PRESENTED BY: DR JOY DUTTA

INTRODUCTION

Diagnosis is the procedure of accepting a patient, recognizing that he has a problem, determining the cause of the problem and developing a treatment plan that will solve or alleviate the problem.

The art of distinguishing one disease from another (Dorland medical dictionary).

DEFINITIONASSESMENT TOOLSVISUAL TACTILE METHODRADIOGRAPHYXERORADIOGRAPHYDIGITAL IMAGINGSUBTRACTION RADIOGRAPHYCOMPUTER IMAGE ANALYSISDYES FOR CARIES DETECTIONELECTRIC MEASUREMENT FOR CARIES FIBEROPTIC TRANSILLUMINATIONCARIES ACTIVITY TESTSCARIOGRAM

CONTENTS:

“Dental caries is an irreversible microbial disease of the calcified tissues of the teeth, characterized by demineralization of the inorganic portion and destruction of the organic substance of the tooth, which often leads to cavitation.”

DEFINITION OF DENTAL CARIES:

SHAFER’S ORAL PATHOLOGY (5TH EDITION)

ASSESSMENT TOOLSStepwise progression toward diagnosis &

treatmentplanning depends on thorough assessment of theFollowing :Patient History Clinical examination Nutritional analysis Salivary analysis Radiographic assessment

HIGH RISKHIGH RISK LOW RISKLOW RISKSocial HistorySocial History

Socially deprivedSocially deprivedHigh caries in siblingsHigh caries in siblingsLow knowledge of cariesLow knowledge of caries

Middle class Middle class Low caries in siblingLow caries in siblingHigh dental aspirationsHigh dental aspirations

Medical HistoryMedical HistoryMedically compromisedMedically compromisedXerostomiaXerostomia

No such problemNo such problem

Dietary habitsDietary habits

Sugar intake: frequentSugar intake: frequent Infrequent Infrequent

HIGH RISKHIGH RISK LOW RISKLOW RISKUse of fluorideUse of fluoride

Non-fluoridated areaNon-fluoridated areaNo fluoride supplementsNo fluoride supplements

Fluoridated areaFluoridated areaFluoride supplements usedFluoride supplements used

Plaque controlPlaque controlPoor oral hygiene Poor oral hygiene maintenancemaintenance

Good oral hygiene Good oral hygiene maintenancemaintenance

SalivaSaliva

Low flow rate& buffering Low flow rate& buffering capacitycapacity S.mutans & lactobacillus S.mutans & lactobacillus countscounts

Normal flow rate& buffering Normal flow rate& buffering capacity capacity S.mutans & lactobacillus S.mutans & lactobacillus countscounts

HIGH RISKHIGH RISK LOW RISKLOW RISKClinical evidenceClinical evidence

New lesionsNew lesionsPremature extractionsPremature extractionsAnterior caries restorationsAnterior caries restorationsMultiple/repeated Multiple/repeated restorationsrestorationsNo fissure sealantsNo fissure sealantsMulti-band orthodonticsMulti-band orthodontics

No new lesionsNo new lesionsNo extraction for cariesNo extraction for cariesSound anterior teethSound anterior teethNo/few restorationsNo/few restorations

Fissure sealedFissure sealedNo appliancesNo appliances

CONVENTIONAL METHODS OF CARIES DETECTIONVISUAL-TACTILE METHODRADIOGRAPHYCARIES DETECTING DYESFIBEROPTIC TRANSILLUMINATIONELECTRONIC CARIES MONITOR

VISUAL-TACTILE METHODS

Detection of white spot, discoloration / frank cavitations

Magnification loupes- Head worn prism loupes (X 4.5) or surgical microscopes(X 16) may be used

comfortable, relatively inexpensive, available in various magnification

Use of temporary elective tooth separation

VISUAL METHOD:

Tactile method:

Explorers are widely used for the detection of carious tooth structure

- Right angled probe- no.6- Back action probe- no.17- Shepherd's crook- no. 23- Cowhorn with curved ends- no.2

Dental floss

RIGHT ANGLED PROBE

BACK ACTION PROBE

SHEPHERDS CROOK EXPLORER

COWHORN EXPLORER

Use of explorer is not advocated because;

Sharp tips physically damage small lesions with intact surfacesProbing can cause fracture & cavitation of

incipient lesion. It may spread the organism in the mouth

Mechanical binding may be due to non-carious reasons

Use of explorer • Explorer is useful to remove plaque

and debris and check the surface characteristics of suspected carious lesions.

• All surfaces of a tooth are cleaned of debris and plaque, using an air syringe and examined visually. Suspicious areas are explored to check for the surface texture.

SMOOTH SURFACE CARIESNon- cavitated:No signs of cavitation after visual or

tactile examination. Location: where dental plaque

accumulates (gingival margin).Surface characteristics: Matted (not

glossy) when a tooth is dried.

Non-cavitated carious lesionENAMEL DENTIN

Cavitated Lesions:Where there is visual breakdown of a tooth

surface, it is classified as cavitated carious lesion. An active cavity on a smooth surface has soft walls or floors shown below:

Questionable Area:All stained smooth coronal tooth surfaces

that do not have the characteristics of non-cavitated or cavitated lesions are classified as questionable shown below

Non-Carious Enamel Opacities

Opacity not fluorosis

Mild Fluorosis

Moderate Fluorosis

Severe Fluorosis

Caries in Pit or Fissure Surfaces All discolored areas should be explored using

gentle pressure. There is no need to penetrate a suspected lesion with an explorer.

If a discolored and non-cavitated area is soft when explored, it is recorded as non-cavitated carious pit or fissure.

A cavity is detected when there is an actual hole in the tooth in which an explorer could easily enter the space.

An active cavity has soft walls or floors (detected using gentle exploring).

If there is visual enamel opacity under an ostensibly sound or stained pit or fissure, then the enamel is undermined because of dental caries and the tooth surface is classified with a non-cavitated carious lesion in dentin.

Enamel

Enamel

Dentin

Enamel

If a discolored area is hard when gently explored then it should be marked as questionable.

Root Caries • Root surface caries comprises of a

continuum of changes ranging from minute discolored areas to cavitation that may extend into the pulp

For diagnostic purpose; they may be:Active root surface lesion:

• well-defined area showing yellowish or light brown discoloration

• covered by visible plaque• presence of softening/ leathery consistency on

probing with moderate pressure

Inactive root surface lesion (arrested):• well-defined dark brown/ black discoloration• smooth and shiny• hard on probing with moderate pressureActive lesion

Questionable

Arrested CariesArrested (remineralized) lesions can

be observed clinically as intact, but discolored, usually brown or black spots.

The change in color is presumably due to trapped organic debris and metallic ions within the enamel.

These discolored, remineralized lesions are intact and are highly resistant to subsequent caries . The arrested caries need not be removed.

Recurrent caries It is diagnosed whenever there is softness due

to caries at a defective margin, and when the tip of a periodontal probe can enter the defect without any resistance.

A restoration with a discolored margin or a small marginal ditch (<0.5 mm or the head of the probe) is recorded as an early recurrent carious area. A larger defect should be classified as advanced recurrent carious area

There are two valid indicators of recurrent (secondary) caries: • softness at the margin of a filling that is detected using an

explorer or • presence of a large defect (a minimum diameter of 0.4 mm) at

a margin of a filling with softness in the area. Large defects are associated with a high level of

colonization with cariogenic bacteria. Marginal discoloration by itself is not a valid sign for dental caries.

Advanced Recurrent Carious lesions

Nursing bottle caries Vs Rampant caries

Specific form of rampant cariesSpecific form of rampant caries Acute, widespread caries with Acute, widespread caries with early pulpal involvement of early pulpal involvement of teeth that are usually immune to teeth that are usually immune to decaydecay

Primary dentition affectedPrimary dentition affected Both dentitions affectedBoth dentitions affected

C/F: specific pattern- maxillary C/F: specific pattern- maxillary incisor incisor molarsmolarsMandibular incisors not affectedMandibular incisors not affected

Rapid appearance of new lesionsRapid appearance of new lesionsMandibular incisors also Mandibular incisors also affectedaffected

RADIOGRAPHYCarious lesions are detectable radiographically when there has been enough demineralization to allow it to be differentiate from normalThey are valuable in detecting proximal caries which may go undetected during clinical examination.On average they have around 50% to 70% sensitivity in detecting carious lesions. 40% demineralization is required for definitive decision on caries

Radiographic examinations include;Bitewing radiographsIOPA radiographs using paralleling techniqueDental panoramic tomograph

The two important decisions related to radiographic examination are (1) when to take a radiograph and (2) how to evaluate a radiograph for presence of signs of dental caries.

PIT & FISSURE PIT & FISSURE CARIESCARIES

Incipient occlusal lesions:Not very effective.Caries starts on the walls of the pits & fissures and tends to spread perpendicular to the DEJOnly detectable change is a fine gray shadow at the DEJ.

Moderate occlusal lesions:First to induce specific changes helping in a definitive diagnosisBroad based, thin radiolucent zone in dentin with minimal or no changes in enamelPresence of a band of increased opacity between the lesion and the pulp chamber due to calcification within primary dentinThis feature is not seen in buccal caries

Severe occlusal lesions:Readily observed both clinically and radiographicallyAppear as large cavities in the crowns of the teethHowever pulp exposure cannot be determined

PROXIMAL CARIES Density along the proximal surface is high which does not permit the detection of loss of small amounts of mineral content

Incipient lesions:Commonly seen in the caries-susceptible zone Presents as a notch on the outer surface not involving more than half of enamelDiagnosis can be missed, best viewed under a magnifying glass.

Moderate proximal lesions:Involve more than outer half of enamel but do not extend into DEJMay have one of type of appearance:67%6 - triangle with broad base towards outer surface16%1 - a diffuse radiolucent image17%1 - combination of both

Advanced proximal lesions:Radiolucent triangular cone invading into the dentinIn addition, it spreads along the DEJ and subsequently into dentinThis forms a 2nd cone with base at DEJDoes not involve more than half of dentinIn some cases, lesions penetrated into dentin may appear not to have penetrated enamel

Severe proximal lesions:Penetrating more than half of dentinNarrow path through enamel, an expanded radiolucency at DEJ, with a progress towards pulpLesions may or may not appear to involve pulpUndermined enamel fractures under masticatory load leaving a large cavity

Facial & Lingual CariesThey start as round lesions and

enlarge to become elliptical or semilunar

Presence of well defined non-carious enamel around radiolucency

When superimposed on DEJ, they may mimic occlusal caries

Clinical examination helps in definitive diagnosis

ROOT SURFACE CARIES

Also called cemental caries with an incidence of 40%- 70% of the aged population

Buccal, lingual, proximalUsually it is a lesion of dentin

associated with recessionIll-defined, saucer-like

radiolucency

RECURRENT CARIESOccurs immediately next to

restorationsResults from microleakage or

residual cariesIncidence- 16%

OTHER RADIOGRAPHIC SHADOWSRadiolucent Cervical Burn out:

- Evident at the neck of tooth well demarcated above by enamel cap& below by alveolar bone level

- It is triangular in shape being less apparent at the center of tooth

-good alveolar bone height will enhance cervical burn-out

Pitfalls Of Radiography2 dimensional view of 3 dimensional objectRadiographic depth of a lesion is often less than actual

depthOverlapping of proximal surfaces on a radiograph Occlusal (incipient) caries of enamel difficult to detectDental anomalies like hypoplastic pits mimic proximal

cariesCervical burnout often confused with root caries

XERORADIOGRAPHY It is similar to photocopy machineConsists of Aluminum plate coated with selenium which

provides a uniform electrostatic chargeX- rays selective discharge of particles Latent imageProcessing unit: Latent image positive imageVery good Edge enhancement i.e., differentiating areas with

different densitiesTwice more sensitive than D speed film, but equivalent to E

speed filmDisadvantages:

Electrostatic charge may cause patient discomfortProcessing to be completed by 15 minutes

DIGITAL IMAGINGA digital image is an image formed & represented by a

spatially distributed set of discrete sensors & pixels2 types of non- film receptors

Direct digital imaging – digital image receptorIndirect digital imaging – video camera for forming

digital images of a radiograph Two types of detectors are used in Direct digital imaging

Photostimulable phosphor ( PSP) –barium

fluorohalideCharged couple device (CCD) – silicon

Image is stored on a computer

DIGITAL IMAGING

Schick System Digora System Trophy System

Manipulation of images1. Magnification 2.Variable contrast 3. variable density 4. Labeling important information 5. Highlighting and colorization Advantages: 1.Images are available in seconds 2. Exposure is reduced 50-90% 3. Image size, contrast and density can be

manipulated to improve interpretation 4. Record keeping is vastly improved. All films are

labeled, filed and retrieved easily. Duplicate hard copies are the same as originals and simple to make

5. Provision of teletransmission

6. Devoloper and fixer solution not required.

SUBTRACTION RADIOGRAPHYStructured noise is reduced in order to increase the

detectablity of changes in the radiographStructured noise refers to the information on the

radiograph which have not diagnostic valueIt requires 2 identical images. The subtracted image

is a composite these two, representing a difference in their densities

Sensitive enough to detect changes of 0.12 mm90% accurate in detecting mineral loss of 5%Black end of gray scale suitable for proximal &

recurrent cariesContrast can be enhanced with color aid.

COMPUTER IMAGE ANALYSISSoftwares have been developed for automated

procedures which are able to overcome the short coming of human eye

Software supports an operation whereby a threshold is set up by the examiner which determines the program’s display of lesion probability

Tuned Aperture Computed Tomography (TACT) involve the tomosynthesis of structures in 3D thereby increasing the accurate detection of caries

Useful for monitoring carious lesionIncreased sensitivity but decreased specificity

DYES FOR CARIES DETECTIONThey selectively complex with carious tooth structure

which is later disclosed with the help of fluorescenceAids in both quantitative & qualitative analysis of the lesionDYES FOR ENAMEL CARIES:

Procion: N2 & (OH) groups irreversibly complex with caries Acts as a fixative

Calcein: complexes with calcium & remains bound to the tooth

Zyglo ZL-22: fluorescent tracer dye, not used in vivoBrilliant blue: 10% aqueous Brilliant Blue, not used in

vivo

DYES FOR DENTIN CARIES:1% acid red 0.2% in propylene glycol complexes

specifically with denatured collagen, hence used to differentiate infected and affected dentin

Iodine penetration method (Pot iodide) for evaluating enamel permeability

DISADVANTAGES• Dye staining and bacterial penetration are independent

phenomena, hence no actual quantification• They also stain food debris, enamel pellicle, other organic

matter• Dye aided carious removal- laborious • Stains DEJ

FIBEROPTIC TRANSILLUMINATIONDifferent index of light transmission

for decayed & sound tooth. Decayed tooth structure has decreased index & appears dark

The tooth is illuminated using fiberoptics

Have a high level intra & inter-examiner variability

Digital imaging FOTI introduced, images captured by a CCD camera & fed into the computer for image analysis

DIFOTI can detect caries on all types of teeth & also detect incipient & recurrent caries before their visibility on radiographs

ELECTRIC MEASUREMENTS FOR CARIESFirst proposed by Magitot in 1878Tooth demineralization due to

caries process causes increased porosity of tooth structure. This porosity contains fluid containing ions. This leads increased electrical conductivity, conversely, leads to decreased electrical resistance or impedance

ECM device uses a fixed-frequency (23 Hz)alternating current which measures ‘bulk resistance’ of tooth

Two systemsVangaurd system – 25 Hz – ordinal scale of 0 –9Caries meter L – 400 Hz – 4 colored lightsgreen –no caries yellow – enamel cariesorange – dentin caries red –pulp involvement

ECM limited to occlusal sites. Cannot be used where amalgam filling is present Materials have different responses at different

frequencies. Electrical Impedance Spectroscopy (EIS) operates over different frequencies & thus determine more accurately these differences. EIS can be used on both occlusal & proximal surfaces

Factors affecting electrical measurements1. Porosity2. Surface area3. Thickness of the tissues4. Hydration of enamel5. Temperature6. Concentrations of ions in the dental tissue fluids

RECENT ADVANCES IN CARIES DETECTIONResearch in the past two decades has lead to the

development of new technologies that asses changes in fluorescence of enamel & dentin due to loss of mineral

Benedict- 1929, normal teeth fluorescenceOptical methods used are

Quantitative light- induced fluorescence- QLF™

Infrared laser fluorescence - DIAGNOdent

•This is a laser fluorescence system that detects changes in the tooth structure due to demineralization•These structural changes cause an increase in the fluorescence at specific excitation wavelengths.•The intensity of the fluorescence depends upon the wavelength of the light as well as the structure and condition of hard dentinal tissues

DIAGNODENT

CARIES RISK ASSESSMENTClinical examination neither predicts

caries activity nor susceptibilityCertain simple reliable lab tests can

facilitate this,which is important because;- need & extent of personalized preventive measures - index for therapeutic measures- patient education- manage progress of restorative procedures- identify high risk groups / individuals

Requisites of testsCorrelation between predicted & actual

caries development Reliability & validity Simple to perform Quick results Measurement of mechanism involved in

caries process

Caries activity Vs Caries susceptibility Caries activity refers to the increment

of active lesions Susceptibility refers to inherent

propensity of the host & target tissue affected by caries

Most of the tests measures the former Caries activity tests measure either the

quantity of specific bacterial group or their ability to produce acids. Hence this must be coupled with clinical examination prior to treatment planning.

Caries Activity TestsLactobacillus colony count test:Introduced by Hadley in 1933Stimulated saliva collected & diluted with distilled

water. Spread evenly on Rogasa’s SL agar plate. Incubated at 37C for 3-4 days. No.of colonies developed counted

No.of org/ mlNo.of org/ ml Degree of caries Degree of caries activityactivity

0 – 10000 – 1000 Little / noneLittle / none1000 – 50001000 – 5000 SlightSlight

5000 – 10,0005000 – 10,000 ModerateModerate> 10,000> 10,000 markedmarked

Calorimetric Snyder test: Measures the ability of micro organisms to form

organic acids in carbohydrate 0.2 ml of patient’s saliva is pipetted into melted

medium at 50C. Incubated for 72 hrs. medium contains bromocresol green which changes color from green to yellow in the range of pH5.4 – 3.8

If yellowIf yellowMarked caries Marked caries activityactivity

If yellowIf yellowDefinite caries Definite caries activityactivity

If yellowIf yellowLimited caries Limited caries activityactivity

If greenIf greenObserve – 48hrsObserve – 48hrs

If greenIf greenObserve –72hrsObserve –72hrs

If greenIf greenCaries inactiveCaries inactive

24 hrs 48 hrs 72 hrs

Swab Test: Developed by Grainger in 1965 Based on the principle of Snyder test Swab is taken from the teeth & incubated in

medium pH change after 48 hrs is read on a pH meter

pH 4.1or lesspH 4.1or less Marked caries Marked caries activityactivity

pH 4.2 – 4.4pH 4.2 – 4.4 ActiveActive

pH 4.5 – 4.6pH 4.5 – 4.6 Slightly activeSlightly activepH 4.6 0r morepH 4.6 0r more Caries inactiveCaries inactive

Salivary buffer capacity: Tests the buffering capacity of bicarbonate ion in

saliva 2 ml of stimulated saliva + 4 ml of distilled water Set up is placed under paraffin seal to prevent loss

of volatile bicarbonate ion Micro-burette & micro glass electrode are

introduced under the seal & the amount of 0.5 N HCl required to bring saliva to pH 5 is measured

Samples requiring less than 0.45 ml of HCl indicate low buffering capacity & vice-versa

Alban test: Simplified substitute of Snyder test Alban test medium – 60 g Snyder test agar + 1 liter

water Patient to expectorate saliva in test tube containing

Alban test medium. Incubated at 37C upto 4 days Tubes are observed daily for:

- change of colour from green to yellow- depth in the medium to which change has occurred

Scale for scoring:color change is noted After 72 hrs/ 96 hrs of

incubation1. No color change2. Beginning of color change = +

(from top to bottom)

3. One half color change = ++4. ¾ color change = +++5. Total color change = ++++

Caries Susceptibility TestEnamel solubility test:When glucose is added to saliva containing powdered

enamel, organic acids are formed. This will decalcify enamel leading to an increase in soluble Ca ions

Amount of Ca obtained gives a direct measure of caries susceptibility

Salivary reductase test:Measures the activity of reductase enzyme in salivary

bacteriaKit commercially available- TreatexSalivary sample mixed with Diazoresorcinol dye

Color changes are tabulated after 15 min

ColorColor Caries Caries conducivenessconduciveness

Blue in 15 minBlue in 15 min Non- ConduciveNon- ConduciveOrchid in15 minOrchid in15 min Slightly ConduciveSlightly ConduciveRed in 15 minRed in 15 min Moderately Moderately

ConduciveConduciveRed immediately Red immediately on mixingon mixing

Highly ConduciveHighly Conducive

Colorless in 15 Colorless in 15 minmin

Extremely Extremely ConduciveConducive

CARIOGRAMIntroduced by Bratthall to assess factors contributing

to development of cariesConsists of a pie diagram divided into 5 sector

- Green – estimation of the chance to avoid caries- Dark blue – Diet- Red – bacteria- amt of plaque & S. mutans- Light Blue – Susceptibility- combination of F

program Saliva secretion & buffering capacity

- Yellow – Circumstances- past caries experience & related disease

CARIOGRAM

•The official journal of laser dentistry ,john DB featherston at al. 2008, vol 16•Bennett T. Amaechia et al. Emerging technologies for diagnosis of dental caries: The road so far, 2009.•N.K.Prabhakar at al. A review of modern non invasive Methods for caries diagnosis, AOSR 2011;1(3):168-177.

REFERENCE

•A review of caries detection technology :Jeffery B Price

•Traditional and Novel Caries Detection Methods, Michele Baffi Diniz at al.

•Clinical occlusal caries detection methods to use in thegeneral practice, Layla Nabaa at al.

.

THANK YOU