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Asymmetrical dental caries and Streptococcus mutans infection
C L IN IC A L
REPORT
Asymmetrical dental caries and Streptococcus mutans infection
Mona Svanberg, LDS Bo Krasse, LDS, O do n t Dr, G o te b o rg , S weden
A 27-year-old w om an chew ed u n ila te ra lly and had re s to ra tio n s and caries o n ly on th e rig h t side o f the d e n titio n . The le ft side had a g re a te r a m o u n t of so ft
Silicate restorations were recorded in the m axil lary right incisors and canines. A t the radiographic and clinical exam ination, one carious lesion on an unrestored surface and ten lesions on previously restored surfaces were recorded. T hirty-seven D M F S w ere recorded, all on the right side o f the dentition. V olum inous soft deposits on the occlusal surfaces and subgingival calculus w ere found on the teeth o f the left side. On the right side, only small am ounts of plaque on
and hard d e p o sits and m ore severe p e rio d o n ta l disease. P laque sam ples fro m o c clu sa l and interpro xim a l to o th surfa ce s w ere co lle cte d and c u l tu re d . The p ro p o rtio n o f S tre p to c o c c u s m u ta n s of th e to ta l a n a e ro b ic c o u n t in th e p la q ue sam ples fro m th e rig h t side was 1,000 to 10,000 tim e s as high as fro m th e le ft side. The p ro p o rtio n o f S m u ta n s of the to ta l s tre p to c o c c u s was 6% to 20% on th e rig h t and less than 1% on th e le ft side.
A 27-year-old wom an was referred to the dental school for crepitations and occasional pain in the right tem porom andibular joint. T he sym ptom s seem ed to be m uscular in origin, and no patholog ical changes of the joints w ere observed. T he patient avoided chewing on left side of the m outh, although a functional analysis showed that bilat eral occlusal contacts existed. D uring the p a tien t’s yearly visits to the dentist, restorations were placed on the right side only. A t recent vis its, subgingival calculus was rem oved only from the left side.
Report of case Amalgam restorations w ere found in all canines, prem olars, and m olars on the right side (Fig 1, 2).
Fig 1 ■ M axillary (top) and m andibular (bottom ) teeth showing restorations on rig h t side only. JADA, Vol. 96, June 1978 ■ 1025
C L IN IC A L
REPORT
Table 1 ■ Clinical observations on each side of the dentition. Function T e m porom andibular jo in t Caries Restorations DMFS Plaque Subgingival calculus, inte rpro xim ally Pocket depth, inte rpro xim ally
Right side
Left side
Chewing Pain and crepitations Present Present 37 Small am ounts only on cervi cal third Absent < 4 mm
No chewing No sym ptom s Absent Absent 0 V olum inous depo sits on all too th surfaces Present 4-6 mm
Table 2 ■ Proportional distribution of Streptococcus mutans in occlusal and approximal plaque from different parts of dentition. S mutans,% of total streptococci* P la q u e M axilla Occlusal Interproxim al M andible Occlusal Interproxim al
S. mutans,t % of total anaerobic counts
Left side
Right side
Left side
Right side
<1 <1
20 13
0.001 0.002
0.6 3.9
<1 <1
6 12
0.0003 0.02
3.3 3.8
'O n m itis salivarius agar. tO n m itis salivarius bacitracin agar. tO n blood agar after five days of incubation.
lected from the occlusal surfaces with hypoder mic needles and from the interproxim al surfaces with dental floss, show ed the values given in T able 2. O n the left side o f the p atien t’s m outh, the proportional distribution of S m utans was low, < 1% of total streptococci, representing 0.002% to 0.003% of the total anaerobic count. In the plaque from the right side, 6% to 20% o f the streptococci were S m utans. O f the total anaerobic count, S m utans was as high as 10,000 times m ore num er ous on the right side.
Fig 2 ■ M axillary (top) and m andibular (bottom ) teeth stained with d isclosin g so lu tio n to show heavy plaque on left side.
the cervical third o f the teeth were observed, and no hard subgingival deposits were found. The overall pocket depth, interproxim ally, was 4 mm on the right side, w hereas on the left side it varied betw een 4 and 6 mm. T he patient said she held her toothbrush in her left hand and was unaw are o f any difference in oral hygiene habits betw een the right and left sides of the m outh. D ental floss and toothpicks were never used. T he clinical findings are sum m arized in Table 1. ■ M icrobiological findings: U nstim ulated saliva show ed a concentration o f 106,000 Streptococcus m utans per milliliter. Pooled plaque sam ples, col1026 ■ JADA, Vol. 96, June 1978
THE AUTHORS
SVANBERG
KRASSE
Dr. Krasse is professor and head and Dr. Svanberg is c linical in stru cto r in the dep artm ent o f cariology, Faculty of O dontology, University of G öteborg, G öteborg 33, Sweden. Address re quests fo r reprints to Dr. Svanberg.
C L IN IC A L
Discussion D ental caries generally occurs sym m etrically,1 and m astication is considered to reduce the caries risk .2 In this patient, carious lesions and resto ra tions w ere found only on the right side in the teeth that w ere used for chewing. Periodontal disease is considered antagonistic to dental caries in that the oral environm ent as sociated with periodontal disease is not conducive to the developm ent o f caries, and vice v ersa.3 In this patient, dental caries was observed only on the right side; on the left side, the periodontal disease was m ore severe. M icrobiological exam ination show ed a high proportion o f S m utans in plaque m aterial from the teeth with caries or restorations, w hereas the proportion of these m icroorganism s was very low in plaque m aterial from the teeth w ithout caries. O bservations indicate that 5 m utans colonizes on the teeth in a highly localized m anner and does not spread rapidly. W hen culturing plaque m ate rial over a long tim e, S m utans was consistently recovered from certain tooth sites, but not from others in the sam e oral environm ent.4 A fter im plantation o f streptom ycin-resistant S m u ta n s, the im planted organism s spread from the im plan tation sites to nearby areas but only occasionally to areas farther aw ay.5,6 Sterile artificial occlusal fissures are preferentially colonized by S m utans from infected teeth adjacent to these fissu res.6 S m utans has often been associated with the developm ent o f ca ries.7 T he observations m ade on this patient indicate that the rem arkable caries situation could be the effect o f a highly localized S m utans infection. T hese observations also sup port the view that 5 m utans can induce dental caries in hum ans. T h e patient has received dental care on a yearly basis for a long time. T he therapy was confined to
REPORT
restorations on the right side and rem oval o f cal culus on the left. T he efforts to reduce o r elimi nate the infection o f pathogenic m icroorganism s apparently w ere insufficient. In consequence, re peated relapses occurred. T he case is an interest ing illustration o f conventional dental treatm ent which is mainly sym ptom atic-oriented and sel dom directed against the cause of the disease.
Sum m ary A ease has been reported in which dental caries w as observed only on the right side o f the p a tien t’s m outh. Periodontal disease was m ore se vere on the left than on the right side. A high proportion o f 5 m utans w as found in plaque m ate rial from the teeth with cavities and restorations, w hereas a low proportion of S m utans w as found in the teeth w ithout caries. T he observations indicate that the rem arkable caries situation could be the effect o f a highly localized S m utans infection. 1. Finn, S.B. Prevalence of dental caries. A survey of the litera ture of dental caries. Publication 225, Washington, DC, National Academy of Science, 1952, p 117. 2. Klatsky, M. A comparative analysis of masticatory function and its relation to dental disease In ancient and in modern man. JADA 24:932 June 1937. 3. Burnett, G.W., and Sherp, H.W. Oral microbiology and infec tious disease: a textbook for students and practitioners of den tistry. Baltimore, Williams & Wilkins, 1968, p 414. 4. DePaola, P.F.; Spinell, D.M.; and Skobe, Z. Interdental lo calization of S trep tococcus m utans as related to dental caries experience. Infect Immun 9:481, 1974. 5. Edman, D.C., and others. Dental floss for implantation and sampling of S treptococcus m utans from approximal surfaces of human teeth. Arch Oral Biol 20:145 Feb 1975. 6. Svanberg, M., and Loesche, W.J. Intraoral spread of S trep tococcus m utans in humans. Arch Oral Biol, to be published. 7. Gibbons, R.J., and van Houte, J. Dental caries. Annu Rev Med 26:121, 1975.
Svanberg— Krasse: ASYMMETRICAL CARIES AND INFECTION ■ 1027
REPORT
Asymmetrical dental caries and Streptococcus mutans infection
Mona Svanberg, LDS Bo Krasse, LDS, O do n t Dr, G o te b o rg , S weden
A 27-year-old w om an chew ed u n ila te ra lly and had re s to ra tio n s and caries o n ly on th e rig h t side o f the d e n titio n . The le ft side had a g re a te r a m o u n t of so ft
Silicate restorations were recorded in the m axil lary right incisors and canines. A t the radiographic and clinical exam ination, one carious lesion on an unrestored surface and ten lesions on previously restored surfaces were recorded. T hirty-seven D M F S w ere recorded, all on the right side o f the dentition. V olum inous soft deposits on the occlusal surfaces and subgingival calculus w ere found on the teeth o f the left side. On the right side, only small am ounts of plaque on
and hard d e p o sits and m ore severe p e rio d o n ta l disease. P laque sam ples fro m o c clu sa l and interpro xim a l to o th surfa ce s w ere co lle cte d and c u l tu re d . The p ro p o rtio n o f S tre p to c o c c u s m u ta n s of th e to ta l a n a e ro b ic c o u n t in th e p la q ue sam ples fro m th e rig h t side was 1,000 to 10,000 tim e s as high as fro m th e le ft side. The p ro p o rtio n o f S m u ta n s of the to ta l s tre p to c o c c u s was 6% to 20% on th e rig h t and less than 1% on th e le ft side.
A 27-year-old wom an was referred to the dental school for crepitations and occasional pain in the right tem porom andibular joint. T he sym ptom s seem ed to be m uscular in origin, and no patholog ical changes of the joints w ere observed. T he patient avoided chewing on left side of the m outh, although a functional analysis showed that bilat eral occlusal contacts existed. D uring the p a tien t’s yearly visits to the dentist, restorations were placed on the right side only. A t recent vis its, subgingival calculus was rem oved only from the left side.
Report of case Amalgam restorations w ere found in all canines, prem olars, and m olars on the right side (Fig 1, 2).
Fig 1 ■ M axillary (top) and m andibular (bottom ) teeth showing restorations on rig h t side only. JADA, Vol. 96, June 1978 ■ 1025
C L IN IC A L
REPORT
Table 1 ■ Clinical observations on each side of the dentition. Function T e m porom andibular jo in t Caries Restorations DMFS Plaque Subgingival calculus, inte rpro xim ally Pocket depth, inte rpro xim ally
Right side
Left side
Chewing Pain and crepitations Present Present 37 Small am ounts only on cervi cal third Absent < 4 mm
No chewing No sym ptom s Absent Absent 0 V olum inous depo sits on all too th surfaces Present 4-6 mm
Table 2 ■ Proportional distribution of Streptococcus mutans in occlusal and approximal plaque from different parts of dentition. S mutans,% of total streptococci* P la q u e M axilla Occlusal Interproxim al M andible Occlusal Interproxim al
S. mutans,t % of total anaerobic counts
Left side
Right side
Left side
Right side
<1 <1
20 13
0.001 0.002
0.6 3.9
<1 <1
6 12
0.0003 0.02
3.3 3.8
'O n m itis salivarius agar. tO n m itis salivarius bacitracin agar. tO n blood agar after five days of incubation.
lected from the occlusal surfaces with hypoder mic needles and from the interproxim al surfaces with dental floss, show ed the values given in T able 2. O n the left side o f the p atien t’s m outh, the proportional distribution of S m utans was low, < 1% of total streptococci, representing 0.002% to 0.003% of the total anaerobic count. In the plaque from the right side, 6% to 20% o f the streptococci were S m utans. O f the total anaerobic count, S m utans was as high as 10,000 times m ore num er ous on the right side.
Fig 2 ■ M axillary (top) and m andibular (bottom ) teeth stained with d isclosin g so lu tio n to show heavy plaque on left side.
the cervical third o f the teeth were observed, and no hard subgingival deposits were found. The overall pocket depth, interproxim ally, was 4 mm on the right side, w hereas on the left side it varied betw een 4 and 6 mm. T he patient said she held her toothbrush in her left hand and was unaw are o f any difference in oral hygiene habits betw een the right and left sides of the m outh. D ental floss and toothpicks were never used. T he clinical findings are sum m arized in Table 1. ■ M icrobiological findings: U nstim ulated saliva show ed a concentration o f 106,000 Streptococcus m utans per milliliter. Pooled plaque sam ples, col1026 ■ JADA, Vol. 96, June 1978
THE AUTHORS
SVANBERG
KRASSE
Dr. Krasse is professor and head and Dr. Svanberg is c linical in stru cto r in the dep artm ent o f cariology, Faculty of O dontology, University of G öteborg, G öteborg 33, Sweden. Address re quests fo r reprints to Dr. Svanberg.
C L IN IC A L
Discussion D ental caries generally occurs sym m etrically,1 and m astication is considered to reduce the caries risk .2 In this patient, carious lesions and resto ra tions w ere found only on the right side in the teeth that w ere used for chewing. Periodontal disease is considered antagonistic to dental caries in that the oral environm ent as sociated with periodontal disease is not conducive to the developm ent o f caries, and vice v ersa.3 In this patient, dental caries was observed only on the right side; on the left side, the periodontal disease was m ore severe. M icrobiological exam ination show ed a high proportion o f S m utans in plaque m aterial from the teeth with caries or restorations, w hereas the proportion of these m icroorganism s was very low in plaque m aterial from the teeth w ithout caries. O bservations indicate that 5 m utans colonizes on the teeth in a highly localized m anner and does not spread rapidly. W hen culturing plaque m ate rial over a long tim e, S m utans was consistently recovered from certain tooth sites, but not from others in the sam e oral environm ent.4 A fter im plantation o f streptom ycin-resistant S m u ta n s, the im planted organism s spread from the im plan tation sites to nearby areas but only occasionally to areas farther aw ay.5,6 Sterile artificial occlusal fissures are preferentially colonized by S m utans from infected teeth adjacent to these fissu res.6 S m utans has often been associated with the developm ent o f ca ries.7 T he observations m ade on this patient indicate that the rem arkable caries situation could be the effect o f a highly localized S m utans infection. T hese observations also sup port the view that 5 m utans can induce dental caries in hum ans. T h e patient has received dental care on a yearly basis for a long time. T he therapy was confined to
REPORT
restorations on the right side and rem oval o f cal culus on the left. T he efforts to reduce o r elimi nate the infection o f pathogenic m icroorganism s apparently w ere insufficient. In consequence, re peated relapses occurred. T he case is an interest ing illustration o f conventional dental treatm ent which is mainly sym ptom atic-oriented and sel dom directed against the cause of the disease.
Sum m ary A ease has been reported in which dental caries w as observed only on the right side o f the p a tien t’s m outh. Periodontal disease was m ore se vere on the left than on the right side. A high proportion o f 5 m utans w as found in plaque m ate rial from the teeth with cavities and restorations, w hereas a low proportion of S m utans w as found in the teeth w ithout caries. T he observations indicate that the rem arkable caries situation could be the effect o f a highly localized S m utans infection. 1. Finn, S.B. Prevalence of dental caries. A survey of the litera ture of dental caries. Publication 225, Washington, DC, National Academy of Science, 1952, p 117. 2. Klatsky, M. A comparative analysis of masticatory function and its relation to dental disease In ancient and in modern man. JADA 24:932 June 1937. 3. Burnett, G.W., and Sherp, H.W. Oral microbiology and infec tious disease: a textbook for students and practitioners of den tistry. Baltimore, Williams & Wilkins, 1968, p 414. 4. DePaola, P.F.; Spinell, D.M.; and Skobe, Z. Interdental lo calization of S trep tococcus m utans as related to dental caries experience. Infect Immun 9:481, 1974. 5. Edman, D.C., and others. Dental floss for implantation and sampling of S treptococcus m utans from approximal surfaces of human teeth. Arch Oral Biol 20:145 Feb 1975. 6. Svanberg, M., and Loesche, W.J. Intraoral spread of S trep tococcus m utans in humans. Arch Oral Biol, to be published. 7. Gibbons, R.J., and van Houte, J. Dental caries. Annu Rev Med 26:121, 1975.
Svanberg— Krasse: ASYMMETRICAL CARIES AND INFECTION ■ 1027