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Incipient Carious Lesion Dr. Akash Ardeshana1st year MDS

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Content IntroductionDefinition Clinical featuresZone of incipient cariesDiagnosis Management

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IntroductionThe initial enamel lesion results from an

imbalance between the processes of demineralisation and remineralisation.

The first changes in enamel appear at those sites where there is plaque biofilm retention and stagnation.

The demineralisation alters the enamel surface, which becomes micro-porous, and with an opaque and matt appearance, characteristic of a white spot lesion.

Roberson T, Heymann H, Swift E. Sturdevant’ Art and Science of Operative dentistry fifth edition 2006.

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DefinitionThe 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.

Roberson T, Heymann H, Swift E. Sturdevant’ Art and Science of Operative dentistry fifth edition 2006.

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Clinical FeaturesCare must be exercised to distinguish

white spots of incipient caries from developmental white spot hypocalcifications of enamel.

Incipient caries will partially or totally disappear visually when the enamel is hydrated (wet), while hypocalcified enamel is relatively unaffected by drying and wetting

Roberson T, Heymann H, Swift E. Sturdevant’ Art and Science of Operative dentistry fifth edition 2006.

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The surface texture of an incipient lesion is unaltered and is undetectable by tactile examination with an explorer.

A more advanced lesion develops a rough surface that is softer than the unaffected, normal enamel.

Softened chalky enamel that can be chipped away with an explorer is a sign of active caries. Roberson T, Heymann H, Swift E.

Sturdevant’ Art and Science of Operative dentistry fifth edition 2006.

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Zone of incipient caries(a). Surface zone(b). Body of the lesion(c). Dark zone(d). Translucent zone

.

Roberson T, Heymann H, Swift E. Sturdevant’ Art and Science of Operative dentistry fifth edition 2006.

8fromLasfargues and Colon, 2010

9Lasfargues JJ, Kaleka R, Louis JJ (2000) Le concept SISTA. Un nouveau guide th_rapeutique en cariologie. Real Clin 11:103–122

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DiagnosisInitial clinical examination:The purpose of the examination is to

detect visually changes of colour, translucency and structure of the enamel.

An initial inspection, tooth by tooth, on wet surfaces can spot cavities and brown or white stains.

Guerrieri, A Gaucher C, Bonte E, Lasfargues JJ. Minimal intervention dentistry: part 4. Detection and diagnosis of initial caries lesions. Br Dent J. 2012 Dec;213(11):551-7

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Radiographic Evaluation

Bitewing radiographs are the method of choice for early detection of carious lesions, especially on proximal surfaces.

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New Diagnostic AidsFluorescence systems

Guerrieri, A Gaucher C, Bonte E, Lasfargues JJ. Minimal intervention dentistry: part 4. Detection and diagnosis of initial caries lesions. Br Dent J. 2012 Dec;213(11):551-7

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Infrared laser

Quantitative light fluorescence (QLF)

Guerrieri, A Gaucher C, Bonte E, Lasfargues JJ. Minimal intervention dentistry: part 4. Detection and diagnosis of initial caries lesions. Br Dent J. 2012 Dec;213(11):551-7

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LED cameras

CarieScan PRO

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Fiberoptic Transillumination

Intraoral Television Camera

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Remineralization of incipient lesionIt now is well-recognized that it is possible to

arrest and even reverse the mineral loss associated with caries at an early stage, before cavitation takes place.

Enamel and dentin demineralization is not a continuous, irreversible process.

Murdoch-Kinch CA, Mclean ME. Minimally invasive dentistry. JADA 2003 Jan; 134: 87-95

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When the pH is less than 5.5, subsurface enamel or dentin will demineralize.

Fluoride enhances the uptake of calcium and phosphate ions and can form fluoroapatite.

Fluorapatite demineralizes at a pH less than 4.5, making it more resistant to demineralization from an acid challenge than hydroxylapatite.

Murdoch-Kinch CA, Mclean ME. Minimally invasive dentistry. JADA 2003 Jan; 134: 87-95

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Remineralising AgentsFluoride Mouth rinseCasein Phosphopeptide- Amorphous Calcium

Phosphate (CPP-ACP).Combination of CPP-ACP and fluorideNovamin (calcium sodium phosposilicate)Resin infiltrant technologyNano hydroxyapatite:

Jingarwar MM, Bajwa NK, Pathak A Minimal Intervention Dentistry – A New Frontier in Clinical Dentistry J Clin Diagn Res. 2014 Jul; 8(7): 4-8.

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Title Clinical evaluation of diagnodent in detection of occlusal caries in children.

Author J Clin Pediatr Dent. 2006 Summer;30(4):287-91.Journal Olmez A1, Tuna D, Oznurhan F.Level of evidence

II

objective The aim of this in vivo study was to evaluate the effectiveness of DIAGNOdent, visual and radiographic examination in detecting non-invasive diagnosis of occlusal caries in children.

Method In this study, 92 untreated molars with sound occlusal surface or enamel and/or dentin caries were selected from 28 healthy patients, aged 7-17 years. All teeth were examined by two researchers using each of three diagnostic system (DIAGNOdent, visual, radiographic). Interpretation of the DIAGNOdent value and the radiolucency on the bitewing film were combined with the visual examination to decide where the teeth had to be opened. Depth of caries was recorded. Sensitivities and specificities were calculated for each diagnostic method using the biopsy scores as gold standard. Sensitivity and specificity for DIAGNOdent, visual examination and bitewing radiography were 0.86/0.80, 0.69/1.00 and 0.36/1.00, respectively

Conclusion It was concluded that Diagnodent with a high sensitivity may be useful adjunct to visual examination with a high specificity in detecting occlusal caries.

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Title Long-term remineralizing effect of casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) on early caries lesions in vivo: a systematic review.

Author Li J, Xie X, Wang Y, Yin W, Antoun JS, Farella M, Mei LJournal J Dent. 2014 Jul;42(7):769-77.Level of evidence

III

objective To assess the long-term (>3 months) remineralizing effect of casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) on early caries lesions in vivo.

Method Of the 738 studies screened, 83 studies were reviewed and eight selected for inclusion in the final sample. The follow-up period of the studies included varied from 3 to 24 months. The long-term remineralizing effect of CPP-ACP in vivo was demonstrated in comparison with placebo in randomized controlled trial. However, there is conflicting evidence regarding the clinical efficacy of CPP-ACP when used in conjunction with fluoride toothpastes. No specific side effect related to CPP-ACP usage was found.

Conclusion CPP-ACP has a long-term remineralizing effect on early caries lesions in comparison with placebo, although this does not appear to be significantly different from that of fluorides. The advantage of using CPP-ACP as a supplement to fluoride-containing products is still unclear. High-quality, well-designed clinical studies in this area are still required before definitive recommendations can be made

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conclusionIn recent years, methods of

detection of early carious lesions have evolved considerably.

So first identification of the earliest mineral changes and then to controlling the demineralisation process using non-operative procedures.

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References Roberson T, Heymann H, Swift E. Sturdevant’ Art and

Science of Operative dentistry fifth edition 2006.

Lasfargues JJ, Kaleka R, Louis JJ (2000) Le concept SISTA. Un nouveau guide th_rapeutique en cariologie. Real Clin 11:103–122.

  Guerrieri, A Gaucher C, Bonte E, Lasfargues JJ. Minimal

intervention dentistry: part 4. Detection and diagnosis of initial caries lesions. Br Dent J. 2012 Dec;213(11):551-7.

Jingarwar MM, Bajwa NK, Pathak A Minimal Intervention Dentistry – A New Frontier in Clinical Dentistry J Clin Diagn Res. 2014 Jul; 8(7): 4-8.

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Murdoch-Kinch CA, Mclean ME. Minimally invasive dentistry. JADA 2003 Jan; 134: 87-95.

 Olmez A, Tuna D, Oznurhan F. Clinical evaluation

of diagnodent in detection of occlusal caries in children. J Clin Pediatr Dent. 2006 Summer;30(4):287-91.

 Li J, Xie X, Wang Y, Yin W, Antoun JS, Farella M, Mei L. Long-term remineralizing effect of casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) on early caries lesions in vivo: a systematic review. J Dent. 2014 Jul;42(7):769-77.

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