caries diagnosis · 2021. 2. 17. · • angmar-månsson and ten bosch, 1993 reviewed optical...

© Dr Julian Holmes 2011

caries diagnosis

research & clinical implications

Masters of Progressive Dentistry


• management of caries

• watch & wait – no longer an option

• failure to diagnose

• prevention & oral hygiene

• drill and fill (amputation)

• pharmaceutical management

research in dental care



which needs to be treated………


• dull / ‟etched‟ when dried

• leathery

• sharp probe will „stick‟

• shiny when dried

• hard (remineralised)

• sharp explorer will not „stick‟

caries – clinical signs

active infection or caries inactive / remineralised caries


clinical assessment

evaluate with clinical criteria

• dry tooth / lesion surface

• colour

• white / dark

• appearance

• dull / etched

• shiny

•lesion hardness

• soft / leathery / hard


• pre-ozone

• dull

• leathery

• post-ozone

• shiny

• hard, remineralised


clinical assessment



• colour – is this a valid criteria?

• white / dark

• appearance

• dull / etched

• shiny

•lesion hardness



• pre-ozone

• dull

• leathery

• post-ozone

• shiny



clinical assessment



• colour

• white / dark

• appearance

• dull / etched

• shiny

•lesion hardness



• pre-ozone

• dull

• leathery

• post-ozone

• shiny



• Caries is regularly found beneath a seemingly intact enamel surface

• Frequently the diagnosis of occlusal caries is less than straightforward

• Chan DCN. Current methods and criteria for finding decay in North America. J Dent Ed 57(6):422-425, 1993

research in dental careliterature overview:


• Brostek A

• Early diagnosis and minimally invasive treatment of occlusal caries--a clinical approach. Oral Health Prev Dent. 2004;2 Suppl 1:313-9.

• …diagnostic accuracy is important;

• it determines the quality of the treatment decisions made• the possibility of unnecessary operative intervention

• …there is a decrease in incidence of cavitated caries

• …common presentation of non-cavitated caries

• …accurate diagnosis more difficult.



~ diagnosis & evaluationthe historical face of dentistry


present dentistry

a low % of cavities initially present as cavitated


~ diagnosis & evaluation

these tools look for preventative & diagnosis failure

reversible early lesion cannot be found with this technology

the historical face of dentistry


• The reliability of carious lesion diagnosis by sharp explorer compared to diagnosis of carious lesion by histological cross section was 25%. A seemingly intact occlusal enamel surface may conceal an extensive lesion of the dentin

• Al-Sehaibany, White & Rainey, J Clin Pediatr Dent 20(4):293-298 1996



• Visual Inspection 49%

• Bitewing Rx 55%

• Electrical Conductance Measurement (ECM) 80-90%

• DIAGNOdent 71-94%

Reproducibility (in-vitro and in-vivo studies);

Lussi et al. 1993, 1995, 1999, 2001Attril 2001; Sheehy 2001; Heinrich 2002; Francescut 2003,

literature overview:research in dental care



present dentistry


• Tranaeus S, Shi XQ, Angmar-Mansson B.

• Caries risk assessment: methods available to clinicians for caries detection. Community Dent Oral Epidemiol. 2005 Aug;33(4):265-273.

• …occlusal lesions are initiated on the fissure walls and can therefore be obscured by sound superficial tissue.

• …one effect of regular use of fluorides is greater opacity of enamel, which may obscure underlying lesions in dentin, the so-called 'hidden lesions'.

• …dental radiographs are inadequate for detecting decay in the occlusal surfaces until the lesion is well advanced through the enamel and into the dentin.

• …the clinician relies on visual observation of texture and discoloration, clinical judgment based upon experience, and on tactile sense by probing with an explorer.



Enamel defects

in fissure wall

Decalcified or

hypocalcific

enamel (caries in

this zone is

undetectable by

probe)

De-mineralizing

dentin

modern fissure caries anatomy model


Not diagnosed by mirror, probe and x-ray examination

Photographs © Dr Graeme Milicich

caries diagnosis


• The reliability of carious lesion diagnosis by sharp explorer compared to diagnosis of carious lesion by histological cross section was 25%. A seemingly intact occlusal enamel surface may conceal an extensive lesion of the dentin

• Al-Sehaibany, White & Rainey, J Clin Pediatr Dent 20(4):293-298 1996




present dentistry

these tools look for preventative failure

impossible to „diagnose‟

reversible early lesion cannot be found with this technology


present dentistry~ diagnosis & evaluation


• Caries detector dye

• Digital imaging of radiographs

• Quantitative Light-induced Fluorescence (QLF)

• Laser fluorescence system (DIAGNOdent)

• Optical Caries Monitor (OCM)

• Near-Infra Red Spectroscopy (NIRS)

• Electrical Caries Monitor (ECM)

• Resilience Caries Monitor (RCM)



• Fusayama (1979) reported a typical caries detector consisting of 0.5% basic fuchsin or 1

% acid red solution in propylene glycol.

• Anderson et al, 1985; Kidd et al, 1993) showed that caries dyes does not necessarily

discriminate infected or sound tissues.

• Kidd et al, 1993 showed the use of dye may lead to over preparation of cavities at the

enamel-dentine junction.

• Yip et al, 1994 showed dyes tend to result in the removal of sclerotic (translucent) and

reparative dentine over the pulpal surface.




• Quantitative Light-induced Fluorescence

(QLF)







• Wenzel and Fejerskov reported on the potential advantages of image enhancement in

1992.

• A total of 124 third molars were radiographed in-vivo and then "captured" digitally using

a charge coupled device (CCD) video camera.

• The in-vitro histological appearances of these teeth were used as a "gold standard".

• The sensitivity and specificity of dentinal caries detection for the conventional

radiographs were 0.48 and 0.81, respectively.

• When these radiographs were digitally enhanced, the sensitivity and specificity became

0.71 and 0.85 respectively.





(QLF)







• Sundström et al, 1985 Teeth illuminated with a blue-violet light will emit green/yellow

light wit a wavelength of 488 nm, the wavelength most suitable for detection of initial

carious lesions.

• Angmar-Månsson and ten Bosch, 1993 reviewed optical methods for the quantification of

enamel caries.





(QLF)







• Lussi et al., 1999 - reported on a laser-based device (DIAGNOdent, KaVo, Biberach,

Germany) for detection of occlusal caries in-vitro and in-vivo.

• Shi et al., 2000 - diagnostic accuracy of DIAGNOdent to detect occlusal caries was

significantly better than that of radiography (p < 0.001) under in-vitro conditions.

• Shi et al., 2001- validation studies and studies on repeatability and reproducibility must

be performed in-vivo before large scale application of this device.

• Lussi et al., 2001 - reported a validation and comparison study on QLF and

DIAGNOdent for the quantification of smooth surface caries. The correlation with the

lesion depth was similar for the two methods tested (r = 0.85).





(QLF)







• measures volume-reflection of teeth in-vivo and in-vitro at two wavelengths at the same

time under daylight conditions.

• Brinkman et al, 1988 studied the OCM to quantify incipient smooth surface carious

lesions in-vivo. The system was validated against natural lesions in extracted teeth, and

the depth of these lesions and their mineral loss were measured by microradiography.

• The correlation coefficient between these two parameters was 0.96 and the correlation

between optical measurement and lesion depth 0.71.





(QLF)







• Borsboom and ten Bosch, 1983; ten Bosch et al, 1985; Mardones et al, 1999. the

application of Near Infra Red Spectroscopy (NIRS) is relatively new in the field of

dentistry. Optical scattering can be used to quantify the degree of demineralisation in

enamel and dentine.

• The degree of reflection of a tooth is determined by its local scattering, absorption and

fluorescent properties.

• In a sound tooth, scattering is more prominent than absorption. Both scattering and

absorption frequently occur along the light path in dentine but this is not seen in enamel.

• Mardones 2000 showed that NIRS was able to detect changes in water content of

demineralised enamel and dentine tissues.





(QLF)







• Pincus in 1951. described electrical conductance measurements in caries detection.

• Borsboom in 1997 developed ECM III (Lode Diagnostics BV, Holland). It measures the electrical

resistance of each carious lesion.

• The principle was described by White et al, 1978. Sound tooth tissue is a good insulator whereas

demineralised tooth tissue is a poor insulator as it contains large quantities of water. Hence, high

resistance measurements indicate well-mineralised tissue, whilst low resistance values are associated

with demineralised tissue.

• Flaitz et al, 1986, Gente & Wenz, 1991 demonstrated that there is a correlation between electrical

resistance and dentine thickness above the pulp; there is a strong correlation between lesion depth in

pits and electrical resistance of the lesions.

• In-vivo studies include White et al, 1981; Rock and Kidd, 1988; Verdonschot et al, 1992; Lussi et al,

1995; Ashley et al, 2000.





(QLF)







ECM

• measures porosity

~ clinical & lesion extent assessment

caries diagnosis


~ clinical & lesion extent assessment

ECM

• measures porosity

• caries extent / severity

caries diagnosis


• The RCM was developed as a diagnostic device to measure the resilience of the surface

layer of dentine providing a quantitative index of the surface texture (Prinz et al, 1998).

• The RCM data, so far exhibited, is shown to present two extreme conditions for root

dentine: (1) demineralised with remaining collagen and (2) sound/high mineral surface

layer or sound tissue. This RCM scale with the two extremes may be used for further

experiments to monitor artificial and natural conditions in the mouth.

• Broman (1999) demonstrated that the RCM was capable of detecting changes in dentine

after a 10 min immersion in 0.1 mM acetic acid, whereas tactile evaluation using a

conventional explorer was unable to detect these changes until a period of three weeks had

elapsed. These data indicate that the RCM is more sensitive than a visual-tactile method

(Prinz et al, 1999).





(QLF)







• González-Cabezas et al, (2001) demonstrated that the Electrical Caries Monitor

(ECM) had a higher specificity than the QLF and laser fluorescence system

(DIAGNOdent) for the detection of root caries in-vitro.

• DIAGNOdent showed higher sensitivity when compared to these detection

systems. These authors concluded that QLF, ECM, DIAGNOdent with visual

examination were equally accurate in detecting caries.

research in dental careliterature overview: conclusions




(QLF)







• Visual Inspection 49%

• Bitewing Rx 55%

• ElectricalConductanceMeasurement 80-90%

• DIAGNOdent 71-94%

Reproducibility (in-vitro and in-vivo studies)

• Attril 2001; Sheehy 2001; Heinrich 2002; Francescut 2003,

• Lussi et al, 1993, 1995, 1999, 2001.



• What works, is easy to use, and has a low learning curve?

• Laser Flourescence – DIAGNOdent, KaVo

research in dental careliterature overview: conclusions




(QLF)







KaVo DIAGNOdent

caries diagnosis

• measures fluorescence

• high correlation with the

ECM (Lode, Holland)

• validated index

Lussi A, Switzerland


caries diagnosis• new generation of DIAGNOdent

• occlusal caries detection

• inter-proximal detection

• integrated design

• wire-free

• rechargeable unit

BUT !• no patient inter-action

• ability to „teach‟ lost

• takes more time to

„map‟

• current research

• no in-vivo studies

• values not comparable

• no validated index

Krause F, Jepsen S, Braun A.

Comparison of two laser

fluorescence devices for the

detection of occlusal caries in vivo.

Eur J Oral Sci 2007; 115: 252–256

study.


what about ?~ diagnosis & evaluation; research results

Lussi A, Caries Research, 1999; 33, 297

DIAGNOdent values No action Prevention Record and monitor Sealant Drilling and filling

0-5

5-10

10-15

15-20

20-25

30+

caries diagnosis


~ diagnosis & evaluation; research results

Holmes J & Lynch E, 2001 (from Lussi A, Caries Research, 1999; 33, 297)

3+ mm into dentine CSI 5> 30Visible on X-rays -> DV

1-2mm into dentine CSI 425~29? visible on X-rays -> DV

at the edj CSI 320~24stain -> DV

confined to enamel CSI 210~19white spot -> DV

extent of carious lesionDIAGNOdent Values

a basic guide to the DIAGNOdent values & The CSI

caries diagnosis


© J

ulia

n H

olm

es 2

007

caries diagnosis


#16

#46

#26

#36

Diagnodent Record at Start

caries diagnosis


Decalcified or

hypocalcific

enamel

Organic plug

Acid percolation

through porous,

hypocalcific

enamel can lead to

failure of the

organic plug

modern fissure caries model


Continuing

decalcification

+dentin caries

Presentation is

inverted

compared to the

traditional

model

modern fissure caries model


Organic plug

(This area may

not be

decalcified

thus a probe

won‟t stick)

Enamel defects

in fissure wall

Decalcified or

hypocalcific

enamel (caries in

this zone is

undetectable by

probe)

De-mineralizing

dentin

modern fissure caries anatomy model(summary of realistic „coke bottle „ shape)


the DIAGNOdent can diagnose this zone in the fissure


As the lesion progresses, the

demineralization in the

enamel fissure walls

becomes more severe

This gives a higher reading,

but this is still not totally

predictive of the depth of the

dentin caries

DIAGNOdent readings


DIAGNOdent readings

Dentin caries developing

under enamel defects in the

depths of the fissure will

give lower readings because

of the thickness of the

overlying sound enamel

This is a form of “hidden

caries”


If a reading is obtained that

causes concern, yet there is

no visible evidence to

support the reading,

minimally invasive

techniques are essential

when investigating the

fissure

step down technique


Carefully open the fissure

entrance with air-abrasion

step down technique


Re scan the fissure. If the

reading drops, the enamel

damage was present in the

fissure opening. If the

reading remains constant, or

increases, there is caries

deeper in the fissure

complex.

step down technique


Sudden increase in reading while rotating

the tip in a fissure

If there is fissure caries

developing in one wall of a

fissure, the initial angulation

of the beam may completely

miss the lesion. As an

example, the reading at this

point the reading may only

be 5-10


As the beam approaches the

carious wall, the reading

will begin to increase




Once the beam is directed at

the lesion, there will be a

rapid increase in the

reading. The reading could

now be 30-40, yet there is

no external evidence of a

lesion.




Many of these lesions are

very localized and subtle

and if the fissure is not

entered with minimally

invasive techniques like Air-

abrasion, they will not be

observed and the reading

from the DIAGNOdent is

consequently discredited.






Readings that oscillate with

simple rotation of the tip are

generally very reliable. If

there was something present

in the fissure entrance to

cause a false positive, the

reading would remain

constantly high, rather than

oscillate with the rotation of

the tip


what do we know about caries?• sugar alone does not cause decay

• teeth must be present

• bacteria must be present

theories of decay

• debris and plaque is where decay starts

• lesions tend to develop over long time periods; up to several years

• over 450 species of bacteria can be found in the mature lesion

• complex interactions between plaque, bacterial colonies & host

• inoculation / immunisations for caries ?

- “multifactorial” -



decay – the chemistry of caries

– bacteria are present in the oral environment, and cover all surfaces of teeth

– there is a balance of mineral loss, and mineral uptake by the tooth surface

– the balance is altered by

– the buffering capacity of saliva

– the pH of the saliva, food, drinks

– the pH of the „normal‟ bacterial community

– the oral hygiene status

– systemic illnesses

– physical characteristics – crowded teeth, decreased ability to

maintain hygiene

– patient‟s choice – avoidance of fluoride tooth pastes.

the historical face of dentistrytheories of decay


decay – the chemistry of caries

– where the balance shifts towards acidic pH and debris collection

– these bacteria form a niche environment that leads to

predominantly acid forming bacteria

– this causes demineralisation of the surrounding enamel, and

dentine, leading to a cavity

– the cavity forms a protected environment for this bacterial colony

– oral hygiene, high-dose fluoride, chlorhexidine, chlorates, do not

RELIABLY prevent or reverse caries

– review in Holmes J Gerodontology 2003;Vol 20, No2, 106-114

the historical face of dentistrytheories of decay


~ prevention & oral hygienethe historical face of dentistry


theories of decay

the bad news for our patients!– recent research suggests fluoride delays the onset of

decay to late teens

– dentists are masters of the process of amputation of the

diseased tissue

– chemo-mechanical (Carisolv), air abrasion, diamond and metal

burs, lasers to dismantle teeth

– and then dentists place a filling that may need to be

replaced in 12-18 months



theories of decay

the good news for our patients!

– we do know that tooth tissue can remineralise in the right

environment, BUT it is unpredictable

– there are no studies that show remineralised areas of tooth

tissue subsequently being involved in further decay

– possible to prevent caries



• prevention or improved oral hygiene alone will not arrest or

reverse caries predictably

• Nyvad B, Fejerskov O. Active root surface caries

converted into inactive caries as a response to oral

hygiene. Scand J Dent Res 1986; 94: 281-284

• Papas A, Russell D, Singh M et al. Double blind clinical

trial of a remineralizing dentifrice in the prevention of

caries in a radiation therapy population. Gerodontology

1999; 16: 2-10



~ concepts of sealantsthe historical face of dentistry


• the key to predictability is the elimination of the acid niche

environment; bacteria and their bio-molecules

• Lynch E, Silwood CJL, Smith C, Grootveld M.

Oxidising actions of an Anti-Bacterial Ozone-

Generating Device towards Root Caries Biomolecules.

IADR Abstract 2002.

• Lynch E , Silwood CJ, Abu-Naba'A L, Al Shorman H,

Baysan A, Holmes J and Grootveld M. Oxidative

Consumption of Root Caries Biomolecules using

Ozone. IADR Abstract 2003.



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watch something

you have to be very sure of what

you are watching


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