org/web/20070109123411weblink |date=2007-01-09 }}, hosted on the American Academy of Periodontology {{webarchive|url=https://web.archive.org/web/20051214140958weblink |date=2005-12-14 }}. Page accessed January 9, 2007. As the gingiva loses attachment to the teeth due to gingival recession, 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.Banting, D. W. "The Diagnosis of Root Caries {{webarchive|url=https://web.archive.org/web/20060930192216weblink |date=2006-09-30 }}." Presentation to the National Institute of Health Consensus Development Conference on Diagnosis and Management of Dental Caries Throughout Life, in pdf format, hosted on the National Institute of Dental and Craniofacial Research, p. 19. Page accessed August 15, 2006. Currently, there is not enough evidence to support a causal relationship between smoking and coronal caries, but evidence does suggest a relationship between smoking and root-surface caries.Executive Summary {{webarchive|url=https://web.archive.org/web/20070216060432weblink |date=2007-02-16 }} of U.S. Surgeon General's report titled, "The Health Consequences of Smoking: A Report of the Surgeon General," hosted on the CDC {{webarchive|url=https://web.archive.org/web/20120320214638weblink |date=2012-03-20 }} website, p. 12. Page accessed January 9, 2007.Exposure of children to secondhand tobacco smoke is associated with tooth decay.JOURNAL, Zhou, S, Rosenthal, DG, Sherman, S, Zelikoff, J, Gordon, T, Weitzman, M, Physical, behavioral, and cognitive effects of prenatal tobacco and postnatal secondhand smoke exposure, Current Problems in Pediatric and Adolescent Health Care, September 2014, 44, 8, 219–41, 25106748, 10.1016/j.cppeds.2014.03.007, 6876620, Intrauterine and neonatal lead exposure promote tooth decay.JOURNAL, 10.1177/00220345560350031401, Brudevold F, Steadman LT, The distribution of lead in human enamel, Journal of Dental Research, 35, 430–437, 1956, 13332147, 3, 5453470, JOURNAL, 10.1177/00220345770560100701, Brudevold F, Aasenden R, Srinivasian BN, Bakhos Y, Lead in enamel and saliva, dental caries and the use of enamel biopsies for measuring past exposure to lead, Journal of Dental Research, 56, 1165–1171, 1977, 272374, 10, 37185511, JOURNAL, Goyer RA, Transplacental transport of lead, Environmental Health Perspectives, 89, 101–105, 1990, 2088735, 10.2307/3430905, 1567784, 3430905, JOURNAL, Moss ME, Lanphear BP, Auinger P, Association of dental caries and blood lead levels, JAMA, 281, 24, 2294–8, 1999, 10386553, 10.1001/jama.281.24.2294, free, JOURNAL, Campbell JR, Moss ME, Raubertas RF, The association between caries and childhood lead exposure, Environmental Health Perspectives, 108, 1099–1102, 2000, 11102303, 10.2307/3434965, 11, 1240169, 3434965, JOURNAL, 10.1289/ehp.021100625, Gemmel A, Tavares M, Alperin S, Soncini J, Daniel D, Dunn J, Crawford S, Braveman N, Clarkson TW, McKinlay S, Bellinger DC, Blood Lead Level and Dental Caries in School-Age Children, Environmental Health Perspectives, 110, A625–A630, 2002, 12361944, 10, 1241049, JOURNAL, Billings RJ, Berkowitz RJ, Watson G, Teeth, Pediatrics, 113, 4, 1120–1127, 2004, 10.1542/peds.113.S3.1120, 15060208, Besides lead, all atoms with electrical charge and ionic radius similar to bivalent calcium,JOURNAL, Leroy N, Bres E, Structure and substitutions in fluorapatite, European Cells and Materials, 2, 36–48, 2001, 14562256, 10.22203/eCM.v002a05, free, such as cadmium, mimic the calcium ion and therefore exposure to them may promote tooth decay.JOURNAL, 10.1289/ehp.10947, Arora M, Weuve J, Schwartz J, Wright RO, Association of environmental cadmium exposure with pediatric dental caries, Environmental Health Perspectives, 116, 6, 821–825, 2008, 18560540, 2430240, Poverty is also a significant social determinant for oral health.JOURNAL, Dye B, 2010, Trends in Oral Health by Poverty Status as Measured by Healthy People 2010 Objectives, 21121227, Public Health Reports, 125, 6, 817–30, 2966663, 10.1177/003335491012500609, Dental caries have been linked with lower socio-economic status and can be considered a disease of poverty.JOURNAL, Selwitz R. H., Ismail A. I., Pitts N. B., 2007, Dental caries, The Lancet, 369, 9555, 51–59, 10.1016/s0140-6736(07)60031-2, 17208642, 204616785, Forms are available for risk assessment for caries when treating dental cases; this system using the evidence-based Caries Management by Risk Assessment (CAMBRA).weblink" title="web.archive.org/web/20150201181112weblink">ADA Caries Risk Assessment Form Completion Instructions. American Dental Association It is still unknown if the identification of high-risk individuals can lead to more effective long-term patient management that prevents caries initiation and arrests or reverses the progression of lesions.JOURNAL, Tellez, M., Gomez, J., Pretty, I., Ellwood, R., Ismail, A., Evidence on existing caries risk assessment systems: are they predictive of future caries?, Community Dentistry and Oral Epidemiology, 41, 1, 67–78, 22978796, 2013, 10.1111/cdoe.12003, Saliva also contains iodine and EGF. EGF results effective in cellular proliferation, differentiation and survival.JOURNAL, Herbst RS, Review of epidermal growth factor receptor biology, International Journal of Radiation Oncology, Biology, Physics, 59, 2 Suppl, 21–6, 2004, 15142631, 10.1016/j.ijrobp.2003.11.041, free, Salivary EGF, which seems also regulated by dietary inorganic iodine, plays an important physiological role in the maintenance of oral (and gastro-oesophageal) tissue integrity, and, on the other hand, iodine is effective in prevention of dental caries and oral health.JOURNAL, Venturi S, Venturi M, Iodine in evolution of salivary glands and in oral health, Nutrition and Health, 20, 2, 119–134, 2009, 19835108, 10.1177/026010600902000204, 25710052,

Pathophysiology

(File:Dental carries anaerobic fermentation.tiff|thumb|443x443px|Microbe communities attach to tooth surface and create a biofilm. As the biofilm grows an anaerobic environment forms from the oxygen being used. Microbes use sucrose and other dietary sugars as a food source. The dietary sugars go through anaerobic fermentation pathways producing lactate. The lactate is excreted from the cell onto the tooth enamel then ionizes. The lactate ions demineralize the hydroxyapatite crystals causing the tooth to degrade.)(File:Pit-and-Fissure-Caries-GIF.gif|thumb|150px|alt=Animated image showing the shape progression of a caries lesion in the fissure of a tooth.|The progression of pit and fissure caries resembles two triangles with their bases meeting along the junction of enamel and dentin.)Teeth are bathed in saliva and have a coating of bacteria on them (biofilm) that continually forms. The development of biofilm begins with pellicle formation. Pellicle is an acellular proteinaceous film which covers the teeth. Bacteria colonize on the teeth by adhering to the pellicle-coated surface. Over time, a mature biofilm is formed, creating a cariogenic environment on the tooth surface.BOOK, Dental caries : the disease and its clinical management,weblink limited, Blackwell Munksgaard, Fejerskov, Ole., Kidd, Edwina A. M., 2008, 978-1-4051-3889-5, 2nd, Oxford, 166–169, 136316302, BOOK, Pickard's manual of operative dentistry, Banerjee, Avijit., Watson, Timothy F., 2011, 978-0-19-100304-2, Ninth, Oxford, 2, 867050322, The minerals in the hard tissues of the teeth {{ndash}} enamel, dentin and cementum {{ndash}} are constantly undergoing demineralization and remineralization. Dental caries result when the demineralization rate is faster than the remineralization, producing net mineral loss, which occurs when there is an ecologic shift within the dental biofilm from a balanced population of microorganisms to a population that produces acids and can survive in an acid environment.Fejerskov O, Nyvad B, Kidd EA (2008) "Pathology of dental caries", pp 20–48 in Fejerskov O, Kidd EAM (eds) Dental caries: The disease and its clinical management. Oxford, Blackwell Munksgaard, Vol. 2. {{ISBN|1444309285}}.

Enamel

Tooth enamel is a highly mineralized acellular tissue, and caries act upon it through a chemical process brought on by the 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 the demineralization of crystals in the enamel, caused by acids, over time until the bacteria physically penetrate the dentin. Enamel rods, which are the basic unit of the enamel structure, run perpendicularly from the surface of the tooth to the dentin. Since demineralization of enamel by caries follows the direction of the enamel rods, the different triangular patterns between pit and fissure and smooth-surface caries develop in the enamel because the orientation of enamel rods are different in the two areas of the tooth.JOURNAL, Kidd EA, Fejerskov O, What constitutes dental caries? Histopathology of carious enamel and dentin related to the action of cariogenic biofilms, Journal of Dental Research, 83 Spec No C, C35–8, 2004, 15286119, 10.1177/154405910408301S07, 12240610, As the enamel loses minerals, and dental caries progresses, the enamel develops 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 surface zone.JOURNAL, Darling AI, Resistance of the enamel to dental caries, Journal of Dental Research, 42, 1 Pt2, 488–96, 1963, 14041429, 10.1177/00220345630420015601, 71450112, The translucent zone is the first visible sign of caries and coincides with a one to two percent loss of minerals.JOURNAL, Robinson C, Shore RC, Brookes SJ, Strafford S, Wood SR, Kirkham J, The chemistry of enamel caries, Critical Reviews in Oral Biology & Medicine, 11, 4, 481–95, 2000, 11132767, 10.1177/10454411000110040601, 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 alternating changes.Nanci, p. 121 The area of greatest demineralization 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.

Dentin

Unlike enamel, the dentin reacts to the progression of dental caries. After tooth formation, the ameloblasts, which produce enamel, are destroyed once enamel formation 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 mechanisms include the formation of sclerotic and tertiary dentin."Teeth & Jaws: Caries, Pulp, & Periapical Conditions {{webarchive|url=https://web.archive.org/web/20070506034332weblink |date=2007-05-06 }}," hosted on the University of Southern California School of Dentistry {{webarchive|url=https://web.archive.org/web/20051207020003weblink |date=2005-12-07 }} website. Page accessed June 22, 2007.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. The advancing front represents a zone of demineralized dentin 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 dentin. The zone of destruction has a more mixed bacterial population where proteolytic enzymes have destroyed the organic matrix. The innermost dentin caries has been reversibly attacked because the collagen matrix is not severely damaged, giving it potential for repair.(File:Smooth Surface Caries GIF.gif|thumb|150px|left|alt=Animated image showing the shape progression of a caries lesion in the cervical region of a tooth.|The faster spread of caries through dentin creates this triangular appearance in smooth surface caries.)

Sclerotic dentin

The structure of dentin is an arrangement of microscopic channels, called dentinal tubules, which radiate outward from the pulp chamber to the exterior cementum or enamel border.Ross, Michael H., Kaye, Gordon I. and Pawlina, Wojciech (2003) Histology: a text and atlas. 4th edition, p. 450. {{ISBN|0-683-30242-6}}. The diameter of the dentinal tubules is largest near the pulp (about 2.5 Î¼m) and smallest (about 900 nm) at the junction of dentin and enamel.Nanci, p. 166 The carious process continues through the dentinal tubules, which are responsible for the triangular patterns resulting from the progression of caries deep into the tooth. The tubules also allow caries to progress faster.In response, the fluid inside the tubules brings immunoglobulins from the immune system to fight the bacterial infection. At the same time, there is an increase of mineralization of the surrounding tubules.Summit, James B., J. William Robbins, and Richard S. Schwartz. Fundamentals of Operative Dentistry: A Contemporary Approach 2nd edition. Carol Stream, Illinois, Quintessence Publishing Co, Inc, 2001, p. 13. {{ISBN|0-86715-382-2}}. This results in a constriction of the tubules, which is an attempt to slow the bacterial progression. In addition, as the acid from the bacteria demineralizes the hydroxyapatite crystals, calcium and phosphorus are released, allowing for the precipitation of more crystals which fall deeper into the dentinal tubule. These crystals form a barrier and slow the advancement of caries. After these protective responses, the dentin is considered sclerotic.According to hydrodynamic theory, fluids within dentinal tubules are believed to be the mechanism by which pain receptors are triggered within the pulp of the tooth.JOURNAL, Dababneh RH, Khouri AT, Addy M, Dentine hypersensitivity â€“ an enigma? A review of terminology, mechanisms, aetiology and management, British Dental Journal, 187, 11, 606–11; discussion 603, December 1999, 16163281, 10.1038/sj.bdj.4800345a, Since sclerotic dentin prevents the passage of such fluids, pain that would otherwise serve as a warning of the invading bacteria may not develop at first.

Tertiary dentin

{{See also|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. 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.JOURNAL, Smith AJ, Murray PE, Sloan AJ, Matthews JB, Zhao S, Trans-dentinal stimulation of tertiary dentinogenesis, Advances in Dental Research, 15, 51–4, August 2001, 12640740, 10.1177/08959374010150011301, 7319363, If the odontoblasts 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, are thought to initiate the production of reparative dentin by fibroblasts and mesenchymal cells of the pulp.Summit, James B., J. William Robbins, and Richard S. Schwartz. "Fundamentals of Operative Dentistry: A Contemporary Approach." 2nd edition. Carol Stream, Illinois, Quintessence Publishing Co, Inc, 2001, p. 14. {{ISBN|0-86715-382-2}}. Reparative dentin is produced at an average of 1.5 Î¼m/day, but can be increased to 3.5 Î¼m/day. The resulting dentin contains irregularly 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.

Cementum

The incidence of cemental caries increases in older adults as gingival recession occurs from either trauma or periodontal 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 restorative challenges and increased tooth loss.Illustrated Embryology, Histology, and Anatomy, Bath-Balogh and Fehrenbach, Elsevier, 2011{{page needed|date=August 2014}}

Diagnosis

File:Dental explorer.png|100px|thumb|alt=Curved tip of a small metal probe, tapering to a point.|The tip of a dental explorerdental explorer(File:Dental infectionMark.png|thumb|A dental infection resulting in an abscess and inflammation of the maxillary sinus)(File:Lp473524f2 online.jpg|thumb|Tooth samples imaged with a non-coherent continuous light source (row 1), LSI (row 2) and pseudo-color visualization of LSI (row 3).)The presentation of caries is highly variable. However, the risk factors and stages of development are similar. Initially, it may appear as a small chalky area (smooth surface caries), which may eventually develop into a large cavitation. Sometimes caries may be directly visible. However other methods of detection such as X-rays are used for less visible areas of teeth and to judge the extent of destruction. Lasers for detecting caries allow detection without ionizing radiation and are now used for detection of interproximal decay (between the teeth).Primary diagnosis involves inspection of all visible tooth surfaces using a good light source, dental mirror and explorer. Dental radiographs (X-rays) may show dental caries before it is otherwise visible, in particular caries between the teeth. Large areas of dental caries are often apparent to the naked eye, but smaller lesions can be difficult to identify. Visual and tactile inspection along with radiographs are employed frequently among dentists, in particular to diagnose pit and fissure caries.Rosenstiel, Stephen F. Clinical Diagnosis of Dental Caries: A North American Perspective {{webarchive|url=https://web.archive.org/web/20060809104659weblink |date=2006-08-09 }}. Maintained by the University of Michigan Dentistry Library, along with the National Institutes of Health, National Institute of Dental and Craniofacial Research. 2000. Page accessed August 13, 2006. Early, uncavitated caries is often diagnosed by blowing air across the suspect surface, which removes moisture and changes the optical properties of the unmineralized enamel.Some dental researchers have cautioned against the use of dental explorers to find caries,Summit, James B., J. William Robbins, and Richard S. Schwartz. Fundamentals of Operative Dentistry: A Contemporary Approach 2nd edition. Carol Stream, Illinois, Quintessence Publishing Co, Inc, 2001, p. 31. {{ISBN|0-86715-382-2}}. in particular sharp ended explorers. In cases where a small area of tooth has begun demineralizing but has not yet cavitated, the pressure from the dental explorer could cause a cavity. Since the carious process is reversible before a cavity is present, it may be possible to arrest caries with fluoride and remineralize the tooth surface. When a cavity is present, a restoration will be needed to replace the lost tooth structure.At times, pit and fissure caries may be difficult to detect. Bacteria can penetrate the enamel to reach dentin, but then the outer surface may remineralize, especially if fluoride is present.JOURNAL, Zadik Yehuda, Bechor Ron, Hidden Occlusal Caries â€“ Challenge for the Dentist, The New York State Dental Journal, 74, 4, 46–50, June–July 2008,weblink 2008-08-08, 18788181, dead,weblink" title="web.archive.org/web/20110722002339weblink">weblink 2011-07-22, These caries, sometimes referred to as "hidden caries", will still be visible on X-ray radiographs, 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 including hypomineralization of the tooth and hypoplasia of the tooth.BOOK, Fejerskov, Ole, Nyvad, Bente, Kidd, Edwina, Dental Caries: The Disease and its Clinical Management, May 2015, John Wiley & Sons, Nashville, TN, 978-1-118-93582-8, 67, 3, The early carious lesion is characterized by demineralization of the tooth surface, altering the tooth's optical properties. Technology using laser speckle image (LSI) techniques may provide a diagnostic aid to detect early carious lesions.JOURNAL, Detection of early carious lesions using contrast enhancement with coherent light scattering (speckle imaging), Laser Physics, 23, 7, 10.1088/1054-660x/23/7/075607, A M, Deana, S H C, Jesus, N H, Koshoji, S K, Bussadori, M T, Oliveira, 075607, 2013, 2013LaPhy..23g5607D, 121571950,

Classification

File:GV-BLACK.JPG|right|thumb|alt=Chart showing digitally drawn images of caries locations and their associated classifications.| G. V. Black Classification of Restorations]]Caries can be classified by location, etiology, rate of progression, and affected hard tissues.BOOK, Sonis, Stephen T.,weblink Dental Secrets, Hanley & Belfus, 2003, 978-1-56053-573-7, 3rd, Philadelphia, 130, registration, These forms of classification can be used to characterize a particular case of tooth decay to more accurately represent the condition to others and also indicate the severity of tooth destruction. In some instances, caries is described in other ways that might indicate the cause. The G. V. Black classification is as follows:

• Class I: occlusal surfaces of posterior teeth, buccal or lingual pits on molars, lingual pit near cingulum of maxillary incisors
• Class II: proximal surfaces of posterior teeth
• Class III: interproximal surfaces of anterior teeth without incisal edge involvement
• Class IV: interproximal surfaces of anterior teeth with incisal edge involvement
• Class V: cervical third of facial or lingual surface of tooth
• Class VI: incisal or occlusal edge is worn away due to attrition

Early childhood caries

File:Suspectedmethmouth09-19-05closeup.jpg|right|thumb|alt=Photograph of teeth and gums on the lower right hand side of the mouth showing large caries lesions on all teeth at the level of the gum|Rampant caries caused by methamphetaminemethamphetamineEarly childhood caries (ECC), also known as "baby bottle caries," "baby bottle tooth decay" or "bottle rot," is a pattern of decay found in young children with their deciduous (baby) teeth. This must include the presence of at least one carious lesion on a primary tooth in a child under the age of 6 years.Sukumaran Anil. Early Childhood Caries: Prevalence, Risk Factors, and Prevention The teeth most likely affected are the maxillary anterior teeth, but all teeth can be affected.ADA Early Childhood Tooth Decay (Baby Bottle Tooth Decay) {{webarchive|url=https://web.archive.org/web/20060813180046weblink |date=2006-08-13 }}. Hosted on the American Dental Association website. Page accessed August 14, 2006. 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 sweetened liquids multiple times during the day.Statement on Early Childhood Caries, American Dental Association at WEB,weblink Statement on Early Childhood Caries, 2013-07-30, live,weblink" title="web.archive.org/web/20130512185623weblink">weblink 2013-05-12, Another pattern of decay is "rampant caries", which signifies advanced or severe decay on multiple surfaces of many teeth.Radiographic Classification of Caries {{webarchive|url=https://web.archive.org/web/20060823184853weblink |date=2006-08-23 }}. Hosted on the Ohio State University website. Page accessed August 14, 2006. Rampant caries may be seen in individuals with xerostomia, poor oral hygiene, stimulant use (due to drug-induced dry mouthADA Methamphetamine Use (METH MOUTH) {{webarchive|url=https://web.archive.org/web/20080601035323weblink |date=2008-06-01 }}. Hosted on the American Dental Association website. Page accessed February 14, 2007.), and/or large sugar intake. If rampant caries is a result of previous radiation to the head and neck, it may be described as radiation-induced caries. Problems can also be caused by the self-destruction of roots and whole tooth resorption when new teeth erupt or later from unknown causes.Children at 6–12 months are at increased risk of developing dental caries. For other children aged 12–18 months, dental caries develop on primary teeth and approximately twice yearly for permanent teeth.BOOK, Prevention and Management of Dental Caries in Children, Scottish Dental Clinical Effectiveness Programme, April 2010, 978-1-905829-08-8, Dundee Dental Education Centre, Frankland Building, Small's Wynd, Dundee DD1 4HN, Scotland, 11, A range of studies have reported that there is a correlation between caries in primary teeth and caries in permanent teeth.JOURNAL, 1747888, 1991, Helfenstein, U., Caries prediction on the basis of past caries including precavity lesions, Caries Research, 25, 5, 372–6, Steiner, M., Marthaler, T. M., 10.1159/000261394, JOURNAL, 10.1111/j.1600-0528.1989.tb00635.x, 2686924, Past caries recordings made in Public Dental Clinics as predictors of caries prevalence in early adolescence, Community Dentistry and Oral Epidemiology, 17, 6, 277–281, 1989, Seppa, Liisa, Hausen, Hannu, Pollanen, Lea, Helasharju, Kirsti, Karkkainen, Sakari,

Rate of progression

{{More citations needed section|date=November 2016}}Temporal descriptions can be applied to caries to indicate the progression rate and previous history. "Acute" signifies a quickly developing condition, whereas "chronic" describes a condition that has taken an extended time to develop, in which thousands of meals and snacks, many causing some acid demineralization that is not remineralized, eventually result in cavities.Recurrent caries, also described as secondary, are caries that appear at a location with a previous history of caries. This is frequently found on the margins of fillings and other dental restorations. On the other hand, incipient caries describes decay at a location that has not experienced previous decay. Arrested caries describes a lesion on a tooth that was previously demineralized but was remineralized before causing a cavitation. Fluoride treatment can help recalcification of tooth enamel as well as the use of amorphous calcium phosphate.Micro-invasive interventions (such as dental sealant or resin infiltration) have been shown to slow down the progression of proximal decay.JOURNAL, Dorri, Mojtaba, Dunne, Stephen M, Walsh, Tanya, Schwendicke, Falk, 2015-11-05, Micro-invasive interventions for managing proximal dental decay in primary and permanent teeth, Cochrane Database of Systematic Reviews, 2015, 11, CD010431, 10.1002/14651858.cd010431.pub2, 26545080, 8504982, 1465-1858,

Affected hard tissue

Depending on which hard tissues are affected, it is possible to describe caries as involving enamel, dentin, or cementum. Early in its development, caries may affect only enamel. Once the extent of decay reaches the deeper layer of dentin, the term "dentinal caries" is used. Since cementum is the hard tissue that covers the roots of teeth, it is not often affected by decay unless the roots of teeth are exposed to the mouth. Although the term "cementum caries" may be used to describe the decay on roots of teeth, very rarely does caries affect the cementum alone.

Prevention

File:Toothbrush 20050716 004.jpg|right|thumb|alt=Head of a toothbrush|ToothbrushToothbrush

Oral hygiene

The primary approach to dental hygiene care consists of tooth-brushing and flossing. The purpose of oral hygiene is to remove and prevent the formation of plaque or dental biofilm,Introduction to Dental Plaque {{webarchive|url=https://web.archive.org/web/20060623041937weblink |date=2006-06-23 }}. Hosted on the Leeds Dental Institute Website. Page accessed August 14, 2006. although studies have shown this effect on caries is limited.JOURNAL, Hujoel, Philippe Pierre, Hujoel, Margaux Louise A., Kotsakis, Georgios A., 2018, Personal oral hygiene and dental caries: A systematic review of randomised controlled trials, Gerodontology, en, 35, 4, 282–289, 10.1111/ger.12331, 29766564, 21697327, 1741-2358, free, While there is no evidence that flossing prevents tooth decay,JOURNAL, Sambunjak, Dario, Nickerson, Jason W, Poklepovic, Tina, Johnson, Trevor M, Imai, Pauline, Tugwell, Peter, Worthington, Helen V, 2011-12-07, Flossing for the management of periodontal diseases and dental caries in adults, Cochrane Database of Systematic Reviews, 12, CD008829, 10.1002/14651858.cd008829.pub2, 22161438, 70702223, 1465-1858, the practice is still generally recommended.JOURNAL, de Oliveira, KMH, Nemezio, MA, Romualdo, PC, da Silva, RAB, de Paula E Silva, FWG, Küchler, EC, Dental Flossing and Proximal Caries in the Primary Dentition: A Systematic Review, Oral Health & Preventive Dentistry, 2017, 15, 5, 427–434, 10.3290/j.ohpd.a38780, 28785751, A toothbrush can be used to remove plaque on accessible surfaces, but not between teeth or inside pits and fissures on chewing surfaces. When used correctly, dental floss removes plaque from areas that could otherwise develop proximal caries but only if the depth of sulcus has not been compromised. Additional aids include interdental brushes, water picks, and mouthwashes. The use of rotational electric toothbrushes might reduce the risk of plaque and gingivitis, though it is unclear whether they are of clinical importance.JOURNAL, 10.1002/14651858.cd004971.pub2, 21154357, Different powered toothbrushes for plaque control and gingival health, Cochrane Database of Systematic Reviews, 12, CD004971, 2010, Deacon, Scott A., Glenny, Anne-Marie, Deery, Chris, Robinson, Peter G., Heanue, Mike, Walmsley, A Damien, Shaw, William C., 2020, 8406707, However, oral hygiene is effective at preventing gum disease (gingivitis / periodontal disease). Food is forced inside pits and fissures under chewing pressure, leading to carbohydrate-fuelled acid demineralisation where the brush, fluoride toothpaste, and saliva have no access to remove trapped food, neutralise acid, or remineralise tooth enamel. (Occlusal caries accounts for between 80 and 90% of caries in children (Weintraub, 2001).) Unlike brushing, fluoride leads to proven reduction in caries incidence by approximately 25%; higher concentrations of fluoride (>1,000 ppm) in toothpaste also helps prevents tooth decay, with the effect increasing with concentration up to a plateau.JOURNAL, Walsh, Tanya, Worthington, Helen V., Glenny, Anne-Marie, Marinho, Valeria Cc, Jeroncic, Ana, 4 March 2019, Fluoride toothpastes of different concentrations for preventing dental caries, The Cochrane Database of Systematic Reviews, 3, 3, CD007868, 10.1002/14651858.CD007868.pub3, 1469-493X, 6398117, 30829399, A randomized clinical trial demonstrated that toothpastes that contain arginine have greater protection against tooth cavitation than the regular fluoride toothpastes containing 1450 ppm alone.JOURNAL, Kraivaphan, Petcharat, Amornchat, Cholticha, Triratana, T, Mateo, L.R., Ellwood, R, Cummins, Diane, Devizio, William, Zhang, Y-P, 2013-08-28, Two-Year Caries Clinical Study of the Efficacy of Novel Dentifrices Containing 1.5% Arginine, an Insoluble Calcium Compound and 1,450 ppm Fluoride,weblink Caries Research, 47, 6, 582–590, 10.1159/000353183, 23988908, 17683424, free, A Cochrane review has confirmed that the use of fluoride gels, normally applied by a dental professional from once to several times a year, assists in the prevention of tooth decay in children and adolescents, reiterating the importance of fluoride as the principal means of caries prevention.JOURNAL, Marinho, Valeria C. C., Worthington, Helen V., Walsh, Tanya, Chong, Lee Yee, 2015-06-15, Fluoride gels for preventing dental caries in children and adolescents, Cochrane Database of Systematic Reviews, 2021, 6, CD002280, 10.1002/14651858.CD002280.pub2, 1469-493X, 26075879, 7138249, Another review concluded that the supervised regular use of a fluoride mouthwash greatly reduced the onset of decay in the permanent teeth of children.JOURNAL, Marinho, Valeria C. C., Chong, Lee Yee, Worthington, Helen V., Walsh, Tanya, 2016-07-29, Fluoride mouthrinses for preventing dental caries in children and adolescents, Cochrane Database of Systematic Reviews, 7, 2, CD002284, 10.1002/14651858.CD002284.pub2, 1469-493X, 27472005, 6457869, Professional hygiene care consists of regular dental examinations and professional prophylaxis (cleaning). Sometimes, complete plaque removal is difficult, and a dentist or dental hygienist may be needed. Along with oral hygiene, radiographs may be taken at dental visits to detect possible dental caries development in high-risk areas of the mouth (e.g. "bitewing" X-rays which visualize the crowns of the back teeth).Alternative methods of oral hygiene also exist around the world, such as the use of teeth cleaning twigs such as miswaks in some Middle Eastern and African cultures. There is some limited evidence demonstrating the efficacy of these alternative methods of oral hygiene.JOURNAL, al-Khateeb TL, O'Mullane DM, Whelton H, Sulaiman MI, 2003, Periodontal treatment needs among Saudi Arabian adults and their relationship to the use of the Miswak, Community Dental Health, 8, 4, 323–328, 1790476, 0265-539X,

Dietary modification

File:Cavity numbers increase exponentially with sugar consumption.jpg|thumb|left|Annual caries incidence increases exponentially with annual per capita sugar consumption. Data based on 10,553 Japanese children whose individual lower first molar teeth were monitored yearly from the age of 6 to 11 years of age. Caries plotted on a logarithmic scale, so line is straight.]]People who eat more free sugars get more cavities, with cavities increasing exponentially with increasing sugar intake. Populations with less sugar intake have fewer cavities. In one population, in Nigeria, where sugar consumption was about 2g/day, only two percent of the population, of any age, had had a cavity.JOURNAL, Sheiham, A, James, WP, A new understanding of the relationship between sugars, dental caries and fluoride use: implications for limits on sugars consumption., Public Health Nutrition, October 2014, 17, 10, 2176–84, 10.1017/S136898001400113X, 24892213, 10282617, free, Chewy and sticky foods (such as candy, cookies, potato chips, and crackers) tend to adhere to teeth longer. However, dried fruits such as raisins and fresh fruit such as apples and bananas disappear from the mouth quickly, and do not appear to be a risk factor. Consumers are not good at guessing which foods stick around in the mouth.JOURNAL, Kashket, S., Van Houte, J., Lopez, L. R., Stocks, S., 1991-10-01, Lack of correlation between food retention on the human dentition and consumer perception of food stickiness, Journal of Dental Research, 70, 10, 1314–1319, 0022-0345, 1939824, 10.1177/00220345910700100101, 24467161, For children, the American Dental Association and the European Academy of Paediatric Dentistry recommend limiting the frequency of consumption of drinks with sugar, and not giving baby bottles to infants during sleep (see earlier discussion).WEB,weblink Nutrition and tooth decay in infancy, European Academy of Paediatric Dentistry, Kyriaki Tsinidou, 2019-04-06, Oral Health Topics: Baby Bottle Tooth Decay {{webarchive|url=https://web.archive.org/web/20060813180046weblink |date=2006-08-13 }}, hosted on the American Dental Association website. Page accessed August 14, 2006. Parents are also recommended to avoid sharing utensils and cups with their infants to prevent transferring bacteria from the parent's mouth.Guideline on Infant Oral Health Care {{webarchive|url=https://web.archive.org/web/20061206020725weblink |date=2006-12-06 }}, hosted on the American Academy of Pediatric Dentistry {{webarchive|url=https://web.archive.org/web/20070112073325weblink |date=2007-01-12 }} website. Page accessed January 13, 2007.Xylitol is a naturally occurring sugar alcohol that is used in different products as an alternative to sucrose (table sugar). As of 2015 the evidence concerning the use of xylitol in chewing gum was insufficient to determine if it is effective at preventing caries.JOURNAL, Twetman, S, The evidence base for professional and self-care prevention--caries, erosion and sensitivity, BMC Oral Health, 2015, 15, Suppl 1, S4, 26392204, 4580782, 10.1186/1472-6831-15-S1-S4, free, JOURNAL, Twetman, S, Dhar, V, Evidence of Effectiveness of Current Therapies to Prevent and Treat Early Childhood Caries, Pediatric Dentistry, 2015, 37, 3, 246–53, 26063553,weblink live,weblink" title="web.archive.org/web/20170328022551weblink">weblink 2017-03-28, JOURNAL, Riley P, Moore D, Ahmed F, Sharif MO, Worthington HV, March 2015, Xylitol-containing products for preventing dental caries in children and adults, Cochrane Database of Systematic Reviews, 2015, 3, CD010743, 10.1002/14651858.CD010743.pub2, 25809586, 9345289,

Other measures

(File:FluorideTrays07-05-05.jpg|thumb|alt=Refer to caption|Common dentistry trays used to deliver fluoride.)(File:Sodium fluoride tablets.jpg|thumb|Fluoride is sold in tablets for cavity prevention.)The use of dental sealants is a means of prevention.JOURNAL, Mejare I, Lingstrom P, Petersson LG, Holm AK, Twetman S, Kallestal C, Nordenram G, Lagerlof F, Soder B, Norlund A, Axelsson S, Dahlgren H, 2003, Caries-preventive effect of fissure sealants: a systematic review, Acta Odontologica Scandinavica, 61, 6, 321–330, 10.1080/00016350310007581, 14960003, 57252105, A sealant is a thin plastic-like coating applied to the chewing surfaces of the molars to prevent food from being trapped inside pits and fissures. This deprives resident plaque bacteria of carbohydrate, preventing the formation of pit and fissure caries. Sealants are usually applied on the teeth of children, as soon as the teeth erupt but adults are receiving them if not previously performed. Sealants can wear out and fail to prevent access of food and plaque bacteria inside pits and fissures and need to be replaced so they must be checked regularly by dental professionals. Dental sealants have been shown to be more effective at preventing occlusal decay when compared to fluoride varnish applications.JOURNAL, Ahovuo-Saloranta, Anneli, Forss, Helena, Hiiri, Anne, Nordblad, Anne, Mäkelä, Marjukka, 2016-01-18, Pit and fissure sealants versus fluoride varnishes for preventing dental decay in the permanent teeth of children and adolescents, The Cochrane Database of Systematic Reviews, 2016, 1, CD003067, 10.1002/14651858.CD003067.pub4, 1469-493X, 26780162, 7177291, {{Update inline|reason=Updated versionweblink|date = January 2021}}Calcium, as found in food such as milk and green vegetables, is often recommended to protect against dental caries. Fluoride helps prevent decay of a tooth by binding to the hydroxyapatite crystals in enamel.Nanci, p. 7 Streptococcus mutans is the leading cause of tooth decay. Low concentration fluoride ions act as bacteriostatic therapeutic agent and high concentration fluoride ions are bactericidal.JOURNAL, A, Deepti, Jeevarathan, J, Muthu, MS, Prabhu V, Rathna, Chamundeswari, 2008-01-01, Effect of Fluoride Varnish on Streptococcus mutans Count in Saliva of Caries Free Children Using Dentocult SM Strip Mutans Test: A Randomized Controlled Triple Blind Study, International Journal of Clinical Pediatric Dentistry, 1, 1, 1–9, 10.5005/jp-journals-10005-1001, 0974-7052, 4086538, 25206081, The incorporated fluorine makes enamel more resistant to demineralization and, thus, resistant to decay.Ross, Michael H., Kaye, Gordon I. and Pawlina, Wojciech (2003). Histology: A Text and Atlas. 4th edition, p. 453. {{ISBN|0-683-30242-6}}. Fluoride can be found in either topical or systemic form.JOURNAL, 10.1002/14651858.cd011850, Fluoride supplementation in pregnant women for preventing dental caries in the primary teeth of their children, Cochrane Database of Systematic Reviews, 8, CD011850, 2015, Takahashi, Rena, Ota, Erika, Hoshi, Keika, Naito, Toru, Toyoshima, Yoshihiro, Yuasa, Hidemichi, Mori, Rintaro, Mori, Rintaro, free, Topical fluoride is more highly recommended than systemic intake to protect the surface of the teeth.Limited evidence suggests fluoride varnish applied twice yearly is effective for caries prevention in children at WEB,weblink ADA â€” EBD::Systematic Reviews,weblink" title="web.archive.org/web/20131203023447weblink">weblink 2013-12-03, dead, 2013-07-30, Topical fluoride is used in toothpaste, mouthwash and fluoride varnish. Standard fluoride toothpaste (1,000–1,500 ppm) is more effective than low fluoride toothpaste (< 600ppm) to prevent dental caries.JOURNAL, Santos, A. P. P., Oliveira, B. H., Nadanovsky, P., 2013-01-01, Effects of low and standard fluoride toothpastes on caries and fluorosis: systematic review and meta-analysis, Caries Research, 47, 5, 382–390, 10.1159/000348492, 1421-976X, 23572031, 207625475, It is recommended that all adult patients to use fluoridated toothpaste with at least 1350ppm fluoride content, brushing at least 2 times per day and brush right before bed. For children and young adults, use fluoridated toothpaste with 1350ppm to 1500ppm fluoride content, brushing 2 times per day and also brush right before bed. American Dental Association Council suggest that for children ., in addition to the Egyptian civilization, had treatments for pain resulting from caries.