Detection And Diagnosis of Dental

CariesPresented By:

1- Ghaith Abdulhadi2- Mahommed Naif

Supervision By:Dr. Mahammed H. Nabulsi

What is diagnosis?

Diagnosis is an art and science that results from the synthesis of scientific knowledge, clinical experience, intuition & common sense

Caries diagnosis implies deciding whether a lesion is active, progressing rapidly or slowly or whether is already arrested.

ASSESSMENT TOOLS

Stepwise progression toward diagnosis & treatment planning depends on thorough assessment of the following

Patient History

Clinical examination

Nutritional analysis

Salivary analysis

Radiographic assessment

HIGH RISK LOW RISK

Social History

Socially deprived

High caries in siblings

Low knowledge of caries

Middle class

Low caries in sibling

High dental aspirations

Medical History

Medically compromised

Xerostomia

Long-term cariogenic

medicine

No such problem

Dietary habits

Sugar intake: frequent Infrequent

HIGH RISK LOW RISK

Use of fluoride

Non-fluoridated area

No fluoride supplements

Fluoridated area

Fluoride supplements used

Plaque control

Poor oral hygiene

maintenance

Good oral hygiene

maintenance

Saliva

Low flow rate& buffering

capacity

S.mutans & lactobacillus

counts

Normal flow rate& buffering

capacity

S.mutans & lactobacillus

counts

CONVENTIONAL METHODS OF CARIES DETECTION

• VISUAL-TACTILE METHOD

• RADIOGRAPHY

• CARIES DETECTING DYES

• FIBEROPTIC TRANSILLUMINATION

• ELECTRONIC CARIES MONITOR

VISUAL-TACTILE METHODS

Visual 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

comfort, relatively inexpensive, available in various magnification

Use of temporary elective tooth separation

Tactile methods:

Explorers are widely used for the detection of carious tooth structure

Dental floss

Use of explorer is not advocated because;

Sharp tips physically damage small lesions with intact surfaces

Probing can cause fracture & cavitation of incipient lesion. It may spread the organism in the mouth

Mechanical binding may be due to non-carious reasons

Shape of fissure

Sharpness of explorer

Force of application

Path of explorer placement

Use of explorer

• Explorer is useful to remove plaque and debris and check the surface characteristics of suspected carious lesions.

• gentle pressure just required to blanch a fingernail without causing any pain or damage

• All surfaces of a tooth are cleaned of debris and plaque, using an air syringe and examined visually.

SMOOTH SURFACE CARIES

Non- 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.

not active non-cavitated carious lesions.

• Visual enamel opacity under sound marginal ridge indicate undermined enamel due to dental caries

Non-cavitated carious lesion

ENAMEL 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:

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.

Pit and Fissure Caries

Non-cavitated carious lesion

Enamel

Enamel

Dentin

Enamel

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

Cavitated Carious lesion

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 pressure

Active lesion

Questionable

Arrested Caries

• Arrested (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.

RADIOGRAPHY Carious lesions are detectable radiographically when

there has been enough demineralization to allow it to be differentiate from normal

They 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 radiographs

IOPA radiographs using paralleling technique

Dental 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.

Severe occlusal lesions:

Readily observed both clinically and radiographically

Appear as large cavities in the crowns of the teeth

However pulp exposure cannot be determined

PROXIMAL CARIES

Incipient lesions:

Commonly seen in the caries-susceptible zone

Presents as a notch on the outer surface not involving more than half of enamel

Density along the proximal surface is high

which does not permit the detection of loss of

small amounts of mineral content

Moderate proximal lesions:

Involve more than outer half of enamel but do not extend into DEJ

May have one of type of appearance:

67% - triangle with broad base towards outer surface

16% - a diffuse radiolucent image

17% - combination of both

Facial & Lingual Caries

They start as round lesions and enlarge to become elliptical or semilunar

ROOT SURFACE CARIES

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

Buccal, lingual, proximal

Ill-defined, saucer-like radiolucency

DYES FOR CARIES DETECTION

• They selectively complex with carious tooth structure which is later disclosed with the help of fluorescence

• Aids in both quantitative & qualitative analysis of the lesion

DYES 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 vivo

Brilliant blue: 10% aqueous Brilliant Blue, not used in vivo

DYES FOR DENTIN CARIES:

1% acid red 52 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 TRANSILLUMINATION

• Different 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

ELECTRIC MEASUREMENTS FOR CARIES

• First proposed by Magitot in 1878

• Tooth 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 systems

Vangaurd system – 25 Hz – ordinal scale of 0 –9

Caries meter L – 400 Hz – 4 colored lights

green –no caries yellow – enamel caries

orange – dentin caries red –pulp involvement

Factors affecting electrical measurements

1. Porosity

2. Surface area

3. Thickness of the tissues

4. Hydration of enamel

5. Temperature

6. Concentrations of ions in the dental tissue fluids

RECENT ADVANCES IN CARIES DETECTION

• Optical methods used are

Quantitative light- induced fluorescence- QLF™

Infrared laser fluorescence - DIAGNOdent

REFERENCES

• 1. Pitts NB. Clinical diagnosis of dental caries: a European perspective. Journal of Dental Education 2001; 65 (10):972–8.

•

• 2. Pitts NB. Diagnostic tools and measurements—impact on appropriate care. Community Dentistry and Oral Epidemiology 1997; 25 (1):24–35.

• 10. Pretty IA, Maupome G. A closer look at diagnosis in clinical dental practice. Part 1. Reliability, validity, specificity and sensitivity of diagnostic procedures. Journal of the Canadian Dental Association 2004; 370 (4):251–5.